At the Pharmacy Counter
John* is a 43-year-old male working in an IT department who has been treated with tofacitinib, a Janus kinase (JAK) inhibitor, for 9 months for rheumatoid arthritis. He had previously failed two tumor necrosis factor (TNF) alpha inhibitors (TNFi). At a 3-month follow-up after starting tofacitinib, his RAPID3 (Routine Assessment of Patient Index Data 3) score significantly improved, suggesting that he had achieved low disease severity.
I performed a routine 6-month check-up via telehealth (audio-visual) to assess safety and efficacy monitoring of tofacitinib. The patient’s activities of daily living (ADLs) were assessed to be at an excellent level. He showed me that his hands were free of swelling, and he could make a tight fist. He had started playing golf again. He had significantly reduced his use of OTC pain medications such as ibuprofen or acetaminophen. A chart review demonstrated that he has been adherent with every 3-month blood labs: liver, kidney, and blood counts were normal. Inflammation markers were also within normal limits. He had no symptoms of infection, and he reported no medication side effects.
He has been taking a statin medication prescribed by his primary provider. His lipid panel revealed elevations in cholesterol and LDL, which had been normal prior to this follow-up. Upon questioning, he reported no other medication change, and his diet was also unchanged. Patient does not smoke or drink alcohol.
The Consult
As an interim change, he reported that he had recently been working overtime due to staff shortages at his workplace. His frequent unexpected schedule changes and night shift work caused him to often forget his evening medications including his statin.
I noted from his chart that he missed a scheduled appointment for the second dose of his shingles vaccine. Patient responded he could not come because he had to work.
John had reached the goal of “treat to target,” which is defined as “low disease activity or remission.”¹˒² John is satisfied with his current treatment regimen.
I had identified a couple of problems with medication therapy management in John: lipid abnormality and missed dose of shingles vaccine.
I provided counseling on the two core problem areas as described below.
Lipid Abnormality
Janus kinase inhibitors, such as tofacitinib, baricitinib, upadacitinib, may cause lipid level abnormalities. This side effect can usually be effectively managed with a lipid-lowering agent. John had been receiving statins to treat hyperlipidemia, and had been in good control, but his most recent lab showed increased lipid level. This may be related to the tofacitinib initiation, poor statin adherence, or both.
My action plan for this patient was to:
Develop a strategy to improve his medication adherence.
Carry a small pocket pill container with evening medication.
Set up a daily alarm to remind him to take his evening medications.
Contact John’s primary care doctor to titrate his statin dose as necessary. Because lipid abnormalities can be managed with lipid-lowering medications and he has received a great benefit from tofacitinib, it is recommended the patient continue tofacitinib and manage this lipid abnormality.
Missed Dose of Shingles Vaccine
I counseled the patient that JAK inhibitor use is associated with a significantly increased risk of shingles activation. In addition, the patient has been working extended hours which can further weaken his immune function. John received the first dose of the shingles vaccine prior to the initiation of tofacitinib, and he has received some protection from that vaccination. However, the completion of the second dose is highly recommended to maximize protection.
My action plan for this patient was to:
Ensure that John received a second dose of the recombinant zoster vaccine (RZV, Shingrix) that day.
Professional Takeaways
Below are a few lessons learned regarding the use of JAK inhibitors and managing medication for those with rheumatoid arthritis.
JAK inhibitors have common side effects including infections, cancer, thrombosis, cytopenia, hepatotoxicity, cholesterol elevation, and bowel perforation.³
Routine lab monitoring is required with JAK inhibitor use.³
Routine monitoring should be continued for safe medication use for the patients who achieved effectiveness goal (low disease activity or remission). Vaccinations are important to mitigate infection risks associated with immunosuppressant use.
Recombinant zoster vaccine (RZV, Shingrix) is a non-live vaccine that can be safely administered during JAK inhibitor (or biologic medication) use. In comparison, herpes zoster live attenuated virus vaccine (Zostavax) is contraindicated for the patients who use immunosuppressants such as JAK inhibitors or biologics. Note that Zostavax is no longer available for use in the US.
The CDC updated Shingrix guidance⁴
recommends that patients with rheumatic conditions who are taking immunosuppressants are eligible for Shingrix vaccine if they are 19 years old or older. In general, the recommendations state: “Adults 50 years and older should get two doses of Shingrix, separated by 2 to 6 months. Adults 19 years and older who have or will have weakened immune systems because of disease or therapy should also get two doses of Shingrix. If needed, people with weakened immune systems can get the second dose 1 to 2 months after the first.”
*Identifying details altered for privacy.