Biologic or JAK inhibitor: tests before treatment and monitoring (anti-TNF, anti-IL6R, anti-IL17, ustekinumab, abatacept, rituximab)

Laboratory tests

• FBC with platelets
• AST
• ALT
• Serum protein electrophoresis
• Hepatitis B serology (HBsAg, anti-HBc, anti-HBs)
• HBV DNA (if anti-HBc antibodies positive with HBsAg negative)if needednon-French guidelineResolved hepatitis B (anti-HBc positive, HBsAg negative): HBV DNA and transaminases at baseline, then regular monitoring, and hepatology opinion ^[2].
• Hepatitis C serology
• HIV serology (with the patient's consent)
• IGRA test (QuantiFERON or T-SPOT.TB)
• Antinuclear antibodies (ANA) (before an anti-TNF)if neededBefore an anti-TNF: the CRI (French rheumatic inflammatory disease reference centre) lists them in the routine tests, a systemic autoimmune disease being a precaution for use ^[3]. Not requested before a JAK inhibitor ^[4].
• Serum creatinine with eGFR (before a JAK inhibitor)if neededBefore a JAK inhibitor: the dose depends on creatinine clearance (baricitinib 2 mg/day between 30 and 60 mL/min, not indicated below 30 mL/min) ^[4].
• Bilirubinif neededBefore a JAK inhibitor: full liver function tests at baseline ^[4].
• GGTif neededBefore a JAK inhibitor: full liver function tests at baseline ^[4].
• Lipid profile (before a JAK inhibitor)if neededBefore a JAK inhibitor: baseline lipid profile ^[4]; baricitinib raises lipids in a dose-dependent manner ^[5].
• Varicella serology (anti-VZV IgG), if no history of varicellaif neededNo history of chickenpox, or doubtful history: if serology is negative, vaccinate against varicella at least 6 weeks before treatment (live vaccine, not possible afterwards) ^[6]. Reimbursed in France “before long-term immunosuppressive treatment” ^[7].
• Serum β-hCG (woman of childbearing potential without effective contraception)if neededJAK inhibitors are contraindicated during pregnancy ^[4]; pregnancy and desire for pregnancy are part of the history before an anti-TNF ^[3]. The test itself is not listed by the CRI: depending on the context.
• Not a laboratory test: chest X-ray; update vaccinations (live vaccines before treatment).

Laboratory tests

• FBC with platelets
• Serum protein electrophoresis
• Hepatitis B serology (HBsAg, anti-HBc, anti-HBs)
• HBV DNA (if anti-HBc antibodies positive with HBsAg negative)if needednon-French guidelineResolved hepatitis B (anti-HBc positive, HBsAg negative): HBV DNA and transaminases at baseline, then regular monitoring, and hepatology opinion ^[2].
• Hepatitis C serology
• HIV serology (with the patient's consent)
• IGRA test (QuantiFERON or T-SPOT.TB)
• ASTif neededBefore an anti-IL6R ^[16] or ustekinumab ^[17]; not listed before an anti-IL17 ^[18].
• ALT (anti-IL6R, ustekinumab)if neededBefore an anti-IL6R ^[16] or ustekinumab ^[17]; not listed before an anti-IL17 ^[18].
• Bilirubinif neededBefore an anti-IL6R (tocilizumab, sarilumab) ^[16].
• GGT (anti-IL6R)if neededBefore an anti-IL6R (tocilizumab, sarilumab) ^[16].
• Lipid profile (anti-IL6R)if neededBefore an anti-IL6R: baseline lipid profile, as these treatments raise lipids ^[16,19].
• Serum creatinine with eGFR (ustekinumab)if neededBefore ustekinumab: “liver and kidney tests” ^[17].
• Varicella serology (anti-VZV IgG), if no history of varicellaif neededNo history of chickenpox, or doubtful history: if serology is negative, vaccinate against varicella at least 6 weeks before treatment (live vaccine, not possible afterwards) ^[6]. Reimbursed in France “before long-term immunosuppressive treatment” ^[7].
• Serum β-hCG (woman of childbearing potential without effective contraception)if neededPregnancy and desire for pregnancy are part of the history before an anti-IL6R ^[16]. The test is not listed by the CRI: depending on the context.
• Not a laboratory test: chest X-ray; update vaccinations (live vaccines before treatment).

Laboratory tests

• FBC with platelets
• AST
• ALT
• Serum creatinine with eGFR
• Serum protein electrophoresis
• Serum immunoglobulins (IgG, IgA, IgM)
• Hepatitis B serology (at least HBsAg and anti-HBc)
• HBV DNA (if anti-HBc antibodies positive with HBsAg negative)if needednon-French guidelineResolved hepatitis B (anti-HBc positive, HBsAg negative): HBV DNA and transaminases at baseline, then regular monitoring, and hepatology opinion ^[2].
• Hepatitis C serology
• HIV serology (with the patient's consent)
• Varicella serology (anti-VZV IgG), if no history of varicellaif neededNo history of chickenpox, or doubtful history: if serology is negative, vaccinate against varicella at least 6 weeks before treatment (live vaccine, not possible afterwards) ^[6]. Reimbursed in France “before long-term immunosuppressive treatment” ^[7].
• IGRA test (if risk of latent tuberculosis)if needednon-French guidelineThe BSR (United Kingdom, 2019) asks for tuberculosis screening before any biologic therapy (grade 1B) ^[10]. The CRI does not include it in the list of tests before rituximab ^[21], and the data are reassuring: a 2014 review found no case of active tuberculosis on rituximab and advised against this screening ^[10]. Not reimbursed in France for this indication ^[7].
• Not a laboratory test: ECG; pneumococcal and influenza vaccines.

Before the end of the 1st month

• FBC with platelets
• AST
• ALT
• Serum creatinine with eGFR (JAK inhibitor)if neededOn a JAK inhibitor: creatinine at each check ^[23].
• Lipid profile (tocilizumab: SmPC, 4 to 8 weeks)if neededOn tocilizumab, the SmPC asks for lipids 4 to 8 weeks after the start ^[19]; the CRI places them at 12 weeks ^[24].

At 3 months

• FBC with platelets
• AST
• ALT
• Lipid profile
• Serum creatinine with eGFR (JAK inhibitor)if neededOn a JAK inhibitor ^[23].

Then every 3 months

• FBC with platelets
• AST
• ALT
• Serum creatinine with eGFR (JAK inhibitor)if neededOn a JAK inhibitor ^[23].

Every 3 months

• FBC with platelets

Before each retreatment

• FBC with platelets
• Serum immunoglobulins (IgG, IgA, IgM)

• No specific laboratory monitoring of the biologic therapy.

Every 6 months (anti-TNF as monotherapy)

• AST
• ALT