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FAQS: JAKi in RA
Frequently Asked Questions JAK Inhibitors in RA

Released: December 10, 2020

Expiration: December 09, 2021

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In this commentary, rheumatologists Stanley B. Cohen, MD; Sheetal Desai, MD, MSEd; and Eric M. Ruderman, MD, answer questions posed by the audience during a CCO Webinar on the management of patients with rheumatoid arthritis (RA) receiving JAK inhibitors. Webinar slides are also available for self-study or to use in your noncommercial presentations.

How often should patients with RA and receiving JAK inhibitors be monitored for adverse events?

Eric M. Ruderman, MD:
Currently, 3 JAK inhibitors are approved by the FDA for treatment of RA: baricitinib, upadacitinib, and tofacitinib. Initially, patients can be monitored as you would with methotrexate by checking their complete blood count and complete metabolic panel more frequently for up to a month after they start the drug.

Stanley B. Cohen, MD:
Yes, the FDA recommends laboratory monitoring to identify changes in lymphocytes, neutrophils, hemoglobin, liver enzymes, and lipids while receiving upadacitinib or baricitinib. Hemoglobin, lymphocyte, neutrophils, and liver enzymes should be evaluated at baseline and per standard of care and lipids should be monitored 4-12 weeks after treatment initiation.

For tofacitinib, hemoglobin, lymphocyte, and neutrophils should be evaluated at baseline and then every 3 months; liver enzymes as per standard of care; and lipids 4-8 weeks after tofacitinib start.

How often should lipid panels be done?

Eric M. Ruderman, MD:
As mentioned above, the recommendation is to monitor lipids anywhere from 4-12 weeks after initiating treatment with JAK inhibitors. Depending on the drug and if the patient is doing well, labs may not need to be done as frequently.

If there is any question about the results, labs can be repeated a few months later or the healthcare team can explore whether lipid-lowering therapy may be warranted.

Should JAK inhibitors be used prior to TNF inhibitors in specific patients?

Sheetal Desai, MD, MSEd:
Although I think JAK inhibitors are an option after failure of methotrexate, I do not think there’s a correct answer to this question and that it really depends on your level of comfort.

Initially, I was concerned and cautious about using JAK inhibitors because I knew how pervasive the JAK/STAT mechanism of action is in intracellular signaling. But over the years of using JAK inhibitors, my patients have done well and I am very comfortable using them as first line instead of a TNF inhibitor.

Patient preferences also play an important role in the treatment decision. Some patients prefer TNF inhibitors because we have 20+ years of data with TNF inhibitor mechanism of action and safety compared with JAK inhibitors.

Eric M. Ruderman, MD:
I have also had patients who were comfortable using injectables because that worked for them and it is easy to use a medication that works. But as time has gone on, I see more and more patients who would prefer to receive oral agents instead of injections.

Stanley B. Cohen, MD:
Future indications for JAK inhibitors include psoriatic arthritis, axial spondylarthritis, lupus, and atopic dermatitis. These medications are going to be ubiquitous and so I think everybody is going to be a lot more comfortable with them.

Your Thoughts
What do you think is the place of JAK inhibitors in the treatment of RA? Please answer the polling question and share your thoughts in the comments box below.

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In your practice, how likely are you to recommend JAK inhibitors before TNF inhibitors for patients with RA?
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