JAK inhibitors are emerging as effective treatments for alopecia areata, said Ottawa-based dermatologist Dr. Jennifer Beecker during a presentation at the Great Lakes Immunodermatology Exchange (GLIDE) 5.5 webinar in April 2024. Her presentation is covered in detail in an article in the September 2024 issue of The Chronicle of Skin & Allergy.
Dr. Beecker is a staff dermatologist at The Ottawa Hospital and an Assistant Professor at The University of Ottawa.
Currently, in Canada, two JAK inhibitors are approved for the treatment of alopecia areata, Dr. Beecker said. Baricitinib inhibits the JAK 1 and JAK 2 pathways, and ritlecitinib targets the JAK 3 pathway.
“I always think it’s better to have more drugs available to treat these problems because different people may have different pathogenesis,” she said. “Interestingly, JAK inhibitors can stimulate hair growth on their own.” However, the cause of this stimulation is less well understood.
Ritlecitinib was approved in Canada in Nov. 2023 for use in patients 12 years of age and older with severe alopecia areata. Baricitinib was approved for adults in Feb. 2024, Dr. Beecker noted. “There are no criteria on the monographs for defining severe alopecia areata, which is a good thing for physicians,” she said, noting that this leaves the decision on whether a patient’s treatment should include one of these medications in the hands of the clinician.
There is more safety data in the literature for baricitinib as it has indications for other diseases, such as rheumatoid arthritis and atopic dermatitis, Dr. Beecker said. “Ritlecitinib was only looked at in alopecia.”
Among the findings of the clinical trials for baricitinib and ritlecitinib is that the duration of the current alopecia episode appears to influence how likely a patient is to respond to one of these JAK inhibitors, Dr. Beecker said.
“This does not mean the time they’ve had alopecia areata because we know patients can have remissions and recurrences,” she said. “It’s the current episode of hair loss that the patient is in right now. . . So keep this in mind: the less time they’ve been in the episode, the better they will respond.”
Dr. Beecker said the baricitinib clinical trial program also examined medication withdrawal and recapture as part of its follow-up protocols.
“We all know that one of the first questions [from patients] is, do I have to be on this forever? And the short answer is yes.” Patients who had baricitinib withdrawn in the study lost response. While some patients were able to recapture response when resuming baricitinib, it was not universal.
“So, it’s a risky thing to withdraw the drug,” she said.
Safety-wise, Dr. Beecker said that the trials for these two medications had similar safety signals to what is often seen with JAK inhibitors as a category. “There seems to be a real dose response with efficacy as well as safety. So, the higher the dose, the better efficacy we see. But we also see more AEs [adverse events].”
“What can we tell our patients to expect [with these medications]?”
Dr. Beecker said that in the baricitinib study, at the 4 mg dose, roughly one-third of patients achieved SALT (Severity of Alopecia Tool) scores of 20 or better by week 36, meaning the patient has less than 20% hair loss. Fewer patients achieved this endpoint on the 2 mg dose. In some cases, patients did not see a clinically significant response until week 52. With ritlecitinib at six months, roughly one-quarter of the patients on the approved dosing achieved SALT 20 or better.
“So when you're talking to patients, I think it is important to know that it’s not a total slam dunk, but it’s still a lot better than what we’ve had,” she said.
With this data Dr. Beecker said that when starting a patient on a JAK inhibitor for alopecia areata, she would counsel them that they may need to trial the medication for a year before deciding whether it is effective.
She said it is essential to keep patients on the dose they respond to, as trial data shows 90% of responders will maintain their degree of response, and those who lose response tend not to lose much.
“Importantly for patients, eyelashes and eyebrows respond as well,” Dr. Beecker said, citing the baricitinib study data. She noted patients had a two-point improvement, or a score of 0 or 1, meaning fully regrown or almost entirely regrown eyebrows and eyelashes.
“Similar to the scalp, the numbers are easy to keep in one’s head,” she said. “On the highest dose, the four-milligram dose, about one-third of the patients achieved that pretty good clinical response of almost fully regrown or regrown [eyebrows and eyelashes].”
This article is an excerpt from a longer article published in The Chronicle of Skin & Allergy (Sept. 2024; 30(6):1,16).
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