Hormone levels and Use of Spironolactone for treating Female Pattern Hair Loss:

Do my hormone levels have to be high in order for me to benefit from spironolactone?

Spironolactone is a hormone blocking pill using to treat genetic hair loss in women (also called female pattern hair loss or "FPHL". Spironolactone can reduce the levels and androgens by the adrenals and ovaries. Studies dating back to 2005 showed the spironolactone can stop hair loss in about 40 % of women and increase hair density in 40 % of women. 

The importance of these early findings was the observation that hormone levels at initiation of therapy did not matter. Women with higher hormone levels (ie higher DHEAS and higher total testosterone) were just as likely to benefit as women with lower or normal levels of these hormones. 

Overall, this study was very important as it suggested that hormone levels in female patients do not necessary sway the decision as to whether to use spironolactone or not.

REFERENCE

Treatment of female pattern hair loss with oral anti androgens. Sinclair R, et al. Br J Dermatol. 2005.

Options for men with poor donor hair

What are my options if I don't have much donor hair?

Patients with insufficient donor hair density (poor donor hair density) have a few options :

1. Body hair transplantation.

• BHT is not an option for everyone, but some men do have chest and back hair that can be moved. Body hair transplants are challenging as the removal of grafts can be challenging. But in the properly selected patient it can loos great. 

2. Hair systems.

• Hair systems, when properly selected can look great too. Choosing a company that specializes in hair systems for men is important. Often the scalp is shaved and the human hair system is attached to the scalp with adhesive. I've been very impressed by many patient's systems. 

3. Scalp micropigmentation (SMP).

SMP involves the tattooing of small circular "dots" on the scalp with tattoo inks. The goal is to created the same look as when the hair on the scalp is shaved. When done well, it can look outstanding for men who wish to wear the hair very short (shaved look).

Zinc deficiency and hair loss

Can zinc deficiency cause hair loss?

 

 

 

Yes, if zinc deficiency is severe enough (meaning zinc levels are low enough), the deficiency can cause hair loss. Zinc deficiency is not all that common in the Western world but the odds of having zinc deficiency increases with the following:

1.  poor dietary intake of zinc containing foods

2. intestinal problems impairing absorption

3. pregnancy

4. alcohol use

5. intense physical training and exercise programs

6. chronic liver disease

7.  weight loss surgery (bariatric surgery)

Testing for Zn deficiency

If one is wondering about zinc defiency, a blood test can be done. The bigger challenge though is having someone knoweldgable interpret those results if low to determine if even relevant to hair loss or not. 

Scalp symptoms (burning, tingling, pain) and chronic telogen effluvium

Trichodynia in CTE: Common but Poorly Understood

"Trichodynia" literally means hair pain (both from the Greek roots  θρίξ ‎(thríx, “hair” and .οδύνη odúnē "pain). Trichodynia is poorly understood and too often incorrectly described.

Trichodynia is not a diagnosis. Rather it's a symptom that patients report of pain and burning. Initial studies by Rebora et al suggested that 34 % of those with hair loss have painful sensations in the scalp. In another study, Grimalt reported that 22 % of women with hair loss had trichodynia. This includes those diagnosed with chronic telogen effluvium but also those with androgenetic alopecia and other types of hair loss. Even those with depression and anxiety can experience scalp pain. Trichodynia is twice as common in women as in men. 

Taken together,  trichodynia is not specific for any one kind of hair loss.  However, it appears to be much more common in those with CTE. In fact, Rebora first proposed that trichodynia was specific for CTE. That however, does not appear to be quite accurate.  Trichodynia is seen in many conditions. Trichodynia is reported by some as synonymous with red scalp syndrome. This too is not true. These two conditions are different. While some patients with red scalp syndrome have trichodynia, most patients with trichodynia do not end up being diagnosed with red scalp syndrome. 

The cause of trichodynia is unknown but probably due to many different factors - all that lead to trichodynia. At a biochemical level, it appears that increased levels of a chemical called substance P in the scalp can contribute to trichodynia. 

Treatment of trichodynia is challenging. My approach is a mix of anti seborrheic shampoos, topical capsaicin shampoos, topical steroids and sometimes pharmacological agents such as gabapentin, amitriptyline, nortriptyline, SSRIs.

View of a Canadian Hair Doc

Toronto is most culturally diverse city in the world

Toronto is an culturally diverse city. With over 200 ethnic groups and 140 languages, it tops the list every year of diverse cities. More than 50 % of people in Toronto were born outside of Canada. Practicing in a city like Toronto is truly amazing. Every day, I see a great number of hair types. You name it and we see it. Men, women, children babies. Caucasian hair, Asian hair, afrotextured hair, and all variations in between.  My Vancouver practice is less diverse but still  diverse nevertheless. Vancouver statistics claim 50 % caucasian, and 40 % South asian/Asian and southeast Asian.

Canada is a great place to be a hair doc.

What's the difference between Androgenetic Alopecia (AGA) and Telogen effluvium (TE)

AGA vs TE in Women

I've reviewed the differences between AGA and TE before but now is a good time to review features again. Often women have both features. 

 AGA is genetic hair loss and a key feature for women is

1. hair fibers get thinner and thinner over time. 

2. shedding occurs in the early stages just like TE

3. more is lost in the frontal and middle than the back but it can be all over

4. treatments like minxoidil, spironolactone, laser, PRP and sometimes hair transplants help. Without treatment, hair loss is progressive over time. 

 

TE, or telogen effluvium, refers to shedding of hair, more than the daily average

 

1. hair fibers are shed from the scalp

2. the fibers stay the same size there is simply less of them

3. shedding occurs all over - the front of the scalp is just as affected as the back

4. often a trigger causes the shedding in the first place - like stress, low iron, medications (especially starting and stopping birth control), crash diets, and a range of illnesses

5. Treatments are geared to fixing the original trigger. If iron is low, the iron must be fixed. if thyroid problems are identified this must be addressed. A TE often stops once the trigger is properly and completely addressed but it may take 6-9 months. 

Often women have both TE and AGA.

Vitamin D Levels in Alopecia Areata and Androgenetic Alopecia: New evidence of a potential role

New evidence of a potential role of Vitamin D Signalling in Alopecia Areata and Androgenetic Alopecia

The precise role of vitamin D in hair loss is still controversial. It’s clear that vitamin D has a role in hair growth since individuals born with abnormalities in the vitamin D receptor are completely bald. However, the role of vitamin D in adults with various types of hair loss is not completely clear.

Researchers from Egypt set out to examine the role of vitamin D in hair loss by comparing the levels of the vitamin D receptor (VDR) in blood and scalp biopsy samples of 60 patients - 20 patients with AA, 20 patients with AGA, and 20 healthy controls.  

What were the results?

Interestingly, both serum and hair biopsy levels of the vitamin D receptor (VDR) were lower in individuals with alopecia areata and genetic hair loss than individuals who did not have the condition.

Conclusion

This is an interesting study that adds to the growing body of knowledge suggesting that vitamin D might have an important role in the steps that ultimately lead to alopecia areata (AA) and genetic hair loss (AGA). The next big question is to understand if (and how much) vitamin supplementation – either topically or by pill form – can benefit individuals with these conditions

REFERENCES

 

Fawzi, M. M. T., Mahmoud, S. B., Ahmed, S. F. and Shaker, O. G. (2016), Assessment of vitamin D receptors in alopecia areata and androgenetic alopecia. Journal of Cosmetic Dermatology. doi: 10.1111/jocd.12224

Platelet rich plasma benefits androgenetic alopecia: A new study

New study confirms benefit of platelet rich plasma benefits androgenetic alopecia

Several studies in the past 4-5 years have pointed to a beneficial role for platelet rich plasma (PRP). What has been missing from many of these studies is proper comparison between areas that received the PRP and area that received a placebo.

A new study looked at the benefits of PRP in 25 patients. PRP was injected into ½ of the head and placebo was injected into the other half. Each of the patients received 3 treatments – one month apart. Then, the researchers looked at the changes in hair growth at times 3 months and 6 months.

The authors used a PRP concentration 3 times higher than the concentration in the whole blood (3 times above baseline) and activated the blood with calcium chloride.

What were the results?

The study showed that PRP treatment led to an increase in anagen (growing hairs), and an increase in hair density at month 3 (when treatment ended) and this was still present 3 months later (at month 6).

Interesting, it appears there is some reduction in the effects of PRP if patients do not receive additional treatments. For example, at month 3 hair density was noted to increase by 14.8 hairs per sq cm in the treatment group and be reduced by 0.7 hairs per sq cm in the control group.  However, by month 6, the hair density was onlyincreased by12.8 hairs per sq cm compared to a reduction in 2 hairs per sq cm in the control group.

Conclusion

This is yet another study supporting the benefits of PRP. There remain many unknowns in PRP including what are the differences between using blood that is 3 times above baseline vs 5 times above baseline, what is is the appropriate amount of PRP to inject, and what is the appropriate method of activation (calcium chloride, calcium gluconate or thrombin).

PRP continues to be an exciting field.  We have an active interest in addressing some of these questions.

REFERENCES

Alves et al. Randomized placebo controlled double blind half head study to assess the efficacy of platelet rich plasma on the treatment of androgenetic alopecia. Deramtologic Surgery. 2016; 42:491-7.

Acute and chronic telogen effluvium - what's the difference?

TE vs CTE

There are a lot of misconceptions about telogen effluvium (sometimes called acute telogen effluvium or just "TE") and chronic telogen effluvium or "CTE". They are very different conditions.

 TE is extremely common and occurs in all ages. It's often results from one or more of the four big categories of 'triggers' -  low iron, stress, endocrine problems (thyroid problems) and medications (especially birth control). However, in one half of cases, the cause is not found. Blood tests are often abnormal in TE and so everyone with TE needs blood tests. 

What about CTE? There is quite a bit of misunderstanding even among physicians about CTE. Some physicians call it when the TE simply goes on more than 6 months. I think that's wrong. For example if you have low iron and develop shedding of hair, we call it 'acute telogen effluvium'. If it goes on for 7 months and the iron has not been replaced then I strictly call it "acute telogen effluvium" from low iron that has not yet been addressed. I don't simply call it CTE once it passes the 6 month mark.   CTE is a condition unto itself.

CTE develops in women 35-60 who often had massive amounts of hair at one time. These women develop shedding when all the blood tests you can order are just perfect. This is CTE. The temples can show recession more than other areas and some days have lots of shedding and other days not so much. Many women with CTE have symptoms (burning, tingling, crawlers). CTE is not just TE that passes the 6 month anniversary.  CTE is very different! Women with CTE once had massive amounts of hair and even when they lose a lot of it - it still looks like they have a lot of hair. 

Understanding SHBG and consideration in women with FPHL

SHBG is a sponge for hormones

Many female patients who have had extensive blood tests to evaluate hormone levels and hormone function will often see a test ordered as "Sex hormone binding globulin (SHBG)." SHBG are often ordered for women with irregular periods, acne, women with insulin resistance, some women with severe thyroid abnormalities. Of course, it's sometimes ordered for women with female pattern hair loss 

What is SHBG?

SHBG is a protein that binds to hormones. SHBG binds to androgens and binds to estrogens.  It essentially sops them up and prevents them from doing their job. SHBG levels are higher in women than men and higher before puberty than after puberty. 

Why evaluate SHBG in female pattern hair loss?

In some young women with female androgenetic hair loss, I order SHBG levels. Sometimes I order the tests to gain a better understanding of the diagnosis (see below for causes of low SHBG), but sometimes I order as a means of monitoring as I hope the SHBG levels rise with treatments (such as starting a birth control pills.)

 

Monitoring SHBG is complex and requires expert input as to causes of low and high levels. 

LOW SHBG:

In general, low SHBG levels are seen in women with polycystic ovarian syndrome (PCOS), obesity, insulin resistance and hyperinsulinemia, growth hormone, hypothyroidism, acromegaly, Cushing syndrome (a condition of excessive steroid production by the body), corticosteroids, and use of androgen hormones (testosterone for women), and some types of synthetic progestins (norethindrone, norgestrel, desogestrel, norgestimate)

ELEVATED SHBG:

Many things elevate SHBG including oral contraceptives, estrogens, thyroid problems, liver problems, pregnancy, extreme dieting, cancers, medications (i.e. dilantin), and smoking. In young women, one of the more common causes of increased SHBG is starting oral contraceptives and pregnancy.  Most OCPs lead to an increase in SHBG levels by 3-4 times over baseline. 

COMMENT

Overall, causes of increased and decreased SHBG are sometimes complex and require careful evaluation by a physician knowledgeable about all these causes. 

Tofacitinib for Alopecia Areata: A look at changes in Inflammatory Markers

CXCL10 Levels drop quickly in a patient successfully treated

You've probably never heard of CXCL10. It's a small protein that gets secreted into the blood when there is inflammation around. Many cells make CXCL10 including blood vessel cells (endothelial cell), fibroblasts, monocytes. The CXCL10 helps attract a variety of inflammatory cells such as T cells, NK cells. 

A new study looked at levels of CXCL10 in a patient successfully treated with tofacitinib. The patient was a 40 year old female with severe alopecia areata treated with 5 mg twice daily of tofacitinib. She regrew hair rapidly on treatment. This was associated with a decrease in the blood levels of CXCL10 within 1 month.  Other inflammatory markers were also altered. 

Conclusion and Comment

We are now entering a new era where blood levels of certain proteins may soon be used to predict responses to treatments as well as monitor the possible chances of relapse. CXCL10 could be an important protein to evaluate in predicting response to treatment. 

Minoxidil plus finasteride: better than either one alone

Minoxidil + Finasteride : How do they add up?

Patients who use minoxidil and finasteride together get better results than those who use just minoxidil or those who use just finasteride. There have been a few studies that have shown this. 

A recently designed study examined the benefits of monoxidil, finasteride and the combination in 450 males with genetic hair loss. The men in the study were randomly assigned to receive:

            finasteride (n = 160 patients), 

            minoxidil (n = 130 patients) 

            combined medication (n = 160 patients) 

In this study, the participants returned to the clinic every 12 weeks for re evaluation.  At the one year mark, 80.5 % of men treated with finasteride, 59% of of men treated with minoxidil, and 94.1% men treated with the combination of both have a benefit, respectively.  

CONCLUSION

The conclusion of the study was that the combination is better than either alone

REFERENCE

Combined treatment with oral finasteride and topical minoxidil in male androgenetic alopecia: a randomized and comparative study in Chinese patients.Hu R, et al. Dermatol Ther. 2015 Sep-Oct.

What's new in Alopecia Areata Research ?

AA Research Moving Ahead at Great Speed

I had the great privilege of joining the Canadian Alopecia Areata Foundation this past weekend at their Spring session. I reviewed the latest research in alopecia areata. There are many interested new studies, but I chose to focus on five including:

1. a review of the benefits of cholesterol medications for alopecia areata treatment

2. The role of platelet rich plasma in treating alopecia areata

3. New evidence that patients with AA have a  reduced risk of skin cancer

4. Evidence confirming that steroid injections are better than topical steroids for treating localized alopecia areata

5. New data on the benefits of tofacitinib and ruxolitinib in treating alopecia areata including new exciting topical formulations that have been studied. 

You can review my slides below:

Is there a reduced risk of skin cancer in patients with alopecia areata?

Decreased risk of skin cancer in patients with AA

Alopecia areata is an autoimmune condition. Recent studies have suggested that a closely related autoimmune condition called vitiligo (whereby skin cells lose pigment) may be associated with a decreased risk of skin cancer.

In a new study, researchers from Harvard looked at the the risk of skin cancer in patents with alopecia areata compared to patients who did not have alopecia areata. A incidence of skin cancer in 1414 patients with alopecia areata was compared to the risk of skin cancer in 4242 patients who did not have alopecia areata.

Overall, there were fewer patients with alopecia areata who were diagnosed with basal cell and squamous cell skin cancers compared to patients who did not have alopecia areata. Interestingly, there was a slightly decreased risk of melanoma as well.

CONCLUSION

Patients with alopecia areata appear to have a 37 % reduction in the risk of squamous cell and basal cell carcinomas. 

REFERENCE:

Mostaghimi et al. Reduced incidence of skin cancer in patients with alopecia areata: A retrospective cohort study. Cancer Epidemiology 2016

PCOS related hair loss - more than one treatment needed

Multimodal treatments are usually necessary for PCOS. The ideal is usually a combination of minoxidil, oral contraceptives, spironolactone and low level laser. I always advise that patients see their dermatologist or endocrinologist for advice. Certainly, these treatments aren't appropriate for everyone. inoxidil helps 30 % of women with genetic hair loss, but not everyone. It helps halt loss and may improve hair density a bit. It can thicken hair a little bit and promote growth of dormant hair. As many are aware,  shedding is common in months 1 and 2. 

PCOS related thinning usually requires more than 1 treatment for most effective results. I like to add zinc (periodically) and selenium to my general recommendations as well. 

Razavi et al studied the effect of receiving either 200 μg selenium daily (n=32) or placebo (n=32) for 8 weeks. Jamilian et al studied the effect of  220 mg zinc sulfate (containing 50 mg zinc) (n = 24) or placebo (n = 24) for 8 weeks.  Although the short in duration, both studies showed an improvement in various clinical parameters and improved hair growth.

REFERENCES

Razavi M, Jamilian M, Kashan ZF et al. Selenium supplementation and the effects on reproductive outcomes, biomarkers of inflammation and oxidative stress in women with polycystic ovarian syndrome.  Horm Metab Res. 2015 Aug 12. [Epub ahead of print]

Jamilian M, Foroozanfard F, Bahmani F et al. Effects of zinc sypplementation on endocrine outcomes in women with polcystic ovarian syndrome: a randomized, double-blind placebo controlled trial. Biol Trace Elem Res. 2015 Aug 28. 

Chronic telogen effluvium vs Genetic hair loss - Easily confused !

CTE vs AGA - easily confused but different conditions

CTE and AGA are often easily confused. Labs normal in both. Family history of hair loss similar in both. Hair check similar in both. Biopsy often unhelpful unless done properly (meaning transverse sections and measurement of terminal to vellus ratios).

CTE takes time to figure out. Info on family history of AGA is not useful at all in diagnosing AGA in women.  AGA doesn't start in the 50s in women. All in all, you'd need a careful examination. CTE is the most challenging of diagnoses.

FEATURES OF CTE

1. CTE leads to fluctuations in shedding with shorter breaks

2. Women often once had thick hair (very thick)

3. Miniaturization not typical

4. Onset is sudden

5. Scalp sensations (tingling, burning) often present

6. Pretty normal looking scalp exam or maybe significant temple recession in some

7. Labs normal

8. Some days 50 hairs lost; some days 350-400

9. After 6-8 months, tends to reach a balance between shedding and growing and patients look similar month after month (despite massive shedding!!!)

10.           Biopsy done with horizontal sections show terminal to vellus ratios above 8:1 (whereas less than 4:1 for AGA)

11.           Central part width not typically widened in CTE

CONCLUSION

I understand how tough it is to get a diagnosis of CTE vs AGA. But they are very different conditions.

What are the most effective and best researched treatments for lichen planopilaris?

LPP treatments: Where does the research point to?

Lichen planopilairis (LPP) is an autoimmune scarring hair loss condition that affected adults between 35 and 60. Patients develop hair loss but also symptoms of itching, burning and pain. The early stages of LPP are accompanied by increased shedding as well. Aggressive and early treatment of LPP is required to stop the hair loss. 

 

What treatments are most effective?

Treatment that block inflammation are most effective. But not any anti-inflammatory can be used. For example, aspirin and ibuprofen don't help. Rather anti-inflammatories belonging to a group of medications known as immunosuppressive and immunomodulatory drugs work best. This includes:

1. Topical steroids (mid to strong potency) and steroid injections

2. Topical tacrolimus (Protopic) and topical pimecrolimus (Elidel)

3. Oral hydroxychloroquine (Plaquenil and generics)

4. Oral tetracyclines (doxycycline, tetracyline, minocycline)

5. Oral cyclosporine (Neoral, prograft, Sandimmune)

6. Oral mycophenolate mofetil (Cellcept, Myfortic)

7. Oral predisone (mainly for flares and early bridging treatment, not long term)

These 7 treatments have the best published evidence for assistance with lichen planopilaris. Any other treatment has less evidence. 

Conclusion

Whenever a patient tells me they have tried treatments for lichen planopilaris and it didn't work, I want to know two things. First, I want to know if they truly have lichen planopilaris as there are many many mimickers. Biopsies can be wrong ... yes! and yes! Conditions like pseudopelade of Brocq can mimic LPP and so can a few other scarring alopecias (discoid lupus and folliculitis decalvans). The second thing I want to know is what treatments the patient has tried.  I've heard countless treatments - perhaps well over 60 to date. Being on treatment does not count unless it's a potentially beneficial one. 

 

References

 

Lichen planopilaris: update on pathogenesis and treatment.

Baibergenova A, Donovan J. Skinmed. 2013 May-Jun;11(3):161-5. Review

Efficacy of oral retinoids in treatment-resistant lichen planopilaris.

Spano F, Donovan JC. J Am Acad Dermatol. 2014 Nov;71(5):1016-8. doi: 10.1016/j.jaad.2014.06.013. Epub 2014 Oct 15.  

Lichen planopilaris following whole brain irradiation.

Perrin AJ, Donovan JC. Int J Dermatol. 2014 Oct;53(10):e468-70. doi: 10.1111/ijd.12576. Epub 2014 Jun 5.  

Scalp trauma: a risk factor for lichen planopilaris?

Montpellier RA, Donovan JC. J Cutan Med Surg. 2014 May-Jun;18(3):214-6.

Lichen planopilaris after hair transplantation: report of 17 cases.

Donovan J. Dermatol Surg. 2012 Dec;38(12):1998-2004.

Genetic hair loss in women: sides and back can be affected too

Genetic hair loss in women is different than men

Genetic hair loss in women classically affects the middle and top of the scalp. The scalp becomes more 'see through'. Hairs become miniaturized. Patterns such as the Ludwig pattern of hair loss and the Olsen pattern of hair loss are often talked about. 

What about the sides and back?

What tends to be forgotten is that the sides and back of the scalp are often affected in many women with genetic hair loss. We call this 'diffuse loss.' Diffuse thinning of hair occurs in many women. The area at the sides of the scalp just above the ear becomes noticeably thinning and the back of the scalp becomes thinner as well. 

Treatments for diffuse androgenetic thinning in women include minoxidil, spironolactone, low level laser therapy, and platelet rich plasma. Women with diffuse thinning are not candidates for hair transplant surgery because the hairs at the back of the scalp are thinning  - the donor area is poor. 

Minoxidil after hair transplantation

Minoxidil after hair transplantation: Is there a role?

I’m often asked whether minoxidil has any role in post operative care after a hair transplant. My general advice is that minoxidil may help reduce shedding of grafts and shedding of existing hair (ie. a post operative telogen effluvium) ...  but does not appear to influence the chance of the grafts surviving.

Here are some studies of note:

In 1987, Kassimir first reported that 2 of 12 patients undergoing a hair transplant showed growth of the grafts without shedding. Thereafter, Singh published a study with 40 patients showing that minoxidil did not affect the survival of grafts after a transplant but did affect the chances that the grafts would be shed. A similar finding was reported by Bouhanna in 1989.

Overall there is a role for minoxidil in pre and post operative care. Minoxidil may reduce shedding of grafts and may reduce the post operative telogen effluvium of existing hair as well. Whether or not one should use it, however, needs to be reviewed on a case by case basis.

STUDIES:

1. Kassimir JJ. Use of topical minoxidil as a possible adjunct to hair transplant surgery. A pilot study. J Am Acad Dermatol. 1987 Mar;16(3 Pt 2):685-7.

2. Bouhanna P. Topical minoxidil used before and after hair transplantation. J Dermatol Surg Oncol. 1989 Jan;15(1):50-3.

3. Singh G. Effect of minoxidil on hair transplantation in alopecia androgenetica. Indian J Dermatol Venereol Leprol. 1998 Jan-Feb;64(1):23-4.

Monitoring blood tests in patients receiving tofacitinib (Xeljanz)

What lab tests are most important to monitor in alopecia areata patients receiving tofacitinib?

Tofacitinib is an oral medication that is used off label for the treatment of alopecia areata.  Research continues into exactly how much it helps patients with alopecia areata.  Frequent blood tests are required during the first few weeks and months of use.

Changes in four main areas are possible.

1.     Changes in blood counts. Tofacitinib can cause a reduction in neutrophils as well as lymphocytes. Patients with more severe reductions in lymphocytes appeaer to be at greatest risk for developing injections. This effect is greatest in patients receiving 10 mg compared to 5 mg.

2.     Increases in cholesterol levels. Patients experience inceases in both LDL and HDL. This effect is greatest in patients receiving 10 mg compared to 5 mg.

3.     Increase in liver enzymes. This is rather uncommon but needs to be monitored.

4.     Increase is creatine phosphokinease (CPK, CK). This occurs in a proportion of patients and is usually withouth consequence for most patients. The drug must be stopped however, when levels increase 50 % above baseline. This effect on CPK levels is greatest in patients receiving 10 mg compared to 5 mg.

Comment: 

Frequent blood tests are needed when starting tofacitinib. Slight changes are not uncommon but more significant changes may require dose reduction or even stopping of the drug. Anyone starting tofacitinib requires close monitoring.