What value do JAK inhibitors have in treating rheumatoid arthritis?

Australian inflammatory bowel disease consensus statements for preconception, pregnancy and breast feeding

OBJECTIVE

Because pregnancy outcomes tend to be worse in women with inflammatory bowel disease (IBD) than in those without, we aimed to update consensus statements that guide the clinical management of pregnancy in patients with IBD.

DESIGN

A multidisciplinary working group was established to formulate these consensus statements. A modified RAND/UCLA appropriateness method was used, consisting of a literature review, online voting, discussion meeting and a second round of voting. The overall agreement among the delegates and appropriateness of the statement are reported.

RESULTS

Agreement was reached for 38/39 statements which provide guidance on management of pregnancy in patients with IBD. Most medications can and should be continued throughout pregnancy, except for methotrexate, allopurinol and new small molecules, such as tofacitinib. Due to limited data, no conclusion was reached on the use of tioguanine during pregnancy. Achieving and maintaining IBD remission before conception and throughout pregnancy is crucial to optimise maternofetal outcomes. This requires a multidisciplinary approach to engage patients, allay anxieties and maximise adherence tomedication. Intestinal ultrasound can be used for disease monitoring during pregnancy, and flexible sigmoidoscopy or MRI where clinically necessary.

CONCLUSION

These consensus statements provide up-to-date, comprehensive recommendations for the management of pregnancy in patients with IBD. This will enable a high standard of care for patients with IBD across all clinical settings.

Evaluating filgotinib for the treatment of rheumatoid arthritis

INTRODUCTION

Despite the availability of an extensive armamentarium, rheumatoid arthritis (RA) remains a therapeutic challenge for rheumatologists. Janus kinase inhibitors (JAKi) are an emerging class of targeted therapies. The number of JAKi has been growing and to date, filgotinib is the latest JAKi to be approved for use in RA.

AREAS COVERED

This review focuses on the pharmacodynamics, pharmacokinetics, efficacy and safety of filgotinib in patients with RA.

EXPERT OPINION

Filgotinib is an oral targeted synthetic disease-modifying antirheumatic drug (DMARD) that specifically inhibits JAKi. Filgotinib monotherapy, or a combination regimen with conventional synthetic (cs) DMARDs, has demonstrated efficacy in decreasing disease activity, with a well-managed safety profile in patients with early RA naive to DMARDs, and in RA that does not adequately respond to csDMARDs and/or biologic DMARDs. The selective inhibition of JAK1 may confer an improved safety profile, but further study is required as a potential testicular toxicity has been suggested. Filgotinib offers several advantages: oral administration, rapidity of action, efficacy as monotherapy, and demonstrated activity in difficult to treat RA. However, the placement of filgotinib in the therapeutic arsenal for RA may be influenced by the ongoing collection of long-term safety data from JAKi as a class.

Filgotinib in Rheumatoid Arthritis: A Profile of Its Use

Filgotinib (Jyseleca^®), an oral Janus kinase (JAK) inhibitor, is approved as monotherapy or in combination with methotrexate to treat moderate to severe active rheumatoid arthritis (RA) in adults who have an inadequate response or intolerance to one or more disease-modifying antirheumatic drugs (DMARDs). In phase 3 trials, once-daily filgotinib was generally well tolerated and associated with an improvement in RA signs and symptoms as well as physical function in patients with an inadequate response to ongoing methotrexate, an inadequate response to ongoing conventional synthetic DMARDs plus an inadequate response or intolerance to prior biologic DMARDs, or limited or no prior exposure to methotrexate. In addition, filgotinib was noninferior to adalimumab in terms of low disease activity response rate (DAS28-CRP ≤ 3.2) in patients with an inadequate response to methotrexate. Filgotinib also appeared to inhibit the radiographic progression of joint damage and led to low disease activity or disease remission (DAS28-CRP < 2.6). Filgotinib showed sustained efficacy, and the safety profile of filgotinib longer term was similar to that in the phase 2 and 3 trials.

Rheumatoid arthritis (RA) is a chronic autoimmune inflammatory disease mainly affecting the small joints of the hands and feet. While there is no cure for RA, biologic disease-modifying antirheumatic drugs (DMARDs), which target the inflammatory cytokines (and their receptors) involved in RA, can achieve low disease activity or disease remission. However, these drugs are not always effective or well tolerated and their administration routes (intravenous or subcutaneous) can be a barrier to use. More recently, oral drugs that act on pathways downstream of cytokine receptors have been developed. These drugs, the Janus kinase (JAK) inhibitors, are targeted synthetic DMARDs. Filgotinib (Jyseleca^®), a second-generation JAK inhibitor, improves joint swelling, disease activity, pain, and physical functioning and reduces progression of joint damage in adults with moderate to severe active RA and is generally well tolerated. Like other JAK inhibitors, filgotinib is recommended in treatment guidelines as an effective alternative to biologic DMARDs in adults with moderate to severe active RA who have not responded adequately to or who do not tolerate other DMARDs.