What Does It Take to Initiate JAK Inhibitors for Psoriasis?

Published on: 

Peter Lio, MD, shares his strategy for advancing severely impacted patients from systemic therapy to either upadacitinib or abrocitinib.

JAK inhibitors have been among the most trending drug classes in recent dermatology research and marketing. For psoriasis, abrocitinib and upadacitinib have provided clinicians a new dimension of care for the most adversely-impacted adult patients.

But what qualities as clinically eligible for these relatively new drugs among real-world patients?

In the second segment of an interview with HCPLive during the 2022 Fall Clinical Dermatology Meeting this week, Peter Lio, MD, clinical assistant professor of dermatology and pediatrics at Northwestern University Feinberg School of Medicine, discussed the one question that trumps all measures of psoriasis burden when considering JAK inhibitor initiation: What’s the disease’s impact on a patient’s quality of life?

“Once we’ve acknowledged and understood that this is having a huge impact, and we’ve really tried things leading up to it—because we generally don’t want to start with a systemic agent—we want to make sure it’s appropriate,” Lio said.

Lio described the treatment strategy escalation for psoriasis as a staircase; patients with uncontrolled disease advance from wet wraps and topical steroids to more advanced options. They’re sometime burdened with atrophic striae or even losing the battle of body surface management with significant amounts of topical steroid application. At that point, Lio and colleagues want to review “the diversity of systemic treatment,” including phototherapy, differing biologics, and conventional immunosuppressants.

JAK inhibitors will generally be considered for patients who failed to manage psoriasis with even one of those options.

When initiating upadacitinib or abrocitinib, it’s important to test patients for tuberculosis and HIV, screen for hepatitis, and check lipid and metabolic levels in a blood test over the first month, Lio said. Real-world dosing and regimen has been consistent with that practiced in clinical trials for each drug.

“It really does feel pretty consistent,” Lio said. “Both of the new JAK inhibitors have a neat dosing variability, which is kind of exciting to have. Everyone starts at the lower dose…and each of them have a higher dose.”

About 9 in every 10 of Lio’s patients find benefit from the lower dose of either JAK inhibitor; those who progress to the higher dose are again monitored for lipid and metabolic level increases.

About 90% simply stay on low dose; the rest advance to the higher dose after a couple months, with increased blood testing again. The increase is generally worth the scrutiny.

“For those super refractory patients, that higher dose may be a real life-saver,” Lio said.