Is it advisable to switch a patient from Xeljanz (tofacitinib) to Rinvoq (upadacitinib)?

From the Guidelines

Switching a patient from Xeljanz (tofacitinib) to Rinvoq (upadacitinib) may be considered in certain clinical situations, such as inadequate response to Xeljanz, unmanageable side effects, or insurance coverage issues, as stated in the EULAR recommendations for the management of psoriatic arthritis with pharmacological therapies: 2023 update 1.

Key Considerations

• Both medications are JAK inhibitors used to treat conditions like rheumatoid arthritis, psoriatic arthritis, and ulcerative colitis, but they have different selectivity profiles and dosing regimens.
• The decision to switch should be made by a healthcare provider familiar with the patient's specific medical history, taking into account the patient's individual response to the medication and potential side effects.
• According to the points to consider for the treatment of immune-mediated inflammatory diseases with Janus kinase inhibitors: a consensus statement, switching between JAK-inhibitors in non-responders or due to lack of tolerability is a topic of ongoing research 1.

Clinical Recommendations

• When switching, there typically isn't a need for a washout period between medications, but the provider should monitor the patient closely during the transition.
• Rinvoq is typically dosed at 15mg once daily for most indications, while Xeljanz dosing varies by condition.
• The switch should include laboratory monitoring of blood counts, liver function, and lipid levels before and during treatment with the new medication.
• Patients should be aware that while both medications target similar pathways, individual response may vary, and the side effect profile might differ slightly between the two medications.

Safety Considerations

• The EULAR recommendations highlight the importance of considering safety aspects, such as the risk of serious infections, malignancies, and venous thromboembolism, when prescribing JAK inhibitors 1.
• The points to consider for the treatment of immune-mediated inflammatory diseases with Janus kinase inhibitors: a consensus statement, also emphasize the need for pre-treatment screening and risks assessment, including patient history, physical examination, and laboratory testing 1.

From the Research

Switching from Xeljanz to Rinvoq

• The decision to switch a patient from Xeljanz (tofacitinib) to Rinvoq (upadacitinib) depends on various factors, including the patient's response to treatment, tolerability, and potential side effects 2, 3.
• Studies have shown that both tofacitinib and upadacitinib are effective in treating rheumatoid arthritis (RA), with similar efficacy in improving RA control 2, 3.
• However, upadacitinib has been shown to have a more selective inhibition of JAK1 relative to JAK3 compared to tofacitinib, which may result in a different safety profile 4, 5.
• A study comparing the efficacy and safety of tofacitinib, baricitinib, and upadacitinib found that upadacitinib had a higher risk of adverse events, including infections, compared to tofacitinib 3.
• Another study found that upadacitinib had a similar magnitude of effect on IL-6-induced pSTAT3 to a lower dose of tofacitinib, suggesting that upadacitinib may be more potent than tofacitinib at lower doses 4.

Considerations for Switching

• Before switching a patient from Xeljanz to Rinvoq, healthcare providers should consider the patient's individual response to treatment, medical history, and potential interactions with other medications 2, 3.
• The patient's disease activity, functional status, and quality of life should also be taken into account when making the decision to switch treatments 2, 3.
• Additionally, healthcare providers should be aware of the potential risks and benefits associated with upadacitinib, including its increased selectivity for JAK1 and potential for adverse events 4, 5.

Potential Benefits of Switching

• Switching to upadacitinib may offer improved efficacy and a more favorable safety profile for some patients, particularly those who have not responded adequately to tofacitinib or have experienced adverse events 2, 3.
• Upadacitinib may also be a viable option for patients with refractory prurigo nodularis, as shown in a case report where a patient experienced significant improvement with upadacitinib treatment 6.