Looking After Yourself Whilst On Biologics Or Biosimilars For Skin Conditions (Self Care)

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Is there a special diet I need to follow?

It is thought you could be more likely to catch infection (food poisoning) from your food if you are on biologics or biosimilars. This is because biologics or biosimilars affect part of your body’s defence (immune) system. We would suggest you don’t eat the following foods to cut down the risk of food poisoning:

• Unpasteurised milk and dairy products, e.g. cheese made from unpasteurised milk
• Mould ripened soft cheeses (e.g. Brie and Camembert) and blue cheeses (whether pasteurised or not), feta and goats cheeses
• Raw eggs, or foods with this in, e.g. home-made mayonnaise
• Raw or undercooked meat and fish
• Cooked rice over 24 hours old and not stored in a fridge (always reheat cooked rice fully)
• All types of paté

Continue to cook using ‘common good sense’, for example:

• Washing your hands and surfaces before cooking
• Washing your fruit and vegetables in clean water before using
• Reheating cooked dishes thoroughly

Should I get a vaccination (injection)?

Being on a biologic means you could be more likely to pick up infections. This includes ‘winter flu’. We would recommend that you have a ‘winter influenza vaccination’ (often called a ‘winter flu’ jab) every year. Your GP (Doctor) may ask you to come to the GP surgery for the vaccine around September/October time.

You should contact your GP surgery if they have not called you for the vaccine. Remind the GP surgery that you are on biologics and have been advised to have the winter flu vaccine. The flu vaccine in an injection form for adults is not what is called a ‘live vaccine’. You should also have the “pneumococcal vaccine’ (also called ‘pneumovax’). This protects you against a few types of pneumonia. Pneumonia is a severe type of chest infection. Your GP surgery may offer this to you. You should contact your GP surgery if they have not called you for this vaccine. It is not a live vaccine. The pneumonia vaccine is usually administered every 5 years. You may need to check with your GP surgery, if, and when, you had the pneumonia vaccine. Contact your dermatology nurse if you are unsure, worried, or have any questions about this.

It is unsafe to have some types of vaccines called ‘live’ vaccines whilst on biologics. This is because you may not respond well (not have a good immune/body-defence reaction), and you may be more likely to have ‘complications’ (more health problems). Examples of live vaccines are polio, yellow fever, rubella (German measles), MMR (measles, mumps and rubella), BCG (tuberculosis), and typhoid. Some of these vaccines can also be given as an ‘inactivated form’; this means they are not ‘live’. It is safe to have inactivated vaccines whilst on biologics.

Always check with the person giving you a vaccine if it is ‘live’. Explain you are on biologics or biosimilars and cannot have live vaccines, if it is ‘live’. Ask if it comes in an inactivated form. Contact your dermatology nurse if you are unsure, worried, or have any questions.

Before you start biologic or biosimilar treatment you may be recommended by the dermatologist or dermatology nurse to have a live vaccine such as a chicken pox vaccine You can have a live vaccine four weeks or more, before starting biologics or biosimilars.

You can have a live vaccine 6 months (or 12 months if it is the shingles vaccine) after stopping biologics or biosimilars, or any other drug that can affect your immune system, such as methotrexate, prednisolone, or ciclosporin.

You can find further information about vaccinations from The British Association of Dermatologists (BAD) in a leaflet called Immunisation recommendations for children and adult patients treated with immune-suppressing medicines.

What happens if I am unwell with an infection?

Biologics can affect your body’s immune (defence) system. This means you might not be able to fight infections so well. It also means that some infections could become severe or very severe. It could also take longer to get better from infection.

It is probably best not to meet with people if you know they have a serious ‘catching’ infection whilst you are on biologics. For example a ‘diarrhoea and vomiting bug’.

For mild or moderate infections that you may ‘catch’ or develop (e.g. coughs, colds, ‘thrush’, ‘athletes foot’, tooth abscess), you should continue to take your biologic or biosimilar as normal.

You should not take your biologic or biosimilar injection or dose, if you have a severe infection. A severe infection may make you feel very unwell, usually for more than a day, and often with a high temperature. A severe infection may also make you feel you need to stay in bed, see your GP, or go to hospital. The biologic or biosimilar may stop or slow your recovery from severe infection, and should be stopped whilst you feel unwell. You can restart your biologic or biosimilar after stopping it for a severe infection, if the infection has got better. All biologics or biosimilars are taken at different time gaps, depending on what biologic or biosimilar it is. Do not shorten the amount of time between doses because you have taken a dose later than you expected because of severe infection. For example, you may normally take your injection once a week on a Tuesday (every biologic or biosimilar has a different time gap between doses). You may have delayed your injection on Tuesday, due to severe infection, and then felt well enough to take it on the Friday. After the injection on Friday, don’t take the following injection on a Tuesday, as there still needs to be a week between injections. In this example, the following injection would be on a Friday. The day of the weekly injections would have moved to a Friday.

Let your dermatologist or dermatology nurse know if you have had a severe infection.

Contact the dermatology nurse (or dermatologist) if you are unsure what to do. It is not always easy to decide when an infection is severe enough to stop taking your biologic. The nurse (or doctor) is there to help you decide if you are unsure.

It is thought that one biologic called Dupilumab (also called Dupixent) may not work so well if it is stopped and re-started.

What happens if I have a change in health?

There may be all sorts of reasons why your health may change. You should see your GP if you have a change in health, for example, a change in bowel habit, a persistent cough, unexplained weight loss, or new pain. Some changes in health could be due to side effects from biologics or biosimilars so it is also important to mention them to your dermatology nurse or dermatologist. It is not always possible to be sure if something is due to a side effect. Should you have a side effect from the biologic or biosimilar, it is important to decide with your dermatology nurse or dermatologist to continue with the biologic or biosimilar or not.

Some changes in health may mean that all or some biologics or biosimilars are not suitable for you. You should tell your dermatology nurse or dermatologist if you have a change in health, become pregnant, or are given a new diagnosis. For example, if you notice an unexplained change in your eyesight and strength, if any heart failure gets worse, or if you are diagnosed with cancer or psoriatic arthritis.

You may be offered routine cancer screening by the NHS depending on your age and gender. We would advise people on biologics or biosimilars to accept cancer screening invitations. For example people may be offered a cervical cancer screening (smear test) or bowel cancer screening.

What happens if I have a ‘hidden’ infection?

Before you start your biologic you will have been tested for infections which include:- TB, HIV, Hepatitis B, and Hepatitis C. You might not be prescribed biologics or biosimilars if you have these infections. Normally, if tests show you have these conditions, we will arrange for advice on treatment for these conditions and if/when it might be possible to prescribe biologics or biosimilars. Often people are not aware that they are infected, which is why blood tests and x-rays are used to check for these before starting a biologic or biosimilar. Being on biologics or biosimilars whilst having an untreated infection such as TB may mean the infection becomes active and severe.

You can also ‘contract’ (catch) one of these infections after you have started biologics or biosimilars. This is more likely if some of your behaviour, social, family, and work life put you more at risk.

Should you feel you are more at risk, talk to your dermatologist or dermatology nurse. You will probably have a more regular blood or chest x-ray for these infections, if your doctor or nurse thinks you are more at risk.

What happens if I need an operation?

There may be an unlikely event, where you need an emergency operation. This might be not long after your last dose of biologic or biosimilar. After the emergency operation you can restart your biologic once your medical/surgical team are happy for you to do so, and they feel that any wound is healing and free of infection. Your medical/ surgical team can contact your dermatologist or dermatology nurse specialist for advice on this.

Ideally, and usually, you should stop your biologic or biosimilar before any planned operation. This is because biologics and biosimilars can effect healing and increase the risk for infection in the operation wound. Different biologic or biosimilars should be stopped at different times before operations. For example:- the biologic and its biosimilar Etanercept (Enbrel, Benepali), will need to be stopped 2 weeks before an operation. You can restart your biologic once your surgeon can see healing has taken place and that there is no infection, and your surgical/medical team are happy for you to do so. Some conditions, for example Hidradenitis Suppurativa, mean that for some operations, you don’t need to stop your biologic or biosimilar. Whatever operation has been planned, you should ask your dermatologist or dermatology nurse for advice about stopping your biologic or biosimilar.

Can I start a family or breast-feed?

Not much is known about the effect of biologics and biosimilars on the unborn baby. We advise men and women to use contraception (e.g. condoms, the coil, the contraceptive pill, etc) to avoid women who are on biologics or biosimilars becoming pregnant. We also advise women who are on biologics and biosimilars not to breast-feed. This is because it is unknown if this is safe for the baby.

Women on biologics or biosimilars, who are wanting to get pregnant will need to stop their biologic or biosimilar drug before trying to get pregnant. After stopping their biologic or biosimilar, women will need to wait for an amount of time before trying to get pregnant. The amount of time women need to wait depends on the biologic drug they are on. For example:

You will need to use contraception until you have waited the right amount of time after stopping your biologic (see above).

Talk to your dermatologist or dermatology nurse if you think you would like to start a family and are female. Your dermatologist can look at different ways of coping with your skin disease whilst you are trying to get pregnant or become pregnant.

It is thought to be safe for men to father children whilst they are on a biologic. However, it could be possible that men may have a lower sperm count whilst on biologics – it is not known for sure. There is not enough known to be certain about this. Also, it is not certain if this lowers the chances of being able to father children.

What happens if I miss a dose of my biologic?

Take your biologic as soon as you remember, if you have forgotten or have been unable, to take it at the right time. Your next dose of biologic will need to be taken with the usual time gap between injections for your type of biologic. This will mean the day of the week you normally take your drug will change.

For example, for people on weekly Etanercept, you might normally have your injection on Mondays. You might forget to take your weekly injection on a Monday, but then remember on Tuesday and take it then; you would then need to change your injection day to Tuesdays for all the following weeks.

For example, for people on fortnightly Adalimumab, you might normally have your injection on Wednesdays. You might forget to take your injection on a Wednesday, but then remember on Friday and take it then; you would then need to change your injection day to Fridays for all the following fortnights.

Forgetting to take your biologic may mean you end up with less control of your disease. Should you find it difficult to keep injecting on the right days, you can discuss this with your dermatology nurse as there may be techniques or a different treatment plan which may help you remember or manage.

What happens if I travel?

You can go on holiday or travel while you are taking biologic or biosimilar medication, as long as you are able to look after your injection(s). It may be easiest to time trips between injections (or infusions/drips for Infliximab). This is so you do not have to take your biologic or biosimilar away with you.

Wherever you travel, you will typically need to take your biologic or biosimilar injections in an insulated cool container. For example, a portable medical travel cooler case or an insulated sandwich bag with an ice pack, both of which are widely available on line or in stores. The aim is to keep the injection(s) constantly cool, but not freezing. (Injections could freeze if placed directly on an ice pack, so make sure the ice pack is insulated, even if only by wrapping a clean tea towel around it, or that the injection does not come in direct contact). When you arrive at your destination, you will need to put your injections in a fridge. Check the fridge is working correctly. Think about who has access to the fridge – some people may tamper, (fiddle with,) or take away, the injections without your knowledge or consent. This is more likely in a communal (shared) fridge. Don’t use the biologic or biosimilar if you see that the injection has been tampered with.

Some biologics or biosimilars can be kept out of the fridge for several days before being used, as long as the temperature is not above 25 degrees centigrade or at freezing or below. This means they do not need to be kept at a constant cool temperature. You can refer to (look at) the information sheet which is packed with each injection on its storage, or you can ask your pharmacist, dermatologist or dermatology nurse specialist to advise you.

You will need a letter from your GP if you are flying, explaining what the injections are for, (if you need to take your injections away with you). We would recommend that you also contact the airline you are flying with, and check their own guidelines for travelling with injections. You should take your injections as ‘hand luggage’, do not leave it in your main luggage to go into the airplane’s luggage hold. Remember, the injections will need to be kept cool, which may be a problem on long haul flights if your insulated ice pack doesn’t last long, (perhaps because it is too small).

You should contact your GP surgery about travel at least 8 weeks before any travel. This is because some countries require vaccinations weeks or months prior to travel. Travelling to countries in northern and central Europe, North America or Australia, means you’re unlikely to need any vaccinations. Many GP surgeries have travel clinics, but not all, and you may be required to obtain advice and vaccinations from a private travel clinic or pharmacy.

Please read the NHS UK web page for useful information on required vaccinations, certificates, and how travel clinics work.

You may find that you are unable to have some vaccinations, as they are ‘live’. This may mean you will have to amend your travel plans, as you cannot receive live vaccines whilst on biologic or biosimilar medication. We generally do not recommend that people travel without the required vaccinations or certificates. We also generally do not recommend that people stop their biologic or biosimilar so that it becomes safe to receive a live vaccine required for travel. You should discuss any issues about live vaccines with your dermatologist or dermatology nurse if you require live vaccines and cannot amend your travel plans.

Make sure you travel with health insurance when abroad, and that you advise the insurer of the biologic or biosimilar medication you are taking. Take an empty injection box, or write down the name of the biologic or biosimilar you are on, (along with any other drugs you are on) when you are away from home. Show this to any doctor, nurse, or pharmacist/chemist, who may treat you, if you are unwell abroad.

Make sure you have enough supplies for your skin condition before you travel. For example, that you have enough emollient (moisturiser), steroid cream, or dressings. This may mean you need to contact your GP surgery in advance of travel to obtain a prescription for enough supplies to use whilst away from home. Contact your home care company to ensure you will receive enough biologic or biosimilar to take away with you from your home delivery, before you travel. Ideally contact them about 4 weeks before you travel.

Do not be afraid to e-mail uhsussex.dermatology.treatment.queries@nhs.net or call 01273 665035, or write (Alison Lowe, Dermatology clinical nurse specialist, Dermatology Department, Brighton General Hospital, Elm Grove, Brighton, BN2 3EW).

E-mail is preferred.

Remember, if the matter is urgent, and the nurse does not get back to you as soon as you need, you can also contact your dermatologist or the ‘on call’ dermatologist through the dermatology secretaries on 01273 665019 Monday to Friday.

On the weekend if the matter is very urgent and cannot wait, you will need to attend your local Accident and Emergency department or ask your on call GP.

The CNS can be contacted on 01273 665035 (answer phone available) or email bsuh.dermatology.treatment.queries@nhs.net. Using email is often the best way to get in contact with the CNS. Replies to phone calls or e-mails can take a few days.

Please ring the dermatology secretaries on 01273 665019 if your question is urgent or you do not get a reply from the nurse.

Other sources of information and support on biologics or biosimilars for skin conditions can be through the following web sites or phone numbers.

Information on various treatments