In this video blog, Michael Hewitt, MD, discusses highlights from his lecture, Lab Monitoring Requirements In Injectable/Small Molecule Patients, on July 27, 2024, during the inaugural Elevate-Derm Alliance Summer Conference at the Westin Copley Place in Boston, Massachusetts.

In this video

Because biologics and small molecules are still relatively new in the grand scheme of medications, Dr. Hewitt says he stays "a little extra careful" and works from a standard set of baseline labs — a CMP, CBC with differential, QuantiFERON-Gold or TB spot test, hepatitis B (surface antibody, surface antigen, core antibody), hepatitis C, and HIV. He orders based on what the package insert requires, but also anticipates other providers adding drugs that might demand more monitoring. For comorbidities, he takes a yes-and-no approach: rather than manage a statin or chase down abnormal results ("the only patient that I've managed a statin on is myself"), he uses a documented counseling clause reminding patients that psoriatic disease carries comorbidities like metabolic syndrome and MACE risk, and directs them to age-appropriate screening, annual labs, vaccines, and a primary care visit.

On JAK inhibitors, Dr. Hewitt tailors monitoring to age and comorbidities. Because Janus kinase inhibitors can be "somewhat unpredictable" in which cell line they affect, he checks a CBC with differential, a CMP or liver function panel, and a fasting lipid profile roughly quarterly — noting the LDL elevation and the higher MACE signal seen in trials like ORAL Surveillance. For younger, healthy patients doing well and not family planning, he eventually spaces labs to every six months, while still running an annual QuantiFERON-Gold or TB spot test and reviewing systems at interval visits.

  • Start biologic and small molecule patients on a standard baseline panel: CMP, CBC with diff, QuantiFERON-Gold or TB spot, hepatitis B (surface antibody/antigen, core antibody), hepatitis C, and HIV.
  • Order labs the package insert requires, but also anticipate additional monitoring another provider's drugs may demand.
  • Rather than manage comorbidities yourself, use a documented counseling clause about metabolic syndrome and MACE risk, and direct patients to primary care, annual labs, cancer screening, and vaccines.
  • For JAK inhibitors, monitor CBC with diff, CMP or LFTs, and fasting lipids quarterly given their unpredictable cell-line effects, LDL elevation, and the MACE signal from ORAL Surveillance.
  • Space JAK inhibitor labs to every six months in young, healthy, stable patients — but keep an annual TB test and review of systems, analogous to TNF monitoring.