Getting Started with Biologics

Biologics or biological treatments refer to a group of treatments derived from living organisms, such as part of a protein. Compared to traditional pharmaceutical drugs, biologics are usually larger and more complex. You may be thinking about starting a biologic treatment for rheumatoid arthritis, inflammatory bowel disease, psoriasis, or for another health condition. But before you do, you’ll need to work with your clinician and undergo certain medical assessments. That will help minimize your chance of side effects and potential problems from using biologics.

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Potential Problems from Biologics

Biologics are a wide group of treatments, including older therapies like vaccines and cutting-edge ones like gene therapies. But the term biologic is often used to refer to specific modern types of medications that are commonly used to treat certain inflammatory diseases, such as rheumatoid arthritis, or to treat certain kinds of cancer.

Many of these modern biologic treatments target a specific part of the immune system. For example, the TNF blocker Enbrel (etanercept) blocks the downstream signaling of a molecule that contributes to inflammation in the body. This can be helpful for several different medical conditions that involve too much inflammation, such as rheumatoid arthritis.

However, these effects on the immune system may cause problems in specific situations. Overall, they may make your body less able to fight off certain kinds of infection. That’s why many of the steps you need to take before starting biologics have to do with trying to prevent future infection.

Medical Assessments Needed

Your clinician will need to do a full medical assessment, including medical history, exam, and certain laboratory tests. Medical imaging is also sometimes needed, as well. This will be tailored to your specific medical situation and the specific biologic you are considering. All of this will help make sure that the biologic is safe for you to take.

For example, people with particular medical conditions, like certain neurological syndromes, may not be able to take biologics safely.

If you have a condition like congestive heart failure, you might need tests like an echocardiogram before starting treatment. If this shows that your congestive heart failure is only mild, you might still be able to take your planned biologic. In other cases, it might show that your disease is too severe for this to be a reasonable risk.

Different biologics have slightly different risks of side effects, so your other medical conditions may impact the type of biologic you decide to use.

Make sure your healthcare provider knows about all of your health conditions before you decide together to start a biologic.

Hepatitis B and C Testing

For many biologics, your clinician will need to screen you for hepatitis B and hepatitis C before starting therapy. Some people are infected with either the hepatitis B or the hepatitis C virus without even knowing it. The virus may be inactive and not causing you any problems.

However, if you start a biologic, the virus might start to become more active. In some cases, this might lead to liver damage or even liver failure. So it’s important to make sure that you don’t have these viruses before starting therapy.

Screening for hepatitis viruses (specifically hepatitis B) is done as part of your medical history—and is recommended for all patients starting biologics.

Some of the groups at higher risk of hepatitis B are:

  • People who have used IV drugs
  • People with a sexual partner who has hepatitis B
  • Men who have sex with men
  • Healthcare workers
  • People on hemodialysis for kidney failure

Your clinician might go ahead and get these blood tests, even if you don’t have any risk factors.

If you are infected with one of these viruses, it doesn’t necessarily mean that you can’t have a biologic treatment, though it might in certain circumstances. That will depend on the specific biologic involved. In some cases, you may be able to start a biologic while you begin antiviral therapy for hepatitis. In other cases, you might opt for a non-biologic treatment.

Tuberculosis (TB) Testing

Tuberculosis screening is also usually done before starting a biologic treatment. Tuberculosis is another important infection that many people might not know that they have. When it is inactive, it may not cause any symptoms at all. But if you have inactive tuberculosis and start taking a biologic, your infection might start to cause you problems.

People are usually tested for tuberculosis with a test called Interferon Gamma Release Assay (IGRA) or with a tuberculin skin test. For the IGRA, you give a blood sample that is tested for tuberculosis. For the tuberculin skin test, you receive a prick to the skin. A few days later, a health professional sees if your skin has shown any signs of a reaction. In most cases, the IGRA test is now preferred.

If either of these tests is worrisome for tuberculosis, you may need follow up tests, like an X-ray of your chest. If it turns out that you do have tuberculosis, you will most likely need to receive treatment before you can start your biologic.

If you have any risk factors for tuberculosis, you may need to have regular screenings as long as you continue your biologic. For example, this might be the case if you regularly visit a part of the world where a lot of people are still infected with TB.

Other Tests

Other tests are usually also needed before you start a biologic. For example, it’s common to get a blood test called a complete blood count (CBC). This is performed from a blood sample. This test can give an idea of whether you might have an active infection or certain other problems, like anemia.

It’s important to wait to start your biologic therapy if you have signs of an active infection.

You are also likely to need another blood test called a complete metabolic profile. This includes information about your electrolytes, your blood glucose, your kidney function, and your liver function. This is important for your healthcare provider to check out ahead of time since certain biologics might cause issues in these areas.

If you are planning to take certain biologics, you might also need to get your lipids and cholesterol checked. It’s important for your healthcare provider to know of any health problems that you might have before you start a biologic.

Depending on your medical history, you may need other tests, like a test for HIV infection. Since the safety of most biologics has not been proven during pregnancy, a pregnancy test is also a good idea for anyone of childbearing potential. 

Cancer Screening

It’s also a good idea to make sure you are up-to-date on all your cancer screenings. Because many biologics impact the immune system, there is a potential concern that they might have an impact on the body’s ability to destroy cancer cells. This might theoretically increase one’s risk of cancer, but the scientific results on this have been unclear. For example, there might be an increased risk of squamous cell carcinoma.

To be on the safe side, it’s a good idea to make sure you get all the regular cancer screenings that you might need. Your healthcare healthcare provider can let you know if you are due for any screenings, like mammography for breast cancer or colonoscopy for colon cancer.

Vaccine Assessment

Certain vaccines cannot be given safely while a person is taking biologics. This particularly applies to certain “live” vaccines, vaccines that contain a small amount of weakened, live virus. For example, it’s recommended that the vaccine for herpes zoster (which causes shingles) not be given to someone who is currently taking a biologic drug.

Other important vaccines to assess might be the measles, mumps, and rubella vaccine, which also cannot be taken while on biologics. On the other hand, other vaccines, like the pneumococcal vaccine (for pneumonia) can be safely taken while on biologics.

Because of this, it’s a good idea for your healthcare healthcare provider to make sure your vaccines are up to date. If not, you and your healthcare provider might opt to get you fully vaccinated. For example, if you are 50 or older, you might opt to get the shingles vaccine before starting biologic therapy.

It’s also good for you and your health provider to communicate about the vaccines you’ll need moving forward.

Many vaccines are safe to take while on biologics. You just need to be clear about which ones.

Because many biologics reduce your natural immunity, you’ll want to take steps to be as protected as possible. You may want to plan to take the “killed” version of the flu shot every year after you’ve started biologic therapy. (But note that some versions of the flu vaccine, like the inhaled nasal version, might not be safe for you.) The main thing is to have an ongoing discussion with your healthcare provider.

Picking the Right Biologic

Before you start biologic therapy, it’s important to have a conversation with your healthcare professional about picking the biologic therapy that is right for you. In many cases, you will have more than one treatment option. For example, several different classes of drugs are now available to treat rheumatoid arthritis, and some of these have different risks of certain side effects.

Within a given class of biologic treatments (such as TNF blockers, IL-6 receptor blocker, etc), there may also be more than one choice.

One key consideration for many people is the mode of administration. Most biologics are given either by IV infusion (done at some sort of health facility) or injection (often done at home). Think about your preferences. Different biologics need to be given more often, so that might also be important for you.

Typically, biologics are expensive treatments, so you may want to consider this as well. Some biologic treatment choices will be more expensive than others, depending on the mode of administration and other factors. In some cases, less expensive biosimilar treatments may be an option. It may take some time to figure out what the real costs will be for you, but it’s worth exploring what options are available.

Getting Clear on Your New Health Plan

Once you’ve chosen your biologic, you’ll want to get clear with your medical provider about your new health plan. You’ll also need to be clear about when and how you’ll be starting treatment.

Some questions you may ask before starting treatment:

  • Will this treatment replace a different therapy you are already taking? Or will you add it on to your existing health regimen?
  • Will you be receiving an infusion, and if so, where?
  • Will you be receiving pre-treatment with anything to help relieve potential side effects, like an antihistamine?
  • If you are taking an injectable biologic, will someone be available to show you how to self-administer it?
  • How do you need to store the biologic? (Read all instructions and take time to get clear about how everything will work.)

It’s possible that you might need to delay starting your biologic therapy, even after you’ve planned to do so. If you need to start an antibiotic for another health condition, or if you are running a fever, you may need to delay starting biologic therapy. When in doubt, call your healthcare provider’s office to discuss your situation.

Biologic Healthcare Provider Discussion Guide

Get our printable guide for your next healthcare provider's appointment to help you ask the right questions.

Doctor Discussion Guide Woman

You’ll also want to make sure your healthcare provider knows if you have any surgeries or healthcare procedures already scheduled. In some cases, you may need to hold off on starting a biologic until these are completed. Your healthcare provider will let you know it is safe to start the biologic.

Get clear about immunosuppression and what that means. Your biologic may put you at higher risk of getting certain infections. Because of that, you may need to avoid certain situations that put you at risk of infection, like nursing homes. You’ll also want to get an idea of some of the other potential side effects from your biologic, so you can know what to look for.

Ask your healthcare provider what to expect in terms of ongoing tests and monitoring.

For example, some people need repeat tuberculosis tests, tests for hepatitis B, other blood tests, and regular checks for skin cancer.

It’s also good to manage your expectations before you start therapy. You may not notice improvements right away. It may take a few weeks before you start seeing positive changes in your symptoms. And in some cases, you may need to switch to another biologic to get the best result.

A Word From Verywell

Biologics are serious therapies, and it’s best to begin them with information and a full health picture. Doing so will give you the best chance of minimizing side effects and improving your overall health with your treatment. Don’t hesitate to ask if you have any questions about what’s involved in starting your treatment. 

8 Sources
Verywell Health uses only high-quality sources, including peer-reviewed studies, to support the facts within our articles. Read our editorial process to learn more about how we fact-check and keep our content accurate, reliable, and trustworthy.
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  5. Centers for Disease Control and Prevention. Hepatitis B questions and answers for the public. Reviewed July 3, 2019. 

  6. American Association of Clinical Chemistry. IGRA TB Test. Reviewed June 8, 2018.

  7. Menter A, Strober BE, Kaplan DH, et al. Joint AAD-NPF guidelines of care for the management and treatment of psoriasis with biologics. J Am Acad Dermatol. 2019;80(4):1029-1072. doi:10.1016/j.jaad.2018.11.057

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Additional Reading

By Ruth Jessen Hickman, MD
Ruth Jessen Hickman, MD, is a freelance medical and health writer and published book author.