Tofacitinib Dosing for Myositis-Associated Interstitial Lung Disease

Critical Pre-Treatment Requirements

Complete tuberculosis screening with interferon-gamma release assay (IGRA) or tuberculin skin test before initiation, with treatment of latent TB for at least 1 month prior to starting tofacitinib, as recommended by the American Academy of Dermatology 1
Administer recombinant zoster vaccine (Shingrix) as a 2-dose series separated by 2-6 months before starting therapy in patients ≥18 years old, according to the American Academy of Dermatology guidelines 1
Obtain baseline complete blood count with differential, comprehensive metabolic panel including liver enzymes and renal function, and lipid profile, as suggested by the American Academy of Dermatology 1
Do not initiate tofacitinib if lymphocyte count, absolute neutrophil count, or hemoglobin are below safe thresholds, as recommended by the American Academy of Dermatology and the Journal of the American Academy of Dermatology 1, 2

Avoid initiating or continuing tofacitinib during any active serious infection, as recommended by the Journal of the American Academy of Dermatology and the American Academy of Dermatology 1, 2

Repeat CBC with differential at 4-8 weeks after starting treatment, then every 3 months, as suggested by the American Academy of Dermatology 1, 3
Check liver enzymes at 4 weeks, then every 3 months as part of comprehensive metabolic panel, according to the American Academy of Dermatology guidelines 1, 3
Measure lipids at 4-12 weeks after initiation, then annually, as recommended by the American Academy of Dermatology 1, 3

Reduce tofacitinib to 5 mg once daily in patients with moderate to severe renal or hepatic impairment, as recommended by the Journal of the American Academy of Dermatology 2
Use 5 mg once daily when combining with potent CYP3A4 inhibitors or medications causing both moderate CYP3A4 inhibition and potent CYP2C19 inhibition, according to the Journal of the American Academy of Dermatology guidelines 2
Hold tofacitinib until hemoglobin values normalize if anemia develops during treatment, as suggested by the Journal of the American Academy of Dermatology 2
Do not combine tofacitinib with other potent immunosuppressants beyond the established triple therapy regimen, and avoid combination with biologics, as recommended by the Journal of the American Academy of Dermatology 2
Patients ≥65 years have significantly higher serious infection rates and should only receive tofacitinib if no alternative exists, according to the American Academy of Dermatology guidelines 1