What investigations are recommended before initiating secukinumab (secukinumab) treatment in a patient with moderate to severe plaque psoriasis?

Pre-Treatment Investigations for Secukinumab in Psoriasis

Screen for tuberculosis and active infections before initiating secukinumab, as these are the critical safety assessments required prior to treatment. 1, 2

Mandatory Screening

Tuberculosis Assessment

• Perform tuberculosis screening before starting secukinumab using either tuberculin skin test (PPD), T-Spot, or QuantiFERON-Gold 1, 2
• Do not administer secukinumab to patients with active tuberculosis 1
• Consider anti-tuberculosis therapy before starting secukinumab in patients with latent TB 1
• If tuberculosis screening is positive, obtain a chest radiograph and refer to infectious disease specialist before initiating therapy 1

Active Infection Screening

• Assess for any clinically important active infections, as this is an absolute contraindication 1, 3
• Active infection or sepsis requires consultation with an infectious disease specialist before initiation 1, 2
• Do not start secukinumab until active infections have completely resolved 1

Relative Contraindications to Assess

Hepatitis B Status

• Screen for untreated hepatitis B infection, which is a relative contraindication 1, 2
• Patients with untreated hepatitis B should be evaluated by an appropriate healthcare professional and may require concomitant anti-viral therapy before starting secukinumab 1
• For patients with confirmed resolved hepatitis B (positive hepatitis B core antibody), ongoing monitoring with hepatitis B surface antigen, anti-hepatitis B core antibody, and liver function tests should be considered 1

Inflammatory Bowel Disease History

• Evaluate for history of inflammatory bowel disease (Crohn's disease or ulcerative colitis) 1, 4
• Secukinumab is not recommended in patients with inflammatory bowel disease, as new cases or exacerbations have been reported 1
• If a patient has pre-existing IBD, secukinumab should be avoided and alternative biologics considered 4

Laboratory Testing (Not Evidence-Based but Commonly Performed)

Baseline Blood Work

• Complete blood count (CBC) with differential and complete metabolic panel (CMP) are not supported by evidence but are performed at the discretion of the treating dermatologist 1
• These tests may help establish baseline values for monitoring but are not required for treatment initiation 1

Assessments NOT Required

HIV Testing

• HIV testing is considered at the treating practitioner's discretion and depends on patient-specific risk factors, not routinely required 1

Hepatitis C Screening

• Not specifically mandated in guidelines for secukinumab initiation 1

Pregnancy Testing

• While pregnancy considerations exist, routine pregnancy testing is not specifically mandated in the pre-treatment guidelines 1

Common Pitfalls to Avoid

• Do not delay tuberculosis screening, as this is the most critical pre-treatment assessment and active TB is an absolute contraindication 1, 2
• Do not overlook inflammatory bowel disease history, as secukinumab may precipitate or worsen IBD, unlike other biologics such as ustekinumab which are safer in this population 1, 4
• Do not initiate therapy during any active infection, even if mild, without infectious disease consultation 1, 2
• Remember that QuantiFERON-Gold can remain positive after treatment of latent TB, so exercise caution when interpreting results in previously treated patients 1