Special Populations
Pregnancy
Antibodies cross the placenta as pregnancy progresses, with the highest rate in the third trimester. Certolizumab pegol has shown the lowest concentrations in infant serum, possibly due to its unique structure lacking the fragment crystallizable region required for passage through the placenta.30 For this reason, certolizumab pegol is a treatment of choice if biologic therapy is warranted during pregnancy.
Much of the pregnancy data for the remaining TNF-α inhibitors come from patients with rheumatoid arthritis or CD. In these populations, rates of major birth defects and miscarriages do not differ greatly from untreated women with these conditions.31 One retrospective study of unintentional pregnancies in women receiving ustekinumab showed rates of AEs similar to the general population.32
Pregnancy data for IL-17 or IL-23 inhibitors are largely limited to animal studies. One retrospective study of women exposed to secukinumab early in gestation showed no increased risk for pregnancy-related AEs.33 Discontinuation is still recommended for patients who become pregnant.
Pediatric Patients
Etanercept is approved for pediatric psoriatic patients 4 years and older. Children with juvenile idiopathic arthritis who are 2 years and older can receive etanercept. Ustekinumab is safe and effective for pediatric psoriatic patients 12 years and older, offering a second biologic option in children.
Although not approved for pediatric psoriasis, adalimumab is approved in pediatric CD (≥6 years of age) and for juvenile idiopathic arthritis (≥2 years of age). Infliximab is approved for children 6 years and older with CD or ulcerative colitis.
Monitoring
Periodic tuberculosis screening is recommended for all biologics. For patients with latent tuberculosis, biologics may be restarted after 1 month of treatment of tuberculosis.
Prior to initiation of biologics, patients should be screened for hepatitis with hepatitis B surface antigen and antibody, hepatitis B core antibody, and hepatitis C antibody. Patients at risk for human immunodeficiency virus also should be screened.
Generally, complete blood cell count and comprehensive metabolic profile are advisable prior to starting a biologic. Opinions differ on frequency of repeating laboratory work. Complete blood cell count and comprehensive metabolic profile should be monitored at least every 3 to 6 months in patients on TNF-α inhibitors, and neutrophil count should be monitored during the induction phase of IL-17 inhibitors.
All patients with psoriasis should maintain age-appropriate cancer screenings, especially those on biologics. If malignancy is discovered, biologic medication should be discontinued. Debate exists as to when therapy can be safely restarted following treatment of malignancy. Patients who are considered at low risk for recurrence may opt to restart a biologic after 5 years, or sooner if symptoms warrant.34 This decision should involve the patient’s cancer specialist.
Conclusion
Treatment choices are based on psoriasis type and severity, comorbidities, patient preferences, and drug accessibility. One approach is detailed in Table 3. As research advances the understanding of psoriasis, this field will continue to rapidly change. Knowledge of the immunopathogenesis of psoriasis and its relation to comorbidities can direct your decision-making for individual patients.