Other Treatments to Incorporate With JAK Inhibitors

This Dermatology Times Expert Perspectives series delves into the multifaceted landscape of atopic dermatitis (AD) care and treatment. Through interviews with 4 leading dermatologists, this series explores key benchmarks, emerging trends, personalized medicine approaches, long-term safety considerations, and the integration of novel therapies in the management of AD. Each episode provides valuable insights into navigating the heterogeneity of AD presentations, selecting appropriate treatment plans tailored to individual patient needs, and incorporating the latest guidelines from the American Academy of Dermatology. From discussing the nuances of patient education and shared decision-making to addressing the intersection of comorbidities with AD management, this series equips dermatology clinicians with the knowledge and strategies necessary to optimize patient outcomes and enhance the quality of care.

In this episode, Ruth Ann Vleugels, MD, MPH, MBA, dermatologist at Brigham and Women’s Hospital and Boston Children’s Hospital in Boston, Massachusetts, delves into patient-specific considerations and action plans when on a JAK inhibitor, including shingles prevention and management.

Episode Transcript

Vleugels: When we're first starting JAK inhibitors on a patient, one of the things that you want to think about is giving a patient 1 dose of the varicella-zoster gE-AS01B (PF) vaccine or Shingrix prior to starting JAK inhibition. Now, keep in mind, patients need 2 doses of that vaccination, but since it's a killed vaccine, we're totally fine giving them their second dose after they've already been on therapy with JAK inhibition. But that's something to remember to reduce the patient's risk of shingles after they start JAK inhibition. When you're considering Shingrix vaccination, I feel like many of my dermatology colleagues recall that traditionally that vaccine was recommended when patients are 50 years or older. But really interestingly, the CDC actually a couple of years ago changed those guidelines and they actually reduced that age down to 18 if the patient is going to be on an immunomodulatory or immunosuppressive therapy, in order to decrease their risk of shingles. So now actually, not only can we recommend it in patients who are 18 and over, but in addition to that, we can also get insurance coverage for our patients. So it's not challenging to get a Shingrix vaccination.
Let's say you have a 36-year old you want to start on a JAK inhibitor for AD. Clearly these are patients who have AD and that need treatment. Often they have moderate to severe skin disease. They have itch. The nice thing about JAK inhibitors is we can tell them that they're going to notice benefit very quickly, because thankfully, these are agents that work rapidly and the nice thing about that is is patients then feel invested in their treatment. So whenever we're starting a patient, we do want to talk about risks of medications. And of course, we're going to speak about things that can come up in patients such as shingles, which is why we already spoke about the fact that we're going to give them a Shingrix vaccine before they start. And then we're actually going to talk to them about the fact that these medicines have been around for quite a while, and so we're very comfortable with their side effect profile. We're going to make sure we select the right patient and ask them some questions to ensure that they're a great candidate for this therapy. And then I often will remind them that the initial data that the long-term safety was done in these patients was done in our patients who have rheumatoid arthritis. So this is a very different disease in our patients with AD. Our rheumatoid arthritis patients tend to be older and, at baseline, they have a higher risk of some things that we saw in the long-term safety data using our initial JAK inhibitors for our patients with arthritis. So those are the patients in which we saw an increased risk of blood clots, cardiac events, and cancer. And in fact, when we look at our longer term safety data with upadacitinib, for example, or other JAK inhibitors, we don't see that same side effect profile as we did in our initial rheumatoid arthritis dose patients.
I think that's an a really important distinction for my dermatology colleagues to understand in AD patients. The rates of these are similar to background, so again, I'm still going to ask my patients about risk factors for those comorbidities and then modify their risk factors and help them if they have any of those. I'm going to feel comfortable using a JAK inhibitor when I need it for AD, given their high efficacy, rapidity of onset, and overall safety profile.

Transcript edited for clarity