Managing Monitoring: Biologic Therapy for Psoriasis

Biologic therapy has become the cornerstone of management for dermatological conditions such as psoriasis. Guidelines suggest routine clinical and laboratory monitoring for all patients at 6-monthly intervals [1] with a resulting impact on patients, health resources and society through environmental implications. A cross-sectional analysis was carried out on patients attending systemic clinics at our tertiary dermatology department. 100 patients aged > 18 years established on biologic therapy for psoriasis were included. Mean age was 47.4 years (range 19–77), 50% were female and mean duration of biologic therapy was 3.2 years (range 0–10 years). Of this cohort, 36% were treated with Ustekinumab, 33% with Adalimumab and 20% with Guselkumab (Figure 1). In 74% of cases, there was no major change in direction of care identified at most recent review. Out of 100 patients, minor intervention was required in 26% (Figure 2). These included activity of psoriasis requiring systemic dose adjustment or switch (n = 6), incidental non-primary skin diagnosis requiring intervention (n = 5) and laboratory abnormality requiring repeat testing without treatment interruption (n = 3). Biologic therapy was not discontinued due to adverse events in any patient in this analysis. Vaccination and screening requirements were discussed in all consultations. Individual-specific health promotions such as cardiovascular health optimisation were discussed in 38% of reviews. Mean interval of follow-up appointments was 5.7 months. While formal guidelines suggest 6-monthly surveillance intervals for patients on biologics [1], the evidence base does not exist for this practice. A recent quantitative study of over 8000 patients on anti-TNF therapy for psoriasis reported 125 treatment discontinuations over a 5-year follow-up, and only 61 after the first year. Biologic discontinuation was mainly due to mildly elevated liver enzymes, independently associated with increasing age, diabetes and liver disease [2]. Co-production in healthcare between patients and healthcare providers is of utmost importance. A 2024 qualitative analysis revealed patients' perspectives on laboratory monitoring for immunosuppressant therapy [3]. Overall, patients were reassured by regular monitoring, but found it burdensome at the current frequency. A move towards patient-initiated follow-up with extension of surveillance intervals for stable biologic patients would be welcomed. From a health economics perspective, each biologic monitoring appointment with blood tests in the UK costs an estimated €25.75 [2]. Extended monitoring periods of annually or biennially were significantly more cost-effective. Healthcare professionals noted that frequent monitoring is resource-intensive, outdated and overly cautious [3]. Resources may be more effectively utilised with a move away from 6-monthly appointments for stable patients. The requirement for 6-monthly in-person consultations also has a negative environmental impact through increased carbon emissions with travel to appointments [4]. Adopting a personalised, risk-stratified approach to monitoring has been estimated to accrue carbon savings of 1355 kg CO2e annually, equivalent to a car driving 3474 miles [4]. We propose the evolution of guidelines to a personalised risk-based approach, as discussed in previous studies [3, 4]. Increasingly utilised newer agents such as anti-interleukin-12/23 have a better risk profile, and monitoring should reflect this. A risk-stratified approach is favoured, with healthcare professionals in support of annual monitoring while on anti-TNF agents due to rare blood test abnormalities [3]. Risk calculation can be performed through consideration of individual factors such as age, co-medications and comorbidities which may increase risk of treatment side effects [3] and influence surveillance intervals. We did not collect data on comorbidities in this study, which is a limitation. In our centre, another proposed change is the incorporation of health promotion strategies through a tailored text message at 6-monthly intervals with an annual in-person review. This would remind patients to engage in vaccination and screening programmes as well as cardiovascular risk factor optimisation as psoriasis is an independent risk factor for cardiovascular disease [5]. A single-centre cross-sectional analysis of 100 patients on biologic therapy for psoriasis attending for 6-monthly review revealed minimal definable change in patient care. It may be time for the guidelines to reflect shift. An individualised risk-stratified approach to biologic monitoring is favoured by healthcare professionals and patients, and would assist in the delivery of sustainable, patient-centred and cost-effective dermatological care. Limitations include the small sample size, cross-sectional design and single-centre nature of our study, which may limit generalisability. Multi-centre studies with larger sample sizes are required to further strengthen our findings. Eimear Gilhooley and Claudine Howard-James conceptualised the study. Claudine Howard-James was responsible for investigations, methodology, data collection, writing – draft, writing – revisions and editing. Eimear Gilhooley was the supervising author, responsible for writing – revisions and editing. The authors received no specific funding for this work. The authors have nothing to report. The authors declare no conflicts of interest. The data that support the findings of this study are available from the corresponding author upon reasonable request.