How JAK Inhibitors Revolutionized Dermatology Care

Last summer, Derm Discussions host Brad Glick, DO, invited Brett King, MD, PhD, Yale School of Medicine, to the program to discuss an emerging class of dermatology therapy known as Janus kinase (JAK) inhibitors.

At the time, small molecule drugs such as upadacitinib (Rinvoq) were approved for the treatment of conditions like rheumatoid arthritis and ulcerative colitis.

Since then, updacacitinib and abrocitinib (Cibinqo) have been approved for use in patients with atopic dermatitis, a skin condition that affects up to 7.3% of adults in the United States alone.

Janus kinase inhibitors modulate the activity of multiple cytokine drivers of atopic dermatitis, and are supported by a variety of positive clinical trial results.

Dr. Glick welcomed Dr. King back to Derm Discussions to provide insight into the role JAK inhibitors play in the ever-growing armamentarium against atopic dermatitis.

King noted that many of the conversations regarding JAK inhibitors relate to the prescribing information of these therapies.

Most JAK inhibitor treatments are recommended for adults with refractory moderate to severe atopic dermatitis whose disease is not adequately controlled by other systemic drug products such as dupilumab.

“Because dupilumab is only rarely inadvisable, if we follow the prescribing information for the oral JAK inhibitors than in the majority of patients their use will be in patients with an inadequate response to dupilumab,” King said. “Of course, we are not robots, and we need to use our better judgment when considering treatment for any particular patient. But I think the prescribing information will prevail in the majority of cases.”

While dupilumab failure is not common in patients with atopic dermatitis, King noted that many patients still need better disease control than what they are getting from the biologic. As such, he considered JAK inhibitors to be “hugely important” in managing skin diseases such as atopic dermatitis.

“Dupilumab revolutionized AD, and so we sort of almost this kind of blind allegiance to it now, and we insist that our patients are doing well, but not everybody does,” he noted. “And now that we have abrocitinib and upadacitinib, the patients who do not have adequate disease control have treatment options. Just as dupilumab was revolutionary to AD, so will be the JAK inhibitors.”

For patients who do not respond to dupilumab, King conducts assessments including the Investigators Global Assessment (IGA), and the pruritis numerical rating scale to determine the severity of their disease and how they might benefit from certain JAK therapies.

He added that reasons for treatment failure are often much more nuanced than would be expected. As such, he recommended that providers utilize these tools to determine an adequate treatment option.

“Using these simple tools, the VIGA, the BSA dermatitis and pruritis NRS, I think that we can begin to sort out adequate response to treatment,” King said. “Of course, the patient's input is going to be critical in the determination of adequate control as well, and ultimately, I just think that with more and more treatments to offer patients, we will strive more and more for near complete remission of both dermatitis and pruritis, that should be our goal.”