Management of Hematuria in Patients Taking Tofacitinib

Initial Diagnostic Approach

Urinary tract infection is the most common serious infection associated with tofacitinib and should be ruled out first with urinalysis and urine culture, according to the American Academy of Dermatology 1, 2, 3
Tofacitinib increases serum creatinine levels in a dose-related manner, as reported by the American Academy of Dermatology 1, 2, 3
Lung and breast cancer are the most common nonhematologic malignancies in tofacitinib-treated patients, highlighting the need for malignancy evaluation, as noted by the American Academy of Dermatology 1, 3

Baseline and ongoing renal function tests are recommended every 3 months in patients on tofacitinib, as suggested by the American College of Rheumatology 4
Tofacitinib causes dose-related elevations of serum creatinine that stabilize after initial increases, according to the American Academy of Dermatology 1, 2, 3
Rising creatinine or declining GFR indicates potential renal parenchymal involvement, as indicated by the American College of Rheumatology 5

For patients with severe renal impairment (CrCl <30 mL/min), tofacitinib dose must be reduced to 5 mg once daily, as recommended by the European League Against Rheumatism 6, 5
Patients with moderate renal impairment (CrCl 30-50 mL/min) require more frequent monitoring for infections and cytopenias, according to the American College of Rheumatology 5
Reduce tofacitinib to 5 mg once daily when used with potent CYP3A4 inhibitors, as suggested by the American College of Rheumatology 5

Complete blood count with differential to assess for cytopenias is recommended, as suggested by the American College of Rheumatology 4
Comprehensive metabolic panel including creatinine and liver enzymes is recommended, according to the American College of Rheumatology 4
Urine culture to exclude infection is recommended, as noted by the American Academy of Dermatology 1
Continue tofacitinib if hematuria is clearly from urologic cause (UTI, stones) that is being appropriately treated, as recommended by the American College of Chest Physicians 7
Temporarily hold tofacitinib pending workup if glomerular source suspected or if gross hematuria with unclear etiology, as suggested by the American College of Chest Physicians 7

Do not attribute hematuria solely to tofacitinib's known effects on creatinine without excluding serious urologic or glomerular pathology, as warned by the American Academy of Dermatology and the American College of Rheumatology 1, 5
Do not continue full-dose tofacitinib in patients with declining renal function without dose adjustment per guidelines, as recommended by the European League Against Rheumatism and the American College of Rheumatology 6, 5
Do not overlook malignancy screening, particularly in older patients (>65 years) who already have increased infection and cardiovascular risks on tofacitinib, as suggested by the European League Against Rheumatism and the American College of Rheumatology 6, 4