Patient Preference & Shared Decision Making in JAK Inhibitor Selection

Jerry Bagel, MD, MS: How do you monitor your oral JAK patients? What blood work do you do before? What’s your standard follow-up?

Brett King, MD, PhD: What gets in the way of uptake of these medicines is if we feel, “Every time I use this 1, I have to monitor a little differently. Every time I use that 1, I’m going to have to monitor a little differently.” Even abiding by the label or what the drug companies are telling us to do, we need to screen prior to starting therapy. We’re going to check for tuberculosis, hepatitis B, hepatitis C, and complete blood count with differential LFTs [liver function tests]. Personally, I think a complete metabolic panel—throw in a creatinine test—because some of these are going to be dosed a little differently if you have moderate renal impairment. What’s a little different is fasting lipids.

Jerry Bagel, MD, MS: Exactly. We’re on the same page. You start it there. When do you check again?

Brett King, MD, PhD: This is where having more of a 1-size-fits-all approach as opposed to, “This label says to check lipids at 12 weeks, and this 1 says 4 weeks.” Four weeks in, check CBC [complete blood count], LFTs or CMP [comprehensive metabolic panel], and then at 12 weeks or longer check fasting lipids. This is important; checking the fasting lipids out at a later time point is important because with more than 1 of these medicines, it’s been shown that some people will have an early rise in lipids that will return to their baseline at week 12. We don’t want to be checking a lab value and then feel, “Now I need to worry about cholesterol.” If you had just waited another 8 weeks, you don’t.

This is the thing: if lipids are normal at 12 weeks or thereafter, we don’t have to check them again. JAK inhibitors are not going to be onerous. Indeed, the label for the ones that we have in dermatology—upadacitinib, abrocitinib, baricitinib—all say per routine. That means CBC and LFTs as you wish. That’s a gift. That means every 6 months for me.

Jerry Bagel, MD, MS: Likewise, we’re on the same page. That’s what I’m doing. I’ve learned a little about this from the rheumatology colleagues who have been using it for longer than we have. I feel pretty comfortable about that.

I’m going to throw out some concepts. Let’s say someone is going on a JAK inhibitor who had a malignancy 3 years ago—not a lymphoma, but something like breast cancer or prostate cancer.

Brett King, MD, PhD: I’m a huge believer in shared decision-making. I’m not the doctor who knows what’s best for you. I like telling you what I believe to be true and letting you decide. Does that mean that for a patient who has recovered from metastatic disease 3 years ago, I’m going to invite them to use an oral JAK inhibitor? No, but it’s nuanced. Some things you’ll be able to wrap your mind around, and some are going to be a hard stop. If we had enough time, we could draw 5 scenarios on a white board. Some of them are going to be hard stops, and some of them are not.

A lot of this is going to be how each of us feels. Over time, we’re going to feel differently. We’re going to use these medicines once or twice. What’s amazing about the class of medicines across all these indications—we don’t even need to specify the indication—is that they’re really effective. You’re not going to have to treat even 2 patients with atopic dermatitis to have a success story and be wowed with the potential. You’re not going to have to treat 2 or 3 patients with alopecia areata to realize how much fun it is to watch somebody grow hair. You’re not going to have to treat 2 or 3 or 4 patients with vitiligo to watch their face return to normal and be absolutely dazzled by the possibility.

Everybody needs to start somewhere. Patient by patient, we’ll get more comfortable. These are complicated questions. For the patient with a malignancy 3 years ago, at the start they’re going to be a hard no. But 3 years in we might have a different feeling.

Jerry Bagel, MD, MS: We’ll have registry data.

Brett King, MD, PhD: That’s right.

Transcript edited for clarity