Alopecia areata and tofacitinib: a prospective multicenter study from a Saudi population

Effectiveness of oral tofacitinib treatment on patients with moderate-to-severe alopecia areata in Iran

INTRODUCTION

Alopecia areata is an inflammatory hair loss and a common autoimmune disease. Conducting treatment studies on alopecia areata is difficult due to unpredictable periods and even spontaneous recovery from the disease. In this study, the effectiveness of tofacitinib in treating alopecia areata was investigated.

MATERIALS AND METHODS

The severity of the disease was evaluated using the Alopecia Severity Tool (SALT), and based on the medical history and patient's documents and photos, the score before and after the treatment was obtained. The patients were prescribed tofacitinib tablets at a dose of 5 mg twice a day for at least 6 months and were followed for a minimum of 18 months.

RESULTS

No side effect was observed in 97.9% of the patients. After 6 months, except for three patients who did not need any maintenance dose, others needed an average daily intake of 7 mg of tofacitinib. After 18 months, the hair loss decreased by 6.45 times compared to the beginning and by 0.5 times compared to the end of 6 months (p < 0.05). In addition, it was found that body hair loss decreased 4 times compared to the beginning and 0.6 times compared to the end of 6 months (p < 0.05). The reduction of nail involvement after 18 months and 6 months was 1.2 times and 0.6, respectively, (p < 0.05).

CONCLUSION

Treatment of alopecia areata with tofacitinib is recommended due to its effectiveness in reducing hair loss on the head, body, and nail involvement with few reversible side effects.

Treatments for Moderate-to-Severe Alopecia Areata: A Systematic Narrative Review

Treatments for alopecia areata (AA) have traditionally been prescribed off-label, and there has been no universal agreement on how to best manage the condition. Baricitinib is the first oral selective Janus kinase (JAK) inhibitor approved for the treatment of adults with severe AA. As a better understanding of the evidence supporting the management of AA in clinical practice is needed, we conducted a systematic literature review and subsequent narrative review to describe available evidence pertaining to the efficacy and tolerability of treatments currently recommended for adults with moderate-to-severe forms of AA. From 2557 identified records, a total of 53 records were retained for data extraction: 9 reported data from 7 randomized controlled trials (RCTs) versus placebo, and 44 reported data from unique RCTs with no placebo arm, non-randomized trials, or observational studies. Across drug classes, data were reported heterogeneously, with little consistency of data collection or clinical endpoints used. The most robust evidence was for the JAK inhibitor class, in particular the JAK1/JAK2 inhibitor baricitinib. Five RCTs (three for baricitinib) demonstrated a consistent benefit of JAK inhibitor therapy over placebo across various clinical outcomes in adult patients with at least 50% scalp hair loss. Overall, hair regrowth varied widely for the other drug classes and was generally low for patients with moderate-to-severe AA. Relapses were commonly observed during treatment and upon discontinuation. Adverse effects were generally consistent with the known safety profile of each intervention. The heterogeneity observed prevented the conduct of a network meta-analysis or an indirect comparison of different treatments. We found that the current management of patients with moderate-to-severe AA often relies on the use of treatments that have not been well evaluated in clinical trials. The most robust evidence identified supported the use of baricitinib, and other oral JAK inhibitors, in patients with severe AA.

Drug Survival and Long-term Outcome of Tofacitinib in Patients with Alopecia Areata: A Retrospective Study

Several non-randomized clinical trials and retrospective studies have demonstrated encouraging efficacy and well-tolerated safety of tofacitinib in the treatment of alopecia areata. However, there are scarce data on a large cohort of patients with alopecia areata in long-term real-world practice. This single-centre, retrospective, observational cohort study included 126 patients with alopecia areata treated with tofacitinib between February 2021 and December 2022. The aims of this study are to evaluate drug survival, effectiveness and safety of tofacitinib for treatment of alopecia areata, and to identify potential factors influencing long-term outcomes. Median duration of treatment was 23.00 (interquartile range (IQR) 15.00, 47.25) weeks. Median all-cause survival time of 126 patients treated with tofacitinib was 44 weeks (95% confidence interval (95% CI) 36.3, 51.7), and the all-cause drug retention rate at 12 weeks, 24 weeks and 48 weeks were 90.0%, 66.4% and 42.3%, respectively. The most common reason for discontinuation was complete remission/satisfaction. A total of 80 patients treated with tofacitinib for over 6 months were included in the efficacy analysis, the overall complete response rate at 24 weeks was 33.8% (27/80). No life-threatening serious adverse events occurred. Sex is an independent risk factor in predicting patient outcomes. This real-world study confirmed the high effectiveness and acceptable safety profile of tofacitinib in alopecia areata, with a satisfactory drug survival rate, and provides supporting data for the clinical application of tofacitinib in Chinese patients with alopecia areata.

Review on Alopecia Areata in the Middle East and Africa: Landscape and Unmet Needs

BACKGROUND

Alopecia areata (AA) is an autoimmune disease characterized by non-scarring hair loss in adults and children. Clinical manifestations range from hair loss in small, well-circumscribed patches to total hair loss on the scalp or any other hair-bearing areas. Although the exact pathogenesis of AA is not fully understood, it is thought that loss of immune privilege caused by immunological dysregulation of the hair follicle is key. Genetic susceptibility also plays a role. Response to currently available treatments is widely variable, causing patient dissatisfaction and creating an unmet need. AA is frequently associated with multiple comorbidities, further affecting patient quality of life.

AIMS AND FINDINGS

AA causes a significant burden on dermatologists and healthcare systems in the Middle East and Africa. There is a lack of data registries, local consensus, and treatment guidelines in the region. Limited public awareness, availability of treatments, and patient support need to be addressed to improve disease management in the region. A literature review was conducted to identify relevant publications and highlight regional data on prevalence rates, diagnosis, quality of life, treatment modalities, and unmet needs for AA in the Middle East and Africa.

The evaluation of JAK inhibitors on effect and safety in alopecia areata: a systematic review and meta-analysis of 2018 patients

Background

JAK inhibitors treat various autoimmune diseases, but an updated systematic review in treating alopecia areata is currently lacking.

Objective

Evaluate the specific efficacy and safety of JAK inhibitors in alopecia areata by systematic review and meta-analysis.

Methods

Eligible studies in PubMed, Embase, Web of Science, and Clinical Trials up to May 30, 2022, were searched. We enrolled in randomized controlled trials and observational studies of applying JAK inhibitors in alopecia areata.

Results

6 randomized controlled trials with 1455 patients exhibited SALT₅₀ (odd ratio [OR], 5.08; 95% confidence interval [CI], 3.49-7.38), SALT₉₀ (OR, 7.40; 95% CI, 4.34-12.67) and change in SALT score (weighted mean difference [WSD], 5.55; 95% CI, 2.60-8.50) compared to the placebo. The proportion of 26 observational studies with 563 patients of SALT₅ was 0.71(95% CI, 0.65-0.78), SALT₅₀ was 0.54(95% CI 0.46-0.63), SALT₉₀ was 0.33(95% CI, 0.24-0.42), and SALT score (WSD, -2.18; 95% CI, -3.12 to -1.23) compared with baseline. Any adverse effects occurred in 921 of 1508 patients; a total of 30 patients discontinued the trial owing to adverse reactions.

Limitations

Few randomized controlled trials met the inclusion criteria and insufficiency of eligible data.

Conclusion

JAK inhibitors are effective in alopecia areata, although associated with an increased risk.

Safety of Janus Kinase inhibitors in Patients with Alopecia Areata: A Systematic Review

BACKGROUND AND OBJECTIVES

Janus kinase (JAK) inhibitors are emerging as a therapeutic option for alopecia areata. The risk of potential adverse events is currently debated. In particular, several safety data for JAK inhibitors are extrapolated from a single study in elderly patients with rheumatoid arthritis treated with tofacitinib or adalimumab/etanercept as a comparator. The population of patients with alopecia areata is clinically and immunologically different from persons with rheumatoid arthritis and tumor necrosis factor (TNF) inhibitors are not effective in these patients. The objective of this systematic review was to analyze available data on the safety of various JAK inhibitors in patients with alopecia areata.

METHODS

The systematic review was performed according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. A literature review was performed by searching PubMed, Scopus and EBSCO databases with the last search on March 13, 2023.

RESULTS

In total, 36 studies were included. The frequency and odds ratio (OR) for most common adverse events versus placebo were: for baricitinib hypercholesterolemia (18.2% vs 10.5%, OR = 1.9) and headache (6.1% vs 5.1%, OR = 1.2), for brepocitinib elevated creatinine level (27.7% vs 4.3%, OR = 8.6) and acne (10.6% vs 4.3%, OR = 2.7), for ritlecitinib acne (10.4% vs 4.3%, OR = 2.6) and headache (12.5% vs 10.6%, OR = 1.2) and for deuruxolitinib headache (21.4% vs 9.1%, OR = 2.7) and acne (13.6% vs 4.5%, OR = 3.3). The respective numbers for upper respiratory infections were: baricitinib (7.3% vs 7.0%, OR = 1.0) and brepocitinib (23.4% vs 10.6%, OR = 2.6); for nasopharyngitis: ritlecitinib (12.5% vs 12.8%, OR = 1.0) and deuruxolitinib (14.6% vs 2.3%, OR = 7.3).

CONCLUSIONS

The most common side effects of JAK inhibitors in patients with alopecia areata were headache and acne. The OR for upper respiratory tract infections varied from over 7-fold increased to comparable to placebo. The risk of serious adverse events was not increased.

Systematic review of newer agents for the management of alopecia areata in adults: Janus kinase inhibitors, biologics and phosphodiesterase-4 inhibitors

Management options for moderate-to-severe alopecia areata (AA) are limited owing to a lack of safe and effective treatments suitable for long-term use. However, newer agents have the potential to induce and maintain hair regrowth in patients with a better side-effects profile compared to systemic steroids or conventional systemic agents. In this article, we conducted a systematic review of newer agents, including Janus kinase (JAK) inhibitors, biologics and phosphodiesterase-4 (PDE-4) inhibitors, for the treatment of AA in adult patients evaluated in randomized controlled trials (RCTs) using the Severity of Alopecia Tool score. A literature search was performed on PubMed and ClinicalTrials.gov, which identified 106 items with 12 RCTs eligible for review. Information regarding the treatment regimen, duration, endpoints, efficacy and adverse events were extracted; product monograph information was also summarized for approved agents with or without indications for AA. Overall, current data suggest the oral JAK inhibitors (baricitinib, ritlecitinib, deuruxolitinib, brepocitinib) as a promising new class of agents that can induce significant hair regrowth, with mild to moderate adverse effects. Baricitinib recently received US FDA approval for the treatment of severe AA, while ritlecitinib and deuruxolitinib have received the breakthrough therapy designation for AA. In contrast, PDE-4 inhibitors (apremilast) and the biologics (dupilumab, secukinumab and aldesleukin) appear to have limited efficacy thus far. Results from ongoing and future long-term studies could shed light on the utility of the newer agents in altering the progression of AA.

JAK inhibitors in dermatology: the road travelled and path ahead, a narrative review

INTRODUCTION

Numerous cutaneous dermatoses mediated by cytokines depend on the JAK STAT pathway for intracellular signaling. JAK inhibitors form a useful therapeutic approach in treating these conditions. The literature on effectiveness of JAK inhibitors in treatment of alopecia areata, vitiligo, atopic dermatitis, psoriasis and several other inflammatory and autoimmune diseases is growing, although very few conditions have sufficiently well performed studies to their credit and barring a few indications, their use in rest remains empirical as yet.

AREAS COVERED

A search of the PubMed database was made using the keywords Janus kinase inhibitors OR JAK inhibitors AND dermatology with the time duration limited to the last 5 years. Here, we review the JAK STAT pathway and the various conditions in which JAK inhibitors are currently used in dermatology and other conditions their use is being explored in.

EXPERT OPINION

The pathology of a large number of dermatological disorders is mediated via inflammatory cytokines which signal via the JAK STAT pathway. JAKinibs have shown great promise in treating cutaneous disorders refractory to conventional therapy. Their current clinical use in dermatology is based on robust evidence (for some), and anecdotal evidence for most other dermatoses.

The efficacy and safety of JAK inhibitors for alopecia areata: A systematic review and meta-analysis of prospective studies

Background: Due to the lack of comprehensive evidence based on prospective studies, the efficacy and safety of Janus Kinase (JAK) inhibitors (including tofacitinib, ruxolitinib, baricitinib, ritlecitinib and brepocitinib) for alopecia areata (AA) are yet to be proved.

Methods: The systematic review and meta-analysis was performed pursuant to the Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) guideline and registered on PROSPERO (CRD42022303007).

Results: Fourteen prospective studies (5 RCTs and 9 non-RCTs), enrolling a total of 1845 patients with AA, were included for quantitative analysis. In RCTs, oral JAK inhibitors resulted in higher good response rate compared with control (RR: 6.86, 95% CI: 2.91–16.16); topical JAK inhibitors did not show any difference compared with control (RR: 1.00, 95% CI: 0.31–3.18). In non-RCTs, the pooled rate of good response to oral, topical and sublingual JAK inhibitors were 63% (95% CI: 44%–80%), 28% (95% CI: 1%–72%) and 11% (95% CI: 1%–29%), respectively. The pooled recurrence rate in patients treated with JAK inhibitors was 54% (95% CI: 39%–69%), mainly due to the withdrawal of JAK inhibitors. In RCTs, no difference was found in the risk of experiencing most kind of adverse events; in non-RCTs, the reported adverse events with high incidence rate were mostly mild and manageable.

Conclusion: JAK inhibitors are efficacious and generally well-tolerated in treating AA with oral administration, whereas topical or sublingual administration lacks efficacy. Subgroup analyses indicate that baricitinib, ritlecitinib and brepocitinib seem to have equal efficacy for AA in RCTs; ruxolitinib (vs. tofacitinib) and AA (vs. AT/AU) are associated with better efficacy outcomes in non-RCT. Due to the high recurrence rate after withdrawal of JAK inhibitors, continuous treatment should be considered to maintain efficacy.

Systematic Review Registration: PROSPERO: CRD 42022303007