Management of psoriatic patients in biologic treatment associated with infectious comorbidities

Abstract

Introduction: Psoriasis is a chronic inflammatory disease affecting about 2% of population, involving both acquired and innate immunity. Psoriasis affects mainly skin, presenting multiple co-morbidities; among them infective ones. Re-activation of tuberculosis or viral hepatitis (HBV and HCV) still represents a therapeutic challenge in patients receiving treatment with biological drugs, as well as HIV infection. For this reason, a multidisciplinary approach with global treatment resulting from active collaboration of different specialists is highly recommended. Aim: To investigate the most common infective diseases as co-morbidities associated with psoriasis and to provide algorithms for screening, follow-up and therapeutic management in psoriatic patients. Material and methods: We examined the main infectious comorbidities that can affect moderate to severe psoriatic patients, influencing the therapeutic choice as during the biological treatment both viral and tuberculosis re-activation may occur. We have therefore evaluated the main diseases (TB, Hepatitis B and C, HIV) and the monitoring of patients during treatment with biological agents. Results: Regular monitoring of psoriatic patients is recommended during long-term treatment with biological drugs in order to identify cases of re-activation of the latent infective agent or de novo acquired infection. Conclusions: Here we report the state of art regarding management of psoriatic patients with these co-morbidities suggesting a specific screening and management for infectious diseases in patients with moderate to severe plaque psoriasis.

Novel Therapeutic Approaches to Psoriasis and Risk of Infectious Disease

“…When plasma HBV-DNA is detectable, treatment with entecavir or tenofovir should be started before biological treatment [ 78 ]. Biological treatment should be initiated when plasma HBV-DNA is either undetectable or at least lower than 2000 UI/mL [ 79 ]. If plasma HBV-DNA is not detectable, it is recommended to start lamivudine (100 mg/daily) 2 weeks before biological drugs and continue up to the end of therapy.…”

“…If plasma HBV-DNA is not detectable, it is recommended to start lamivudine (100 mg/daily) 2 weeks before biological drugs and continue up to the end of therapy. HBcAb appears with acute infection and persists for life, prophylaxis is not required when Abs are the only sign of the infection, but clinical and laboratory monitoring is recommended [ 79 ]. The isolated presence of HBsAb indicates either recovery or immunity because of vaccination and no measures are required [ 21 ].…”

“…A patient with a positive result must undergo HCV-RNA testing, or HCV-core-antigen testing whenever HCV-RNA assays are uunavailable or not affordable, to diagnose an active infection [ 93 ]. If HCV-RNA is positive, it is mandatory to test liver functions and to start antiviral treatment with direct-acting antivirals (DAA), which are effective in eradicating the infection; biological therapies should not be commenced if cirrhosis is not controlled [ 79 ]. Unlike HBV reactivation, HCV reactivation is quite uncommon, occurring primarily with immunosuppressive drugs administered to chronically infected patients who were not carefully evaluated and did not receive antiviral therapy [ 94 ].…”

Risks of Biologic Therapy and the Importance of Multidisciplinary Approach for an Accurate Management of Patients with Moderate-Severe Psoriasis and Concomitant Diseases

“…Biologic therapy presents new safety issues to be taken into consideration in different populations affected by psoriasis: demyelination, chronic viral infections, cardiovascular outcome, lymphoma, tuberculosis, pregnancy, surgery, and vaccination, to name a few [ 77 ]. A review from 2020 by Bernadini N et al emphasizes the importance of both careful screening for infectious diseases in psoriasis patients candidates to begin biologic therapy, as well as on the close collaboration with the infectious diseases physician in patients with personal history of tuberculosis, human immunodeficiency virus infection or chronic hepatitis B or C virus infection [ 78 ]. The authors advise active collaboration with the infectious diseases physician for a successful approach of the psoriasis patient with infectious comorbidities [ 78 ].…”

“…A review from 2020 by Bernadini N et al emphasizes the importance of both careful screening for infectious diseases in psoriasis patients candidates to begin biologic therapy, as well as on the close collaboration with the infectious diseases physician in patients with personal history of tuberculosis, human immunodeficiency virus infection or chronic hepatitis B or C virus infection [ 78 ]. The authors advise active collaboration with the infectious diseases physician for a successful approach of the psoriasis patient with infectious comorbidities [ 78 ]. In 2019, a review by Olveira A, Herranz P, and Montes ML on the cooperation between dermatologists and hepatologists regarding the approach of patients affected by psoriasis hepatopathies was published [ 79 ].…”