Tofacitinib in Moderate to Severe Plaque Psoriasis

Introduction to Tofacitinib

The American Academy of Dermatology recommends tofacitinib as an off-label treatment option for moderate to severe plaque psoriasis in adult patients who have failed or are intolerant to other systemic therapies, with careful patient selection and heightened vigilance due to significant safety concerns 1, 2

The recommended off-label dosing for psoriasis is 5 mg orally twice daily, with 10 mg twice daily reserved for patients requiring greater efficacy despite accepting higher adverse event risks, as recommended by the American Academy of Dermatology 1, 2
For patients with moderate to severe renal or hepatic impairment, the dose should be reduced to 5 mg once daily, according to the American Academy of Dermatology 1, 2

The American Academy of Dermatology advises that tofacitinib should be avoided during active serious infections and used with extreme caution in patients with recurrent infection history, due to increased risk of herpes zoster and other serious infections 1, 2, 3, 4, 5
Patients with a history of malignancy should be treated with caution, as tofacitinib carries FDA boxed warnings for malignancy risk, including lung cancer and breast cancer, as noted by the American Academy of Dermatology and Praxis Medical Insights 5, 6

The American Academy of Dermatology recommends baseline screening, including complete blood count with differential, comprehensive metabolic panel, lipid profile, tuberculosis screening, and hepatitis B and C screening, before initiating tofacitinib therapy 1, 2, 6
Ongoing monitoring is required, including regular complete blood counts and liver function tests, to discontinue tofacitinib if lymphocyte count <500 cells/mm³, ANC <500 cells/mm³, or hemoglobin decreases by ≥2 g/dL, as recommended by the American Academy of Dermatology 1, 2

The American Academy of Dermatology advises that tofacitinib can be combined with methotrexate but should not be combined with potent immunosuppressants, biologics used for psoriasis, or live vaccines, due to increased risk of adverse events 1, 2, 5

The American Academy of Dermatology recommends that tofacitinib can be used during pregnancy only if the potential benefit justifies the potential risk to the fetus, and JAK inhibitors are generally advised against in pregnancy and lactation due to potential teratogenic effects 1, 2, 6

The American Academy of Dermatology recommends using tofacitinib in psoriasis when patients have moderate to severe plaque psoriasis, have failed or are intolerant of conventional systemic therapies, and have no active serious infection, with careful consideration of patient risk factors and baseline laboratory parameters 1, 2, 5, 6