What is the biologic of choice in a patient with RA and history of non-melanoma skin cancer?

We have long known that patients treated with TNF inhibitors (TNFi) have a higher risk of developing non-melanoma skin cancers. For this reason, all patients prescribed these drugs should undergo annual full-body dermatology skin exams. If this recommendation is followed, there should be no contraindication to using these drugs in this population of patients. Regarding the other biologicals, the risk for developing skin cancer is not as compelling as with TNFi and they can all be prescribed in patients with non-melanoma skin cancers. For this population, annual skin examinations also make good sense. 

The literature has demonstrated an increased risk of varying degrees of nonmelanoma skin cancer with all biologics. Comparative studies are difficult to interpret as most RA patients have received other biologic therapies prior to the use of nonTNFi biologics or methotrexate, which itself has been associated with a higher incidence of nonmelanoma skin cancer. Content experts at the time of the 2015 ACR Guidelines for treatment of RA agreed that a history of NMSC should not preclude treatment with a biologic as could be easily monitored by regular skin exams. My personal recommendations for my patients are to have a total body skin survey either before or during the first 3 months of therapy with a biologic and repeated at a minimum 6 to 12 months later during the first year of therapy. I educate my patients to specifically state their chief complaint to the dermatologist a request for a total body skin survey as feedback from patients revealed they do not always receive this standard of care from all providers.