Adalimumab Initiation in Recent Acetabular Fracture with Psoriasis
Adalimumab should be delayed until the acetabular fracture has achieved adequate healing and any acute infection risk has resolved, as TNF-α inhibitors significantly increase infection risk during the critical healing period.
Primary Safety Concern: Infection Risk During Fracture Healing
The critical issue is not the fracture itself, but the substantially elevated infection risk that adalimumab poses during the vulnerable post-fracture period:
- TNF-α inhibitors carry FDA warnings about serious infections, including opportunistic infections, which would be catastrophic in the setting of recent orthopedic trauma 1, 2
- Acetabular fractures often require surgical fixation with hardware, creating additional infection susceptibility that is incompatible with immunosuppression 1
- The American Academy of Dermatology guidelines emphasize that adalimumab increases risk of serious infections requiring hospitalization 2
Recommended Timeline for Initiation
Wait minimum 6-8 weeks post-fracture (or post-surgery if operative fixation was performed) before considering adalimumab:
- Ensure fracture stability and adequate callus formation on imaging
- Confirm absence of any signs of infection (wound healing complete, no fever, normal inflammatory markers)
- Verify patient is fully weight-bearing or near full mobility without complications 1
Pre-Treatment Screening Requirements
Before initiating adalimumab once fracture healing permits, complete mandatory screening:
- Tuberculosis testing with PPD or interferon-gamma release assay 3
- Baseline complete blood count and liver function tests 3
- Hepatitis B screening in appropriate clinical settings 3
- Physical examination to exclude active infection 3
Adalimumab Dosing for Psoriasis Once Cleared
When medically appropriate to start, use the standard licensed regimen:
- 80 mg subcutaneously at week 0 (given as two 40-mg injections) 1
- 40 mg at week 1 1
- 40 mg every other week thereafter 1
- Assess disease response at 3-4 months 1
- Consider dose escalation to 40 mg weekly if inadequate response (PASI >10 despite initial response), though this requires special approval 1
Alternative Considerations During Waiting Period
While awaiting fracture healing, consider:
- Topical therapies with high-potency corticosteroids and vitamin D analogues for localized disease 1
- Phototherapy (narrowband UVB) if psoriasis severity warrants systemic intervention but biologics remain contraindicated 1
- These bridging therapies avoid immunosuppression during the critical healing window
Critical Pitfalls to Avoid
- Never initiate adalimumab with active infection or during acute fracture healing phase - the infection risk outweighs psoriasis treatment benefits 1, 2
- Do not use adalimumab in patients with sepsis 3
- Avoid in patients with NYHA class III/IV heart failure or demyelinating diseases 3
- Interrupted therapy after starting should be avoided as it increases risk of antibody formation and reduced efficacy on retreatment 1
Efficacy Data Supporting Eventual Use
Once safe to initiate, adalimumab demonstrates excellent efficacy: