Early Experience with tofacitinib for Alopecia Areata Looks Promising

By: Denise Fulton, Frontline Medicial News

NEWPORT BEACH, CALIF. – JAK-STAT inhibitors, newer drugs that are approved for rheumatoid arthritis and myelofibrosis, are showing promise for treating alopecia areata, Dr. Carolyn Goh said at the PDA 2016 Annual Meeting.

Alopecia areata is not common; some estimates show that patients with alopecia areata comprise between 0.7% and 4% of all patients seen by U.S. dermatologists, said Dr. Goh, assistant clinical professor of dermatology at UCLA. Lifetime risk of developing alopecia areata previously has been estimated at about 1.7%; however, more recent data from the Mayo Clinic’s Rochester Epidemiology Project puts estimated lifetime risk at 2.1%. “It does appear that the incidence may be increasing, which is in line with what we are seeing in other autoimmune disease,” Dr. Goh said.

Dr. Goh discussed a proposed protocol developed by Dr. Melissa Piliang at the Cleveland Clinic for treating alopecia areata with the JAK-STAT inhibitor tofacitinib. The protocol calls for patients to be off all other treatments before tofacitinib is initiated.

Baseline testing includes complete blood count, comprehensive metabolic panel, and lipid levels, as well as screening for hepatitis B, hepatitis C, HIV, and tuberculosis. Photos should be taken at baseline and each follow up visit, and Severity of Alopecia Tool (SALT) scores and patient assessment of hair loss should be recorded. Patients are started on 5 mg tofacitinib twice daily for 3 months.

“In actual practice, however, it’s hard to follow a protocol and what I have found is that rheumatology referral is very helpful” when treating alopecia areata with tofacitinib. “Rheumatologists are familiar with the drug and familiar with the alternative systemic agents. They have much more time in terms of their appointment to discuss risks with patients. They also have samples of tofacitinib -- the rheumatologists I work with have provided those samples to many of my patients.”

Follow-up is every 12 weeks, and labs are checked again after 4-6 weeks, Dr. Goh said. In most patients, dosing was increased after 3 months and several of her patients had their dosages increased up to 10 mg twice a day. Starting with intralesional steroid injections can be helpful.

Regarding outcomes, Dr. Goh noted that patients who start treatment with a little bit of spontaneous hair regrowth tend to have an earlier response. Even in these patients, patchy hair loss often recurs when dosage and frequency is reduced.

Dr. Goh said that in her experience, it takes 3-6 months or more –even up to a year – to see a good benefit. The drug is fairly well tolerated, although a few patients experienced an increase in acne, and some reported gastrointestinal side effects. Insurance coverage is very difficult to get, although not impossible, Dr. Goh added.

Several trials of JAK-STAT inhibitors for dermatologic diseases are ongoing, including trials of topical ruxolitinib for alopecia areata and topical tofacitinib for psoriasis. Small clinical trials of oral formulations of both JAK-STAT inhibitors are ongoing as well, Dr. Goh said.

Dr. Goh said that she had no relevant conflicts of interest regarding her presentation.