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Kochhar GS, Khataniar H, Jairath V, Farraye FA, Desai A. Comparative Effectiveness of Upadacitinib and Tofacitinib in Ulcerative Colitis: A US Propensity-Matched Cohort Study. Am J Gastroenterol 2024:00000434-990000000-01234. [PMID: 38976357 DOI: 10.14309/ajg.0000000000002947] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/25/2024] [Accepted: 07/02/2024] [Indexed: 07/10/2024]
Abstract
INTRODUCTION There are limited real-world data comparing the effectiveness of upadacitinib and tofacitinib in patients with ulcerative colitis (UC). METHODS We conducted a retrospective cohort study using TriNetX, a multi-institutional database, to compare the effectiveness of upadacitinib and tofacitinib in patients with UC. The primary aim was to assess the risk of a composite outcome of hospitalization requiring intravenous steroids and/or colectomy within 6 and 12 months. One-to-one propensity score matching was performed for demographics, comorbid conditions, mean hemoglobin, C-reactive protein, albumin, and calprotectin, and prior UC medications including recent oral or intravenous steroid use between the cohorts. Risk was expressed as adjusted odds ratio (aOR) with 95% confidence intervals (CI). RESULTS There were 526 patients in the upadacitinib cohort (mean age 40.4 ± 16.3, 44.8% female sex, 76.6% White race) and 1,149 patients in the tofacitinib cohort (mean age 42 ± 17.1, 41.9% female sex, 76% White race). After propensity score matching, there was no significant difference in the risk of the composite outcome of need for intravenous steroids and/or colectomy within 6 months (aOR 0.75, 95% CI 0.49-1.09). However, there was a lower risk of the composite outcome (aOR 0.63, 95% CI 0.44-0.89) in the upadacitinib cohort compared with the tofacitinib cohort within 12 months. There was no difference in the risk of intravenous steroid use (aOR 0.70, 95% CI 0.48-1.02) but lower risk of colectomy (aOR 0.46, 95% CI 0.27-0.79). In sensitivity analysis, there was also a lower risk of the composite outcome (aOR 0.64, 95% CI 0.44-0.94), including lower risk of intravenous steroid use (aOR 0.67, 95% CI 0.45-0.99) and colectomy (aOR 0.49, 95% CI 0.26-0.92) in the upadacitinib cohort compared with the tofacitinib cohort within 12 months. DISCUSSION This study utilizing real-world data showed that upadacitinib was associated with improved disease-specific outcomes at 12 months compared with tofacitinib in patients with UC.
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Affiliation(s)
- Gursimran S Kochhar
- Division of Gastroenterology, Hepatology and Nutrition, Allegheny Health Network, Pittsburgh, Pennsylvania, USA
| | - Himsikhar Khataniar
- Department of Medicine, Allegheny Health Network, Pittsburgh, Pennsylvania, USA
| | - Vipul Jairath
- Department of Epidemiology & Biostatistics, Western University, London, Ontario, Canada
| | - Francis A Farraye
- Division of Gastroenterology and Hepatology, Mayo Clinic, Jacksonville, Florida, USA
| | - Aakash Desai
- Division of Gastroenterology and Hepatology, Mayo Clinic, Jacksonville, Florida, USA
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Sakai R, Tanaka E, Inoue E, Harigai M. Increased risk of cardiovascular events under the treatments with Janus kinase inhibitors versus biological disease-modifying antirheumatic drugs in patients with rheumatoid arthritis: a retrospective longitudinal population-based study using the Japanese health insurance database. RMD Open 2024; 10:e003885. [PMID: 38886005 PMCID: PMC11184193 DOI: 10.1136/rmdopen-2023-003885] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2023] [Accepted: 05/31/2024] [Indexed: 06/20/2024] Open
Abstract
OBJECTIVES To compare the risk of cardiovascular events among Janus kinase inhibitors (JAKIs), biological disease-modifying antirheumatic drugs (bDMARDs) (tumour necrosis factor inhibitors (TNFIs) and non-TNFIs) and methotrexate (MTX) in Japanese patients with rheumatoid arthritis (RA). METHODS Using Japanese claims data, patients with RA were enrolled in this study if they had at least one ICD-10 code (M05 or M06), were new users of JAKIs, bDMARDs or MTX between July 2013 and July 2020 and being 18 years old or older. The incidence rate (IR), IR ratio and adjusted hazard ratio (aHR (95% CI)) of cardiovascular events including venous thromboembolism, arterial thrombosis, acute myocardial infarction and stroke were calculated. A time-dependent Cox regression model adjusted for patient characteristics at baseline was used to calculate aHR. RESULTS In 53 448 cases, IRs/1000 patient-years of the overall cardiovascular events were 10.1, 6.8, 5.4, 9.1 and 11.3 under the treatments with JAKIs, bDMARDs, TNFIs, non-TNFIs and MTX, respectively. The adjusted HRs of JAKIs for overall cardiovascular events were 1.7 (1.1 to 2.5) versus TNFIs without MTX and 1.7 (1.1 to 2.7) versus TNFIs with MTX. CONCLUSIONS Among patients with RA, individuals using JAKIs had a significantly higher risk of overall cardiovascular events than TNFIs users, which was attributed to the difference in the risk between JAKIs and TNFIs versus MTX. These data should be interpreted with caution because of the limitations associated with the claims database.
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Affiliation(s)
- Ryoko Sakai
- Department of Publich Health and Epidemiology, Meiji Pharmaceutical University, Kiyose, Tokyo, Japan
- Division of Rheumatology, Department of Internal Medicine, Tokyo Women's Medical University School of Medicine, Shinjuku-ku, Tokyo, Japan
| | - Eiichi Tanaka
- Division of Rheumatology, Department of Internal Medicine, Tokyo Women's Medical University School of Medicine, Shinjuku-ku, Tokyo, Japan
- Institute of Rheumatology, Tokyo Women's Medical University Hospital, Shinjuku-ku, Tokyo, Japan
| | - Eisuke Inoue
- Showa University Research Administration Center, Showa University, Shinagawa-ku, Tokyo, Japan
| | - Masayoshi Harigai
- Division of Rheumatology, Department of Internal Medicine, Tokyo Women's Medical University School of Medicine, Shinjuku-ku, Tokyo, Japan
- Institute of Rheumatology, Tokyo Women's Medical University Hospital, Shinjuku-ku, Tokyo, Japan
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3
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Liew JW, Treu T, Park Y, Ferguson JM, Rosser MA, Ho YL, Gagnon DR, Stovall R, Monach P, Heckbert SR, Gensler LS, Liao KP, Dubreuil M. The association of TNF inhibitor use with incident cardiovascular events in radiographic axial spondyloarthritis. Semin Arthritis Rheum 2024; 68:152482. [PMID: 38865875 DOI: 10.1016/j.semarthrit.2024.152482] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2024] [Revised: 04/02/2024] [Accepted: 05/20/2024] [Indexed: 06/14/2024]
Abstract
BACKGROUND Whether tumor necrosis factor inhibitor (TNFi) use is cardioprotective among individuals with radiographic axial spondyloarthritis (r-axSpA), who have heightened cardiovascular (CV) risk, is unclear. We tested the association of TNFi use with incident CV outcomes in r-axSpA. METHODS We identified a r-axSpA cohort within a Veterans Affairs database between 2002 and 2019 using novel phenotyping methods and secondarily using ICD codes. TNFi use was assessed as a time-varying exposure using pharmacy dispense records. The primary outcome was incident CV disease identified using ICD codes for coronary artery disease, myocardial infarction or stroke. We fit Cox models with inverse probability weights to estimate the risk of each outcome with TNFi use versus non-use. Analyses were performed in the overall cohort, and separately in two periods (2002-2010, 2011-2019) to account for secular trends. RESULTS Using phenotyping we identified 26,928 individuals with an r-axSpA diagnosis (mean age 63.4 years, 94 % male); at baseline 3633 were TNFi users and 23,295 were non-users. During follow-up of a mean 3.3 ± 4.2 years, 674 (18.6 %) TNFi users had incident CVD versus 11,838 (50.8 %) non-users. In adjusted analyses, TNFi use versus non-use was associated with lower risk of incident CVD (HR 0.34, 95 % CI 0.29-0.40) in the cohort overall, and in the two time periods separately. CONCLUSION In this r-axSpA cohort identified using phenotyping methods, TNFi use versus non-use had a lower risk of incident CVD. These findings provide reassurance regarding the CV safety of TNFi agents for r-axSpA treatment. Replication of these results in other cohorts is needed.
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Affiliation(s)
- Jean W Liew
- Section of Rheumatology, Boston University Chobanian & Avedisian School of Medicine, Boston, MA, USA.
| | - Timothy Treu
- Massachusetts Veterans Epidemiology Research and Information Center (MAVERIC), VA Boston Healthcare System, Boston, MA, USA
| | - Yojin Park
- Massachusetts Veterans Epidemiology Research and Information Center (MAVERIC), VA Boston Healthcare System, Boston, MA, USA
| | - Jacqueline M Ferguson
- Center for Innovation to Implementation, Veterans Affairs Palo Alto Health Care System, Menlo Park, CA, USA
| | - Morgan A Rosser
- Duke University, Department of Anesthesiology, Durham, NC, USA
| | - Yuk-Lam Ho
- Massachusetts Veterans Epidemiology Research and Information Center (MAVERIC), VA Boston Healthcare System, Boston, MA, USA
| | - David R Gagnon
- Massachusetts Veterans Epidemiology Research and Information Center (MAVERIC), VA Boston Healthcare System, Boston, MA, USA; Department of Biostatistics, Boston University School of Public Health, Boston, MA, USA
| | - Rachael Stovall
- Division of Rheumatology, University of Washington, Seattle, WA, USA
| | - Paul Monach
- Rheumatology Section, VA Boston Healthcare System, Boston, MA, USA
| | - Susan R Heckbert
- Department of Epidemiology, University of Washington, Seattle, WA, USA
| | - Lianne S Gensler
- Division of Rheumatology, Department of Medicine, University of California San Francisco, San Francisco, CA, USA
| | - Katherine P Liao
- Brigham and Women's Hospital, Boston, MA, USA; Harvard Medical School, Boston, MA, USA, VA Boston Healthcare System, Boston, MA, USA; Section of Rheumatology, VA Boston Healthcare System; Division of Rheumatology, Inflammation, and Immunity, Brigham and Women's Hospital, Boston, MA, USA
| | - Maureen Dubreuil
- Section of Rheumatology, Boston University Chobanian & Avedisian School of Medicine, VA Boston Healthcare System, Boston, MA, USA
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Lowell JA, Sharma G, Swaminath A, Sultan K. Pharmacologic Anticoagulation Is Associated With a Lower Risk of Recurrent Venous Thromboembolic Events During Janus Kinase Inhibitor Use for Patients With a Prior Thrombosis. Inflamm Bowel Dis 2024:izae100. [PMID: 38704439 DOI: 10.1093/ibd/izae100] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/03/2024] [Indexed: 05/06/2024]
Abstract
BACKGROUND Janus kinase (JAK) inhibitors tofacitinib and upadacitinib are effective therapies for inflammatory bowel disease and rheumatologic disorders but currently possess a warning for increased venous thromboembolism (VTE) risk. Some patients with a history of VTE may benefit from a JAK inhibitor, but the risk of recurrent VTE with JAK inhibitor use is unclear. Our goal was to observe rates of new VTE events after starting JAK inhibitor therapy in patients with a prior VTE, and observe whether concurrent anticoagulation (AC) reduces this risk. METHODS We conducted a review of adults prescribed tofacitinib or upadacitinib between January 1, 2000, and June 30, 2023, with a prior history of VTE. Patient charts were reviewed for demographic data, disease type, and VTE date(s), and to verify duration of JAK inhibitor use along with any concurrent AC. VTEs following JAK inhibitor initiation were identified by International Classification of Diseases-Tenth Revision code and verified by physician documentation and imaging. RESULTS We identified 79 patients with a documented VTE history before initiating JAK inhibitors, 47 of whom began a JAK inhibitor with concurrent AC. Of these, 15 patients discontinued AC while receiving JAK inhibitors. In total, 5 new VTE events were observed during 55.42 patient-years of JAK inhibitor treatment without concurrent AC (9.0 events per 100 patient-years), while no new VTE events occurred during 65.2 patient-years of JAK inhibitor treatment with concurrent AC, demonstrating a lower risk of recurrent VTE (P = .020). CONCLUSIONS These results suggest that for patients with a prior VTE history there is a high risk for recurrent VTE while receiving JAK inhibitors. Concurrent use of AC with JAK inhibitors appears to be protective against recurrent VTEs in this population.
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Affiliation(s)
- Jeffrey A Lowell
- Department of Medicine, Zucker School of Medicine at Hofstra University, Northwell Health, Manhasset, NY, USA
| | - Garvita Sharma
- Department of Preclinical Medicine, Arkansas College of Osteopathic Medicine, Fort Smith, AR, USA
- The Feinstein Institutes for Medical Research, Northwell Health, Manhasset, NY, USA
| | - Arun Swaminath
- Division of Gastroenterology, Lenox Hill Hospital, Northwell Health, New York, NY, USA
| | - Keith Sultan
- Department of Gastroenterology, Northwell Health, Zucker School of Medicine at Hofstra/Northwell, Manhasset, NY, USA
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Wu G, Cao B, Zhai H, Liu B, Huang Y, Chen X, Ling H, Ling S, Jin S, Yang X, Wang J. EPO promotes the progression of rheumatoid arthritis by inducing desialylation via increasing the expression of neuraminidase 3. Ann Rheum Dis 2024; 83:564-575. [PMID: 38272667 DOI: 10.1136/ard-2023-224852] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2023] [Accepted: 01/17/2024] [Indexed: 01/27/2024]
Abstract
OBJECTIVE Erythropoietin (EPO) known as an erythrocyte-stimulating factor is increased in patients with rheumatoid arthritis (RA). Nevertheless, the function of EPO in the process of RA and relative mechanism needs to be further clarified. METHODS The level of EPO in serum and synovial fluid from patients with RA and healthy controls was determined by . Collagen-induced arthritis (CIA) mice were constructed to confirm the role of EPO on RA pathogenesis. Differentially expressed genes (DEGs) of EPO-treated fibroblast-like synoviocyte (FLS) were screened by transcriptome sequencing. The transcription factor of neuraminidase 3 (NEU3) of DEGs was verified by double luciferase reporting experiment, DNA pulldown, electrophoretic mobility shift assay and chromatin immunoprecipitation-quantitative PCR (qPCR) assay. RESULTS The overexpression of EPO was confirmed in patients with RA, which was positively associated with Disease Activity Score 28-joint count. Additionally, EPO intervention could significantly aggravate the joint destruction in CIA models. The upregulation of NEU3 was screened and verified by transcriptome sequencing and qPCR in EPO-treated FLS, and signal transducer and activator of transcription 5 was screened and verified to be the specific transcription factor of NEU3. EPO upregulates NEU3 expression via activating the Janus kinase 2 (JAK2)-STAT5 signalling pathway through its receptor EPOR, thereby to promote the desialylation through enhancing the migration and invasion ability of FLS, which is verified by JAK2 inhibitor and NEU3 inhibitor. CONCLUSION EPO, as a proinflammatory factor, accelerates the process of RA through transcriptional upregulation of the expression of NEU3 by JAK2/STAT5 pathway.
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Affiliation(s)
- Gan Wu
- Department of Anesthesia and Critical Care, The Second Affiliated Hospital and Yuying Children's Hospital of Wenzhou Medical University, Wenzhou, Zhejiang, China
- Key Laboratory of Pediatric Anesthesiology, Ministry of Education, Wenzhou Medical University, Wenzhou, Zhejiang, China
| | - Ben Cao
- Institute of Autoimmune Diseases, School of Basic Medical Sciences, Wenzhou Medical University, Wenzhou, Zhejiang, China
| | - Haige Zhai
- Institute of Autoimmune Diseases, School of Basic Medical Sciences, Wenzhou Medical University, Wenzhou, Zhejiang, China
| | - Bin Liu
- Institute of Autoimmune Diseases, School of Basic Medical Sciences, Wenzhou Medical University, Wenzhou, Zhejiang, China
| | - Yuan Huang
- Institute of Autoimmune Diseases, School of Basic Medical Sciences, Wenzhou Medical University, Wenzhou, Zhejiang, China
| | - Xiaowei Chen
- Department of Immunology and Rheumatology, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, Zhejiang, China
| | - Hanzhi Ling
- Department of Immunology and Rheumatology, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, Zhejiang, China
| | - Sunwang Ling
- Institute of Autoimmune Diseases, School of Basic Medical Sciences, Wenzhou Medical University, Wenzhou, Zhejiang, China
| | - Shengwei Jin
- Department of Anesthesia and Critical Care, The Second Affiliated Hospital and Yuying Children's Hospital of Wenzhou Medical University, Wenzhou, Zhejiang, China
- Key Laboratory of Pediatric Anesthesiology, Ministry of Education, Wenzhou Medical University, Wenzhou, Zhejiang, China
| | - Xinyu Yang
- Department of Medicinal Chemistry, School of Pharmaceutical Sciences, Wenzhou Medical University, Wenzhou, Zhejiang, China
| | - Jianguang Wang
- Department of Anesthesia and Critical Care, The Second Affiliated Hospital and Yuying Children's Hospital of Wenzhou Medical University, Wenzhou, Zhejiang, China
- Key Laboratory of Pediatric Anesthesiology, Ministry of Education, Wenzhou Medical University, Wenzhou, Zhejiang, China
- Institute of Autoimmune Diseases, School of Basic Medical Sciences, Wenzhou Medical University, Wenzhou, Zhejiang, China
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Zisapel M, Seyman E, Molad J, Hallevi H, Mauda-Havakuk M, Jonas-Kimchi T, Elkayam O, Eviatar T. Case report: Cerebral sinus vein thrombosis in VEXAS syndrome. Front Med (Lausanne) 2024; 11:1377768. [PMID: 38651063 PMCID: PMC11033418 DOI: 10.3389/fmed.2024.1377768] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2024] [Accepted: 03/26/2024] [Indexed: 04/25/2024] Open
Abstract
VEXAS (vacuoles, E1 enzyme, X-linked, autoinflammatory, and somatic) syndrome is a newly described hemato-inflammatory acquired monogenic entity that presents in adulthood. One of the main features of VEXAS syndrome is a high venous thromboembolism (VTE) burden, with approximately 30-40% experiencing lower extremity deep vein thrombosis and a lower incidence of pulmonary embolism at approximately 10%. To date, VEXAS syndrome has not been associated with rarer forms of VTE such as cerebral sinus vein thrombosis (CSVT) and Budd-Chiari syndrome, which are well-recognized vascular manifestations in Behcet's disease, another autoinflammatory vasculitic disease. Herein, we describe a case of acute severe extensive and fatal CSVT in a patient with VEXAS syndrome. The event occurred during a period of apparently quiescent inflammatory status, while the patient was receiving tocilizumab and a low dose of glucocorticoids. Despite treatment with anticoagulation, high-dose glucocorticoids, endovascular thrombectomy, and intracranial pressure-lowering agents, the patient suffered severe neurologic damage and ultimately succumbed to the condition 3 weeks after the onset of CSVT. To the best of our knowledge, this is the first reported case of CVST in a patient with VEXAS syndrome.
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Affiliation(s)
- Michael Zisapel
- Rheumatology Department, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel
- Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Estelle Seyman
- Neurology Division, Rambam Medical Center, Haifa, Israel
| | - Jeremy Molad
- Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
- Department of Stroke and Neurology, Tel-Aviv Sourasky Medical Center, Tel Aviv, Israel
| | - Hen Hallevi
- Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
- Department of Stroke and Neurology, Tel-Aviv Sourasky Medical Center, Tel Aviv, Israel
| | - Michal Mauda-Havakuk
- Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
- Department of Radiology, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel
| | - Tali Jonas-Kimchi
- Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
- Department of Radiology, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel
| | - Ori Elkayam
- Rheumatology Department, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel
- Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Tali Eviatar
- Rheumatology Department, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel
- Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
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Jiang W, Jia W, Dong C. Under the dual effect of inflammation and pulmonary fibrosis, CTD-ILD patients possess a greater susceptibility to VTE. Thromb J 2024; 22:34. [PMID: 38576023 PMCID: PMC10993540 DOI: 10.1186/s12959-024-00599-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2023] [Accepted: 03/18/2024] [Indexed: 04/06/2024] Open
Abstract
As an autoimmune disease, the persistent systemic inflammatory response associated with connective tissue disease (CTD) is involved in the development of venous thromboembolism (VTE). However, clinical data showed that the risk of VTE in patients differed between subtypes of CTD, suggesting that different subtypes may have independent mechanisms to promote the development of VTE, but the specific mechanism lacks sufficient research at present. The development of pulmonary fibrosis also contributes to the development of VTE, and therefore, patients with CTD-associated interstitial lung disease (CTD-ILD) may be at higher risk of VTE than patients with CTD alone or patients with ILD alone. In addition, the activation of the coagulation cascade response will drive further progression of the patient's pre-existing pulmonary fibrosis, which will continue to increase the patient's risk of VTE and adversely affect prognosis. Currently, the treatment for CTD-ILD is mainly immunosuppressive and antirheumatic therapy, such as the use of glucocorticoids and janus kinase-inhibitors (JAKis), but, paradoxically, these drugs are also involved in the formation of patients' coagulation tendency, making the clinical treatment of CTD-ILD patients with a higher risk of developing VTE challenging. In this article, we review the potential risk factors and related mechanisms for the development of VTE in CTD-ILD patients to provide a reference for clinical treatment and prevention.
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Affiliation(s)
- Wenli Jiang
- Department of Pulmonary and Critical Care Medicine, Second Hospital, Jilin University, 130041, Changchun, China
| | - Wenhui Jia
- Department of Pulmonary and Critical Care Medicine, Second Hospital, Jilin University, 130041, Changchun, China
| | - Chunling Dong
- Department of Pulmonary and Critical Care Medicine, Second Hospital, Jilin University, 130041, Changchun, China.
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Momen Majumder MS, Hasan ATMT, Choudhury MR, Ahmed S, Miah MT, Amin MR, Shahin MA, Islam A, Shazzad MN, Hassan MM, Ahmedullah AK, Rahman MM, Yesmeen S, Uddin T, Haq SA. 2023 Management Recommendations of Bangladesh Rheumatology Society on Pharmacological Treatment of Rheumatoid Arthritis With Synthetic and Biologic Disease-Modifying Drugs. Cureus 2024; 16:e59395. [PMID: 38707172 PMCID: PMC11070067 DOI: 10.7759/cureus.59395] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/30/2024] [Indexed: 05/07/2024] Open
Abstract
Rheumatoid arthritis (RA) is the most common inflammatory polyarthritis in Bangladesh. Bangladesh Rheumatology Society (BRS) proposes these management recommendations to treat the considerable burden of RA in the resource-constrained situation based on the best current evidence combined with societal challenges and opportunities. BRS formed a task force (TF) comprising four rheumatologists. The TF searched for all available literature, including updated American College of Rheumatology (ACR), European Alliance of Associations for Rheumatology (EULAR), and Asia-Pacific League of Associations for Rheumatology (APLAR) and several other guidelines, and systematic literature reviews until October 2023, and then a steering committee was formed, which included rheumatologists and internists. We followed the EULAR standard operating procedures to categorize levels of evidence and grading of recommendations. This recommendation has two parts -- general (diagnosis of RA, nomenclature of disease-modifying anti-rheumatic drugs [DMARDs], disease activity indices) and management portion. The TF agreed on four overarching principles and 12 recommendations. Overarching principles deal with early diagnosis and disease activity monitoring. Recommendations 1-5 discuss using glucocorticoids, NSAIDs, and conventional synthetic DMARDs (csDMARD). Recommendations 6-9 stretch the use of targeted synthetic DMARDs (tsDMARDs) and biological DMARDs (bDMARDs). The suggested DMARD therapy includes initiation with methotrexate (MTX) or another csDMARD (in case of contraindication to MTX) in the first phase and the addition of a tsDMARD in the second phase, switching to an alternative tsDMARDs or bDMARDs in the subsequent phases. The TF included the Padua prediction score for the thromboembolism risk estimation. Recommendations 10-12 cover infection screening, vaccination, and DMARD tapering. Bangladesh has a higher prevalence of RA. This recommendation will serve as a tool to treat this high burden of patients with RA scientifically and more effectively.
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Affiliation(s)
| | | | | | - Shamim Ahmed
- Rheumatology, Bangabandhu Sheikh Mujib Medical University, Dhaka, BGD
| | - Md Titu Miah
- Internal Medicine, Directorate General of Medical Education, Mohakhali, Dhaka, BGD
| | - Md Robed Amin
- Internal Medicine, Directorate General of Health Services (DGHS), Dhaka, BGD
| | - Md A Shahin
- Rheumatology, Bangabandhu Sheikh Mujib Medical University, Dhaka, BGD
| | - Ariful Islam
- Rheumatology, Bangabandhu Sheikh Mujib Medical University, Dhaka, BGD
| | | | - M Masudul Hassan
- Rheumatology, Bangabandhu Sheikh Mujib Medical University, Dhaka, BGD
| | | | | | - Sabrina Yesmeen
- Rheumatology, BIRDEM (Bangladesh Institute of Research and Rehabilitation in Diabetes, Endocrine and Metabolic Disorders) General Hospital, Dhaka, BGD
| | - Taslim Uddin
- Rehabilitation Medicine, Bangabandhu Sheikh Mujib Medical University, Dhaka, BGD
| | - Syed A Haq
- Rheumatology, Bangabandhu Sheikh Mujib Medical University, Dhaka, BGD
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López-Navarro B, Simón-Fuentes M, Ríos I, Schiaffino MT, Sanchez A, Torres-Torresano M, Nieto-Valle A, Castrejón I, Puig-Kröger A. Macrophage re-programming by JAK inhibitors relies on MAFB. Cell Mol Life Sci 2024; 81:152. [PMID: 38528207 PMCID: PMC10963568 DOI: 10.1007/s00018-024-05196-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2023] [Revised: 03/01/2024] [Accepted: 03/02/2024] [Indexed: 03/27/2024]
Abstract
Monocyte-derived macrophages play a key pathogenic role in inflammatory diseases. In the case of rheumatoid arthritis (RA), the presence of specific synovial tissue-infiltrating macrophage subsets is associated with either active disease or inflammation resolution. JAK inhibitors (JAKi) are the first targeted synthetic disease-modifying antirheumatic drugs (tsDMARD) approved for treatment of RA with comparable efficacy to biologics. However, the effects of JAKi on macrophage specification and differentiation are currently unknown. We have analyzed the transcriptional and functional effects of JAKi on human peripheral blood monocyte subsets from RA patients and on the differentiation of monocyte-derived macrophages promoted by granulocyte-macrophage colony-stimulating factor (GM-CSF), a factor that drives the development and pathogenesis of RA. We now report that JAKi Upadacitinib restores the balance of peripheral blood monocyte subsets in RA patients and skewed macrophages towards the acquisition of an anti-inflammatory transcriptional and functional profile in a dose-dependent manner. Upadacitinib-treated macrophages showed a strong positive enrichment of the genes that define synovial macrophages associated to homeostasis/inflammation resolution. Specifically, Upadacitinib-treated macrophages exhibited significantly elevated expression of MAFB and MAFB-regulated genes, elevated inhibitory phosphorylation of GSK3β, and higher phagocytic activity and showed an anti-inflammatory cytokine profile upon activation by pathogenic stimuli. These outcomes were also shared by macrophages exposed to other JAKi (baricitinib, tofacitinib), but not in the presence of the TYK2 inhibitor deucravacitinib. As a whole, our results indicate that JAKi promote macrophage re-programming towards the acquisition of a more anti-inflammatory/pro-resolution profile, an effect that correlates with the ability of JAKi to enhance MAFB expression.
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Affiliation(s)
- Baltasar López-Navarro
- Unidad de Inmunometabolismo e Inflamación, Instituto de Investigación Sanitaria Gregorio Marañón, Hospital General Universitario Gregorio Marañón, Madrid, Spain
| | | | - Israel Ríos
- Myeloid Cell Laboratory, Centro de Investigaciones Biológicas, Madrid, Spain
| | - María Teresa Schiaffino
- Unidad de Inmunometabolismo e Inflamación, Instituto de Investigación Sanitaria Gregorio Marañón, Hospital General Universitario Gregorio Marañón, Madrid, Spain
| | - Alicia Sanchez
- Unidad de Inmunometabolismo e Inflamación, Instituto de Investigación Sanitaria Gregorio Marañón, Hospital General Universitario Gregorio Marañón, Madrid, Spain
| | - Mónica Torres-Torresano
- Unidad de Inmunometabolismo e Inflamación, Instituto de Investigación Sanitaria Gregorio Marañón, Hospital General Universitario Gregorio Marañón, Madrid, Spain
| | - Alicia Nieto-Valle
- Unidad de Microscopía Confocal, Instituto de Investigación Sanitaria Gregorio Marañón, Hospital General Universitario Gregorio Marañón, Madrid, Spain
| | - Isabel Castrejón
- Servicio de Reumatología, Instituto de Investigación Sanitaria Gregorio Marañón, Hospital General Universitario Gregorio Marañón, Madrid, Spain
- Departamento de Medicina, Universidad Complutense de Madrid, Madrid, Spain
| | - Amaya Puig-Kröger
- Unidad de Inmunometabolismo e Inflamación, Instituto de Investigación Sanitaria Gregorio Marañón, Hospital General Universitario Gregorio Marañón, Madrid, Spain.
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10
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Daza Zapata AM, Álvarez K, Vásquez Duque G, Palacio J, Rojas López M. Janus kinase inhibitors modify the fatty acid profile of extracellular vesicles and modulate the immune response. Heliyon 2024; 10:e24710. [PMID: 38314280 PMCID: PMC10837569 DOI: 10.1016/j.heliyon.2024.e24710] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2023] [Revised: 01/11/2024] [Accepted: 01/12/2024] [Indexed: 02/06/2024] Open
Abstract
Background Janus kinase inhibitors (jakinibs) are immunomodulators used for treating malignancies, autoimmune diseases, and immunodeficiencies. However, they induce adverse effects such as thrombosis, lymphocytosis, and neutropenia that could be mediated by extracellular vesicles (EVs). These particles are cell membrane-derived structures that transport cellular and environmental molecules and participate in intercellular communication. Jakinibs can modify the content of EVs and enable them to modulate the activity of different components of the immune response. Objective to evaluate the interactions between immune system components of healthy individuals and EVs derived from monocytic and lymphoid lineage cells generated in the presence of baricitinib (BARI) and itacitinib (ITA) and their possible effects. Methods EVs were isolated from monocytes (M) and lymphocytes (L) of healthy individuals, as well as from U937 (U) and Jurkat (J) cells exposed to non-cytotoxic concentrations of BARI, ITA, and dimethyl sulfoxide (DMSO; vehicle control). The binding to and engulfment of EVs by peripheral blood leukocytes of healthy individuals were analyzed by flow cytometry using CFSE-stained EVs and anti-CD45-PeCy7 mAb-labeled whole blood. The effect of EVs on respiratory burst, T-cell activation and proliferation, cytokine synthesis, and platelet aggregation was evaluated. Respiratory burst was assessed in PMA-stimulated neutrophils by the dihydrorhodamine (DHR) test and flow cytometry. T-cell activation and proliferation and cytokine production were assessed in CFSE-stained PBMC cultures stimulated with PHA; expression of the T-cell activation markers CD25 and CD69 and T-cell proliferation were analyzed by flow cytometry, and the cytokine levels were quantified in culture supernatants by Luminex assays. Platelet aggregation was analyzed in platelet-rich plasma (PRP) samples by light transmission aggregometry. The EVs' fatty acid (FA) profile was analyzed using methyl ester derivatization followed by gas chromatography. Results ITA exposure during the generation of EVs modified the size of the EVs released; however, treatment with DMSO and BARI did not alter the size of EVs generated from U937 and Jurkat cells. Circulating neutrophils, lymphocytes, and monocytes showed a 2-fold greater tendency to internalize ITA-U-EVs than their respective DMSO control. The neutrophil respiratory burst was attenuated in greater extent by M-EVs than by L-EVs. Autologous ITA-M-EVs reduced T-cell proliferation by decreasing IL-2 levels and CD25 expression independently of CD69. A higher accumulation of pro-inflammatory cytokines was observed in PHA-stimulated PBMC cultures exposed to M-EVs than to L-EVs; this difference may be related to the higher myristate content of M-EVs. Platelet aggregation increased in the presence of ITA-L/M-EVs by a mechanism presumably dependent on the high arachidonic acid content of the vesicles. Conclusions Cellular origin and jakinib exposure modify the FA profile of EVs, enabling them, in turn, to modulate neutrophil respiratory burst, T-cell proliferation, and platelet aggregation. The increased T-cell proliferation induced by BARI-L/M-EVs could explain the lymphocytosis observed in patients treated with BARI. The higher proportion of arachidonic acid in the FA content of ITA-L/M-EVs could be related to the thrombosis described in patients treated with ITA. EVs also induced a decrease in the respiratory burst of neutrophils.
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Affiliation(s)
- Ana María Daza Zapata
- Grupo de Inmunología Celular e Inmunogenética, Sede de Investigación Universitaria (SIU), Universidad de Antioquia (UDEA), Medellín, Colombia
| | - Karen Álvarez
- Grupo de Inmunología Celular e Inmunogenética, Sede de Investigación Universitaria (SIU), Universidad de Antioquia (UDEA), Medellín, Colombia
| | - Gloria Vásquez Duque
- Grupo de Inmunología Celular e Inmunogenética, Sede de Investigación Universitaria (SIU), Universidad de Antioquia (UDEA), Medellín, Colombia
| | - Juliana Palacio
- Grupo De Investigación Ciencia de Los Materiales, Instituto de Química, Facultad de Ciencias Exactas Y Naturales, Universidad de Antioquia (UdeA), Calle 70 No. 52-21, Colombia
- Universidad Nacional de Colombia,SedeMedellín, Escuela de Química- Carrera 65 A No 59A-110, Medellín, 4309000, Colombia
| | - Mauricio Rojas López
- Grupo de Inmunología Celular e Inmunogenética, Sede de Investigación Universitaria (SIU), Universidad de Antioquia (UDEA), Medellín, Colombia
- Unidad de Citometría de Flujo, Sede de Investigación Universitaria (SIU), Universidad de Antioquia (UDEA), Medellín, Colombia
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11
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Fazal ZA, Avina-Galindo AM, Marozoff S, Kwan J, Lu N, Avina-Zubieta JA. Risk of venous thromboembolism in patients with rheumatoid arthritis: a meta-analysis of observational studies. BMC Rheumatol 2024; 8:5. [PMID: 38308337 PMCID: PMC10836002 DOI: 10.1186/s41927-024-00376-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2023] [Accepted: 01/21/2024] [Indexed: 02/04/2024] Open
Abstract
BACKGROUND Thrombotic events, such as venous thromboembolism (VTE) are a major health complication linked to rheumatoid arthritis (RA). We performed a meta-analysis to evaluate the risk of VTE, including deep vein thrombosis (DVT) and pulmonary embolism (PE), in adults with RA compared to the general population. METHODS MEDLINE and EMBASE databases were searched from inception to April 2022 to identify publications meeting the following criteria: (1) prospective and retrospective original data from cohort or case-control studies; (2) pre-specified RA definition; (3) clearly defined VTE outcomes; (4) reported risk estimate and 95% confidence intervals (95% CIs); (5) at least sex- and age-matched to comparison group; and (6) English language. Of 372 studies screened, 14 were included (602,760 RA patients, 123,076 VTE events) and their quality was assessed by an adaptation of the STROBE quality scoring scale. RESULTS The pooled risk ratios of VTE, DVT and PE in patients with RA were 1.57 (95% CI 1.41-1.76), 1.58 (95% CI 1.26-1.97) and 1.57 (95% CI 1.30-1.88), respectively. The I2 value of 92%, 94% and 92% for VTE, DVT and PE analyses, suggesting considerable heterogeneity. There were no significant differences in risk estimates among the five subgroup analyses: quality score (P = 0.35, I2 = 0%); sex (P = 0.31, I2 = 1.7%); study year (P = 0.81, I2 = 0%); population source (P = 0.35, I2 = 0%); study design (P = 0.62, I2 = 0%). CONCLUSIONS Results show that patients with RA are at a higher risk of VTE, DVT and PE compared to the general population.
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Affiliation(s)
- Zahra A Fazal
- Arthritis Research Canada, 230-2238 Yukon Street, BC, V5Y 3P2, Vancouver, Canada
- Faculty of Land and Food Systems, University of British Columbia, Vancouver, Canada
| | | | - Shelby Marozoff
- Arthritis Research Canada, 230-2238 Yukon Street, BC, V5Y 3P2, Vancouver, Canada
| | - Jessie Kwan
- Arthritis Research Canada, 230-2238 Yukon Street, BC, V5Y 3P2, Vancouver, Canada
- Faculty of Science, University of British Columbia, Vancouver, Canada
| | - Na Lu
- Arthritis Research Canada, 230-2238 Yukon Street, BC, V5Y 3P2, Vancouver, Canada
| | - J Antonio Avina-Zubieta
- Arthritis Research Canada, 230-2238 Yukon Street, BC, V5Y 3P2, Vancouver, Canada.
- Division of Rheumatology, Department of Medicine, University of British Columbia, Vancouver, Canada.
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12
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Honap S, Agorogianni A, Colwill MJ, Mehta SK, Donovan F, Pollok R, Poullis A, Patel K. JAK inhibitors for inflammatory bowel disease: recent advances. Frontline Gastroenterol 2024; 15:59-69. [PMID: 38487554 PMCID: PMC10935522 DOI: 10.1136/flgastro-2023-102400] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/20/2023] [Accepted: 08/29/2023] [Indexed: 03/17/2024] Open
Abstract
Inflammatory bowel disease (IBD) commonly requires immunosuppressive treatments to induce and maintain durable remission. Janus kinase inhibitors (JAKis) are a novel group of orally administered, small molecule drugs that work by attenuating multiple cytokine signalling pathways to mediate dysregulated immune responses involved in the pathogenesis of IBD. Tofacitinib, filgotinib and upadacitinib have demonstrated efficacy against placebo and are licensed for the treatment of moderate to severe ulcerative colitis; upadacitinib is the only JAKi also currently approved for the treatment of Crohn's disease. Safety concerns stratified by age have led to class-wide regulatory restrictions for JAKi use across all inflammatory diseases. It is important for gastroenterologists managing patients with IBD to be aware of the key pivotal trial outcomes, to identify appropriate patients in whom to commence a JAKi, and to understand the safety considerations and ways to mitigate these risks in the patients they treat. This review provides a contemporaneous overview of this emerging therapeutic class and provides a practical guide for healthcare practitioners for initiating and monitoring JAKi in IBD.
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Affiliation(s)
- Sailish Honap
- Department of Gastroenterology and Hepatology, St George's University Hospitals NHS Foundation Trust, London, UK
- School of Immunology and Microbial Sciences, King's College, London, UK
| | - Alexandra Agorogianni
- Department of Gastroenterology and Hepatology, St George's University Hospitals NHS Foundation Trust, London, UK
| | - Michael J Colwill
- Department of Gastroenterology and Hepatology, St George's University Hospitals NHS Foundation Trust, London, UK
| | - Sonia Kalyanji Mehta
- Department of Gastroenterology and Hepatology, St George's University Hospitals NHS Foundation Trust, London, UK
| | - Fiona Donovan
- Department of Gastroenterology and Hepatology, St George's University Hospitals NHS Foundation Trust, London, UK
| | - Richard Pollok
- Department of Gastroenterology and Hepatology, St George's University Hospitals NHS Foundation Trust, London, UK
- Institute of Infection and Immunity, St George's University, London, UK
| | - Andrew Poullis
- Department of Gastroenterology and Hepatology, St George's University Hospitals NHS Foundation Trust, London, UK
| | - Kamal Patel
- Department of Gastroenterology and Hepatology, St George's University Hospitals NHS Foundation Trust, London, UK
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13
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Ma L, Peng L, Zhao J, Bai W, Jiang N, Zhang S, Wu C, Wang L, Xu D, Leng X, Wang Q, Zhang W, Zhao Y, Tian X, Li M, Zeng X. Efficacy and safety of Janus kinase inhibitors in systemic and cutaneous lupus erythematosus: A systematic review and meta-analysis. Autoimmun Rev 2023; 22:103440. [PMID: 37678618 DOI: 10.1016/j.autrev.2023.103440] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2023] [Accepted: 09/03/2023] [Indexed: 09/09/2023]
Abstract
BACKGROUND Janus kinase (JAK) inhibitors have been proven to be effective and safe in various autoimmune diseases. However, there is still a lack of comprehensive evidence regarding their efficacy and safety in systemic and cutaneous lupus erythematosus. METHODS We searched for systemic and cutaneous lupus erythematosus patients who were treated with JAK inhibitors in PubMed, Embase, Web of Science, and the Cochrane Library until February 28, 2023. The quality of clinical trials was assessed using the Cochrane risk-of-bias tool. Meta-analysis was conducted when at least three studies had comparable measures of outcome. If meta-analysis was not feasible, a descriptive review was carried out. RESULTS We included 30 studies, consisting of 10 randomized controlled trials and 20 case series or reports, with a total of 2,460 patients. JAK inhibitors were found to be more effective than placebo in systemic lupus erythematosus (SLE) based on the percentage of achieving SLE Responder Index (SRI)-4 response (RR = 1.18; 95% CI 1.07 to 1.31; p = 0.001), British Isles Lupus Assessment Group -based Composite Lupus Assessment (BICLA) response (RR = 1.16; 95% CI 1.02 to 1.31; p = 0.02), Lupus Low Disease Activity State (LLDAS) (RR = 1.28; 95% CI 1.07 to 1.54; p = 0.008), and Systemic Lupus Erythematosus Disease Activity Index 2000 (SLEDAI-2 K) remission of arthritis or rash (RR = 1.09; 95% CI 1.00 to 1.18; p = 0.04), particularly in treating musculoskeletal and mucocutaneous involvement. However, the effect of JAK inhibitors on cutaneous lupus erythematosus was uncertain. JAK inhibitors and placebo had a similar incidence of adverse events (RR = 1.01; 95% CI 0.97 to 1.04; p = 0.65). CONCLUSION JAK inhibitors could be a potential treatment option for systemic and cutaneous lupus erythematosus, particularly in treating cutaneous and musculoskeletal lesions of SLE. JAK inhibitors had a safe profile.
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Affiliation(s)
- Leyao Ma
- Department of Rheumatology and Clinical Immunology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing, China; National Clinical Research Center for Dermatologic and Immunologic Diseases (NCRC-DID), Ministry of Science & Technology, Beijing, China; State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Beijing, China; Key Laboratory of Rheumatology and Clinical Immunology, Ministry of Education, Beijing, China
| | - Liying Peng
- Department of Rheumatology and Clinical Immunology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing, China; National Clinical Research Center for Dermatologic and Immunologic Diseases (NCRC-DID), Ministry of Science & Technology, Beijing, China; State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Beijing, China; Key Laboratory of Rheumatology and Clinical Immunology, Ministry of Education, Beijing, China
| | - Jiuliang Zhao
- Department of Rheumatology and Clinical Immunology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing, China; National Clinical Research Center for Dermatologic and Immunologic Diseases (NCRC-DID), Ministry of Science & Technology, Beijing, China; State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Beijing, China; Key Laboratory of Rheumatology and Clinical Immunology, Ministry of Education, Beijing, China.
| | - Wei Bai
- Department of Rheumatology and Clinical Immunology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing, China; National Clinical Research Center for Dermatologic and Immunologic Diseases (NCRC-DID), Ministry of Science & Technology, Beijing, China; State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Beijing, China; Key Laboratory of Rheumatology and Clinical Immunology, Ministry of Education, Beijing, China
| | - Nan Jiang
- Department of Rheumatology and Clinical Immunology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing, China; National Clinical Research Center for Dermatologic and Immunologic Diseases (NCRC-DID), Ministry of Science & Technology, Beijing, China; State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Beijing, China; Key Laboratory of Rheumatology and Clinical Immunology, Ministry of Education, Beijing, China
| | - Shangzhu Zhang
- Department of Rheumatology and Clinical Immunology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing, China; National Clinical Research Center for Dermatologic and Immunologic Diseases (NCRC-DID), Ministry of Science & Technology, Beijing, China; State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Beijing, China; Key Laboratory of Rheumatology and Clinical Immunology, Ministry of Education, Beijing, China
| | - Chanyuan Wu
- Department of Rheumatology and Clinical Immunology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing, China; National Clinical Research Center for Dermatologic and Immunologic Diseases (NCRC-DID), Ministry of Science & Technology, Beijing, China; State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Beijing, China; Key Laboratory of Rheumatology and Clinical Immunology, Ministry of Education, Beijing, China
| | - Li Wang
- Department of Rheumatology and Clinical Immunology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing, China; National Clinical Research Center for Dermatologic and Immunologic Diseases (NCRC-DID), Ministry of Science & Technology, Beijing, China; State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Beijing, China; Key Laboratory of Rheumatology and Clinical Immunology, Ministry of Education, Beijing, China
| | - Dong Xu
- Department of Rheumatology and Clinical Immunology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing, China; National Clinical Research Center for Dermatologic and Immunologic Diseases (NCRC-DID), Ministry of Science & Technology, Beijing, China; State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Beijing, China; Key Laboratory of Rheumatology and Clinical Immunology, Ministry of Education, Beijing, China
| | - Xiaomei Leng
- Department of Rheumatology and Clinical Immunology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing, China; National Clinical Research Center for Dermatologic and Immunologic Diseases (NCRC-DID), Ministry of Science & Technology, Beijing, China; State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Beijing, China; Key Laboratory of Rheumatology and Clinical Immunology, Ministry of Education, Beijing, China
| | - Qian Wang
- Department of Rheumatology and Clinical Immunology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing, China; National Clinical Research Center for Dermatologic and Immunologic Diseases (NCRC-DID), Ministry of Science & Technology, Beijing, China; State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Beijing, China; Key Laboratory of Rheumatology and Clinical Immunology, Ministry of Education, Beijing, China
| | - Wen Zhang
- Department of Rheumatology and Clinical Immunology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing, China; National Clinical Research Center for Dermatologic and Immunologic Diseases (NCRC-DID), Ministry of Science & Technology, Beijing, China; State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Beijing, China; Key Laboratory of Rheumatology and Clinical Immunology, Ministry of Education, Beijing, China
| | - Yan Zhao
- Department of Rheumatology and Clinical Immunology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing, China; National Clinical Research Center for Dermatologic and Immunologic Diseases (NCRC-DID), Ministry of Science & Technology, Beijing, China; State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Beijing, China; Key Laboratory of Rheumatology and Clinical Immunology, Ministry of Education, Beijing, China
| | - Xinping Tian
- Department of Rheumatology and Clinical Immunology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing, China; National Clinical Research Center for Dermatologic and Immunologic Diseases (NCRC-DID), Ministry of Science & Technology, Beijing, China; State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Beijing, China; Key Laboratory of Rheumatology and Clinical Immunology, Ministry of Education, Beijing, China.
| | - Mengtao Li
- Department of Rheumatology and Clinical Immunology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing, China; National Clinical Research Center for Dermatologic and Immunologic Diseases (NCRC-DID), Ministry of Science & Technology, Beijing, China; State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Beijing, China; Key Laboratory of Rheumatology and Clinical Immunology, Ministry of Education, Beijing, China.
| | - Xiaofeng Zeng
- Department of Rheumatology and Clinical Immunology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing, China; National Clinical Research Center for Dermatologic and Immunologic Diseases (NCRC-DID), Ministry of Science & Technology, Beijing, China; State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Beijing, China; Key Laboratory of Rheumatology and Clinical Immunology, Ministry of Education, Beijing, China
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14
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Castelo-Soccio L, Kim H, Gadina M, Schwartzberg PL, Laurence A, O'Shea JJ. Protein kinases: drug targets for immunological disorders. Nat Rev Immunol 2023; 23:787-806. [PMID: 37188939 PMCID: PMC10184645 DOI: 10.1038/s41577-023-00877-7] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/24/2023] [Indexed: 05/17/2023]
Abstract
Protein kinases play a major role in cellular activation processes, including signal transduction by diverse immunoreceptors. Given their roles in cell growth and death and in the production of inflammatory mediators, targeting kinases has proven to be an effective treatment strategy, initially as anticancer therapies, but shortly thereafter in immune-mediated diseases. Herein, we provide an overview of the status of small molecule inhibitors specifically generated to target protein kinases relevant to immune cell function, with an emphasis on those approved for the treatment of immune-mediated diseases. The development of inhibitors of Janus kinases that target cytokine receptor signalling has been a particularly active area, with Janus kinase inhibitors being approved for the treatment of multiple autoimmune and allergic diseases as well as COVID-19. In addition, TEC family kinase inhibitors (including Bruton's tyrosine kinase inhibitors) targeting antigen receptor signalling have been approved for haematological malignancies and graft versus host disease. This experience provides multiple important lessons regarding the importance (or not) of selectivity and the limits to which genetic information informs efficacy and safety. Many new agents are being generated, along with new approaches for targeting kinases.
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Affiliation(s)
- Leslie Castelo-Soccio
- Dermatology Branch, National Institute of Arthritis and Musculoskeletal and Skin Diseases, National Institutes of Health, Bethesda, MD, USA
| | - Hanna Kim
- Juvenile Myositis Pathogenesis and Therapeutics Unit, National Institute of Arthritis and Musculoskeletal and Skin Diseases, National Institutes of Health, Bethesda, MD, USA
| | - Massimo Gadina
- Translational Immunology Section, National Institute of Arthritis and Musculoskeletal and Skin Diseases, National Institutes of Health, Bethesda, MD, USA
| | - Pamela L Schwartzberg
- National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, MD, USA
| | - Arian Laurence
- Department of Immunology, Royal Free London Hospitals NHS Foundation Trust, London, UK.
- University College London Hospitals NHS Foundation Trust, London, UK.
| | - John J O'Shea
- Molecular Immunology and Inflammation Branch, National Institute of Arthritis and Musculoskeletal and Skin Diseases, National Institutes of Health, Bethesda, MD, USA
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15
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Nishii Y, Okamoto M, Zaizen Y, Kojima T, Nouno T, Naitou-Nishida Y, Matsuo N, Takeoka H, Ishida M, Nakamura M, Masuda T, Tanaka T, Miyamura T, Hoshino T. Successful Treatment of a Patient with Drug-Refractory Rheumatoid Arthritis-Associated Interstitial Lung Disease with Upadacitinib: A Case Report. MEDICINA (KAUNAS, LITHUANIA) 2023; 59:1960. [PMID: 38004009 PMCID: PMC10673512 DOI: 10.3390/medicina59111960] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/19/2023] [Revised: 10/30/2023] [Accepted: 11/03/2023] [Indexed: 11/26/2023]
Abstract
Insufficient evidence exists regarding the efficacy of Janus kinase inhibitors (JAKis), a class of targeted synthetic disease-modifying anti-rheumatic drugs (tsDMARDs), in the treatment of rheumatoid arthritis (RA)-associated interstitial lung disease (ILD). Herein, we present a case of RA-ILD refractory to previous treatments that exhibited favorable response to upadacitinib. A 69-year-old man, former smoker, was diagnosed with RA-ILD based on persistent symmetric polyarthritis, elevated C-reactive protein levels and erythrocyte sedimentation rate, reduced diffusing capacity for carbon monoxide/alveolar volume (DLCO 69.9%), and bilateral ground-glass attenuation with traction bronchiectasis, predominantly in the lower lung lobe. Initial treatment with oral prednisolone and methotrexate was started; however, the patient showed worsening dyspnea, chest high-resolution computed tomography abnormalities, and decreased pulmonary function. The dose of prednisolone was increased, and methotrexate was shifted to tacrolimus; however, tacrolimus was eventually discontinued because of renal dysfunction. Subsequent treatment changes included abatacept followed by intravenous cyclophosphamide, but ILD activity continued to worsen and met the criteria of progressive pulmonary fibrosis. Approximately 4.5 years after the RA diagnosis, dyspnea, radiological abnormalities, and DLCO improved following treatment switch to upadacitinib, one of JAKis. JAKi therapy may have potential as a treatment option for refractory RA-ILD.
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Affiliation(s)
- Yuuya Nishii
- Department of Respirology, NHO Kyushu Medical Center, 1-8-1 Jigyohama, Chuo-ku, Fukuoka 810-0065, Japan
- Division of Respirology, Neurology and Rheumatology, Department of Internal Medicine, Kurume University School of Medicine, 67 Asahi-machi, Kurume 830-0011, Japan
| | - Masaki Okamoto
- Department of Respirology, NHO Kyushu Medical Center, 1-8-1 Jigyohama, Chuo-ku, Fukuoka 810-0065, Japan
- Division of Respirology, Neurology and Rheumatology, Department of Internal Medicine, Kurume University School of Medicine, 67 Asahi-machi, Kurume 830-0011, Japan
| | - Yoshiaki Zaizen
- Division of Respirology, Neurology and Rheumatology, Department of Internal Medicine, Kurume University School of Medicine, 67 Asahi-machi, Kurume 830-0011, Japan
| | - Takashi Kojima
- Department of Respirology, NHO Kyushu Medical Center, 1-8-1 Jigyohama, Chuo-ku, Fukuoka 810-0065, Japan
- Division of Respirology, Neurology and Rheumatology, Department of Internal Medicine, Kurume University School of Medicine, 67 Asahi-machi, Kurume 830-0011, Japan
| | - Takashi Nouno
- Department of Respirology, NHO Kyushu Medical Center, 1-8-1 Jigyohama, Chuo-ku, Fukuoka 810-0065, Japan
- Division of Respirology, Neurology and Rheumatology, Department of Internal Medicine, Kurume University School of Medicine, 67 Asahi-machi, Kurume 830-0011, Japan
| | - Yoshiko Naitou-Nishida
- Department of Respirology, NHO Kyushu Medical Center, 1-8-1 Jigyohama, Chuo-ku, Fukuoka 810-0065, Japan
- Division of Respirology, Neurology and Rheumatology, Department of Internal Medicine, Kurume University School of Medicine, 67 Asahi-machi, Kurume 830-0011, Japan
| | - Norikazu Matsuo
- Department of Respirology, NHO Kyushu Medical Center, 1-8-1 Jigyohama, Chuo-ku, Fukuoka 810-0065, Japan
- Division of Respirology, Neurology and Rheumatology, Department of Internal Medicine, Kurume University School of Medicine, 67 Asahi-machi, Kurume 830-0011, Japan
| | - Hiroaki Takeoka
- Department of Respirology, NHO Kyushu Medical Center, 1-8-1 Jigyohama, Chuo-ku, Fukuoka 810-0065, Japan
- Division of Respirology, Neurology and Rheumatology, Department of Internal Medicine, Kurume University School of Medicine, 67 Asahi-machi, Kurume 830-0011, Japan
| | - Motoko Ishida
- Department of Internal Medicine and Rheumatology, NHO Kyushu Medical Center, 1-8-1 Jigyohama, Chuo-ku, Fukuoka 810-0065, Japan
| | - Masataka Nakamura
- Department of Internal Medicine and Rheumatology, NHO Kyushu Medical Center, 1-8-1 Jigyohama, Chuo-ku, Fukuoka 810-0065, Japan
| | - Toru Masuda
- Department of Internal Medicine and Rheumatology, NHO Kyushu Medical Center, 1-8-1 Jigyohama, Chuo-ku, Fukuoka 810-0065, Japan
| | - Takafumi Tanaka
- Department of Internal Medicine and Rheumatology, NHO Kyushu Medical Center, 1-8-1 Jigyohama, Chuo-ku, Fukuoka 810-0065, Japan
| | - Tomoya Miyamura
- Department of Internal Medicine and Rheumatology, NHO Kyushu Medical Center, 1-8-1 Jigyohama, Chuo-ku, Fukuoka 810-0065, Japan
| | - Tomoaki Hoshino
- Division of Respirology, Neurology and Rheumatology, Department of Internal Medicine, Kurume University School of Medicine, 67 Asahi-machi, Kurume 830-0011, Japan
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16
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Harrington R, Harkins P, Conway R. Janus Kinase Inhibitors in Rheumatoid Arthritis: An Update on the Efficacy and Safety of Tofacitinib, Baricitinib and Upadacitinib. J Clin Med 2023; 12:6690. [PMID: 37892827 PMCID: PMC10607454 DOI: 10.3390/jcm12206690] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2023] [Revised: 10/14/2023] [Accepted: 10/18/2023] [Indexed: 10/29/2023] Open
Abstract
Janus kinase inhibitors (JAKis) are the most recent new drug class to arrive to the market for rheumatoid arthritis (RA) treatment. While they have proven to be a very effective treatment option, there remains significant concern regarding the risk of cardiovascular events, thrombosis and malignancy, particularly given the findings of the post-marketing ORAL Surveillance study and FDA black box warnings. This article reviews the key findings of the most impactful cohort of studies and registry data since ORAL Surveillance. It also evaluates the role of JAKis in practice and offers guidance on risk stratifying patients and determining their suitability for a JAKi.
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Affiliation(s)
- Robert Harrington
- Department of Rheumatology, St. James’s Hospital, James Street, Dublin 8, D08 NHY1 Dublin, Ireland;
| | | | - Richard Conway
- Department of Rheumatology, St. James’s Hospital, James Street, Dublin 8, D08 NHY1 Dublin, Ireland;
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Campanaro F, Zaffaroni A, Cacioppo E, Cappelli A, Bertù L, Donadini MP, Squizzato A, Batticciotto A. Venous and arterial thromboembolic risk of Janus kinase inhibitors: a systematic review with meta-analysis. Rheumatology (Oxford) 2023; 62:3245-3255. [PMID: 37202344 DOI: 10.1093/rheumatology/kead211] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2022] [Revised: 04/02/2023] [Accepted: 04/20/2023] [Indexed: 05/20/2023] Open
Abstract
OBJECTIVE Preliminary data led licencing authorities to alert clinicians of an increased venous thrombotic risk associated to the use of Janus kinase (JAK) inhibitors (JAKi). We performed a systematic review to estimate the risk of venous and arterial thrombosis associated to JAKi for the treatment of immune-mediated inflammatory diseases (IMIDs). METHODS Randomized controlled trials (RCTs) on JAKi in patients with IMIDs were identified by the MEDLINE and EMBASE databases until October 2021. Risk of bias was assessed according to Cochrane criteria. The beta-binomial model was applied to calculate pooled odds ratio (OR) and corresponding 95% CI. The PROSPERO registration number is CRD42022324143. RESULTS We have included one phase I, 21 phase II, three phase II-III and 36 phase III RCTs for a total of 19 443 patients in the JAKi group and 6354 in the control group. Thirty-one (unweighted rate 0.16%; 95% CI: 0.10, 0.21) events were reported in the JAKi group and 20 (unweighted rate 0.22%; 95% CI: 0.12, 0.32) in the control group in a mean follow-up of 16.8 weeks. IMID patients treated with JAKi did not have an increased thromboembolic risk compared with those treated with placebo (OR 0.82; 95% CI: 0.43, 1.56). No statistically different results were seen in subanalyses for each investigated IMID, drug and dosage. CONCLUSION JAKi do not increase thromboembolic risk compared with placebo in IMID patients enrolled in selected RCTs.
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Affiliation(s)
- Francesco Campanaro
- Rheumatology Unit, Internal Medicine Department, ASST Sette Laghi, Ospedale Di Circolo-Fondazione Macchi, Varese, Italy
| | - Andrea Zaffaroni
- School of Medicine, Department of Medicine and Surgery, University of Insubria, Varese and Como, Italy
| | - Elettra Cacioppo
- School of Medicine, Department of Medicine and Surgery, University of Insubria, Varese and Como, Italy
| | - Antonella Cappelli
- Rheumatology Unit, Internal Medicine Department, ASST Sette Laghi, Ospedale Di Circolo-Fondazione Macchi, Varese, Italy
| | - Lorenza Bertù
- Research Center on Thromboembolic Diseases and Antithrombotic Therapies, Department of Medicine and Surgery, University of Insubria, Varese and Como, Italy
| | - Marco Paolo Donadini
- Research Center on Thromboembolic Diseases and Antithrombotic Therapies, Department of Medicine and Surgery, University of Insubria, Varese and Como, Italy
- Medicina d'Urgenza e Centro Trombosi ed Emostasi, Dipartimento Di Area Emergenza e Urgenza, Ospedale di Circolo-Fondazione Macchi, ASST Sette Laghi, Varese, Italy
| | - Alessandro Squizzato
- Research Center on Thromboembolic Diseases and Antithrombotic Therapies, Department of Medicine and Surgery, University of Insubria, Varese and Como, Italy
- Dipartimento Di Medicina, Internal Medicine Unit, 'Sant'Anna' Hospital, ASST Lariana, Como, Italy
| | - Alberto Batticciotto
- Rheumatology Unit, Internal Medicine Department, ASST Sette Laghi, Ospedale Di Circolo-Fondazione Macchi, Varese, Italy
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Corbella-Bagot L, Riquelme-McLoughlin C, Morgado-Carrasco D. Long-Term Safety Profile and Off-Label Use of JAK Inhibitors in Dermatological Disorders. ACTAS DERMO-SIFILIOGRAFICAS 2023; 114:T784-T801. [PMID: 37543140 DOI: 10.1016/j.ad.2023.08.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2023] [Accepted: 06/12/2023] [Indexed: 08/07/2023] Open
Abstract
JAK inhibitors target specific inflammatory cytokines involved in various inflammatory diseases. Four molecules have been approved for dermatological use: upadacitinib, baricitinib, abrocitinib and topical ruxolitinib. Off-label prescriptions for other dermatological conditions have been reported. We conducted a narrative review of the literature to assess the long-term safety profile of currently approved JAK inhibitors in dermatology, and their off-label use in skin disorders. We performed literature searches with PubMed and Google Scholar from January 2000 to January 2023, using the keywords "Janus kinase inhibitors", "JAK inhibitors","off-label", "dermatology", "safety", "adverse events", "ruxolitinib", "upadacitinib","abrocitinib" and "baricitinib". Our search yielded a total of 37 dermatological disorders with studies supporting the use of these JAK inhibitors. Preliminary studies indicate that JAK inhibitors generally have a favorable safety profile and can be considered as an option in many dermatological disorders.
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Affiliation(s)
- L Corbella-Bagot
- Departamento de Dermatología, Hospital Clínic de Barcelona, Universitat de Barcelona, Barcelona, España
| | - C Riquelme-McLoughlin
- Departamento de Dermatología, Hospital Clínic de Barcelona, Universitat de Barcelona, Barcelona, España
| | - D Morgado-Carrasco
- Departamento de Dermatología, Hospital Clínic de Barcelona, Universitat de Barcelona, Barcelona, España; Departamento de Dermatología, Hospital de Figueres, Fundació Salut Empordà, Figueres, España.
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19
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Corbella-Bagot L, Riquelme-McLoughlin C, Morgado-Carrasco D. Long-Term Safety Profile and Off-Label Use of JAK Inhibitors in Dermatological Disorders. ACTAS DERMO-SIFILIOGRAFICAS 2023; 114:784-801. [PMID: 37331618 DOI: 10.1016/j.ad.2023.06.012] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2023] [Revised: 06/05/2023] [Accepted: 06/12/2023] [Indexed: 06/20/2023] Open
Abstract
JAK inhibitors target specific inflammatory cytokines involved in various inflammatory diseases. Four molecules have been approved for dermatological use: upadacitinib, baricitinib, abrocitinib and topical ruxolitinib. Off-label prescriptions for other dermatological conditions have been reported. We conducted a narrative review of the literature to assess the long-term safety profile of currently approved JAK inhibitors in dermatology, and their off-label use in skin disorders. We performed literature searches with Pubmed and Google Scholar from January 2000 to January 2023, using the keywords "Janus kinase inhibitors", "JAK inhibitors", "off-label", "dermatology", "safety", "adverse events", "ruxolitinib", "upadacitinib", "abrocitinib" and "baricitinib". Our search yielded a total of 37 dermatological disorders with studies supporting the use of these JAK inhibitors. Preliminary studies indicate that JAK inhibitors generally have a favorable safety profile and can be considered as an option in many dermatological disorders.
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Affiliation(s)
- L Corbella-Bagot
- Department of Dermatology, Hospital Clínic de Barcelona, Universitat de Barcelona, Spain
| | - C Riquelme-McLoughlin
- Department of Dermatology, Hospital Clínic de Barcelona, Universitat de Barcelona, Spain
| | - D Morgado-Carrasco
- Department of Dermatology, Hospital Clínic de Barcelona, Universitat de Barcelona, Spain; Department of Dermatology, Hospital de Figueres, Fundació Salut Empordà, Figueres, Spain.
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20
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Massironi S, Pirola L, Mulinacci G, Ciaccio A, Viganò C, Palermo A, Zilli A, Invernizzi P, Danese S. Use of IBD Drugs in Patients With Hepatobiliary Comorbidities: Tips and Tricks. Inflamm Bowel Dis 2023; 29:1477-1487. [PMID: 36040402 DOI: 10.1093/ibd/izac189] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/17/2022] [Indexed: 12/09/2022]
Abstract
Advanced therapies (biologic agents and small molecules) for inflammatory bowel diseases (IBD) have radically changed the management of these diseases during the last decade. Data about these drugs in patients with hepatic disorders derive mainly from real-life studies, as these conditions often represent an exclusion criterion from pivotal drug developmental trials. However, IBD patients sometimes have concomitant liver diseases. Nonalcoholic fatty liver disease is the most prevalent hepatic comorbidity, whereas viral hepatitis, primary sclerosing cholangitis, primary biliary cholangitis, autoimmune hepatitis, and hepatic vascular disorders are less frequent. This review aimed at describing the real-life data about the use of advanced therapies for IBD in patients with concomitant hepatobiliary disorders. Hepatitis B virus and hepatitis C virus infections do not represent an absolute contraindication for novel IBD therapeutic agents. Data from the literature suggest a safe hepatobiliary profile of biologic agents and small molecules in the case of nonalcoholic fatty liver disease, autoimmune hepatitis, primary sclerosing cholangitis, primary biliary cholangitis, and portal vein thrombosis. Consequently, although the liver disease does not affect a different therapeutic approach in patients with concomitant IBD and liver disease, a close risk/benefit analysis for each drug should be performed in these patients, especially in cirrhotic patients and in the postliver transplant setting.
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Affiliation(s)
- Sara Massironi
- Division of Gastroenterology and Center for Autoimmune Liver Diseases, European Reference Network on Hepatological Diseases (ERN RARE-LIVER), San Gerardo Hospital, Monza, Italy
- Department of Medicine and Surgery, University of Milano-Bicocca, Monza, Italy
| | - Lorena Pirola
- Division of Gastroenterology and Center for Autoimmune Liver Diseases, European Reference Network on Hepatological Diseases (ERN RARE-LIVER), San Gerardo Hospital, Monza, Italy
| | - Giacomo Mulinacci
- Division of Gastroenterology and Center for Autoimmune Liver Diseases, European Reference Network on Hepatological Diseases (ERN RARE-LIVER), San Gerardo Hospital, Monza, Italy
| | - Antonio Ciaccio
- Division of Gastroenterology and Center for Autoimmune Liver Diseases, European Reference Network on Hepatological Diseases (ERN RARE-LIVER), San Gerardo Hospital, Monza, Italy
- Department of Medicine and Surgery, University of Milano-Bicocca, Monza, Italy
| | - Chiara Viganò
- Division of Gastroenterology and Center for Autoimmune Liver Diseases, European Reference Network on Hepatological Diseases (ERN RARE-LIVER), San Gerardo Hospital, Monza, Italy
| | - Andrea Palermo
- Division of Gastroenterology and Center for Autoimmune Liver Diseases, European Reference Network on Hepatological Diseases (ERN RARE-LIVER), San Gerardo Hospital, Monza, Italy
| | - Alessandra Zilli
- Gastroenterology and Endoscopy, IRCCS Ospedale San Raffaele, Milan, Italy
- Vita-Salute San Raffaele University, Milan, Italy
| | - Pietro Invernizzi
- Division of Gastroenterology and Center for Autoimmune Liver Diseases, European Reference Network on Hepatological Diseases (ERN RARE-LIVER), San Gerardo Hospital, Monza, Italy
- Department of Medicine and Surgery, University of Milano-Bicocca, Monza, Italy
| | - Silvio Danese
- Gastroenterology and Endoscopy, IRCCS Ospedale San Raffaele, Milan, Italy
- Vita-Salute San Raffaele University, Milan, Italy
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21
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Munera-Campos M, Carrascosa JM. Janus Kinase Inhibitors in Atopic Dermatitis: New Perspectives. ACTAS DERMO-SIFILIOGRAFICAS 2023; 114:680-707. [PMID: 37105270 DOI: 10.1016/j.ad.2023.04.025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2022] [Revised: 04/10/2023] [Accepted: 04/13/2023] [Indexed: 04/29/2023] Open
Abstract
The JAK/STAT (Janus kinase/signal transducer and activator of transcription) pathway is an essential final step in the signaling process of most interleukins with a critical role in the pathogenesis of atopic dermatitis. By achieving broad, intermittent inhibition of the activity of multiple cytokines, JAK inhibitors help modulate T helper 2 cell-mediated inflammation, epidermal barrier dysfunction, and itch signaling. This comprehensive blockade, however, can result in a wider range of adverse effects. We review a number of JAK inhibitors that have been recently approved for use in atopic dermatitis, such as baricitinib, upadacitinib, and abrocitinib, as well as others that are currently in the pipeline or under development, such as gusacitinib, delgocitinib, ruxolitinib, brepocitinib, tofacitinib, and cerdulatinib. The use of JAK inhibitors to block the signaling of numerous cytokines with a critical role in the pathogenesis of atopic dermatitis has revolutionized the treatment of this pathogenically complex, phenotypically heterogeneous skin disease.
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Affiliation(s)
- M Munera-Campos
- Servicio de Dermatología, Hospital Universitari Germans Trias i Pujol, Universitat Autònoma de Barcelona, Instituto de Investigación Germans Trias i Pujol (IGTP), Badalona, Barcelona, España.
| | - J M Carrascosa
- Servicio de Dermatología, Hospital Universitari Germans Trias i Pujol, Universitat Autònoma de Barcelona, Instituto de Investigación Germans Trias i Pujol (IGTP), Badalona, Barcelona, España
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22
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Munera-Campos M, Carrascosa JM. [Translated article] Janus Kinase Inhibitors in Atopic Dermatitis: New Perspectives. ACTAS DERMO-SIFILIOGRAFICAS 2023; 114:T680-T707. [PMID: 37453538 DOI: 10.1016/j.ad.2023.07.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2022] [Accepted: 04/13/2023] [Indexed: 07/18/2023] Open
Abstract
The JAK/STAT (Janus kinase/signal transducer and activator of transcription) pathway is an essential final step in the signaling process of most interleukins with a critical role in the pathogenesis of atopic dermatitis. By achieving broad, intermittent inhibition of the activity of multiple cytokines, JAK inhibitors help to modulate T helper 2 cell-mediated inflammation, epidermal barrier dysfunction, and itch signaling. This comprehensive blockade, however, can result in a wider range of adverse effects. We review a number of JAK inhibitors that have been recently approved for use in atopic dermatitis, such as baricitinib, upadacitinib, and abrocitinib, as well as others that are currently in the pipeline or under development, such as gusacitinib, delgocitinib, ruxolitinib, brepocitinib, tofacitinib, and cerdulatinib. The use of JAK inhibitors to block the signaling of numerous cytokines with a critical role in the pathogenesis of atopic dermatitis has revolutionized the treatment of this pathogenically complex, phenotypically heterogeneous skin disease.
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Affiliation(s)
- M Munera-Campos
- Servicio de Dermatología, Hospital Universitari Germans Trias i Pujol, Universitat Autònoma de Barcelona, Instituto de Investigación Germans Trias i Pujol (IGTP), Badalona, Barcelona, Spain.
| | - J M Carrascosa
- Servicio de Dermatología, Hospital Universitari Germans Trias i Pujol, Universitat Autònoma de Barcelona, Instituto de Investigación Germans Trias i Pujol (IGTP), Badalona, Barcelona, Spain
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23
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Wei Q, Wang H, Zhao J, Luo Z, Wang C, Zhu C, Su N, Zhang S. Cardiovascular safety of Janus kinase inhibitors in patients with rheumatoid arthritis: systematic review and network meta-analysis. Front Pharmacol 2023; 14:1237234. [PMID: 37614310 PMCID: PMC10442954 DOI: 10.3389/fphar.2023.1237234] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2023] [Accepted: 07/31/2023] [Indexed: 08/25/2023] Open
Abstract
Background: Janus kinase (JAK) inhibitors have emerged as a progressively utilized therapeutic approach for the management of rheumatoid arthritis (RA). However, the complete determination of their cardiovascular safety remains inconclusive. Hence, the primary objective of this network meta-analysis is to meticulously assess and juxtapose the cardiovascular risks linked to distinct JAK inhibitors employed in RA patients. Methods: A systematic review and network meta-analysis were meticulously conducted, encompassing a collection of randomized controlled trials (RCTs) that focused on investigating the incidence of major adverse cardiovascular events (MACE) and all-cause mortality associated with Janus kinase (JAK) inhibitors administered to patients with rheumatoid arthritis (RA). Extensive exploration was performed across multiple electronic databases, incorporating studies published until March 2023. To be included in this analysis, the RCTs were required to involve adult participants diagnosed with RA who received treatment with JAK inhibitors. To ensure accuracy, two authors independently undertook the selection of eligible RCTs and meticulously extracted aggregate data. In order to examine the outcomes of MACE and all-cause mortality, a frequentist graph theoretical approach within network meta-analyses was employed, utilizing random-effects models. Third study has been registered on PROSPERO under the reference CRD42022384611. Findings: A specific selection encompassing a total of 14 meticulously chosen randomized controlled trials was undertaken, wherein 13,524 patients were assigned randomly to distinct treatment interventions. The analysis revealed no notable disparity in the occurrence of major adverse cardiovascular events (MACE) between the interventions and the placebo group. However, in comparison to adalimumab, the employment of JAK inhibitors exhibited an association with higher rates of all-cause mortality [odds ratio (OR): 1.7, 95% confidence interval (CI): 1.02-2.81]. This observed increase in risk primarily stemmed from the usage of tofacitinib (OR: 1.9, 95% CI: 1.12-3.23). None of the other JAK inhibitors exhibited a statistically significant variance in all-cause mortality when compared to adalimumab. Interpretation: Our study suggests that JAK inhibitors may not increase the risk of MACE in RA patients but may be associated with a higher risk of all-cause mortality compared to adalimumab, primarily due to tofacitinib use. Rheumatologists should carefully consider the cardiovascular risks when prescribing JAK inhibitors, particularly tofacitinib, for RA patients. Systematic Review Registration: https://www.crd.york.ac.uk/PROSPERO/display_record.php?RecordID=384611, CRD42022384611.
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Affiliation(s)
- Qige Wei
- Department of Pharmacy, Karamay Central Hospital/Karamay Hospital of Xinjiang Uygur Autonomous Region People’s Hospital, Karamay, China
- Xinjiang Clinical Research Center for Precision Medicine of Digestive System Tumor, Karamay, China
- Xinjiang Key Laboratory of Clinical Genetic Testing and Biomedical Information, Karamay, China
| | - Hui Wang
- Department of Pharmacy, Karamay Central Hospital/Karamay Hospital of Xinjiang Uygur Autonomous Region People’s Hospital, Karamay, China
- Xinjiang Clinical Research Center for Precision Medicine of Digestive System Tumor, Karamay, China
- Xinjiang Key Laboratory of Clinical Genetic Testing and Biomedical Information, Karamay, China
| | - Jianglin Zhao
- Department of Pharmacy, Karamay Central Hospital/Karamay Hospital of Xinjiang Uygur Autonomous Region People’s Hospital, Karamay, China
- Xinjiang Clinical Research Center for Precision Medicine of Digestive System Tumor, Karamay, China
- Xinjiang Key Laboratory of Clinical Genetic Testing and Biomedical Information, Karamay, China
| | - Zhongping Luo
- Department of Pharmacy, Karamay Central Hospital/Karamay Hospital of Xinjiang Uygur Autonomous Region People’s Hospital, Karamay, China
- Xinjiang Clinical Research Center for Precision Medicine of Digestive System Tumor, Karamay, China
- Xinjiang Key Laboratory of Clinical Genetic Testing and Biomedical Information, Karamay, China
| | - Chufeng Wang
- Xinjiang Clinical Research Center for Precision Medicine of Digestive System Tumor, Karamay, China
- Xinjiang Key Laboratory of Clinical Genetic Testing and Biomedical Information, Karamay, China
- Department of Nephropathy and Rheumatology, Karamay Central Hospital/Karamay Hospital of Xinjiang Uygur Autonomous Region People’s Hospital, Karamay, China
| | - Chunmei Zhu
- Department of Pharmacy, Karamay Central Hospital/Karamay Hospital of Xinjiang Uygur Autonomous Region People’s Hospital, Karamay, China
- Xinjiang Clinical Research Center for Precision Medicine of Digestive System Tumor, Karamay, China
- Xinjiang Key Laboratory of Clinical Genetic Testing and Biomedical Information, Karamay, China
| | - Na Su
- Department of Pharmacy, West China Hospital, Sichuan University, Chengdu, China
| | - Shengzhao Zhang
- Department of Pharmacy, Karamay Central Hospital/Karamay Hospital of Xinjiang Uygur Autonomous Region People’s Hospital, Karamay, China
- Xinjiang Clinical Research Center for Precision Medicine of Digestive System Tumor, Karamay, China
- Xinjiang Key Laboratory of Clinical Genetic Testing and Biomedical Information, Karamay, China
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Song YJ, Cho SK, Kim JY, You SH, Kim H, Jung SY, Sung YK. Risk of venous thromboembolism in Korean patients with rheumatoid arthritis treated with Janus kinase inhibitors: A nationwide population-based study. Semin Arthritis Rheum 2023; 61:152214. [PMID: 37172496 DOI: 10.1016/j.semarthrit.2023.152214] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2022] [Revised: 02/17/2023] [Accepted: 05/02/2023] [Indexed: 05/15/2023]
Abstract
OBJECTIVE There was a safety concern about an increased risk of thromboembolic events in patients with rheumatoid arthritis (RA) treated with Janus kinase inhibitors (JAKis). This study aimed to determine the risk of venous thromboembolism (VTE) in Korean patients with RA treated with JAKis compared with tumour necrosis factor (TNF) inhibitors. METHODS Using the National Health Insurance Service database between 2015 and 2019, patients with prevalent RA who started JAKi or TNF inhibitor were selected as the study population. All participants were naïve to targeted therapy. Patients that had experienced any VTE event or used anticoagulant agents within 30 days were excluded. Demographic and clinical characteristics were all balanced by stabilised inverse probability of treatment weighting (sIPTW) using propensity score. The Cox proportional hazard model considering death as a competing risk was used to evaluate the risk of VTE in JAKi users compared with TNF inhibitor users. RESULTS A total of 4,178 patients were included: 871 JAKi users and 3,307 TNF inhibitor users were followed up for 1,029.2 person-years (PYs) and 5,940.3 PYs, respectively. With a balanced sample after sIPTW, the incidence rates (IR) of VTE were 0.06 per 100 PYs (95% confidence interval [CI] 0.00-1.23) in JAKi users and 0.38 per 100 PYs (95% CI 0.25-0.58) in TNF inhibitor users. The hazard ratio was 0.18 (95% CI 0.01-3.47) after adjusting for unbalanced variables after performing sIPTW. CONCLUSION There is no increased risk of VTE in RA patients treated with JAKis compared with TNF inhibitors in Korea.
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Affiliation(s)
- Yeo-Jin Song
- Department of Rheumatology, Hanyang University Hospital for Rheumatic Diseases, Seoul, Republic of Korea; Hanyang University Institute for Rheumatology Research, Seoul, Republic of Korea
| | - Soo-Kyung Cho
- Department of Rheumatology, Hanyang University Hospital for Rheumatic Diseases, Seoul, Republic of Korea; Hanyang University Institute for Rheumatology Research, Seoul, Republic of Korea
| | - Jeong-Yeon Kim
- College of Pharmacy, Chung-Ang University, Seoul, Republic of Korea
| | - Seung-Hun You
- College of Pharmacy, Chung-Ang University, Seoul, Republic of Korea
| | - Hyoungyoung Kim
- Department of Rheumatology, Hanyang University Hospital for Rheumatic Diseases, Seoul, Republic of Korea; Hanyang University Institute for Rheumatology Research, Seoul, Republic of Korea
| | - Sun-Young Jung
- College of Pharmacy, Chung-Ang University, Seoul, Republic of Korea.
| | - Yoon-Kyoung Sung
- Department of Rheumatology, Hanyang University Hospital for Rheumatic Diseases, Seoul, Republic of Korea; Hanyang University Institute for Rheumatology Research, Seoul, Republic of Korea.
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Melki I, Frémond ML. JAK Inhibition in Juvenile Idiopathic Arthritis (JIA): Better Understanding of a Promising Therapy for Refractory Cases. J Clin Med 2023; 12:4695. [PMID: 37510809 PMCID: PMC10381267 DOI: 10.3390/jcm12144695] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2023] [Revised: 07/03/2023] [Accepted: 07/08/2023] [Indexed: 07/30/2023] Open
Abstract
Juvenile idiopathic arthritis (JIA) is a heterogeneous group of diseases with probably differential underlying physiopathology. Despite the revolutionary era of biologics, some patients remain difficult to treat because of disease severity, drug adverse events, drug allergy or association with severe comorbidities, i.e., uveitis, interstitial lung disease and macrophagic activation syndrome. Janus Kinase (JAK) inhibitors are small molecules that target JAK/Signal Transducers and Activators of Transcription (STAT) pathways, which could then prevent the activity of several proinflammatory cytokines. They may provide a useful alternative in these cases of JIA or in patients actually affected by Mendelian disorders mimicking JIA, such as type I interferonopathies with joint involvement, and might be the bridge for haematopoietic stem cell transplantation in these disabling conditions. As these treatments may have side effects that should not be ignored, ongoing and further controlled studies are still needed to provide data underlying long-term safety considerations in children and delineate subsets of JIA patients that will benefit from these promising treatments.
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Affiliation(s)
- Isabelle Melki
- General Paediatrics, Department of Infectious Disease and Internal Medicine, Robert Debré University Hospital, APHP, Nord-Université Paris Cité, F-75020 Paris, France
- Paediatrics, Rheumatology and Paediatric Internal Medicine, Children's Hospital, F-33000 Bordeaux, France
- Laboratory of Neurogenetics and Neuroinflammation, Imagine Institute, Université Paris Cité, Inserm UMR 1163, F-75015 Paris, France
| | - Marie-Louise Frémond
- Laboratory of Neurogenetics and Neuroinflammation, Imagine Institute, Université Paris Cité, Inserm UMR 1163, F-75015 Paris, France
- Paediatric Haematology-Immunology and Rheumatology Unit, Necker Hospital, APHP, Centre-Université Paris Cité, F-75015 Paris, France
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Taylor PC, Laedermann C, Alten R, Feist E, Choy E, Haladyj E, De La Torre I, Richette P, Finckh A, Tanaka Y. A JAK Inhibitor for Treatment of Rheumatoid Arthritis: The Baricitinib Experience. J Clin Med 2023; 12:4527. [PMID: 37445562 DOI: 10.3390/jcm12134527] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2023] [Revised: 06/22/2023] [Accepted: 06/26/2023] [Indexed: 07/15/2023] Open
Abstract
Baricitinib, an oral selective Janus kinase (JAK)1/JAK2 inhibitor, is approved as monotherapy or in combination with methotrexate for treating adults with moderate-to-severe active rheumatoid arthritis (RA) and provides improvements in clinical signs, symptoms and patient-reported outcomes. Currently, baricitinib is approved for treating RA in more than 75 countries. In several pivotal Phase II and III RA trials (RA-BALANCE, RA-BEGIN, RA-BEAM, RA-BUILD, RA-BEACON, RA-BEYOND), up to seven years of baricitinib treatment was well tolerated and provided rapid and sustained efficacy, which was confirmed in real-world settings. Safety signals for another JAK inhibitor, tofacitinib, have emerged, as observed in the post-marketing Phase IIIb/IV trial Oral Rheumatoid Arthritis Trial (ORAL) Surveillance; safety signals were subsequently highlighted in a retrospective study of baricitinib and consequently new recommendations and warnings and precautions for all JAK inhibitors have been issued. Ongoing studies to further characterise and clarify the benefit:risk of JAK inhibitors include registries and controlled trials. This capstone review summarises clinical and real-world data outlining the benefit:risk profile of baricitinib, confirming that the improved disease activity and physical function of patients with RA treated with this JAK inhibitor observed in clinical trials is translated into effectiveness in clinical practice, with a low rate of discontinuations.
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Affiliation(s)
- Peter C Taylor
- Botnar Research Centre, Nuffield Department of Orthopaedics, Rheumatology, and Musculoskeletal Sciences, University of Oxford, Oxford OX3 7LD, UK
| | | | - Rieke Alten
- Internal Medicine II, Rheumatology, SCHLOSSPARK-KLINIK, University Medicine Berlin, 14059 Berlin, Germany
| | - Eugen Feist
- Department of Rheumatology, Helios Clinic Vogelsang-Gommern, Cooperation Partner of the Otto-von-Guericke University Magdeburg, 39245 Magdeburg, Germany
| | - Ernest Choy
- Division of Infection and Immunity, Cardiff University School of Medicine, Cardiff CF14 4YS, UK
| | - Ewa Haladyj
- Eli Lilly and Company, Indianapolis, IN 46285, USA
| | | | - Pascal Richette
- Service de Rhumatologie, Hôpital Lariboisière, 75010 Paris, France
- Inserm, UMR-S 1132, Bioscar, Université de Paris, 75010 Paris, France
| | - Axel Finckh
- Division of Rheumatology, Department of Medicine, Geneva University Hospitals, 1205 Geneva, Switzerland
| | - Yoshiya Tanaka
- First Department of Internal Medicine, University of Occupational and Environmental Health, Kitakyushu 807-0804, Japan
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Wu XP, Lu XK, Wang ZT, Huang L, Cai RW, Yu HM, Li JY, Xiao J. Post-Marketing Safety Concerns with Upadacitinib: A Disproportionality Analysis of the FDA Adverse Event Reporting system. Expert Opin Drug Saf 2023; 22:975-984. [PMID: 37310063 DOI: 10.1080/14740338.2023.2223952] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2023] [Accepted: 05/05/2023] [Indexed: 06/14/2023]
Abstract
BACKGROUND Upadacitinib was approved to treat rheumatoid arthritis, psoriasis, ulcerative colitis, ankylosing spondylitis, and atopic dermatitis. This study assessed the adverse events (AEs) associated with upadacitinib by mining data from the US Food and Drug Administration Adverse Event Reporting System (FAERS). METHODS Disproportionality analyses, including the reporting odds ratio (ROR), the proportional reporting ratio (PRR), the Bayesian confidence propagation neural network (BCPNN), and the multi-item gamma Poisson shrinker (MGPS) algorithms, were employed to quantify the signals of upadacitinib-associated AEs. RESULTS A total of 3,837,420 reports of AEs were collected from the FAERS database, of which 4494 reports were identified with upadacitinib as the "primary suspect (PS)". Upadacitinib-induced AEs occurrence targeted 27 system organ clases (SOCs). A total of 200 significant disproportionality PTs conforming to the four algorithms were simultaneously retained. Unexpected significant AEs, such as arthralgia, musculoskeletal stiffness, diverticulitis, and cataract might also occur. The median onset time of upadacitinib-associated AEs was 65 days (interquartile range [IQR] 21-182 days), and most of the onsets occurred within the first 1, 2, 3, and 4 months after initiation of upadacitinib. CONCLUSION This study found potential new AEs signals and might provide important support for clinical monitoring and risk identification of upadacitinib.
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Affiliation(s)
- Xiang-Ping Wu
- Department of Pharmacy, Xiangya Hospital, Central South University, Changsha, China
- College of Pharmacy, Dali University, Dali, Yunnan, China
- Department of Pharmacy, Institute for Rational and Safe Medication Practices, National Clinical Research Center for Geriatric Disorders, Xiangya Hospital, Central South University, Changsha, China
| | - Xi-Kui Lu
- Department of Pharmacy, Xiangya Hospital, Central South University, Changsha, China
- College of Pharmacy, Dali University, Dali, Yunnan, China
- Department of Pharmacy, Institute for Rational and Safe Medication Practices, National Clinical Research Center for Geriatric Disorders, Xiangya Hospital, Central South University, Changsha, China
| | - Zhen-Ting Wang
- Department of Pharmacy, Xiangya Hospital, Central South University, Changsha, China
- College of Pharmacy, Dali University, Dali, Yunnan, China
- Department of Pharmacy, Institute for Rational and Safe Medication Practices, National Clinical Research Center for Geriatric Disorders, Xiangya Hospital, Central South University, Changsha, China
| | - Ling Huang
- Department of Pharmacy, Xiangya Hospital, Central South University, Changsha, China
- Department of Pharmacy, Institute for Rational and Safe Medication Practices, National Clinical Research Center for Geriatric Disorders, Xiangya Hospital, Central South University, Changsha, China
| | - Ru-Wen Cai
- Department of Pharmacy, Xiangya Hospital, Central South University, Changsha, China
- College of Pharmacy, Dali University, Dali, Yunnan, China
- Department of Pharmacy, Institute for Rational and Safe Medication Practices, National Clinical Research Center for Geriatric Disorders, Xiangya Hospital, Central South University, Changsha, China
| | - Hui-Min Yu
- Department of Pharmacy, Xiangya Hospital, Central South University, Changsha, China
- Department of Pharmacy, Institute for Rational and Safe Medication Practices, National Clinical Research Center for Geriatric Disorders, Xiangya Hospital, Central South University, Changsha, China
| | - Jing-Yang Li
- Department of Pharmacy, Xiangya Hospital, Central South University, Changsha, China
- Department of Pharmacy, Institute for Rational and Safe Medication Practices, National Clinical Research Center for Geriatric Disorders, Xiangya Hospital, Central South University, Changsha, China
| | - Jian Xiao
- Department of Pharmacy, Xiangya Hospital, Central South University, Changsha, China
- Department of Pharmacy, Institute for Rational and Safe Medication Practices, National Clinical Research Center for Geriatric Disorders, Xiangya Hospital, Central South University, Changsha, China
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Tokareva K, Reid P, Yang V, Liew D, Peterson AC, Baraff A, Giles J, Singh N. JAK inhibitors and black box warnings: what is the future for JAK inhibitors? Expert Rev Clin Immunol 2023; 19:1385-1397. [PMID: 37596779 PMCID: PMC10615860 DOI: 10.1080/1744666x.2023.2249237] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2023] [Revised: 08/07/2023] [Accepted: 08/14/2023] [Indexed: 08/20/2023]
Abstract
INTRODUCTION Janus kinase inhibitors (JAKi) have dramatically improved the treatment of various autoimmune and myeloproliferative disorders. Recently, concern has arisen regarding their safety in patients with rheumatoid arthritis. AREAS COVERED Here, we provide a comprehensive summary of the major current and emerging JAKi and their indications, address recent studies on comparative safety, and provide insight into their future and use. We emphasize that the application of the research findings on a case-by-case basis should consider a patient's age, comorbidities, disease for which JAKi is being considered, disease activity, the JAKi target(s), alternate treatment options available for the patient, and the planned duration of JAKi. EXPERT OPINION Rheumatologists are used to prescribing therapies in which a risk-to-benefit assessment is required as well as to screening and monitoring the safety of medications. Thus, rheumatologists are already practiced in applying specific criteria to effectively screen and monitor patients who are candidates for JAKi therapy. Ongoing research will help to clarify any mechanisms underlying differential safety signals between JAK and other therapies, what the balance between risk and efficacy is, who the susceptible subpopulations are, and whether safety signals are shared between different JAKis and across indications.
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Affiliation(s)
- Kate Tokareva
- Medical Student, University of Washington, Seattle, WA, USA
| | - Pankti Reid
- Division of Rheumatology and Committee on Clinical Pharmacology and Pharmacogenomics, Department of Medicine, University of Chicago Biological Sciences Division, Chicago, Illinois, USA
| | - Victor Yang
- Department of Rheumatology, Austin Health, Melbourne, Victoria, Australia
| | - David Liew
- Department of Rheumatology, Austin Health, Melbourne, Victoria, Australia
- Department of Clinical Pharmacology and Therapeutics, Austin Health, Melbourne, Victoria, Australia
| | | | - Aaron Baraff
- VA Puget Sound Healthcare System, Seattle, WA, USA
| | - Jon Giles
- Columbia University, New York, NY, USA
| | - Namrata Singh
- Division of Rheumatology, Department of Medicine, University of Washington, Seattle, WA, USA
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Zhang J, Li W, Gong M, Gu Y, Zhang H, Dong B, Guo Q, Pang X, Xiang Q, He X, Cui Y. Risk of venous thromboembolism with janus kinase inhibitors in inflammatory immune diseases: a systematic review and meta-analysis. Front Pharmacol 2023; 14:1189389. [PMID: 37351513 PMCID: PMC10282754 DOI: 10.3389/fphar.2023.1189389] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2023] [Accepted: 05/22/2023] [Indexed: 06/24/2023] Open
Abstract
Objectives: This study aimed to evaluate the risk of venous thrombosis (VTE) associated with Janus kinase (JAK) inhibitors in patients diagnosed with immune-mediated inflammatory diseases. Methods: We conducted a comprehensive search of PUBMED, Cochrane, and Embase databases for randomized controlled trials evaluating venous thromboembolic incidence after administering JAK inhibitors in patients with immune-mediated inflammatory diseases. The studies were screened according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, and a meta-analysis was performed. Results: A total of 16 studies, enrolling 17,242 participants, were included in this review. Four approved doses of JAK inhibitors were administered in the included studies. The meta-analysis revealed no significant difference in the incidence of VTE between patients receiving JAK inhibitors, a placebo, or tumor necrosis factor (TNF) inhibitors (RR 0.72, 95% CI (0.33-1.55); RR 0.94, 95%CI (0.33-2.69)). Subgroup analysis showed a lower risk of VTE with lower doses of JAK inhibitors [RR 0.56, 95%CI (0.36-0.88)]. Compared with the higher dose of tofacitinib, the lower dose was associated with a lower risk of pulmonary embolism [RR 0.37, 95%CI (0.18-0.78)]. Conclusion: Our meta-analysis of randomized controlled trials observed a potential increase in the risk of VTE in patients with immune-mediated inflammatory diseases treated with JAK inhibitors compared to placebo or tumor necrosis factor inhibitors, though statistical significance was not attained. Notably, a higher risk of pulmonary embolism was observed with high doses of tofacitinib. Our findings provide valuable insights for physicians when evaluating the use of JAK inhibitors for patients with immune-mediated inflammatory diseases. Systematic Review Registration: https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42023382544, identifier CRD42023382544.
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Affiliation(s)
- Juqi Zhang
- Department of Pharmacy, Peking University First Hospital, Beijing, China
- Institute of Clinical Pharmacology, Peking University First Hospital, Beijing, China
- Department of Pharmacy Administration and Clinical Pharmacy, School of Pharmaceutical Sciences, Peking University, Beijing, China
| | - Wenhui Li
- Department of Pharmacy, Peking University First Hospital, Beijing, China
- Institute of Clinical Pharmacology, Peking University First Hospital, Beijing, China
- Department of Pharmacy Administration and Clinical Pharmacy, School of Pharmaceutical Sciences, Peking University, Beijing, China
| | - Mingli Gong
- Department of Pharmacy, Xu Zhou Medical University, Xuzhou, China
| | - Yanlun Gu
- Department of Pharmacy, Peking University First Hospital, Beijing, China
- Institute of Clinical Pharmacology, Peking University First Hospital, Beijing, China
- Department of Pharmacy Administration and Clinical Pharmacy, School of Pharmaceutical Sciences, Peking University, Beijing, China
| | - Hanxu Zhang
- Department of Pharmacy, Peking University First Hospital, Beijing, China
- Institute of Clinical Pharmacology, Peking University First Hospital, Beijing, China
- Department of Pharmacy Administration and Clinical Pharmacy, School of Pharmaceutical Sciences, Peking University, Beijing, China
| | - Bingqi Dong
- Department of General Surgery, Peking University First Hospita, Beijing, China
| | - Qi Guo
- Institute of Clinical Pharmacology, Peking University First Hospital, Beijing, China
- Department of Pharmacy Administration and Clinical Pharmacy, School of Pharmaceutical Sciences, Peking University, Beijing, China
- Department of Pharmacy, Peking University Third Hospital, Beijing, China
| | - Xiaocong Pang
- Department of Pharmacy, Peking University First Hospital, Beijing, China
- Institute of Clinical Pharmacology, Peking University First Hospital, Beijing, China
| | - Qian Xiang
- Department of Pharmacy, Peking University First Hospital, Beijing, China
- Institute of Clinical Pharmacology, Peking University First Hospital, Beijing, China
| | - Xu He
- Department of Pharmacy, Peking University First Hospital, Beijing, China
- Institute of Clinical Pharmacology, Peking University First Hospital, Beijing, China
| | - Yimin Cui
- Department of Pharmacy, Peking University First Hospital, Beijing, China
- Institute of Clinical Pharmacology, Peking University First Hospital, Beijing, China
- Department of Pharmacy Administration and Clinical Pharmacy, School of Pharmaceutical Sciences, Peking University, Beijing, China
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Boyce EG, Rogan EL, C Lui M. Upadacitinib for the Treatment of Rheumatoid Arthritis: An Extensive Review. Ann Pharmacother 2023; 57:450-462. [PMID: 35919945 DOI: 10.1177/10600280221113092] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
OBJECTIVES To review the characteristics, efficacy, safety, pharmacoeconomics, and place in therapy of upadacitinib, a Janus kinase (JAK) inhibitor, in the treatment of rheumatoid arthritis (RA). DATA SOURCES PubMed (January 2003-May 2022) was searched using upadacitinib and ABT-494. STUDY SELECTION AND DATA EXTRACTION Human studies published in peer-reviewed publications in English were the primary sources for efficacy and safety data. DATA SYNTHESIS In randomized, double-blind, controlled clinical studies, upadacitinib demonstrated statistically significant improvement in RA symptoms as monotherapy and in combination with conventional synthetic disease-modifying antirheumatic drugs (csDMARDs) when compared with csDMARD monotherapy or to adalimumab or abatacept in combination with csDMARD therapy in patients with RA. American College of Rheumatology 20% response rates were 68% to 79% for upadacitinib monotherapy and 64% to 84% for upadacitinib plus csDMARD therapy, compared with 28% to 59% for csDMARD-only therapy and 63% to 74% for biologic DMARD (bDMARD) plus csDMARD therapy. Long-term extension studies demonstrated similar findings. Upadacitinib had similar rates of serious infections, herpes zoster, major cardiovascular events, and venous thromboembolic events as other JAK inhibitors. Upadacitinib was similar in cost to tofacitinib and twice as high as baricitinib based on current estimated costs to patients, but actual costs may vary. RELEVANCE TO PATIENT CARE AND CLINICAL PRACTICE Upadacitinib is an alternative therapy to other JAK inhibitors and bDMARDs in patients with moderate to severe RA who have had an inadequate response to a tumor necrosis factor inhibitor alone or in combination with a csDMARD. CONCLUSIONS Upadacitinib is an effective JAK inhibitor for use in RA.
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Affiliation(s)
- Eric G Boyce
- Department of Pharmacy Practice, Thomas J. Long School of Pharmacy, University of the Pacific, Stockton, CA, USA
| | - Edward L Rogan
- Department of Pharmacy Practice, Thomas J. Long School of Pharmacy, University of the Pacific, Stockton, CA, USA
| | - May C Lui
- Department of Pharmacy Practice, Thomas J. Long School of Pharmacy, University of the Pacific, Stockton, CA, USA
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Molander V, Bower H, Askling J. Validation and characterization of venous thromboembolism diagnoses in the Swedish National Patient Register among patients with rheumatoid arthritis. Scand J Rheumatol 2023; 52:111-117. [PMID: 35023437 DOI: 10.1080/03009742.2021.2001907] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
OBJECTIVE To assess the validity of venous thromboembolism (VTE) diagnoses registered in the Swedish National Patient Register (NPR) in patients with rheumatoid arthritis (RA). METHOD We performed a validation study using manual chart reviews to validate ICD-10 codes for VTE from the NPR. We took a random sample of 269 VTE events registered at hospitals in Region Stockholm from 2009 to 2018 in patients with RA. RESULTS Medical records for all 269 VTE events were available for review. Overall, the positive predictive value (PPV) for a VTE diagnosis was 95%. For incident VTE events, the PPV was 87% and ranged from 80% to 98% across six more or less restricted alternative definitions of incident VTE event. Out of 235 confirmed incident VTE events, the vast majority were diagnosed independently of the RA disease (three cases occurred as a result of clinical work-up for a presumed RA-related sign or symptom, and in 17 cases did the work-up involve a rheumatologist). CONCLUSIONS This study demonstrates high validity for VTE diagnoses recorded in the NPR for patients with RA, thus confirming that the NPR may be used to identify prevalent VTE as well as incident VTE events in patients with RA. Our results further demonstrate that in patients with RA, diagnoses of VTE are only marginally influenced by work-up related to the rheumatic disease, suggesting a modest impact of surveillance or diagnostic bias.
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Affiliation(s)
- V Molander
- Clinical Epidemiology Division, Department of Medicine Solna, Karolinska Institutet, Stockholm, Sweden.,Rheumatology, Karolinska University Hospital, Stockholm, Sweden
| | - H Bower
- Clinical Epidemiology Division, Department of Medicine Solna, Karolinska Institutet, Stockholm, Sweden
| | - J Askling
- Clinical Epidemiology Division, Department of Medicine Solna, Karolinska Institutet, Stockholm, Sweden.,Rheumatology, Karolinska University Hospital, Stockholm, Sweden
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Upadacitinib for Patients with Rheumatoid Arthritis: A Comprehensive Review. J Clin Med 2023; 12:jcm12051734. [PMID: 36902522 PMCID: PMC10002765 DOI: 10.3390/jcm12051734] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2023] [Revised: 02/07/2023] [Accepted: 02/13/2023] [Indexed: 02/24/2023] Open
Abstract
Upadacitinib is a selective and reversible Janus kinase (JAK) inhibitor recently approved by the European Medicine Agency and the Food and Drug Administration for the treatment of rheumatoid arthritis (RA) at a dose of 15 mg/day. We present the chemical structure and mechanism of action of upadacitinib together with a comprehensive review of the efficacy of this drug in RA based on the SELECT clinical trial program and its safety profile. Its role in the management and therapeutic strategy of RA is also discussed. Upadacitinib in the different clinical trials has shown similar rates of clinical response, including the remission rates, regardless of the population analyzed (methotrexate-naïve, methotrexate-failure or biologic failure). In a head-to-head randomized clinical trial, upadacitinib plus methotrexate was superior to adalimumab when given on background methotrexate (MTX) in patients who have experienced an inadequate response to MTX. Upadacitinib also demonstrated superiority over abatacept in patients with RA after failure to previous biologic drugs. The safety profile of upadacitinib is generally consistent with those observed with biological or other JAK inhibitors.
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Yang F, Lu C, Wang Y, Liu H, Leng X, Zeng X. Efficacy and safety of Janus kinase inhibitors in patients with psoriasis and psoriatic arthritis: a systematic review and meta-analysis. Clin Rheumatol 2023; 42:1593-1605. [PMID: 36763226 DOI: 10.1007/s10067-023-06529-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2022] [Revised: 11/30/2022] [Accepted: 01/28/2023] [Indexed: 02/11/2023]
Abstract
OBJECTIVES To evaluate the efficacy and safety of Janus kinase (JAK) inhibitors (Jakinibs) in the treatment of psoriasis and psoriatic arthritis (PsA). METHODS Databases including PubMed, Embase, Web of Science, and Cochrane Library were searched for randomized controlled trials on the efficacy and safety of Jakinibs in treating psoriasis and PsA from inception to July 2021. A systematic review and meta-analysis were performed to estimate pooled relative risk (RR) and 95% confidence interval (CI). RESULTS Seventeen clinical trials (16 publications) comprising 6802 patients were included. All Jakinibs demonstrated significantly higher response rates compared with placebo (ACR20: RR 2.09, 95% CI 1.90-2.30; PASI75: RR 4.03, 95% CI 3.13-5.18). Within the subgroup analysis, the response rates defined by ACR20 were highest for filgotinib (RR 2.40, 95% CI 1.67-3.45), followed by upadacitinib, tofacitinib, and deucravacitinib. The proportion of patients achieving PASI75 response in the tofacitinib 10 mg twice daily group was significantly higher than that in the tofacitinib 5 mg group. Regarding safety, the incidence of adverse events (AEs) was significantly higher for Jakinibs compared with placebo (RR 1.17, 95% CI 1.11-1.23). Of note, a considerable increase in the risk of infections including upper respiratory tract and herpes zoster infection was observed among patients in the treatment group. For tofacitinib, upadacitinib, and filgotiniband, infection was the most prevalent AE. Moreover, AEs in the 10 mg tofacitinib group were higher than those in the 5 mg tofacitinib group. CONCLUSION Jakinibs are efficacious interventions for the treatment of psoriasis and PsA, but they are associated with an increased risk of AEs when compared with placebo. The long-term efficacy and safety data require further evaluation. Key Points • This systematic review investigated and compared the efficacy and safety of different Jakinibs including the novel selective TYK2 inhibitors. • Jakinibs are efficacious interventions for the treatment of psoriasis and PsA. • A relatively higher dosing schedule of Jakinibs is associated with increased toxicity.
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Affiliation(s)
- Fan Yang
- Department of Rheumatology and Clinical Immunology, Chinese Academy of Medical Sciences & Peking Union Medical College, NO.1 Shuaifuyuan, Dongcheng District, Beijing, 100730, China
- National Clinical Research Center for Dermatologic and Immunologic Diseases (NCRC-DID), Ministry of Science & Technology, Beijing, China
- State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital (PUMCH), Beijing, China
- Key Laboratory of Rheumatology and Clinical Immunology, Ministry of Education, Beijing, China
| | - Chaofan Lu
- Department of Rheumatology and Clinical Immunology, Chinese Academy of Medical Sciences & Peking Union Medical College, NO.1 Shuaifuyuan, Dongcheng District, Beijing, 100730, China
- National Clinical Research Center for Dermatologic and Immunologic Diseases (NCRC-DID), Ministry of Science & Technology, Beijing, China
- State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital (PUMCH), Beijing, China
- Key Laboratory of Rheumatology and Clinical Immunology, Ministry of Education, Beijing, China
| | - Yanhong Wang
- Department of Epidemiology and Bio-Statistics, Institute of Basic Medical Sciences, China Academy of Medical Sciences & Peking Union Medical College, Beijing, China
| | - Huilan Liu
- Department of Rheumatology and Clinical Immunology, Chinese Academy of Medical Sciences & Peking Union Medical College, NO.1 Shuaifuyuan, Dongcheng District, Beijing, 100730, China
- National Clinical Research Center for Dermatologic and Immunologic Diseases (NCRC-DID), Ministry of Science & Technology, Beijing, China
- State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital (PUMCH), Beijing, China
- Key Laboratory of Rheumatology and Clinical Immunology, Ministry of Education, Beijing, China
| | - Xiaomei Leng
- Department of Rheumatology and Clinical Immunology, Chinese Academy of Medical Sciences & Peking Union Medical College, NO.1 Shuaifuyuan, Dongcheng District, Beijing, 100730, China.
- National Clinical Research Center for Dermatologic and Immunologic Diseases (NCRC-DID), Ministry of Science & Technology, Beijing, China.
- State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital (PUMCH), Beijing, China.
- Key Laboratory of Rheumatology and Clinical Immunology, Ministry of Education, Beijing, China.
| | - Xiaofeng Zeng
- Department of Rheumatology and Clinical Immunology, Chinese Academy of Medical Sciences & Peking Union Medical College, NO.1 Shuaifuyuan, Dongcheng District, Beijing, 100730, China.
- National Clinical Research Center for Dermatologic and Immunologic Diseases (NCRC-DID), Ministry of Science & Technology, Beijing, China.
- State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital (PUMCH), Beijing, China.
- Key Laboratory of Rheumatology and Clinical Immunology, Ministry of Education, Beijing, China.
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Combe B, Besuyen R, Gómez-Centeno A, Matsubara T, Sancho Jimenez JJ, Yin Z, Buch MH. Geographic Analysis of the Safety and Efficacy of Filgotinib in Rheumatoid Arthritis. Rheumatol Ther 2023; 10:35-51. [PMID: 36205910 PMCID: PMC9931958 DOI: 10.1007/s40744-022-00494-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2022] [Accepted: 09/14/2022] [Indexed: 10/10/2022] Open
Abstract
INTRODUCTION Global clinical trials in rheumatoid arthritis (RA) often do not recruit enough patients from diverse racial and ethnic backgrounds to identify any potential differences in treatment outcome across such groups. To overcome this limitation, using data from five previous clinical trials and two ongoing trial extensions, this study aimed to assess the efficacy and safety of filgotinib in patients with RA across geographic regions. METHODS This was a post hoc, exploratory analysis of data from male and female patients with RA meeting the 2010 RA criteria as defined by the American College of Rheumatology (ACR) and European Alliance of Associations for Rheumatology. Data were analyzed from phase 2 (DARWIN 1-2) and phase 3 (FINCH 1-3) clinical trials, as well as two long-term extension studies (DARWIN 3, FINCH 4), of filgotinib. Efficacy endpoints included ACR 20%/50%/70% improvement (ACR20/50/70) responses, disease activity score in 28 joints using C-reactive protein [DAS28(CRP)], Clinical Disease Activity Index scores, Boolean remission, and change from baseline in Health Assessment Questionnaire-Disability Index (HAQ-DI). Safety data were presented as exposure-adjusted incidence rates per 100 patient-years of exposure of treatment-emergent adverse events. RESULTS Compared with placebo, at week 12 a greater proportion of patients receiving filgotinib 200 mg (FIL200) or 100 mg (FIL100) achieved ACR20 (p < 0.01), with similar outcomes in most regions. Overall, the reduction in HAQ-DI with FIL200 or FIL100 was greater than with placebo (p < 0.05) at week 12. Compared with placebo, at week 24 the proportions of patients achieving DAS28(CRP) ≤ 3.2 were greater for both doses of FIL, as seen in most regions (p < 0.01). Safety outcomes did not indicate regional or ethnic differences in the safety profile of filgotinib. CONCLUSION Filgotinib efficacy and safety in patients with RA were generally consistent across geographic regions. CLINICALTRIALS GOV TRIAL REGISTRATION NUMBERS NCT02889796; NCT02873936; NCT02886728; NCT03025308; NCT01888874; NCT01894516; NCT02065700.
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Affiliation(s)
| | | | | | | | | | - Zhaoyu Yin
- Gilead Sciences, Inc., Foster City, CA, USA
| | - Maya H Buch
- NIHR Manchester Biomedical Research Centre, University of Manchester, AV Hill, Manchester, M13 9PT, UK.
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Misra DP, Ahmed S, Goyal M, Sharma A, Agarwal V. Venous Thromboembolism in the Inflammatory Rheumatic Diseases. Rheum Dis Clin North Am 2023; 49:97-127. [PMID: 36424029 DOI: 10.1016/j.rdc.2022.08.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
Venous thromboembolism (VTE), which includes deep venous thrombosis and pulmonary embolism, is a cardiovascular event whose risk is increased in most inflammatory rheumatic diseases (IRDs). Mechanisms that increase VTE risk include antiphospholipid antibodies (APLs), particularly anticardiolipin antibodies, anti-beta2glycoprotein I antibodies and lupus anticoagulant present together, and inflammation-mediated endothelial injury. Patients with IRDs should receive long-term anticoagulation drugs when the risk of VTE recurrence is high. In the light of recent warnings from regulatory agencies regarding heightened VTE risk with Janus kinase inhibitors, these drugs should be initiated only after a careful assessment of VTE risk in those with IRDs.
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Affiliation(s)
- Durga Prasanna Misra
- Department of Clinical Immunology and Rheumatology, C block, Sanjay Gandhi Postgraduate Institute of Medical Sciences (SGPGIMS), Rae Bareli Road, Lucknow 226014, India.
| | - Sakir Ahmed
- Department of Clinical Immunology and Rheumatology, Kalinga Institute of Medical Sciences (KIMS), Bhubaneswar 751024, India. https://twitter.com/sakir_rheum
| | - Mohit Goyal
- Department of Rheumatology and Clinical Immunology, CARE Pain and Arthritis Centre, Udaipur 313002, Rajasthan, India. https://twitter.com/drmohitgoyal
| | - Aman Sharma
- Department of Internal Medicine, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh 160012, India. https://twitter.com/Amansharmapgi
| | - Vikas Agarwal
- Department of Clinical Immunology and Rheumatology, C block, Sanjay Gandhi Postgraduate Institute of Medical Sciences (SGPGIMS), Rae Bareli Road, Lucknow 226014, India. https://twitter.com/vikasagrIMMUNO
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Misra DP, Pande G, Agarwal V. Cardiovascular risks associated with Janus kinase inhibitors: peering outside the black box. Clin Rheumatol 2023; 42:621-632. [PMID: 36264400 DOI: 10.1007/s10067-022-06415-5] [Citation(s) in RCA: 9] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2022] [Revised: 09/21/2022] [Accepted: 10/16/2022] [Indexed: 01/29/2023]
Abstract
Considerable controversy related to the cardiovascular safety of Janus kinase inhibitors (JAKinibs) has arisen following the results of the ORAL Surveillance trial. In this trial of rheumatoid arthritis (RA) ≥ 50 years with at least one prevalent cardiovascular disease (CVD) risk factor, tofacitinib was not found to be non-inferior to tumour necrosis factor-alpha inhibitors (TNFi) with regards to the risk for major adverse cardiovascular events (MACE), venous thromboembolism (VTE) or malignancy. Following the results of ORAL Surveillance, the United States Food and Drug Administration (US FDA) issued a boxed warning regarding increased risks of MACE, VTE and malignancy with tofacitinib, baricitinib or upadacitinib in inflammatory arthritis or ulcerative colitis. Analysis of data from other trials (including long-term follow-up studies) of tofacitinib in RA, psoriasis, psoriatic arthritis, spondyloarthritis and inflammatory bowel diseases suggests an overall similar risk of MACE or VTE with tofacitinib when compared with TNFi. In specific patient populations with risk factors for or prior history of MACE or VTE, the risk of subsequent MACE or VTE with tofacitinib use is considerably heightened. Post-hoc analyses from ORAL Surveillance presented at the recent EULAR meeting further help to delineate patients with RA at increased risk of MACE/VTE with tofacitinib. Based on the available literature from trials and long-term follow-up studies of baricitinib and upadacitinib, there exists insufficient evidence to extend the warning of MACE/VTE with tofacitinib to these drugs. Ongoing post-marketing surveillance studies of JAKinibs in immune-mediated inflammatory diseases should help clarify CVD risk with JAKinibs.
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Affiliation(s)
- Durga Prasanna Misra
- Department of Clinical Immunology and Rheumatology, Sanjay Gandhi Postgraduate Institute of Medical Sciences (SGPGIMS), Lucknow-226014, India.
| | - Gaurav Pande
- Department of Gastroenterology, Sanjay Gandhi Postgraduate Institute of Medical Sciences (SGPGIMS), Lucknow-226014, India
| | - Vikas Agarwal
- Department of Clinical Immunology and Rheumatology, Sanjay Gandhi Postgraduate Institute of Medical Sciences (SGPGIMS), Lucknow-226014, India
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Fonseca D, Nogueira M, Torres T. Upadacitinib for the treatment of psoriatic arthritis. Drugs Context 2023; 12:dic-2022-11-6. [PMID: 36876156 PMCID: PMC9983629 DOI: 10.7573/dic.2022-11-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2022] [Accepted: 01/20/2023] [Indexed: 03/03/2023] Open
Abstract
Psoriatic arthritis is a chronic systemic inflammatory disease that presents with a variable clinical course and is typically associated with joint inflammation, together with cutaneous psoriasis. In recent decades, knowledge of the pathogenesis of psoriatic arthritis has advanced considerably and has allowed for development of new highly effective therapies, transforming the treatment landscape. Upadacitinib is a Janus kinase inhibitor (JAK) that is orally reversible with high selectivity for JAK1 and its signal transduction molecules. The results obtained in the phase III clinical trials (SELECT-PsA 1 and SELEC-PsA 2) demonstrated that upadacitinib was highly effective over placebo and non-inferior to adalimumab in several important domains of the disease. Improvements were observed in dactylitis, enthesitis and spondylitis as well as in physical function, pain, fatigue and overall quality of life. The safety profile of these results resembled that of adalimumab, apart from a slightly higher rate of herpes zoster infection, an increase of creatine kinase and an incidence of lymphopenia. However, none of these events was considered a serious adverse advent. Additionally, another analysis demonstrated that combining upadacitinib with methotrexate was associated with a similar efficacy to upadacitinib in monotherapy, both for patients that are naive to biologics treatment and for those previously treated with biologics. Therefore, upadacitinib is a new option for the treatment of psoriatic arthritis, presenting a series of beneficial characteristics. At this stage, it is important to collect long-term data to confirm the efficacy and safety profiles shown in clinical trials.
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Affiliation(s)
- Diogo Fonseca
- Department of Rheumatology, Centro Hospitalar Vila Nova de Gaia/Espinho, Vila Nova de Gaia, Portugal
| | - Miguel Nogueira
- Department of Dermatology, Centro Hospitalar Universitário do Porto, Porto, Portugal
| | - Tiago Torres
- Department of Dermatology, Centro Hospitalar Universitário do Porto, Porto, Portugal.,Instituto de Ciências Biomédicas Abel Salazar, University of Porto, Porto, Portugal
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Jones E. Clinical Issues-January 2023. AORN J 2023; 117:70-75. [PMID: 36573746 DOI: 10.1002/aorn.13848] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2022] [Accepted: 09/02/2022] [Indexed: 12/28/2022]
Abstract
Janus kinase inhibitor therapy and venous thromboembolism risk factors Key words: Janus kinase (JAK) inhibitor, tofacitinib, inflammatory bowel disease (IBD), ulcerative colitis, extended-duration prophylaxis. Identifying validated venous thromboembolism risk assessment tools Key words: venous thromboembolism (VTE) protocol, Caprini risk assessment model (RAM), risk identification, clinical workflow, bleeding risk. Timing of the preoperative venous thromboembolism risk assessment Key words: Caprini risk assessment model (RAM), venous thromboembolism (VTE) risk, patient assessment, presurgical testing visit, family history. Communicating venous thromboembolism and bleeding risk after surgery Key words: venous thromboembolism (VTE) risk, bleeding risk, hand over, postanesthesia care unit RN, intraoperative events.
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Herrera-deGuise C, Serra-Ruiz X, Lastiri E, Borruel N. JAK inhibitors: A new dawn for oral therapies in inflammatory bowel diseases. Front Med (Lausanne) 2023; 10:1089099. [PMID: 36936239 PMCID: PMC10017532 DOI: 10.3389/fmed.2023.1089099] [Citation(s) in RCA: 14] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2022] [Accepted: 02/09/2023] [Indexed: 03/06/2023] Open
Abstract
Inflammatory bowel disease (IBD) is a chronic immune-mediated condition of the gastrointestinal tract that requires chronic treatment and strict surveillance. Development of new monoclonal antibodies targeting one or a few single cytokines, including anti-tumor necrosis factor agents, anti-IL 12/23 inhibitors, and anti-α4β7 integrin inhibitors, have dominated the pharmacological armamentarium in IBD in the last 20 years. Still, many patients experience incomplete or loss of response or develop serious adverse events and drug discontinuation. Janus kinase (JAK) is key to modulating the signal transduction pathway of several proinflammatory cytokines directly involved in gastrointestinal inflammation and, thus, probably IBD pathogenesis. Targeting the JAK-STAT pathway offers excellent potential for the treatment of IBD. The European Medical Agency has approved three JAK inhibitors for treating adults with moderate to severe Ulcerative Colitis when other treatments, including biological agents, have failed or no longer work or if the patient cannot take them. Although there are currently no approved JAK inhibitors for Crohn's disease, upadacitinib and filgotinib have shown increased remission rates in these patients. Other JAK inhibitors, including gut-selective molecules, are currently being studied IBD. This review will discuss the JAK-STAT pathway, its implication in the pathogenesis of IBD, and the most recent evidence from clinical trials regarding the use of JAK inhibitors and their safety in IBD patients.
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Philippoteaux C, Deprez V, Nottez A, Cailliau E, Houvenagel E, Deprez X, Philippe P, Pascart T, Flipo RM, Goëb V, Letarouilly JG. Characteristics of Patients Treated with JAK Inhibitors in Rheumatoid Arthritis before versus after VTE Risk Warnings. J Clin Med 2022; 12:jcm12010207. [PMID: 36615007 PMCID: PMC9820905 DOI: 10.3390/jcm12010207] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2022] [Revised: 12/20/2022] [Accepted: 12/22/2022] [Indexed: 12/29/2022] Open
Abstract
BACKGROUND Baricitinib (BARI) or Tofacitinib (TOFA) were the first Janus Kinase Inhibitors (JAKi) to be marketed in rheumatoid arthritis (RA). Concerns regarding venous thromboembolism (VTE) risk have emerged during the past years. The aim of the study was to compare the baseline characteristics of patients initiating BARI or TOFA in RA before versus after European Medicine Agency (EMA)'s VTE warnings and to compare real-world persistence with these two drugs. METHODS In this multicentric cohort study, RA patients initiating BARI or TOFA were included from October 2017, date of BARI marketing authorization in France, to September 2020. Baseline characteristics regarding VTE risk were compared (before vs. after May 2019) by using pre-specified statistical tests. Comparison of persistence was assessed by using propensity-score methods. RESULTS 232 patients were included; 155 with BARI and 77 with TOFA. Baseline characteristics of patients regarding VTE risk factors were not statistically different when Janus Kinase inhibitor (JAKi) was initiated before vs. after EMA's warnings although a trend towards a lower proportion of VTE history was observed. Five VTE events occurred, four with BARI, one with TOFA. Cumulative persistence rate at 2 years was similar between BARI and TOFA: HR 0.96; 95% Cl: 0.52 to 1.74; p = 0.89. CONCLUSIONS Our study did not show a significant change in patients characteristics starting a JAKi after the EMA's warnings, probably due to a lack of power. Though, the lower proportion of VTE history in patients after May 2019 suggests that rheumatologists have taken into account the potential VTE risk. These results need to be confirmed by further evidence.
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Affiliation(s)
- Cécile Philippoteaux
- Department of Rheumatology, Lille University Hospital, 59000 Lille, France
- Correspondence:
| | - Valentine Deprez
- Department of Rheumatology, Amiens University Hospital, 80000 Amiens, France
| | - Aurore Nottez
- Department of Rheumatology, Dunkerque Hospital, 59240 Dunkerque, France
| | - Emeline Cailliau
- Department of Biostatistics, Lille University Hospital, 59000 Lille, France
- ULR 2694—METRICS: Evaluation of Health Technologies and Medical Practices, Lille University, 59000 Lille, France
| | - Eric Houvenagel
- Department of Rheumatology, Catholic Saint Philibert Hospital, 59160 Lomme, France
| | - Xavier Deprez
- Department of Rheumatology, Valenciennes Hospital, 59300 Valenciennes, France
| | - Peggy Philippe
- Department of Rheumatology, Lille University Hospital, 59000 Lille, France
| | - Tristan Pascart
- Department of Rheumatology, Catholic Saint Philibert Hospital, 59160 Lomme, France
| | - René-Marc Flipo
- Department of Rheumatology, Lille University Hospital, 59000 Lille, France
| | - Vincent Goëb
- Department of Rheumatology, Amiens University Hospital, 80000 Amiens, France
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Huang IH, Chung WH, Wu PC, Chen CB. JAK-STAT signaling pathway in the pathogenesis of atopic dermatitis: An updated review. Front Immunol 2022; 13:1068260. [PMID: 36569854 PMCID: PMC9773077 DOI: 10.3389/fimmu.2022.1068260] [Citation(s) in RCA: 48] [Impact Index Per Article: 24.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2022] [Accepted: 11/22/2022] [Indexed: 12/13/2022] Open
Abstract
Atopic dermatitis (AD) is a chronic, inflammatory, pruritic form of dermatosis with heterogeneous manifestations that can substantially affect patients' quality of life. AD has a complex pathogenesis, making treatment challenging for dermatologists. The Janus kinase (JAK)-signal transducer and activator of transcription (STAT) pathway plays a central role in modulating multiple immune axes involved in the immunopathogenesis of AD. In particular, Th2 cytokines, including interleukin (IL)-4, IL-5, IL-13, IL-31, and thymic stromal lymphopoietin, which contribute to the symptoms of chronic inflammation and pruritus in AD, are mediated by JAK-STAT signal transduction. Furthermore, JAK-STAT is involved in the regulation of the epidermal barrier and the modulation of peripheral nerves related to the transduction of pruritus. Targeting the JAK-STAT pathway may attenuate these signals and show clinical efficacy through the suppression of various immune pathways associated with AD. Topical and oral JAK inhibitors with variable selectivity have emerged as promising therapeutic options for AD. Notably, topical ruxolitinib, oral upadacitinib, and oral abrocitinib were approved by the U.S. Food and Drug Administration for treating patients with AD. Accordingly, the present study reviewed the role of JAK-STAT pathways in the pathogenesis of AD and explored updated applications of JAK inhibitors in treating AD.
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Affiliation(s)
- I-Hsin Huang
- Drug Hypersensitivity Clinical and Research Center, Chang Gung Memorial Hospital, Linkou, Taipei, and Keelung, Taoyuan, Taiwan,Department of Dermatology, Chang Gung Memorial Hospital, Linkou, Taipei and Keelung, Taiwan,Research Center of Big Data and Meta-analysis, Wan Fang Hospital, Taipei Medical University, Taipei, Taiwan
| | - Wen-Hung Chung
- Drug Hypersensitivity Clinical and Research Center, Chang Gung Memorial Hospital, Linkou, Taipei, and Keelung, Taoyuan, Taiwan,Department of Dermatology, Chang Gung Memorial Hospital, Linkou, Taipei and Keelung, Taiwan,Cancer Vaccine and Immune Cell Therapy Core Laboratory, Chang Gung Memorial Hospital, Linkou, Taiwan,Chang Gung Immunology Consortium, Chang Gung Memorial Hospital, Linkou, and Chang Gung University, Taoyuan, Taiwan,Department of Dermatology, Xiamen Chang Gung Hospital, Xiamen, China,Xiamen Chang Gung Allergology Consortium, Xiamen, Xiamen Chang Gung Hospital, Xiamen, China,College of Medicine, Chang Gung University, Taoyuan, Taiwan,Whole-Genome Research Core Laboratory of Human Diseases, Chang Gung Memorial Hospital, Keelung, Taiwan,Immune-Oncology Center of Excellence, Chang Gung Memorial Hospital, Linkou, Taiwan,Genomic Medicine Core Laboratory, Chang Gung Memorial Hospital, Linkou, Taiwan
| | - Po-Chien Wu
- Drug Hypersensitivity Clinical and Research Center, Chang Gung Memorial Hospital, Linkou, Taipei, and Keelung, Taoyuan, Taiwan,Department of Dermatology, Chang Gung Memorial Hospital, Linkou, Taipei and Keelung, Taiwan,Research Center of Big Data and Meta-analysis, Wan Fang Hospital, Taipei Medical University, Taipei, Taiwan
| | - Chun-Bing Chen
- Drug Hypersensitivity Clinical and Research Center, Chang Gung Memorial Hospital, Linkou, Taipei, and Keelung, Taoyuan, Taiwan,Department of Dermatology, Chang Gung Memorial Hospital, Linkou, Taipei and Keelung, Taiwan,Cancer Vaccine and Immune Cell Therapy Core Laboratory, Chang Gung Memorial Hospital, Linkou, Taiwan,Chang Gung Immunology Consortium, Chang Gung Memorial Hospital, Linkou, and Chang Gung University, Taoyuan, Taiwan,Department of Dermatology, Xiamen Chang Gung Hospital, Xiamen, China,Xiamen Chang Gung Allergology Consortium, Xiamen, Xiamen Chang Gung Hospital, Xiamen, China,College of Medicine, Chang Gung University, Taoyuan, Taiwan,Whole-Genome Research Core Laboratory of Human Diseases, Chang Gung Memorial Hospital, Keelung, Taiwan,Immune-Oncology Center of Excellence, Chang Gung Memorial Hospital, Linkou, Taiwan,Genomic Medicine Core Laboratory, Chang Gung Memorial Hospital, Linkou, Taiwan,Graduate Institute of Clinical Medical Sciences, College of Medicine, Chang Gung University, Taoyuan, Taiwan,School of Medicine, National Tsing Hua University, Hsinchu, Taiwan,*Correspondence: Chun-Bing Chen,
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Mosli MH, Almudaiheem HY, AlAmeel T, Bakkari SA, Alharbi OR, Alenzi KA, Khardaly AM, AlMolaiki MA, Al-Omari BA, Albarakati RG, Al-Jedai AH, Saadah OI, Almadi MA, Al-Bawardy B. Saudi Arabia consensus guidance for the diagnosis and management of adults with inflammatory bowel disease. Saudi J Gastroenterol 2022; 29:361671. [PMID: 36412460 PMCID: PMC10540981 DOI: 10.4103/sjg.sjg_277_22] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/24/2022] [Revised: 08/23/2022] [Accepted: 09/05/2022] [Indexed: 02/10/2023] Open
Abstract
Optimal management of inflammatory bowel disease (IBD) relies on a clear understanding and tailoring evidence-based interventions by clinicians in partnership with patients. This article provides concise guidelines for the management of IBD in adults, based on the most up-to-date information at the time of writing and will be regularly updated. These guidelines were developed by the Saudi Ministry of Health in collaboration with the Saudi Gastroenterology Association and the Saudi Society of Clinical Pharmacy. After an extensive literature review, 78 evidence-and expert opinion-based recommendations for diagnosing and treating ulcerative colitis and Crohn's disease in adults were proposed and further refined by a voting process. The consensus guidelines include the finally agreed on statements with their level of evidence covering different aspects of IBD diagnosis and treatment.
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Affiliation(s)
- Mahmoud H. Mosli
- Department of Internal Medicine, Faculty of Medicine, King Abdulaziz University, Jeddah, Saudi Arabia
- Inflammatory Bowel Disease Unit, King Abdulaziz University Hospital, Jeddah, Saudi Arabia
| | | | - Turki AlAmeel
- Department of Medicine, King Fahad Specialist Hospital, Dammam, Saudi Arabia
| | - Shakir A. Bakkari
- Division of Gastroenterology, King Saud Medical City, Riyadh, Saudi Arabia
| | - Othman R. Alharbi
- Department of Medicine, College of Medicine, King Khalid University Hospital, King Saud University, Riyadh, Saudi Arabia
| | - Khalidah A. Alenzi
- Regional Drug Information and Pharmacovigilance Center, Ministry of Health, Tabuk, Saudi Arabia
| | | | - Maha A. AlMolaiki
- Department of Pharmaceutical Care, National Guard Health Affairs, Riyadh, Saudi Arabia
| | - Bedor A. Al-Omari
- Pharmaceutical Care Services, Prince Sultan Military Medical City, Riyadh, Saudi Arabia
| | - Rayan G. Albarakati
- Department of Obstetrics and Gynecology, Majmaah University, Riyadh, Saudi Arabia
| | - Ahmed H. Al-Jedai
- Deputyship of Therapeutic Affairs, Ministry of Health, Riyadh, Saudi Arabia
| | - Omar I. Saadah
- Inflammatory Bowel Disease Unit, King Abdulaziz University Hospital, Jeddah, Saudi Arabia
- Department of Pediatrics, Faculty of Medicine, King Abdulaziz University, Jeddah, Saudi Arabia
| | - Majid A. Almadi
- Department of Medicine, College of Medicine, King Khalid University Hospital, King Saud University, Riyadh, Saudi Arabia
| | - Badr Al-Bawardy
- Section of Digestive Diseases, Yale School of Medicine, New Haven, CT, USA
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Kochar BD, Cheng D, Cai T, Ananthakrishnan AN. Comparative Risk of Thrombotic and Cardiovascular Events with Tofacitinib and Anti-TNF Agents in Patients with Inflammatory Bowel Diseases. Dig Dis Sci 2022; 67:5206-5212. [PMID: 35113275 DOI: 10.1007/s10620-022-07404-z] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/20/2021] [Accepted: 01/13/2022] [Indexed: 01/05/2023]
Abstract
BACKGROUND Tofacitinib and inflammatory bowel disease (IBD) have been associated with increased risks for thromboembolic and cardiovascular events, but drug attributable risk is unknown. METHODS We conducted a retrospective cohort study in a US claims database. We identified patients with IBD by International Classification of Disease (ICD) codes, stipulated 180 days of continuous enrollment prior to tofacitinib or anti-tumor necrosis factor (TNF) initiation to determine new users. Primary outcomes were ICD codes for venous thromboembolism (VTE) and cardiovascular (CV) events. We constructed propensity score (PS)-weighted Cox proportional hazard models to estimate hazard ratios (HRs) and time-to-event outcomes comparing tofacitinib and anti-TNF. We conducted a subgroup analysis of patients ≥ 50 years. RESULTS We identified 305 patients with IBD initiating tofacitinib and compared them with 19,096 initiating anti-TNFs. After weighting, balance was achieved across all demographic covariates. VTE occurred in 5% of patients treated with tofacitinib and 4% of anti-TNF users; in a PS-weighted cohort, tofacitinib did not confer a significantly elevated VTE risk compared with anti-TNF therapy (HR: 1.72, 95% CI: 0.74-3.01). A major CV event (MACE) occurred in 2% of tofacitinib users and 1% of anti-TNF users; tofacitinib also did not confer a significantly elevated risk for MACE (HR: 2.50, 95% CI: 0.37-6.18). Those with a Charlson comorbidity index ≥ 2 had greater risks for thromboembolic and cardiovascular events. Similar findings were noted in patients ≥ 50 years. CONCLUSIONS In this large, active comparator, study, we demonstrate that tofacitinib was not associated with a higher risk of adverse thrombotic events compared with anti-TNFs in patients with IBD.
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Affiliation(s)
- Bharati D Kochar
- Division of Gastroenterology, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
| | - David Cheng
- Biostatistics Center, Massachusetts General Hospital, Boston, MA, USA
| | - Tianxi Cai
- Department of Biomedical Informatics, Harvard Medical School, Boston, MA, USA
| | - Ashwin N Ananthakrishnan
- Division of Gastroenterology, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA. .,, Boston, USA.
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Abstract
Background: The treatment of chronic refractory moderate-to-severe atopic dermatitis (AD) has traditionally relied on broad-spectrum systemic anti-inflammatory agents. With the introduction of biologics and Janus kinase inhibitors (Jakinib), the step management of moderate-to-severe AD is rapidly changing; however, guidelines have yet to provide formal recommendations for how to best incorporate these agents into the treatment plan. Objective: To summarize the updated evidence-based medical treatment for AD, including a proposed position for biologics and Jakinibs in the treatment algorithm. Methods: A literature search of several medical literature data bases for guidelines, position papers, systematic reviews, and clinical trials from 2012 to 2022 on the treatment of moderate-to-severe AD was conducted to prepare this narrative review. Results: Emollients and topical corticosteroids are the mainstay for treating acute flares and for maintaining chronic control. Second-line topical agents include calcineurin inhibitors, e.g., tacrolimus and pimecrolimus; crisaborole; and ruxolitinib. For acute flares, cyclosporine is preferred over systemic corticosteroids. For chronic treatment, phototherapy should be considered before systemic anti-inflammatory agents. Of the traditional anti-inflammatory agents, cyclosporine is the first-line choice, with methotrexate and azathioprine equal secondary choices. Although abrocitinib may have better efficacy then dupilumab based on indirect comparisons, abrocitinib requires closer monitoring for adverse events. Based on package labeling, Jakinibs, e.g., abrocitinib and upadacitinib, should be used only after failure with other systemic agents, including biologics (e.g., dupilumab and tralokinumab). Biologics and Jakinibs should be considered before the traditional systemic anti-inflammatory agents. Conclusion: Clinicians should consider a modified step management for AD as they await the development of national and international guideline recommendations for how best to position the biologics and Jakinibs into the AD treatment algorithm.
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Braun J, Kiltz U, Baraliakos X. Management of Axial Spondyloarthritis - Insights into Upadacitinib. Drug Des Devel Ther 2022; 16:3609-3620. [PMID: 36268520 PMCID: PMC9578786 DOI: 10.2147/dddt.s330413] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2022] [Accepted: 09/13/2022] [Indexed: 11/05/2022] Open
Abstract
Although the pathogenesis of spondyloarthritis (SpA) has still not been elucidated our options to treat SpA have definitely improved in the last decades. There are two main types of SpA: (i) axial spondyloarthritis (axSpA), also covering the classical ankylosing spondylitis (AS) which is largely equivalent to radiographic (r)-axSpA but different from non-radiographic (nr)-axSpA, and (ii) peripheral SpA (pSpA) also covering psoriatic arthritis (PsA) as the main subtype. The subtype nr-axSpA has historically developed because the approval of drugs for AS did not cover forms without structural changes in the sacroiliac joints which is mandatory in the 1984 New York criteria. The definitions for axSpA are based on the 2009 Assessments in AxSpA International Society (ASAS) classification criteria. Several biologic disease modifying anti-rheumatic drugs (bDMARDs) such as the tumor necrosis factor alpha inhibitors (TNFi) and the interleukin-17-inhibitors (IL-17i) are approved mostly for the whole spectrum of SpA including axSpA and PsA but L-17i does not work in inflammatory bowel disease (IBD). Targeted synthetic (ts) DMARDs cover mainly the janus kinase (JAK)-inhibitors which have recently been developed to inhibit inflammation in several rheumatic and other immune mediated diseases such as IBD. Indeed, the physiologic mechanism of JAK-mediated signal transduction has been recognized as an important target because the inhibition of its actions was shown to successfully work as a therapeutic mechanism. There are now 4 small molecule JAK inhibitors (JAKi) that currently play a role in rheumatology with variable selectivity for the four different JAK isoforms: tofacitinib, baricitinib, upadacitinib and filgotinib. In this review, we summarize current clinical trial data and evaluate the use of the JAK1 selective inhibitor upadacitinib in the treatment of axSpA, including nr-axSpA and r-axSpA. Even though the efficacy and safety of upadacitinib over shorter periods of time has been convincing to date, long-term trials are needed to fully establish its performance and also evaluate the safety at higher doses, and its use in PsA.
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Affiliation(s)
- Jürgen Braun
- Rheumazentrum Ruhrgebiet and Ruhr University Bochum, Herne, Germany,Correspondence: Jürgen Braun, Rheumazentrum Ruhrgebiet, Claudiusstr.45, Herne, 44649, Germany, Tel +492325592131, Email
| | - Uta Kiltz
- Rheumazentrum Ruhrgebiet and Ruhr University Bochum, Herne, Germany
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Omair MA, Alkhelb SA, Ezzat SE, Boudal AM, Bedaiwi MK, Almaghlouth I. Venous Thromboembolism in Rheumatoid Arthritis: The Added Effect of Disease Activity to Traditional Risk Factors. Open Access Rheumatol 2022; 14:231-242. [PMID: 36276408 PMCID: PMC9586712 DOI: 10.2147/oarrr.s284757] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2022] [Accepted: 09/28/2022] [Indexed: 11/05/2022] Open
Abstract
Many epidemiological studies have shown an increased risk of venous thromboembolism (VTE) in patients with rheumatoid arthritis (RA). RA and VTE share some background factors, such as increasing age, smoking, and obesity. At the same time, other VTE factors, such as knee replacement and oral contraceptive pills, occur commonly in RA patients. In addition, the chronic inflammatory state of RA might hypothetically lead to endothelial injury and a hypercoagulable state. Two critical pathophysiological pathways lead to VTE. Recently, concerns increased about the increased risk of VTE in patients using Janus Kinase inhibitors. This review aims at reviewing the risk of VTE in RA and the role of traditional risk factors and disease-related inflammation and develops a conceptual framework that describes the interaction between these factors.
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Affiliation(s)
- Mohammed A Omair
- Rheumatology Unit, Department of Medicine, King Saud University, Riyadh, Saudi Arabia,Correspondence: Mohammed A Omair, Rheumatology Unit, Department of Medicine, King Saud University, Riyadh, Saudi Arabia, Tel +966505270513, Email
| | - Sara A Alkhelb
- Rheumatology Unit, Department of Medicine, King Saud University, Riyadh, Saudi Arabia
| | - Sadeen E Ezzat
- Rheumatology Unit, Department of Medicine, King Saud University, Riyadh, Saudi Arabia
| | - Ayah M Boudal
- Rheumatology Unit, Department of Medicine, King Saud University, Riyadh, Saudi Arabia
| | - Mohammed K Bedaiwi
- Rheumatology Unit, Department of Medicine, King Saud University, Riyadh, Saudi Arabia
| | - Ibrahim Almaghlouth
- Rheumatology Unit, Department of Medicine, King Saud University, Riyadh, Saudi Arabia
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Liu L, Yan YD, Shi FH, Lin HW, Gu ZC, Li J. Comparative efficacy and safety of JAK inhibitors as monotherapy and in combination with methotrexate in patients with active rheumatoid arthritis: A systematic review and meta-analysis. Front Immunol 2022; 13:977265. [PMID: 36248913 PMCID: PMC9556706 DOI: 10.3389/fimmu.2022.977265] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2022] [Accepted: 09/15/2022] [Indexed: 11/13/2022] Open
Abstract
Background We aim to evaluate the efficacy and tolerability of Janus kinase inhibitors (JAKi) as monotherapy and in combination with methotrexate (MTX) in active rheumatoid arthritis (RA). Methods Medline, EMBASE, and Cochrane Library were systematically searched to identify relevant randomized controlled trials (RCTs). Pooled analysis was conducted using random-effects model, along with the risk difference (RD) and 95% confidence intervals (CIs). Results Three RCTs, including 2,290 patients, were included. JAKi (tofacitinib, baricitinib, and filgotinib) plus MTX displayed a higher proportion of patients meeting the American College of Rheumatology (ACR) criteria than JAKi alone at week 52 (ACR20 RD 0.032; 95% CI −0.027 to 0.091; ACR50 RD 0.050; 95% CI 0.003 to 0.097; ACR70 RD 0.056; 95% CI 0.012 to 0.100). Similar results were observed for ACR20/50/70 at week 24. No significant difference was found between two regimens for the proportion of patients achieving Health Assessment Questionnaire disability index (HAQ-DI) improvement ≥ 0.22 at weeks 24 and 52. Regarding low disease activity and remission achievement, JAKi in combination with MTX, contributed higher response rates than JAKi alone at weeks 24 and 52. Compared with JAKi monotherapy, combination therapy had a higher risks of treatment-emergent adverse events (TEAEs) and adverse events (AEs) leading to study discontinuation. Conclusion JAKi combined with MTX demonstrated superiority to JAKi monotherapy in terms of ACR responses, low disease activity and remission achievement. The two regimens presented comparable physical functioning measured by HAQ-DI improvement and similar tolerability, except for high risks of TEAEs and AEs leading to study discontinuation in combination therapy. Systematic Review Registration https://www.crd.york.ac.uk/PROSPERO/, identifier CRD42021288907.
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Affiliation(s)
- Li Liu
- Department of Pharmacy, Ren Ji Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Yi-Dan Yan
- Department of Pharmacy, Ren Ji Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Fang-Hong Shi
- Department of Pharmacy, Ren Ji Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Hou-Wen Lin
- Department of Pharmacy, Ren Ji Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
- School of Medicine, Tongji University, Shanghai, China
| | - Zhi-Chun Gu
- Department of Pharmacy, Ren Ji Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Jia Li
- Department of Rheumatology, Ren Ji Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
- *Correspondence: Jia Li,
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Berthe P, Scailteux LM, Lescoat A, Staumont D, Coiffier G, Guéret P, Dupuy A, Oger E, Droitcourt C. Oral Janus kinase inhibitors and venous thromboembolic events in atopic dermatitis: protocols for a case-time control study and a nested case-control study based on the French national health insurance (SNDS) cohort. BMJ Open 2022; 12:e059979. [PMID: 36130766 PMCID: PMC9494565 DOI: 10.1136/bmjopen-2021-059979] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
INTRODUCTION Atopic dermatitis (AD) is a highly prevalent, chronic, inflammatory skin disease. Several orally administered Janus kinase inhibitors (JAKis, including baricitinib, upadacitinib and abrocitinib) have received a marketing authorisation for AD.Clinical trials in rheumatoid arthritis (RA) have flagged up a potential risk of JAKi-induced venous thromboembolic events (VTEs). Accordingly, the summary of product characteristics for a JAKi must mention VTEs as potential adverse drug reactions. In contrast to RA, AD per se is not associated with an elevated risk of VTEs. Assessing this potential risk among patients with AD would shed further light on the putative underlying relationship between JAKis and VTEs.Our research question is to investigate whether JAKi administration increases the risk of VTEs in adults with AD. Our primary objective is to assess the risk of VTEs in adults with AD exposed to JAKis compared to AD adults not exposed to JAKis, and our secondary objective is to evaluate whether JAKi initiation acts as a trigger of VTEs in adults with AD within 3 months. METHODS AND ANALYSIS Hence, we have designed (1) a nested case-control study and (2) a case-time control study in a cohort of adults with AD with data from the French national health insurance system (2017-2025).Here, we describe the study protocol, our methodological choices and certain novel aspects, including the combined value of the two assumptions and the use of an exhaustive national health insurance database with potentially greater statistical power for studying rare events in the population of patients with AD at a low risk of VTEs (thus limiting the influence of confounding factors). ETHICS AND DISSEMINATION The protocol has been approved by an independent ethics committee and registered with the French National Data Protection Commission. The study's findings will be published in peer-reviewed scientific journals and presented at international conferences.
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Affiliation(s)
| | - Lucie-Marie Scailteux
- Pharmacovigilance and Pharmacoepidemiology, CHU Rennes, Rennes, France
- Univ Rennes, INSERM, EHESP, Irset (Institut de recherche en santé, environnement et travail) - UMR_S 1085, Rennes, France
| | - Alain Lescoat
- Univ Rennes, INSERM, EHESP, Irset (Institut de recherche en santé, environnement et travail) - UMR_S 1085, Rennes, France
- Internal Medicine and Clinical Immunology, CHU Rennes, Rennes, France
| | - Delphine Staumont
- Department of Dermatology, Lille University Hospital Center, Lille, France
| | - Guillaume Coiffier
- Department of Rheumatology, CH Dinan, Dinan, France
- INSERM, INRA, Institut NUMECAN (Nutrition Metabolism and Cancer), Rennes, France
| | | | - Alain Dupuy
- Department of Dermatology, CHU Rennes, Rennes, France
- Univ Rennes, INSERM, EHESP, Irset (Institut de recherche en santé, environnement et travail) - UMR_S 1085, Rennes, France
| | - Emmanuel Oger
- Pharmacovigilance and Pharmacoepidemiology, CHU Rennes, Rennes, France
- Univ Rennes, INSERM, EHESP, Irset (Institut de recherche en santé, environnement et travail) - UMR_S 1085, Rennes, France
| | - Catherine Droitcourt
- Department of Dermatology, CHU Rennes, Rennes, France
- Univ Rennes, INSERM, EHESP, Irset (Institut de recherche en santé, environnement et travail) - UMR_S 1085, Rennes, France
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Burningham KM, Cao J, Dominguez AR. Successful treatment of recalcitrant mucous membrane pemphigoid with multisystem involvement with baricitinib and methotrexate. JAAD Case Rep 2022; 27:67-69. [PMID: 35990232 PMCID: PMC9388867 DOI: 10.1016/j.jdcr.2022.07.013] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023] Open
Affiliation(s)
- Kevin M Burningham
- UT Southwestern School of Medicine, UT Southwestern Medical Center, Dallas, Texas
| | - Jennifer Cao
- Department of Ophthalmology, UT Southwestern Medical Center, Dallas, Texas
| | - Arturo R Dominguez
- Departments of Dermatology and Internal Medicine, UT Southwestern Medical Center, Dallas, Texas
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Li S, Li F, Mao N, Wang J, Xie X. Janus kinase inhibitors in patients with ankylosing spondylitis: Great news, but some concerns on cardiovascular disease risk still exist. Author's reply. Eur J Intern Med 2022; 103:109-110. [PMID: 35840508 DOI: 10.1016/j.ejim.2022.07.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/27/2022] [Accepted: 07/06/2022] [Indexed: 11/29/2022]
Affiliation(s)
- Shu Li
- Department of Rheumatology, The Second Xiangya Hospital of Central South University, Changsha, Hunan, China
| | - Fen Li
- Department of Rheumatology, The Second Xiangya Hospital of Central South University, Changsha, Hunan, China
| | - Ni Mao
- Department of Rheumatology, The Second Xiangya Hospital of Central South University, Changsha, Hunan, China
| | - Jia Wang
- Department of Rheumatology, The Second Xiangya Hospital of Central South University, Changsha, Hunan, China
| | - Xi Xie
- Department of Rheumatology, The Second Xiangya Hospital of Central South University, Changsha, Hunan, China.
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