Indications and pre-treatment screening for immunosuppressant and biological agents in management of inflammatory bowel disease

Agents

Biologic agents (anti-TNF, anti-integrin, anti-IL-12/23, JAK inhibitors) used in moderate-severe inflammatory bowel disease require structured pre-treatment screening given their immunosuppressive effect and the risk of reactivating latent infection or unmasking malignancy
Biologics are used across a substantial proportion of moderate-severe Crohn's disease and ulcerative colitis patients, particularly those failing conventional therapy, making pre-treatment screening a routine, high-volume clinical process

Anti-TNF and other biologic agents impair specific components of immune surveillance/function relevant to containing latent infection (particularly TB and hepatitis B) and, for some agents, are associated with a modestly increased risk of certain malignancies (particularly relevant for combination immunosuppression, e.g. anti-TNF plus a thiopurine)

Mandatory pre-treatment screening: latent TB screening (IGRA or tuberculin skin test + chest X-ray - anti-TNF therapy specifically carries a recognised risk of reactivating latent TB), hepatitis B serology (risk of reactivation with immunosuppression - HBsAg, anti-HBc, anti-HBs), hepatitis C serology, varicella immunity status (given the risk of severe primary varicella/reactivation with significant immunosuppression), and baseline bloods (FBC, LFTs, renal function)
Skin cancer screening/sun protection counselling is relevant given some evidence of increased skin malignancy risk with certain agents, particularly with combination immunosuppression

Latent TB identified -> complete TB prophylaxis (or at minimum, initiate it concurrently with close monitoring) before or alongside starting the biologic, per current TB management guidelines
Hepatitis B core antibody positive (even if surface antigen negative) -> antiviral prophylaxis or close monitoring given reactivation risk with immunosuppression
Update vaccinations (particularly non-live vaccines) before starting therapy where possible, and avoid live vaccines once significant immunosuppression has begun (see immunisation in the immunocompromised)

Latent TB reactivation, hepatitis B reactivation, opportunistic infection risk with immunosuppression, malignancy risk with combination immunosuppression
Skipping pre-treatment screening is a recognised, preventable cause of serious complications (TB reactivation, fulminant hepatitis B reactivation) once a biologic is started - this screening should be treated as a mandatory, non-negotiable step before initiation, not an optional adjunct

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