Brett King, MD, discusses highlights from his lecture on All Things JaK on Thursday, November 9, 2023, at the 4th Annual Elevate-Derm PA/NP Conference in Coachella Valley, California.

In this video

Dr. King traces the JAK inhibitor box warning back to its true source: it wasn't born of dermatology clinical trials, but of the ORAL Surveillance long-term safety study of tofacitinib — a drug not even used in dermatology — in rheumatoid arthritis patients 50 and older who also carried a cardiovascular risk factor. In that population, "optimized" for major adverse events and malignancy, those events happened more often than with a TNF inhibitor, but not dramatically. As he puts it, "those patients just aren't our patients in dermatology."

He argues that clinicians have to get comfortable with the class themselves and communicate effectively, or patients will never take these medicines that "do things that no other medicine can do." His approach: don't be dismissive of the box warning, but tell patients "you don't look like the patient in this clinical trial that gave us the boxed warning," and "I wouldn't be offering it if I didn't think it was the right medicine for you." He points to data on upadacitinib and baricitinib showing that rates of malignancy, thrombosis, and major adverse events are much lower in dermatology patients than in rheumatology patients — "it's not opinion," our dermatology patients are on the whole healthier.

  • The JAK box warning comes from the ORAL Surveillance study of tofacitinib in older RA patients with cardiovascular risk factors — not from dermatology trials.
  • Dermatology patients don't resemble that high-risk trial population, so the risk of a JAK inhibitor in them isn't the same.
  • Data on upadacitinib and baricitinib show malignancy, thrombosis, and major adverse event rates are much lower in dermatology than rheumatology patients.
  • Effective patient conversations matter: acknowledge the box warning without being dismissive, then explain why the patient doesn't fit the trial population.
  • With good information, patients can make good decisions for themselves about this uniquely powerful class of medicines.