Are Biologics Worth the Risk? Usage, Benefits, and Side Effects

The development of biologics has dramatically improved the treatment of psoriasis, especially in people with moderate-to-severe forms of the disease who haven’t responded well to first-line treatments like topical medications or phototherapy.

However, there are risks to taking biologics, including an increased risk of infection. The medication is not right for everyone, including people with a history of latent tuberculosis or congestive heart failure. 

Keep reading to learn more about the possible risks and benefits of biologics and whether or not the medication may be right for you.  

What Are Biologics?

Biologics are medicines made from biological, or living, sources. These medicines are used in the prevention, diagnosis, or treatment of many diseases, including psoriasis, Crohn’s disease, osteoporosis, and cancer. They are generally given by injection or IV infusion.  

Vaccines, insulin, monoclonal antibodies, and immunosuppressants are all examples of different types of biologics. 

Biologics work by targeting specific cells or proteins of the immune system that contribute to the development of the disease. 

Examples of the types of biologics used to treat psoriasis include:

• Tumour necrosis factor (TNF)-alpha inhibitors: Including adalimumab, etanercept, and infliximab. 
• Interleukin (IL)-12 and IL-23 inhibitors: Including ustekinumab.
• Interleukin (IL)-17 inhibitors: Including secukinumab, ixekizumab, and brodalumab.
• Interleukin (IL)-23 inhibitors: Including risankizumab, tildrakizumab, and guselkumab. 

The anti-IL-17 and 23 drugs are part of a newer class of biologic drugs sometimes referred to as “newer biologics.” 

The Risks and Side Effects of Biologics

There are risks and possible side effects when taking biologics, as with any medication. Some of these risks are more serious than others and depend on your individual health and health history. 

It’s important to talk with your healthcare provider before starting biologics to assess whether or not these medications are right for you. 

Common Side Effects

Each biologic used to treat psoriasis has its own list of potential side effects. Depending on which biologic your provider recommends, possible side effects may include: 

• Injection side irritation.
• Flu-like symptoms. 
• Allergic reaction.
• Headache.
• Gastrointestinal (GI) issues, including stomach ache, nausea, or diarrhea.
• Muscle aches. 
• Itching.

Serious Risks and Long-Term Concerns

One of the most common, and potentially serious, risks when taking biologics is an increased risk of infection.

Taking biologics weakens the immune system, leaving you more vulnerable to infections, including upper respiratory infections like the flu or COVID-19 or urinary infections.

Anti-TNF biologics can also increase the risk of reactivation of tuberculosis (TB) in people with the latent form of the disease. 

Additional possible, though rare, risks and long-term concerns include:

• Worsened congestive heart failure (CHF) in people with moderate to severe CHF NYHA class III or IV (only applies to TNF inhibitors)
• Rare central nervous system disorders (primarily with anti-TNF drugs)
• Drug-induced systemic lupus erythematosus, a lupus-like syndrome
• Worsened psoriasis flares
• New joint pain
• Liver issues

Though rare, some biologics carry a black box warning for potential malignancy risk, especially in younger patients. For this reason, your provider may recommend periodic monitoring (including blood tests and TB screening) while taking the medication.

Because of the risk mentioned above, TNF inhibitors are generally avoided in people with moderate to severe CHF. For patients with mild CHF (NYHA class I or II), these medications may still be considered but with caution and close monitoring (a cardiologist will ultimately make this decision).

Cost and Accessibility

The cost for biologics for psoriasis will vary depending on the type of medication you’re taking and your insurance coverage. However, in general, these types of medications are expensive. 

According to one review of sales-based costs of biologics for psoriasis in 2014, one year of treatment with the following biologics cost:

• $53,909 for ustekinumab out-of-pocket.
• $46,395 for etanercept out-of-pocket.
• $39,041 for adalimumab out-of-pocket.

The same data also showed that the cost of these medications are increasing at a rate of an average of 20% per year.  

Are They Worth the Risk?

Biologics have revolutionized the management and treatment of psoriasis. They are considered to be safe and effective for many people with the disease. Screening guidelines for clinicians have helped to mitigate the risks of these medications for many people. 

Though biologics help many people manage their psoriasis, it’s not right for everyone. It’s important to talk with your healthcare provider to assess your individual risk-benefit ratio when it comes to biologic treatment of psoriasis.  

Who Should Consider Biologics?

Biologics can be a very effective treatment option for people with moderate-to-severe plaque psoriasis or psoriatic arthritis, especially if they haven’t responded well to other treatments. 

Both the Joint American Academy of Dermatology (AAD)- National Psoriasis Foundation (NPF) and the European guidelines recommend biologics for people with severe psoriasis that doesn’t respond to conventional treatment.

Who Should Avoid Biologics?

People with a history of certain medical conditions may want to avoid taking biologics, including:

• Latent tuberculosis. 
• Congestive heart failure. 
• Demyelinating disease.
• HIV.
• Chronic hepatitis B.

Some biologics, like IL-17 inhibitors, can worsen inflammatory bowel disease (IBD). However, other biologics, like anti-TNF and ustekinumab, can be used to treat IBD. If you have IBD, consult with your healthcare provider about which biologic is best for you.

Anti-TNFs were originally contraindicated during pregnancy and lactation, but more recent research supports the use of some of these medications in pregnant people with arthritis. 

Alternative Treatments to Biologics

There are several different types of treatments for psoriasis. The first line of treatment usually includes topical medications, phototherapy, and oral anti-inflammatory medications. 

Many experts believe that diet and stress management can also help to treat and manage the condition.