Expert Perspectives on JAK Inhibitors in Dermatology Care - Episode 4
Jerry Bagel, MD, MS, and Brett King, MD, PhD, explore how severity of disease factors into treatment selection regarding the use of JAK inhibitors.
Jerry Bagel, MD, MS: Dr King, when you look at psoriasis with adalimumab—straight psoriasis vs psoriatic arthritis with adalimumab and methotrexate and RA [rheumatoid arthritis] with methotrexate and Crohn [disease]—do you think this is like the [Gerd] Burmester data [in the SELECT-NEXT trial] from Abbvie? There was always an increase in tuberculosis, with serious infections, and there always is an increase in lymphomas. But when you look at the psoriasis data with adalimumab as a monotherapy, they were clean. The biggest danger is after the world news, in the beginning of Jeopardy, when you have 3 commercials for psoriasis or atopic dermatitis [AD]. They talk about the risks extrapolated from other diseases, and it scares everybody. I applaud you for your New England Journal of Medicine first-author article on alopecia areata [AA]. What is the extent of disease that you need someone to have to be treated with a JAK inhibitor for AA?
Brett King, MD, PhD: For AA?
Jerry Bagel, MD, MS: Yeah. How extensive, how severe, how long? Some clinical parameters.
Brett King, MD, PhD: One thing we hate is the labels because they can say things that scare us. They say things that are borrowed from other JAK inhibitors in other diseases, but we also have to embrace the part of the labels that let us practice medicine. The label for the oral JAK inhibitors in atopic dermatitis say when those therapies are inadvisable. In alopecia areata, we have a label that says it’s for severe alopecia areata. Baricitinib is approved for adult patients with severe alopecia areata. In clinical trials, patients had 50% to 100% scalp hair loss. But nowhere in the label does it mention a SALT score [Severity of Alopecia Tool]. Nowhere in the label does it say a percentage of scalp hair loss. It’s indicated for adults with severe alopecia areata.
This doesn’t mean that payers won’t come around and say, “I want to see documented in your note a percentage of scalp hair loss.” To some degree, the label lets us decide, as a community, what’s severe. There’s not a lot of difference between 35% and 50% scalp hair loss. The person with 35% scalp hair loss needs to spend a lot of time every day to disguise it. If you miss an eyebrow, that’s 10% scalp hair loss. That’s bad disease. That’s a gift to us, but it also means stewardship. As a community, we’re going to have to decide what’s severe, what’s moderate, what’s mild. We’ve never had to ask ourselves this question before because we didn’t have anything for the disease.
Jerry Bagel, MD, MS: Once you start somebody on baricitinib for alopecia areata, what percentage of people respond well? And what is well, and for how long?
Brett King, MD, PhD: This is fun stuff because it’s brand-new to us. We’ve never had to ask these questions before, so we don’t have answers. In the baricitinib clinical trials, there are 2 doses: a 2-mg dose and a 4-mg dose. About 20% of patients on a 2-mg dose achieve 20% or less scalp hair loss over 36 weeks of treatment or a SALT score of less than or equal to 20. This is the primary end point in all alopecia areata clinical trials: 20% or less scalp hair loss. With the 2-mg dose, about 20% of people get there over 36 weeks. With the 4-mg dose, one-third of patients get to 20% or less scalp hair loss over 36 weeks of treatment. When you look out at longer time points—out to a year—those numbers rise. It’s important for us to understand that alopecia areata is not atopic dermatitis. It’s not psoriasis. We give people a biologic or an oral JAK inhibitor for AD. AD and psoriasis evaporate in weeks. It takes months to grow hair, so we’re going to have to learn patience when we’re trying to grow hair, which doesn’t come easy to us in dermatology.
Transcripts edited for clarity