Biologics for Psoriasis: What to Know Before You Start

Many people have questions before starting biologic or biosimilar treatment. Here’s what to expect when getting started on these medications.

Who Gets Prescribed a Biologic?

“Biologics are indicated for moderate to severe psoriasis and for active psoriatic arthritis,” says Saakshi Khattri, M.D., a board-certified rheumatologist and dermatologist and assistant professor of dermatology at the Icahn School of Medicine at Mount Sinai Hospital in New York City.

They’re also a treatment option for people who have not responded to other medications, who’ve experienced harmful side effects from those other medications, or who have comorbidities such as kidney or liver disease where other oral systemic treatments may not be recommended. If any of these factors are true for you, your doctor may prescribe biologic treatment.

Are Biologic Medications Covered by Insurance?

You’ll have to check with your insurance company to see if your biologic treatment is covered by your plan. Prescription drug insurance plans each have a formulary list.

“If a particular biologic is on that list, it will be covered—but if your doctor prescribes a biologic that’s not on your formulary, coverage may be denied,” explains Khattri.

And, depending on your specific insurance coverage, it’s possible that you may need to try other medications without success before your plan will cover a specific biologic treatment, adds Khattri. This is a practice referred to as step therapy, which is designed to manage health care costs. Many psoriasis advocacy groups are working to create legislation against step therapy to improve patient access to the best therapy possible sooner rather than later.

That doesn’t mean the biologic will definitely be out of your budget. If you need to take a biologic that your insurance won’t cover, the drug manufacturer may offer a prescription assistance program that may help you get the medication for a reduced out-of-pocket cost.

What Tests Are Needed Before Starting Biologic Treatment?

Expect to go through a full blood panel, including liver and kidney function testing, screenings for hepatitis B and C, tuberculosis, syphilis, HIV, and possibly a chest x-ray, says Nilanjana Bose, M.D., a rheumatologist at the Rheumatology Center of Houston in Texas.

“These tests are used both to rule out any active disease that may be masquerading as psoriasis or psoriatic arthritis, and to make sure there’s no latent infection that could flare,” says Bose. Since biologics are aimed to reduce an overactive immune response, these medications may also increase the risk of infection.

How Will I Take My Biologic?

Biologics are administered one of two ways: via intravenous (IV) infusion or injection.

A biologic that’s administered as an IV infusion is usually given at an infusion center, explains Bose. How often you’ll get the infusion partially depends on which drug you’re receiving. Also, you may need to go more often in the beginning and less often as time goes on. For example, you may receive your first infusion, then go back for a second two weeks after that, then have a third dose a month later, and then go back for maintenance visits every eight weeks.

There are also many injections that can be done at home, without a special visit to a medical center, says Khattri. “Most are subcutaneous injections that can be self-administered, or given by a family member if you’re not comfortable doing it yourself,” she explains. Subcutaneous means it’s injected just under the skin, in the tissue layer between the skin and the muscle.

The frequency of self-injections can range from every week to every two weeks to every month, or even every two to three months, depending on which biologic you’re given, says Bose.

What Happens If I Miss a Dose of My Biologic?

It’s important to take your treatment exactly as directed to reap its full benefits. However, sometimes, life happens, and you may miss a dose.

“Missing a dose is tricky, as different biologics have different schedules,” says Khattri. If you miss a dose of your biologic medication, reach out to your doctor to confirm next steps. Generally speaking, your doctor will likely recommend administering the missed dose as soon as you can, and resetting the clock, so you’re waiting the full amount of time before taking the following dose, adds Khattri.

Will Taking a Biologic Hurt?

An infusion requires an IV needle to be inserted into a vein in your hand or arm, which can hurt but is usually no more painful than a pinch.

As for injections, some medications may hurt more than others, says Khattri. For example, in the self-injectable biologics, “the needle is thin, and it hardly hurts, according to most patients,” adds Bose. “There are no complaints, for the most part.”

If you have a fear of or aversion to needles, talk it over with your doctor to see what your best options are. You may be able to choose a treatment that isn’t given as frequently or uses a thinner needle than others.

What Types of Side Effects Can There Be When Taking a Biologic?

Some people have initial reactions to taking the medications. “With the infused biologics, there’s a risk of local reaction at the IV site, as well as a fever, rash, or chills,” explains Bose. “There should be a nurse at the infusion center who can pre-medicate you before the infusion to help avoid these types of reactions.”

If you’re sensitive to a medication that’s being injected into your skin, you may get a local reaction like redness or swelling around the injection site. “Cool it down with ice, take Tylenol or Benadryl, and rotate the injection site—it usually takes some trial and error to find which part of the body tolerates it better,” says Bose.

There are some more serious potential side effects, too. “Since these drugs are immune suppressants, you may experience infections,” says Khattri. Be sure to contact your doctor if you develop a fever, cough, or flu-like symptoms.

Other side effects may vary by the medication, so it’s important to talk to your doctor about the risks of the exact biologic you’re prescribed and any other health conditions or family history you may already have. For example, some TNF inhibitors may increase cancer risk, and some IL-17 blockers can increase the risk of inflammatory bowel disease, says Khattri.

However, in most cases, the benefits gained from biologic treatment outweigh the risks and potential side effects, which are rare.

How Long Does It Take for Biologics to Start Working?

How long it takes to see results from a biologic can vary from person to person. “The skin tends to respond quickly, so it’s possible to see improvement in psoriasis within a month of starting biologics,” says Khattri. “For psoriatic arthritis, it can take longer. Most doctors will say to give it at least three to four months to see a response.”

“Most of the time, patients do well on biologics,” adds Bose. “If not, we can add an oral disease-modifying anti-rheumatic drug to increase the efficacy of the biologic, or switch to another biologic altogether.”

Will I Have to Take a Biologic Forever?

Biologic treatment is often most effective when taken continuously. If you do stop and restart treatment, the medication could become less effective or trigger side effects. So, in most cases, you should continue taking your biologic to experience a reduction or elimination of psoriatic symptoms.

“Sometimes, you can wean down the frequency and dosing interval, so you’re getting less medication—but you’re still getting it,” says Bose. “It’s really case by case.”

If you’re considering tampering down your medications, be sure to discuss the risks and benefits with your doctor. “They’ll want to keep a close eye on you,” explains Bose. “You’ll need to get labs and check in with your doctor on a regular basis to make sure you’re not relapsing.”

Can My Biologic Stop Working?

Yes. Biologic drugs can become less effective over time, even when taken continuously. “That’s called secondary loss of efficacy,” says Khattri. “When that happens, we can switch you to a different biologic.”

If you still have questions about starting biologic treatment, be sure to bring them up with your doctor.

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