Table 9.

Initial Visit:

History and Physical

·        History of malignancy or serious infections (hepatitis, TB, HIV, other)?

·        Total body skin exam for skin cancer

·        Check for HSM, cervical/axillary/inguinal lymphadenopathy

·        Medications:  other immunosuppressive agents

·        Live vaccine within past month – you or household member?

·        Major surgery in next month?

·        Active infection?  Hold dose for infection or sepsis

·        History of cirrhosis or active hepatitis or other liver disease?

Labs

·        Baseline CBC, CMP

·        Baseline CD4 count; hold for < 250 cells/uL

·        TB test (for PPD, consider >5mm as positive)

·        Hepatitis B screen:  Hepatitis B sAg, Hepatitis B sAb, Hepatitis B cAb

·        Hepatitis C ELISA screen

·        Influenza vaccine (if flu season)

·        HIV (optional) – especially with erythrodermic psoriasis

·        Cardiovascular risk panel:  CRP, homocysteine, HbA1C (if screening for psoriasis) (optional)

·        Pneumovax (optional)

Counseling/Other

·        Injections under supervision of health care professional

·        Can worsen existing malignancies

·        Malignancy:  non-melanoma skin cancer, lymphomas, melanoma, solid organ malignancies

·        Risk of hepatotoxicity and liver failure

·        Risk of new or worsening bacterial and viral infections, including HIV, hepatitis, and tuberculosis

·        Injection site reaction and angioedema

·        Avoid live vaccines – self and household members

·        While the package insert states to avoid phototherapy, phototherapy is used routinely with alefacept^29-31.

Follow-up Visit:

History and Physical

·        Every six months:  Total body skin exam for skin cancer

·        Every six months:  Check for HSM, cervical/axillary/inguinal lymphadenopathy

·        Any new infection – hold dose for active infection or sepsis

·        Major surgery in next month?

·        Is there sustained clinical efficacy as measured by 2 weeks after the 12th dose?

·        Other interval history

Labs

·        Prior to every other injection:  CBC, CD4; hold for < 250 cells/uL (then check weekly; discontinue alefacept if CD4 < 250 cells/uL for one month)

·        Monthly to one month after last injection:  CMP

·        Every year:  TB test (consider induration of >5mm as positive)

·        Influenza vaccine annually (in flu season)

·        In HBV carriers, check liver panel for laboratory signs of hepatitis B reactivation

Other

·        Any live vaccines in past month?

·        Any household members getting live vaccine?