Contraindications and Precautions for Biologic Therapies in Psoriasis

Absolute Contraindications

The American Academy of Dermatology recommends that TNF-α inhibitors are absolutely contraindicated in patients with severe congestive heart failure (NYHA class III or IV), active serious infections, and demyelinating disease 1, 2
Active serious infections are an absolute contraindication for TNF-α inhibitors, and treatment must not be initiated during active serious infections, including sepsis, abscess, or opportunistic infections 1, 2
Active tuberculosis is an absolute contraindication until TB is adequately treated, and all patients require TB screening before initiation of TNF-α inhibitors 1, 2

The British Journal of Dermatology suggests that TNF-α inhibitors should be used with caution in patients with mild-moderate heart failure (NYHA class I-II), and requires careful assessment and close monitoring 2
The American Academy of Dermatology recommends that patients with a history of malignancy require careful risk-benefit assessment before initiating TNF-α inhibitors 1
Hepatitis B infection is not an absolute contraindication for TNF-α inhibitors, but requires hepatology consultation, antiviral prophylaxis, and monitoring of HB surface antigen, anti-HB core antibody, and liver function tests 1
HIV infection is not an absolute contraindication for TNF-α inhibitors, but can be used only if patient is on highly active antiretroviral therapy (HAART) with normalized CD4+ counts, undetectable viral load, and no recent opportunistic infections 1

The American Academy of Dermatology recommends mandatory screening for tuberculosis, hepatitis B and C serology, and assessment for active infections before initiating TNF-α inhibitors 1, 2
Tuberculosis screening should include tuberculin skin test or interferon-gamma release assay (IGRA), and chest X-ray if positive 1, 2
Hepatitis B screening should include HB surface antigen, anti-HB core antibody, and anti-HB surface antibody 1
Hepatitis C screening should include anti-HCV antibody 1

The British Journal of Dermatology notes that failing to screen for latent tuberculosis before initiating TNF-α inhibitors is a critical error, as reactivation risk is approximately six times higher than in untreated patients 2
TNF-α inhibitors carry significantly more contraindications than IL-23 inhibitors, making IL-23 inhibitors preferable for patients with cardiac disease, demyelinating conditions, or complex medical histories 3, 4
Combination immunosuppression increases risk, and adding other immunosuppressants to TNF-α inhibitors may alter the safety profile and increase malignancy risk 1
Prior PUVA therapy may be a risk factor for malignancy when treated with biologics 2