A practical guide to using oral Janus kinase inhibitors for atopic dermatitis from the International Eczema Council

Background Janus kinase inhibitors (JAKi) have the potential to alter the landscape of atopic dermatitis (AD) management dramatically, owing to promising efficacy results from phase III trials and their rapid onset of action. However, JAKi are not without risk, and their use is not appropriate for all patients with AD, making this a medication class that dermatologists should understand and consider when treating patients with moderate-to-severe AD.Objectives To provide a consensus expert opinion statement from the International Eczema Council (IEC) that provides a pragmatic approach to prescribing JAKi, including choosing appropriate patients and dosing, clinical and laboratory monitoring and advice about long-term use.Methods An international cohort of authors from the IEC with expertise in JAKi selected topics of interest were placed into authorship groups covering 10 subsections. The groups performed topic-specific literature reviews, consulted up-to-date adverse event (AE) data, referred to product labels and provided analysis and expert opinion. The manuscript guidance and recommendations were reviewed by all authors, as well as the IEC Research Committee.Results We recommend that JAKi be considered for patients with moderate-to-severe AD seeking the benefits of a rapid reduction in disease burden and itch, oral administration and the potential for flexible dosing. Baseline risk factors should be assessed prior to prescribing JAKi, including increasing age, venous thromboembolisms, malignancy, cardiovascular health, kidney/liver function, pregnancy and lactation, and immunocompetence. Patients being considered for JAKi treatment should be current on vaccinations and we provide a generalized framework for laboratory monitoring, although clinicians should consult individual product labels for recommendations as there are variations among the different JAKi. Patients who achieve disease control should be maintained on the lowest possible dose, as many of the observed AEs occurred in a dose-dependent manner. Future studies are needed in patients with AD to assess the durability and safety of continuous long-term JAKi use, combination medication regimens and the effects of flexible, episodic treatment over time.Conclusions The decision to initiate JAKi treatment should be shared between the patient and provider, accounting for AD severity and personal risk-benefit assessment, including consideration of baseline health risk factors, monitoring requirements and treatment costs.Janus kinase inhibitors (JAKi) have the potential to alter the landscape of atopic dermatitis (AD) management dramatically, given the promising efficacy results from phase III trials, coupled with the rapid onset of action of JAKi. However, JAKi are not without risk, and their use is not appropriate for all patients with AD. This consensus expert opinion statement provides a pragmatic approach to prescribing JAKi, including choosing appropriate patients, dosing, and clinical and laboratory monitoring, as well as long-term use.Drugs called Janus kinase inhibitors ('JAKi' for short) have the potential to change how atopic dermatitis (or 'AD') is treated. Promising results from clinical trials and their ability to work quickly make JAKi a type of medication that should be considered for treating moderate-to-severe AD. There are some risks with JAKi treatment and they are not appropriate for all people with AD.Researchers from around the world reviewed the published information on JAKi. We provide a sensible approach to prescribing these drugs. We considered three JAKi used to treat AD. Although each JAKi is different in how effective it is and what the side effects are, we have tried to provide general guidance that may be used for all JAKi.This guidance allows for standardization and simplification of prescribing JAKi to treat AD. However, some procedures or how often monitoring is done, are slightly different for each JAKi. Using the most current safety data, we provide recommendations that cover all JAKi.