Janus Kinase (JAK) Inhibitors

Administration: Oral

Dose:

• 4mg orally once daily with or without food
• 2mg daily if - >75 years old, eGFR 30-60ml/min, or on OAT3 inhibitor such as Probenecid

Time to response: Up to 24 weeks

Indications: Rheumatoid Arthritis.

Contraindications:

• Pregnancy & breast feeding.
• Active infection including HBV, HCV & HIV.
• Active/latent TB.
• ALT/AST >5x upper limit of normal.
• Neutrophils < 1x10⁹/l, lymphocytes <0.5x10⁹/l or Hb <8g/dL.
• Uncontrolled hyperlipidaemia.

Cautions:

• Patients with risk factors for DVT/PE.
• Those with a history of diverticular disease particularly if on concomitant medications with increased risk of diverticulitis.

Monitoring:

• Fasting lipid profile 12 weeks after starting drug
• FBC, U&E, LFTs at 4 weeks, 12 weeks and every 3 months thereafter

Vaccinations:

• Avoid live attenuated vaccines.
• Offer annual influenza vaccination.
• In those who are biologic naïve pneumococcal vaccination and Sars-Cov-2 vaccination should ideally be performed at least 2 weeks before commencing biologic treatment.
• Assuming no contraindications before starting treatment:
  • Patients >50 should undergo vaccination against HZV.
  • Those who are varicella zoster negative should be offered varicella vaccination.

In the event of:

• Hyperlipidaemia - treat with lipid lowering agents.
• Infection - withhold BARICITINIB until infection treated.
• Confirmed DVT/PE - BARICITINIB treatment should be stopped.
• Diverticular perforation – BARICITINIB should be stopped.
• ALT/AST > 3x upper limit of normal – stop BARICITINIB
• Neutrophils < 1x10⁹/l, lymphocytes <0.5x10⁹/l, Hb <8g/dL– stop BARICITINIB.
• Effective contraception whilst on treatment and for 1 week after receiving BARICITINIB.

Administration: Oral

Dose:

• 200mg taken orally once daily with or without food.
• A starting dose of 100 mg once daily is recommended for patients aged ≥75 years and for patients with moderate or severe renal impairment.

Time to response: up to 24 weeks

Indications: Rheumatoid Arthritis.

Contraindications:

• Pregnancy & breast feeding.
• Active infection including HBV, HCV & HIV.
• Active/latent TB.
• Neutrophils < 1x10⁹/l, lymphocytes <0.5x10⁹/l or Hb <8g/dL.
• Creatinine clearance <15ml/min.
• Child Pugh C hepatic impairment.
• Patients with rare hereditary problems of galactose intolerance, total lactase deficiency or glucose-galactose malabsorption.

Cautions:

• Patients with risk factors for DVT/PE.
• The potential risk of reduced fertility or infertility should be discussed with male patients before initiating treatment.

Monitoring:

• Fasting lipid profile 12 weeks after starting drug.
• FBC, U&E, LFTs at 4 weeks, 12 weeks and every 3 months thereafter.

Vaccinations:

• Avoid live attenuated vaccines.
• Offer annual influenza vaccination.
• In those who are biologic naïve pneumococcal vaccination and Sars-Cov-2 vaccination should ideally be performed at least 2 weeks before commencing biologic treatment.
• Assuming no contraindications before starting treatment:
  • Patients >50 should undergo vaccination against HZV.
  • Those who are varicella zoster negative should be offered varicella vaccination.

In the event of:

• Hyperlipidaemia - treat with lipid lowering agents.
• Infection - withhold FILGOTINIB until infection treated.
• Confirmed DVT/PE - FILGOTINIB treatment should be stopped.
• Diverticular perforation – FILGOTINIB should be stopped.
• Child Pugh C– stop FILGOTINIB.
• Neutrophils < 1x10⁹/l, lymphocytes <0.5x10⁹/l, Hb <8g/dL– stop FILGOTINIB.
• Effective contraception whilst on treatment and for 1 week after receiving FILGOTINIB.

Administration: Oral

Dose: 5mg orally twice daily with or without food

Time to response: Up to 24 weeks

Indications:

• Rheumatoid Arthritis.
• Psoriatic Arthritis.

Contraindications:

• Pregnancy & breast feeding.
• Active infection including HBV, HCV & HIV.
• Active/ latent TB.
• ALT/AST >5X upper limit of normal.
• Neutrophils < 1x10⁹/l, lymphocytes <0.5x10⁹/l or Hb <8g/dL.
• Uncontrolled hyperlipidaemia.
• Pregnancy.

Cautions:

• Should be used with caution in patients with risk factors for DVT/PE.
• Those >65 years are at risk of serious infections and should be treated with TOFACITINIB only if there is no alternative treatment.
• Preliminary data from a clinical trial of patients with rheumatoid arthritis suggested a higher risk of major adverse cardiovascular events and malignancies (excluding non-melanoma skin cancer).

Monitoring:

• Fasting lipid profile 8 weeks after starting drug
• FBC, U&E, LFTs every 3-6 months

Vaccinations:

• Avoid live attenuated vaccines.
• Offer annual influenza vaccination.
• In those who are biologic naïve pneumococcal vaccination and Sars-Cov-2 vaccination should ideally be performed at least 2 weeks before commencing biologic treatment.
• Assuming no contraindications before starting treatment:
  • Patients >50 should undergo vaccination against HZV.
  • Those who are varicella zoster negative should be offered varicella vaccination.

In the event of:

• ALT/AST > 3x upper limit of normal – stop TOFACITINIB.
• Neutrophils < 1x10⁹/l, lymphocytes <0.5x10⁹/l, Hb <8g/dL– stop TOFACITINIB.
• Hyperlipidaemia - treat with lipid lowering agents.
• Infection - withhold tofacitinib until infection treated.
• Suspected DVT/PE – TOFACITINIB treatment should be temporarily interrupted and patients should be evaluated promptly, followed by appropriate treatment.
• Effective contraception whilst on treatment and for 1 week after receiving TOFACITINIB.

Administration: Oral

Dose:

• 15mg orally once daily with or without food
• No dose adjustment required in mild to moderate renal or hepatic impairment.

Time to response: Up to 24 weeks

Indications:

• Rheumatoid Arthritis.
• Psoriatic Arthritis.
• Ankylosing Spondylitis.

Contraindications:

• Pregnancy & breast feeding.
• Active infection including HBV, HCV & HIV.
• Active/latent TB
• ALT/AST >5x upper limit of normal.
• Neutrophils < 1x10⁹/l, lymphocytes <0.5x10⁹/l or Hb <8g/dL.
• Uncontrolled hyperlipidaemia.
• Hypersensitivity to active substances or to any of the excipients.

Cautions:

• Patients with risk factors for DVT/PE.
• Those with a history of diverticular disease particularly if on concomitant medications with increased risk of diverticulitis.

Monitoring:

• Fasting lipid profile 12 weeks after starting drug.
• FBC, U&E, LFTs at 4 weeks, 12 weeks and every 3 months thereafter.

Vaccinations:

• Avoid live attenuated vaccines.
• Offer annual influenza vaccination.
• In those who are biologic naïve pneumococcal vaccination and Sars-Cov-2 vaccination should ideally be performed at least 2 weeks before commencing biologic treatment.
• Assuming no contraindications before starting treatment:
  • Patients >50 should undergo vaccination against HZV.
  • Those who are varicella zoster negative should be offered varicella vaccination.

In the event of:

• Hyperlipidaemia - treat with lipid lowering agents.
• Infection - withhold UPADACITINIB until infection treated.
• Confirmed DVT/PE - UPADACITINIB treatment should be stopped.
• Diverticular perforation – UPADACITINIB should be stopped.
• ALT/AST > 3x upper limit of normal – stop UPADACITINIB.
• Neutrophils < 1x10⁹/l, lymphocytes <0.5x10⁹/l, Hb <8g/dL– stop UPADACITINIB.
• Effective contraception whilst on treatment and for 4 weeks after receiving UPADACITINIB.