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Monitoring is key during JAK inhibitor therapy

Presented by
Prof. Jonathan Silverberg
AAD 2022
Different lectures at the 2022 AAD Annual Meeting dealt with ways to ensure the safe use of Janus kinase (JAK) inhibitors in dermatologic indications. The right choice for the patient and monitoring the therapy are key to successful therapy with these agents.

“Severe side effects with JAK inhibitor therapy are probably less common in atopic dermatitis (AD) patients than in the elderly rheumatoid population, but the risk is not zero. We see herpes infections as a class-wide phenomenon,” said Prof. Jonathan Silverberg (George Washington University School of Medicine, Washington DC, USA) in his talk on JAK inhibitors in AD [1]. However, the rates of herpes zoster infections were relatively low in AD trials with abrocitinib, baricitinib, and upadacitinib. Though it should be noted that patients with disseminated herpes zoster and herpes simplex infections and those with recurrent, localised herpes zoster and a history of eczema herpeticum were excluded from the studies. “If you treat these patients, the rates of herpes zoster are expected to be higher,” Prof. Silverberg warned. Therefore, if indicated, patients should receive a herpes zoster vaccine before treatment with a JAK inhibitor.

In Prof. Silverberg’s opinion, age is a big risk factor for therapy with all JAK inhibitors. Side effects differ between the different JAK inhibitors, even between selective JAK1 inhibitors. In patients treated with upadacitinib, in a real-world scenario, there is a stronger acne signal: about 10% of patients will get acne. “But patients are finally itch-free, so they do not care about acne. It is a mixed bag, sometimes patients develop folliculitis on the back,” Prof. Silverberg said. Patients treated with abrocitinib also often suffer from nausea. Overall, the safety profile of these 2 agents is fairly comparable.
Always start with the lower dose

Prof. Silverberg recommended starting with the lower dose (i.e. abrocitinib 100 mg, upadacitinib 15 mg), and to increase in case of an inadequate response. In general, only low doses should be used in both adolescents and seniors. Recently, 29 rheumatologists developed a set of lab checks in a consensus statement (see Table). “The recommendation is to monitor patients, even if it is unnecessary 95% of the time,” Prof. Silverberg concluded.

Table: What and when to check during JAK inhibitor therapy. Derived from [2]

    1. Silverberg JI. Atopic Dermatitis. F074, AAD 2022 Annual Meeting, 25–29 March, Boston, MA, USA.

    2. Nash P, et al. Ann Rheum Dis 2021;80:71–87.

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