The Pre-Biologic Checklist: Navigating Your Transition to Advanced Crohn’s Therapy

But deciding to begin a biologic isn’t as simple as picking up a prescription and hoping for the best. There’s a lot to think through first: what safety screenings are needed, how the drug will fit into everyday life, and what kind of follow-up will happen after treatment starts. Preparation, including knowing what to consider and what to expect, can make the transition feel much more manageable.

That’s why a pre-biologic checklist can help. Here are six important things to discuss with your IBD care team before starting a biologic for Crohn’s disease.

1. Get the Right Safety Screenings Before Your First Dose

One of the first steps before starting a biologic for Crohn’s disease is getting an infection screening. Because biologics suppress parts of the immune system, doctors need to make sure there are no hidden infections or other health issues that could become more dangerous once treatment begins, says Alan Moss, MD, chief scientific officer at the Crohn’s & Colitis Foundation and a professor of gastroenterology at Boston University’s Chobanian & Avedisian School of Medicine.

“Before starting biologic therapy, we routinely screen for infections such as tuberculosis, hepatitis B and often C, and, depending on history and risk factors, sometimes HIV and other latent infections. This step is key because biologics can allow silent infections to reactivate and become serious,” Dr. Moss says.

“If these screenings identify a possible infection, then getting that evaluated further and treated if needed is really important, so that it doesn’t worsen when the immune system is weakened and may not be able to fight off the infection on its own,” says Michelle Becker, PharmD, a spokesperson for the American Gastroenterological Association and a clinic-based pharmacist specializing in working with patients with IBD.

• Cervical cancer
• Colon cancer
• Skin cancer
• Mental health conditions, such as depression
• Osteoporosis

Screening may also include checks for patient-specific risk factors, as well as other issues such as liver function, heart failure, or multiple sclerosis, says Becker.

2. Review Your Vaccines Before Treatment Begins

“Vaccines are important as they give our bodies protection against infections. Vaccines can greatly reduce the risk of having an infection, or if it occurs, reduce the severity of the infection,” Becker says.

• Influenza (flu) vaccine
• COVID-19 vaccine and boosters (Moderna, Pfizer, Novavax)
• Pneumococcal (pneumonia) vaccine (Capvaxive, Pneumovax 23, Prevnar 20, Vaxneuvance)
• Shingles (recombinant herpes zoster) vaccine (Shingrix)
• Hepatitis A vaccine (Havrix, Vaqta)
• Hepatitis B vaccine (Engerix B, Heplisav-B, Recombivax HB)
• Hepatitis A and B combination vaccine (Twinrix)
• Tdap (tetanus, diphtheria, pertussis) vaccine (Adacel, Boostrix)
• HPV vaccine (Gardasil-9, Cervarix)

• MMR (measles, mumps, and rubella) vaccine (M-M-R II, Priorix)
• Varicella (chickenpox) vaccine (Varivax)
• Oral typhoid vaccine (Vivotif)
• Yellow fever vaccine (YF-Vax)

3. Discuss Your Options With Your IBD Care Team

Learning about your biologic therapy, including how it works, how it’s given, and its side effects is an important part of the process.

Your options are determined by certain factors, including disease severity, location, or history, response to previous treatments, and how quickly a medicine can work, Becker says. There are even considerations outside of the gut, from co-occurring conditions and complications to insurance coverage.

Expect to talk to your gastroenterologist about your biologic treatment plan. “In my conversations with patients, we review how each option works, its side effects, and how it is given and how often, so the choice truly feels shared rather than one-sided,” Moss says.

These conversations have become much more detailed because there are more options than there used to be, says Anish Sheth, MD, a gastroenterologist and codirector of the Center for Digestive Health at Penn Medicine Princeton Health in Plainsboro, New Jersey.

You can also ask whether it is considered safe during pregnancy or breastfeeding. “For some people, family planning, treatment frequency, and convenience may play just as big a role as mechanism of action,” he says.

4. Expect Regular Monitoring After You Start

Biologic therapy requires ongoing monitoring, it’s not a “set-it-and-forget-it” approach, Moss says. He notes that monitoring is built into the process from the beginning, including:

• Regular blood tests (for blood counts, liver function, and inflammation markers)
• Stool tests, such as fecal calprotectin
• Periodic imaging via endoscopy (upper endoscopy, colonoscopy, or both) to confirm inflammation is under control

Dr. Sheth says monitoring is a crucial step, especially since symptoms and inflammation don’t always line up. Expect monitoring closer together at first, during the induction phase. That could look like blood work and visits within the first three to six months, followed by a repeat endoscopy within the first year to confirm that the intestines are actually healing, he says.

5. Understand What Success Should Look Like — and When You Need to Pivot

Expectations need to be set early. That’s because one of the most common pitfalls is assuming a biologic isn’t working quickly enough. “One mistake I can see is not giving a treatment enough time, thinking it isn’t going to work after just one or two doses,” Becker says. “Most of these medicines do take time to work.”

Sheth says success is measured in two ways: clinical remission and endoscopic remission. “You should be feeling better, but your inflammation should also be under control,” he says, noting that resolved inflammation is confirmed via blood work, stool tests, and an endoscopy.

And if a biologic doesn’t help with easing symptoms or reducing inflammation within these timeframes, your gastroenterologist may check on drug levels and antibodies, adjust dosages or frequency, or switch to a different class of biologic or advanced therapy altogether, Moss says. “Having to pivot does not mean you have failed treatment,” he says.

6. Make Sure the Treatment Fits Into Your Daily Life

“For most people, biologics become part of the routine of life, either a scheduled self-injection at home or periodic infusions at a clinic, rather than something that dominates every day. When biologics are effective, many patients find that improved symptom control, more energy, and fewer flares actually give them more freedom at work, school, and in social and family life,” Moss says.

Getting into that rhythm from the start can make staying on treatment much easier over time.