Three JAK Inhibitors Get Boxed Warnings, Modified Indications

Jennifer Lubell

September 01, 2021

UPDATED with comments September 7, 2021 // The arthritis and ulcerative colitis medicine tofacitinib (Xeljanz, Xeljanz XR) poses an increased risk of serious cardiac events such as heart attack or stroke, cancer, blood clots, and death, the US Food and Drug Administration (FDA) announced today.

Manufacturers of this drug along with other Janus kinase (JAK) inhibitors baricitinib (Olumiant) and upadacitinib (Rinvoq) must update their boxed warnings to include information about these health risks. The FDA made the determination after new study data from Pfizer, which manufacturers Xeljanz, found an association between a lower dose of Xeljanz and increased risk of blood clots and death.

"Recommendations for healthcare professionals will include consideration of the benefits and risks for the individual patient prior to initiating or continuing therapy," the agency stated.

The FDA is limiting all approved uses of these three medications to patients who have not responded well to tumor necrosis factor (TNF) blockers to ensure their benefits outweigh their risks. Tofacitinib is indicated for rheumatoid arthritis, psoriatic arthritis, ulcerative colitis, and polyarticular course juvenile idiopathic arthritis

The FDA included baricitinib and upadacitinib in the warning because of the similar properties they share with Xeljanz, even though they haven't been studied as extensively.

"We believe this update will bring important clarity for healthcare plans on the risk/benefit profile of Xeljanz, which is a medicine informed by more clinical data than any other JAK inhibitor," Pfizer said in a statement.

Investigators for the ORAL Surveillance trial compared two doses of tofacitinib (5 mg twice daily and 10 mg twice daily) with TNF blockers in patients with rheumatoid arthritis age 50 years or older with at least one additional cardiovascular risk factor.

For both dose regimens of tofacitinib, they found an increased risk of major adverse cardiovascular events, malignancies, thrombosis, and death compared with the TNF blocker regimen. Additionally, rates of lung cancers and lymphomas were higher with tofacitinib. In trial data released earlier this year, Pfizer revealed that the tofacitinib group had a much higher incidence of adjudicated malignancies compared with the TNF blocker group (1.13 vs 0.77 per 100 person-years; hazard ratio, 1.48; 95% CI, 1.04 - 2.09).

Impact on Clinical Practice

Physicians treating patients who have rheumatoid arthritis with tofacitinib may initially decrease prescriptions following the FDA's drug safety communication, said Daniel E. Furst, MD, professor of medicine (emeritus) at the University of California, Los Angeles, adjunct professor at the University of Washington, Seattle, and a research professor at the University of Florence (Italy) — particularly those with a principal mechanism of action slightly different from tofacitinib, he added.

"Tofacitinib is principally a JAK 1,3 inhibitor at usual concentrations, whereas upadacitinib and baricitinib are JAK 1,2 inhibitors. Thus, I speculate that the tofacitinib prescriptions will go down more than the upadacitinib and baricitinib prescriptions," he said in an interview.

Some patients may also be worried about taking tofacitinib, particularly those with previous events or predisposing conditions, Furst noted.

"First and foremost, I think we need to actually look at the data in a publication rather than just an FDA statement before making huge changes in our practice," he advised.

"I am looking forward to the data finally being published.... It's interesting that the full data still isn't really out there beyond the press releases and an abstract. I think there's a lot more to learn about how these drugs work and who is really at risk for harmful events," said Alexis R. Ogdie, MD, MSCE, associate professor of medicine and epidemiology at the University of Pennsylvania, Philadelphia.

Pfizer's data may be affecting FDA approvals of other JAK inhibitors. This past summer, AbbVie and Eli Lilly stated that the FDA's ongoing assessment of the safety trial was delaying the agency's decisions about expanding use of their respective drugs upadacitinib and baricitinib.

"I think many rheumatologists have already taken this information in and begun to incorporate it into their discussions with their patients," since it has been over a year since the first public release of information about the ORAL Surveillance trial, said Arthur Kavanaugh, MD, professor of medicine at the University of California, San Diego. "I don't know that it will affect the approvals, but it will impact their labels."

Wariness to prescribe tofacitinib may be lower for patients younger than those in the ORAL Surveillance trial without additional cardiovascular risk factors taking tofacitinib for nonrheumatoid arthritis indications, said gastroenterologist Miguel Regueiro, MD.

"The JAK inhibitor warning by the FDA is an important consideration for any prescriber or patient. The risk of cardiovascular disease and venous thromboembolism with this class of medicine appears higher in older rheumatoid arthritis patients with underlying cardiovascular disease. While the warning applies to all JAK inhibitors and likely the newer selective JAK inhibitors to come, we need to weigh the risk and benefit based on the indication for prescribing," said Regueiro, chair of the Digestive Disease and Surgery Institute and of the department of gastroenterology, hepatology, and nutrition at the Cleveland Clinic in Ohio.

"I do think that there will be a heightened awareness and wariness for older rheumatoid arthritis patients and for the prescribers. However, for inflammatory bowel disease (and other nonrheumatoid arthritis indications), it does not appear that the risk for cardiovascular disease and VTE are significantly increased. To that end, in my own practice, I still use tofacitinib for ulcerative colitis and will do the same for the selective JAK inhibitors to come for IBD. Of course, as with any medication, we need to have discussions with our patients, alert them to potential side effects, and have an open line of communication for any questions or concerns."

Gastroenterologist Stephen Hanauer, MD, professor of medicine at Northwestern University, Chicago, Illinois, thought that although patients with RA have many other treatment options besides JAK inhibitors, fewer options available to patients with IBD "may motivate the use of oral [sphingosine-1-phosphate receptor modulator] agents such as ozanimod, although IBD patients are younger and [have fewer] MACE risk factors than rheumatoid arthritis patients, so absolute risk is very small in the ulcerative colitis population."

The agency's decision corroborates an earlier 2019 warning about the increased risk of blood clots and of death in patients with ulcerative colitis taking 10 mg tofacitinib twice daily.

The FDA said that two other JAK inhibitors, ruxolitinib (Jakafi) and fedratinib (Inrebic), are not indicated for the treatment of arthritis and other inflammatory conditions, and so are not a part of the updates being required.

FDA Review for Atopic Dermatitis

Baricitinib, abrocitinib, and upadacitinib are currently under FDA review for the treatment of atopic dermatitis. A topical formulation of the JAK1/2 inhibitor ruxolitinib is under review for the treatment of atopic dermatitis. Reviews for all four JAK inhibitors have been extended.

In September 2020, baricitinib was approved for the treatment of moderate to severe atopic dermatitis in Europe at a dose of 4 mg/day, with recommendations that the dose be reduced to 2 mg/day once the disease is under control and the dose may need to be reduced in patients with impaired kidney function, at increased risk of infections, and older than aged 75 years.

In an interview, Jacob Thyssen, MD, PhD, professor of dermatology at the University of Copenhagen, Denmark, said that in the EU, there has been "extensive education" about cardiovascular risks with baricitinib, "and it is my impression that payers and dermatologists in Europe are confident that it is safe to use in atopic dermatitis." In addition, there has been an emphasis on the differences in cardiovascular risk factors between patients with rheumatoid arthritis and atopic dermatitis, "given that the latter group is generally young and lean." In the United States, he added, it will be interesting to see which doses of the JAK inhibitors will be approved for atopic dermatitis.

Thyssen has disclosed being a speaker, advisory board member, and/or investigator for Regeneron, Sanofi-Genzyme, Eli Lilly, Pfizer, Leo Pharma, AbbVie, and Almirall.

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