COVID 19 Infection in Alopecia Areata Patients on Tofacitinib: Do we stop the drug?

Stopping Tofacitinib May not Be Necessary for Patients with COVID 19

Tofacitinib is a JAK inhibitor and is currently used off label for treating alopecia areata. Use of the drug may increase the risk of patients developing infection. Viral infections, bacterial infections and fungal infections are among the infections that may be increased.

A great amount of attention has focused on viral infections - especially herpes zoster (shingles) and COVID 19 infections. What should we do if patients get infections with these viruses? Stopping the drug had been the standard of care for shingles infections in the past even though new data is now suggesting that continuing the drug may not carry a much higher chance of worse outcomes in rheumatoid arthritis patients.

For alopecia areata patients using tofacitinib, the standard of care in the early pandemic had been to stop the drug if a patient gets COVID 19. However, soon thereafter it became increasingly clear that some JAK inhitors like baricitinib can actually be used to treat severe COVID 19. Trials have shown that baricitinib use reduced hospitalization times and was associated with fewer adverse events and less severe events. On Nov 19 2020, baricitinib received emergency use authorization by the FDA for use with remdesivir for treating COVID 19 in hospitalized patients. On May 11 2022, baricitinib received formal FDA approval for treating COVID 19.

The question then becomes - do we really need to be telling alopecia aretaa patients using tofacitinib to stop tofacitinib if they get COVID 19 infection?

Youssef et al, 2022

Authors from New York set out to retrospectively evaluate whether or not oral tofacitinib among AA patients affected clinical outcomes (hospitalization, oxygen supplementation, intensive care unit (ICU) admission) after controlling for baseline AA patient characteristics.

The authors identified 73 chart-documented COVID-19 cases among alopecia areata patients. Among these 73 patients, there were 29 tofacitinib treated (TT) and 44 treatment-naïve (TN) AA patients. All 29 TT patients were on 10 mg twice a day dosing.

Results

a) Baseline characteristics

The authors controlled for variables known to lead to a worse outcome among COVID-19 patients. Median age was slightly higher in treatment naive AA (34.5 vs 31, p=0.057) and this group had more females (59.1% vs 41.4%) patients compared to the tofacitinib treated group. (p=0.158) compared to TT AA. Race and ethnicity distributions were different between treatment groups with tofa treated AA group mostly being White (87% vs 33.3%, p<0.001), Non-Hispanic (100% vs 46.7%, p<0.001). More patients had hypertension (15.9% vs 0%, p=0.037) and cardiovascular disease (20.5% vs 0%, p=0.009) in treatment naive AA group

b) Outcomes

No tofacitinib treated AA patients had deterioration (hospitalization, oxygen requirement, ICU admission) in infection course. In the treatment naive AA cohort, 5/44 were hospitalized (2 on oxygen nasal cannula, intubated for 3 days, and 1 intubated with complicated ICU course).

Conclusions

The authors show in a small study that use of tofacitinib did not appear to causes worse outcomes and in fact may even had a somewhat protective protective effect.

It is not clear that stopping tofacitinib should be a standard of care when alopecia areata patients are infected with COVID 19.

In light of the bacicitinib approval for COVID 19, it may be reasonable in some patients to continue tofacitinib despite COVID 19 infection. This needs to be taken on a case by case basis.

REFERENCE

Youssef S et al. Tofacitinib Therapy for Alopecia Areata is not Associated with Adverse Events during COVID-19 Infection. J Am Acad Dermatol. 2022 May 9;S0190-9622(22)00795-2.