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Screening guide designed for use prior to immunosuppressive therapy

A recently-published guide for dermatologists can serve as a pocket reference to screening patients for infection prior to starting them on immunosuppressive agents for their dermatologic conditions, according to the guide’s lead author.

The guide was needed because of the entry of many new immunosuppressive drugs into the market for dermatologic conditions, particularly biologics, said Dr. Marisa G. Ponzo.

In dermatology alone there has been an ‘explosion’ in biologic medications, she said.

Helps achieve best outcome

“They can treat a number of skin conditions, and they have good to excellent effect. But like any drug that modulates the immune system, these medications are generally safe but we have to worry about them causing the patient to be more susceptible to infection or to the resurfacing of any preexisting infection they may have."

Dr. Ponzo, a dermatology resident in the Department of Dermatology and Skin Science at the University of British Columbia in Vancouver and her colleague Dr. ChihHo Hong, a clinical assistant professor in the department, published the guide online in Skin Therapy Letter (Jan. 2017; 22(1):8– 11). The guide can be read at:

Other medical specialties, including gastroenterology and rheumatology, have guideline documents for infection screening in patients being treated with immunosuppressants, but dermatology-specific guidelines did not exist, said Dr. Ponzo.

Immune-suppressing medications

Two sections of the guideline introduce agents of interest. The first is on nonbiologic therapies such as corticosteroids, cyclosporine, and methotrexate, and the latter details biologic agents, including etanercept, infliximab, and ustekinumab. Both sections detail the mechanism of action of the agent, as well as specific infectious pathogens of concern for different agents.

“There are many immunosuppressant medications that are available in dermatologic practice, and there are many coming in the future,” said Dr. Ponzo.

While these medications are generally safe, it is still imperative to screen patients for potential serious infection complications.”

While the biologics can be extremely effective, and new ones continue to become available, Dr.Ponzo said that she felt it was important to include more traditional immunosuppressant medications as well.

"The traditional, older immunosuppressive drugs are also effective," she said. “They may be primarily indicated, depending on the clinical context.” More than 30 years of medical experience with the traditional agents, and their often lower cost to patients, can make them a desirable option for many patients and clinicians.

Patient work-up

The third main section in the guide is a recommended pre-treatment infection workup. This is divided into four sections: Screening a patient for risk factors of infection; considering laboratory screening on a case-by-case basis; ensuring patients’ immunizations are up to date, based on the latest recommendations; and educating the patient on minimizing infection risk.

Screening patients for risk factors should include factors such as age, occupation, and comorbid medical conditions, but also historical factors, according to the guide.

Travel history is particularly important for fungal infections, which some immunosuppressants can cause to flare.

"It is important screening for that," said Dr.Ponzo. "We would ask the patient, specifically for fungal infections, about places where they have travelled to. Certain fungal infections are endemic to certain areas in North America and throughout the world.”

Patient education during the screening is another important step recommended by the guideline. This not only includes advocating frequent handwashing and avoidance of high-risk infectious exposures such as crowded areas, farms, compost, or travel to areas where some diseases are endemic, but also instructions on what early signs and symptoms of infection patients should watch for.

Overall, Dr.Ponzo said that while the guide was published primarily with dermatologists in mind, it could be of use to other physicians as well. “Possibly pediatricians, internists, and family physicians who feel comfortable prescribing these medications and managing their complications.”

Originally published in The Chronicle of Skin & Allergy (Sept. 2017; 23(6):1,14).

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