JAK Inhibitors in Autoimmune Diseases

Approved Indications and Dosing

The American College of Rheumatology recommends JAK inhibitors for rheumatoid arthritis (RA), psoriatic arthritis (PsA), ankylosing spondylitis (AS), ulcerative colitis (UC), atopic dermatitis, and polyarticular juvenile idiopathic arthritis, with specific agents approved for specific conditions 1
Baricitinib (Olumiant) is approved for moderately to severely active RA after failure of conventional synthetic DMARDs, as recommended by the European League Against Rheumatism 2, 1
Upadacitinib (Rinvoq) is approved for RA with similar indications, as recommended by the American College of Rheumatology 1
Tofacitinib demonstrated PASI75 response rates of 43% in methotrexate-inadequate responders and 21% in TNF-inhibitor failures at 12 weeks with the 10 mg twice daily dose, as reported by the National Psoriasis Foundation 3, 4

The standard dose of tofacitinib for RA and PsA is 5 mg orally twice daily, as recommended by the American College of Rheumatology 1, 7
The standard dose of baricitinib for RA is 2 mg or 4 mg orally once daily, as recommended by the European League Against Rheumatism 2, 1
The standard dose of upadacitinib for RA is 15 mg orally once daily, as recommended by the American College of Rheumatology 1
The standard dose of upadacitinib for atopic dermatitis is 15 mg or 30 mg orally once daily, as recommended by the American Academy of Dermatology 1, 6

The Centers for Disease Control and Prevention recommends tuberculosis screening per national guidelines (tuberculin skin test or interferon-gamma release assay) before initiating JAK inhibitors 1, 7, 6
The American College of Rheumatology recommends hepatitis B and C testing before initiating JAK inhibitors 1, 6
The American College of Rheumatology recommends HIV testing in high-risk populations before initiating JAK inhibitors 1, 6

The American College of Rheumatology recommends monitoring complete blood count, liver enzymes, and renal function regularly during treatment with tofacitinib 1, 6
The American College of Rheumatology recommends checking lipid levels 4-8 weeks after initiation of tofacitinib and as needed thereafter 1, 6
The American Academy of Dermatology recommends checking complete blood count and liver enzymes at baseline and 4 weeks after initiation or dose escalation of abrocitinib 1, 6

The FDA has issued black box warnings for JAK inhibitors based on the ORAL Surveillance trial in RA patients ≥50 years with cardiovascular risk factors, including increased risk of major adverse cardiovascular events (MACE), venous thromboembolism (VTE), malignancies, and death 6
The American College of Rheumatology recommends preferring biologics over JAK inhibitors for patients ≥50 years with cardiovascular risk factors due to black box warnings 6

The American College of Rheumatology recommends JAK inhibitors as appropriate first-line options after csDMARD failure for patients <50 years without cardiovascular risk factors, no malignancy history, and no active infections 6
The American College of Rheumatology recommends preferring biologics over JAK inhibitors for patients ≥50 years with cardiovascular risk factors due to black box warnings 6

The American College of Rheumatology recommends that patients can expect initial response within 2-4 weeks for most indications, with maximal benefit by 3-6 months 7
The American College of Rheumatology recommends that response may be observed as early as week 2 with upadacitinib for AS 3