In a 27‑year‑old man with hip synovial chondromatosis diagnosed 4 years ago and early osteoarthritis on ultrasound, who has been taking tofacitinib 5 mg daily with occasional severe stiffness, should the tofacitinib be continued?

Discontinue Tofacitinib Immediately in This Patient

Tofacitinib is not approved for osteoarthritis or synovial chondromatosis and should be stopped immediately. 1 This patient has been inappropriately prescribed a JAK inhibitor for a non-inflammatory mechanical joint condition, exposing him to serious cardiovascular, thrombotic, infectious, and malignancy risks without any evidence-based benefit.

Why Tofacitinib Must Be Stopped

Lack of Indication

• Tofacitinib is FDA-approved only for rheumatoid arthritis, psoriatic arthritis, ulcerative colitis, and polyarticular juvenile idiopathic arthritis—not for osteoarthritis or synovial chondromatosis. 1
• No major rheumatology or orthopedic guidelines recommend tofacitinib for OA treatment due to complete absence of clinical trial data supporting its use in OA patients. 1
• Synovial chondromatosis is a mechanical disorder characterized by cartilaginous loose bodies, not an autoimmune inflammatory arthritis requiring immunosuppression. 1

Serious Safety Risks Without Benefit

• In patients over 50 years with cardiovascular risk factors, tofacitinib carries a five-fold increased risk of pulmonary embolism compared to TNF inhibitors. 2
• The ORAL Surveillance trial demonstrated increased major adverse cardiovascular events (MACE) and venous thromboembolism in older RA patients with cardiovascular risk factors receiving JAK inhibitors. 2
• Tofacitinib is associated with elevated rates of serious infections, particularly herpes zoster, tuberculosis, and opportunistic infections. 1, 3
• There is an increased cancer risk in patients over 50 with cardiovascular risk factors. 1
• Hematologic effects include lymphocytopenia and anemia requiring ongoing monitoring. 1

What This Patient Actually Needs

Appropriate Management of Synovial Chondromatosis

• Synovial chondromatosis is a mechanical problem requiring surgical intervention (arthroscopic synovectomy and loose body removal), not immunosuppression. The stiffness this patient experiences is from mechanical obstruction by cartilaginous bodies and secondary osteoarthritis, not from inflammatory synovitis that would respond to JAK inhibition.
• The early OA diagnosed on ultrasound is a consequence of the underlying synovial chondromatosis and mechanical joint damage.

Evidence-Based OA Management

• NSAIDs at the minimum effective dose for the shortest duration after evaluation of gastrointestinal, renal, and cardiovascular risks. 4
• Intra-articular glucocorticoid injections for relief of local symptoms of inflammation. 4
• Non-pharmacological interventions including dynamic exercises and occupational therapy as adjuncts to treatment. 4
• Weight control and management of comorbidities should be part of overall patient care. 4

Critical Safety Pitfall

The most dangerous aspect of this case is that the patient attributes symptom improvement to tofacitinib, creating a false sense of therapeutic benefit. Any perceived improvement is likely due to:

• Natural disease fluctuation
• Placebo effect
• Concurrent use of rose hip extract (which has some anti-inflammatory properties)
• Time-dependent reduction in acute inflammatory response to loose bodies

This misattribution prevents the patient from seeking appropriate surgical management while exposing him to serious medication risks.

Immediate Action Plan

1. Discontinue tofacitinib immediately 1
2. Refer to orthopedic surgery for evaluation of arthroscopic synovectomy and loose body removal
3. Initiate appropriate OA management with NSAIDs (if no contraindications), physical therapy, and weight optimization 4
4. Screen for complications from tofacitinib exposure including tuberculosis screening, complete blood count, liver function tests, and lipid panel 2
5. Counsel the patient that his condition requires mechanical intervention, not immunosuppression

The occasional severe stiffness he experiences is likely from loose body migration causing mechanical locking, not from inadequate immunosuppression—further confirming that tofacitinib is the wrong treatment approach entirely.