Is Xeljanz (tofacitinib) effective for treating Crohn's disease and psoriatic arthritis?

Xeljanz (Tofacitinib) for Psoriatic Arthritis and Crohn's Disease

Xeljanz (tofacitinib) is recommended for psoriatic arthritis but is not recommended for Crohn's disease based on current guidelines. While tofacitinib is an established treatment option for psoriatic arthritis, it lacks approval and supportive evidence for Crohn's disease management.

Efficacy in Psoriatic Arthritis

Tofacitinib is recognized as an effective treatment option for psoriatic arthritis in multiple guidelines:

• It is listed as a Janus kinase inhibitor (JAKi) approved for psoriatic arthritis in the 2024 EULAR recommendations 1
• Tofacitinib demonstrated significant efficacy in clinical trials for psoriatic arthritis, particularly in patients who had inadequate response to TNF inhibitors 2
• It improves multiple domains of psoriatic arthritis including:
  • Joint symptoms (ACR20/50 responses)
  • Skin manifestations (PASI75 responses)
  • Physical functioning (HAQ-DI scores)
  • Dactylitis and enthesitis 3

The 2024 EULAR guidelines position JAK inhibitors like tofacitinib after inadequate response to at least one conventional synthetic DMARD and at least one biologic DMARD, or when a biologic DMARD is not appropriate 1.

Limitations for Crohn's Disease

For Crohn's disease, tofacitinib is not recommended:

• The 2022 GRAPPA guidelines specifically recommend against using IL-17 inhibitors for inflammatory bowel disease and recommend TNF inhibitors (except etanercept), IL-12/23 inhibitors, IL-23 inhibitors, and JAK inhibitors for ulcerative colitis, but do not specifically recommend tofacitinib for Crohn's disease 1
• The 2024 Italian consensus guidelines mention JAK inhibitors (including tofacitinib) for ulcerative colitis but not specifically for Crohn's disease 1

Safety Considerations

Important safety concerns with tofacitinib include:

• Increased risk of herpes zoster infections 2
• Safety signals for deep vein thrombosis, particularly with higher doses and in patients with cardiovascular risk factors 1
• Elevated liver enzymes (aspartate and alanine aminotransferase) 2
• Serious infections 2

Treatment Algorithm for Psoriatic Arthritis

For psoriatic arthritis management:

1. First-line: Conventional synthetic DMARDs (methotrexate, leflunomide, sulfasalazine)
2. Second-line: Biologic DMARDs (TNF inhibitors, IL-17 inhibitors, IL-12/23 inhibitors)
3. Third-line: JAK inhibitors like tofacitinib or other biologics after failure of initial biologic therapy

Special Considerations

• Tofacitinib may be particularly useful when a patient prefers an oral medication over injectable biologics 1
• The recommended dose is 5 mg twice daily, with the 10 mg twice daily dose showing increased efficacy but also more adverse events 3
• According to European Medicines Agency approval, tofacitinib should be prescribed with methotrexate for psoriatic arthritis 1

Conclusion

Tofacitinib is an effective option for psoriatic arthritis, particularly after failure of conventional and biologic DMARDs, but it is not currently recommended for Crohn's disease management. Treatment decisions should prioritize TNF inhibitors or IL-12/23 inhibitors for patients with both psoriatic arthritis and Crohn's disease.