tofacitinib (Rx)

Brand and Other Names:Xeljanz, Xeljanz XR
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Dosing & Uses

AdultPediatric

Dosage Forms & Strengths

tablet (Xeljanz)

  • 5mg

tablet, extended-release (Xeljanz XR)

  • 11mg
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Rheumatoid Arthritis

Indicated as second-line treatment for moderate-to-severe active rheumatoid arthritis in patients with an inadequate response or intolerance to methotrexate; may be used as monotherapy or in combination with methotrexate or other nonbiologic DMARDs

Tablet: 5 mg PO BID

Extended-release tablet: 11 mg PO qDay

Psoriatic Arthritis

Indicated for active psoriatic arthritis who have had an inadequate response or intolerance to methotrexate or other DMARDs

Recommended dose of in combination with nonbiologic DMARDs

  • Tablet: 5 mg PO BID
  • Extended-release tablet: 11 mg PO qDay

Dosage Modifications

Coadministration with strong CYP3A4 inhibitors: Not to exceed 5 mg qDay

Coadministration with 1 or more drugs that result in both moderate CYP3A4 inhibition and strong CYP2C19 inhibition (eg, fluconazole): Not to exceed 5 mg qDay

Coadministration with strong CYP3A4 inducers: May result in loss of or reduced clinical response; coadministration is not recommended

Coadministration with methotrexate: No dosage adjustment required

Coadministration with P-gp inhibitors: No dosage adjustment required

Renal impairment

  • Mild: No dosage adjustment required
  • Moderate-to-severe: Not to exceed 5 mg qDay (tablet)

Hepatic impairment

  • Mild: No dosage adjustment required
  • Moderate-to-severe: Not to exceed 5 mg qDay (tablet)
  • Severe: Not recommended

Serious infection

  • Interrupt treatment if serious infection develops until infection is controlled
  • Lymphocytes ≥500/mm³: Maintain dose
  • Lymphocytes <500/mm³: Confirmed by repeat testing; discontinue until infection controlled

Neutropenia

  • ANC >1000/mm³: Maintain dose
  • ANC 500-1000/mm³: Interrupt dosing for persistent decreases; when ANC >1000/mm³, resume dose at 5 mg BID (tablet)/ 11 mg qDay (extended-release tablet)
  • ANC <500/mm³: Confirmed by repeat testing; discontinue

Anemia

  • Hgb ≤2 g/dL decrease and level ≥9.0 g/dL: Maintain dose
  • Hgb >2g/dL decrease or level <8.0 g/dL: Confirmed by repeat testing; interrupt treatment until Hgb levels have normalized

Dosing Considerations

Should not be used in combination with biologic DMARDs or potent immunosuppressive agents (eg, azathioprine, cyclosporine)

There is a higher incidence of infections in geriatric patients; use with caution

Switching from regular tablets to extended-release tablets

  • 5Patients treated with tofacitinib 5 mg PO BID may be switched to tofacitinib extended-release 11 mg PO qDay the day following the last dose of tofacitinib 5 mg

Safety and efficacy not established

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Interactions

Interaction Checker

and tofacitinib

No Results

     activity indicator 
    No Interactions Found
    Interactions Found

    Contraindicated

      Serious - Use Alternative

        Significant - Monitor Closely

          Minor

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            Adverse Effects

            >10%

            Overall infections (20-22%)

            1-10%

            URTI (4.5%)

            Headache (4.3%)

            Diarrhea (4%)

            Nasopharyngitis (3.8%)

            UTI (2%)

            Hypertension (1.6%)

            <1%

            ANC <500/mm³ (0.07%)

            Lymphocytes <500/mm³ (0.04%)

            Frequency Not Defined

            Serious infections: 1.7 events per 100 patient-years

            Malignancies: 0.3 events per 100 patient-years

            Blood and lymphatic system disorders: Anemia

            Infections and infestations: Diverticulitis

            Metabolism and nutrition disorders: Dehydration

            Psychiatric disorders: Insomnia

            Nervous system disorders: Paresthesia

            Respiratory, thoracic and mediastinal disorders: Dyspnea, cough, sinus congestion, interstitial lung disease (some fatal)

            Gastrointestinal disorders: Abdominal pain, dyspepsia, vomiting, gastritis, nausea

            Hepatobiliary disorders: Hepatic steatosis

            Skin and subcutaneous tissue disorders: Rash, erythema, pruritus

            Musculoskeletal, connective tissue and bone disorders: Musculoskeletal pain, arthralgia, tendonitis, joint swelling

            Neoplasms benign, malignant and unspecified (including cysts and polyps): Non-melanoma skin cancers

            General disorders and administration site conditions: Pyrexia, fatigue, peripheral edema

            Postmarketing reports

            Diverticulitis

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            Warnings

            Black Box Warnings

            Serious infections

            • Increased risk for developing serious infections that may lead to hospitalization or death; most patients who developed these infections were taking concomitant immunosuppressants (eg, methotrexate, corticosteroid)
            • If serious infection develops, interrupt until infection controlled
            • Reported infections include active TB, invasive fungal infections, and bacterial, viral, or other opportunistic pathogens
            • Test patients for latent TB before and during tofacitinib treatment; treatment for latent TB infection should be initiated prior to tofacitinib treatment

            Malignancies

            • Lymphoma and other malignancies reported
            • Epstein Barr virus-associated post-transplant lymphoproliferative disorder has been observed at an increased rate in renal transplant patients treated with tofacitinib and concomitant immunosuppressive medications

            Contraindications

            None

            Cautions

            Malignancy and lymphoproliferative disorders reported (see Black Box Warnings); malignancies were observed in clinical studies and the post-marketing setting, including, but not limited to, lung cancer, breast cancer, melanoma, prostate cancer, and pancreatic cancer

            GI perforation reported, although role of JAK inhibition in these events is unknown; caution in patients at increased risk for gastrointestinal perforation (eg, diverticulitis)

            Associated with gradual decrease in lymphocyte and neutrophils counts, and hemoglobin levels that may require treatment interruption (see Dosage Modifications)

            Associated with increased LFTs

            Associated with increase lipid parameters including total cholesterol, LDL, and HDL

            Not recommended with severe hepatic impairment

            Viral reactivation, including cases of herpes virus reactivation (e.g., herpes zoster), reported; impact on chronic viral hepatitis reactivation unknown; perform screening for viral hepatitis in accordance with clinical guidelines before starting therapy

            Non-melanoma skin cancers (NMSCs) reported; periodic skin examination recommended for patients at increased risk for skin cancer

            Decreased dose required with moderate hepatic impairment or moderate-to-severe renal impairment (see Dosage Modifications)

            Use caution when treating patients with diabetes; higher incidence of infection in diabetic population in general reported

            Diverticulitis reported

            Structural joint damage progression

            • Radiographic response data from the ORAL Scan and ORAL Start studies evaluated the efficacy of tofacitinib on structural joint damage progression as measured by mean change from baseline in van der Heijde modified Total Sharp Score (mTSS) and its components, erosion score, and joint space narrowing (JSN) score
            • In ORAL Scan, 74% of patients in the placebo/methotrexate group experienced no radiographic progression at Month 6 compared to 84% of patients treated with tofacitinib 5mg BID plus methotrexate
            • In ORAL Start, 55% of patients in the methotrexate group experienced no radiographic progression at Month 6 compared to 73% of patients treated with tofactinib 5mg BID

            Serious infections

            • Serious and sometimes fatal infections reported due to bacterial, mycobacterial, invasive fungal, viral, or other opportunistic pathogens; the most common serious infections reported have included pneumonia, cellulitis, herpes zoster, urinary tract infection, diverticulitis, and appendicitis; among opportunistic infections, tuberculosis and other mycobacterial infections, cryptococcosis, esophageal candidiasis, pneumocystosis, multidermatomal herpes zoster, cytomegalovirus infections, BK virus infection, and listeriosis reported
            • Caution is recommended in patients with a history of chronic lung disease, or in those who develop interstitial lung disease, as they may be more prone to infections
            • Risk of infection may be higher with increasing degrees of lymphopenia; consideration should be given to lymphocyte counts when assessing individual patient risk of infection
            • Avoid use in patients with an active, serious infection, including localized infections
            • Consider the risks and benefits of tofacitinib prior to initiating treatment
              • Patients with chronic or recurrent infection
              • Patients who have been exposed to tuberculosis
              • Patients with a history of a serious or an opportunistic infection
              • Patients who have resided or traveled in areas of endemic tuberculosis or endemic mycoses
              • Patients with underlying conditions that may predispose them to infection

            Extended-release tablet

            • Patients may notice an inert tablet shell passing in the stool or via colostomy
            • Caution when administering the extended-release tablet to patients with pre-existing severe gastrointestinal narrowing (pathologic or iatrogenic); rare reports of obstructive symptoms with strictures in association with the ingestion of other drugs utilizing a non-deformable extended release formulation

            Drug interactions overview

            • Strong CYP3A4 inducers may decrease clinical response
            • Decreased dose required if coadministered with strong CYP3A4 inhibitors, or moderate CYP3A4 inhibitors plus CYP2C19 inhibitors (see Dosage Modifications)
            • Avoid coadministration with live virus vaccines
            • Risk of added immunosuppression when tofacitinib is concomitantly used with potent immunosuppressive drugs (eg, azathioprine, tacrolimus, cyclosporine); combined use of multiple dose tofacitinib with potent immunosuppressants has not been studied in rheumatoid arthritis and psoriatic arthritis
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            Pregnancy & Lactation

            Pregnancy

            There is a pregnancy exposure registry that monitors pregnancy outcomes in women during pregnancy; patients can call the toll free number 1-877-311-8972

            There are no adequate and well-controlled studies therapy in pregnant women

            In the tofacitinib clinical development programs, birth defects and miscarriages were reported

            Animal data

            • Based on animal studies, tofacitinib has the potential to affect a developing fetus
            • Feticidal and teratogenic effects were noted when pregnant rats and rabbits received tofacitinib during the period of organogenesis at exposures multiples of 146 times and 13 times the human dose of 5 mg BID, respectively
            • In a peri and post-natal study in rats, tofacitinib resulted in reductions in live litter size, postnatal survival, and pup body weights at exposure multiples of approximately 73 times the human dose of 5 mg BID
            • Based on findings in rats, females of reproductive potential taking tofacitinib may result in reduced fertility

            Contraception

            • Advise females of reproductive potential to use effective contraception during treatment and for >4 weeks after the last dose
            • Advise females to inform their healthcare provider if they become pregnant, or if pregnancy is suspected, during treatment

            Lactation

            It is not known whether the drug is excreted in human milk

            There are no data to assess effects of drug on breastfed child; drug is excreted in rat milk at concentrations higher than in maternal serum

            Women should not breastfeed while treated; a decision should be made whether to discontinue breastfeeding or to discontinue therapy

            Pregnancy Categories

            A:Generally acceptable. Controlled studies in pregnant women show no evidence of fetal risk.

            B:May be acceptable. Either animal studies show no risk but human studies not available or animal studies showed minor risks and human studies done and showed no risk.

            C:Use with caution if benefits outweigh risks. Animal studies show risk and human studies not available or neither animal nor human studies done.

            D:Use in LIFE-THREATENING emergencies when no safer drug available. Positive evidence of human fetal risk.

            X:Do not use in pregnancy. Risks involved outweigh potential benefits. Safer alternatives exist.

            NA:Information not available.

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            Pharmacology

            Mechanism of Action

            Janus kinases (JAKs) pathways inhibitor; JAK consists of a group of intracellular tyrosine kinases that transmit signals from cytokine or growth factor-receptor interactions on the cellular membrane to influence cellular processes of hematopoieses and immune cell function

            Within the signaling pathway, JAKs phosphorylate and activate signal transducers and activators of transcription (STATs) which modulate intracellular activity including gene expression; tofacitinib modulates the signaling pathway at the point of JAKs, preventing the phosphorylation and activation of STATs

            These signals are essential in maintaining the inflammatory condition in rheumatoid arthritis (RA); inhibition of JAKs reduces production of and modulates proinflammatory cytokines central to RA

            Absorption

            Tablet

            • Bioavailability: 74%
            • Peak Plasma Time: 0.5-1 hr
            • Coadministration with high-fat meal resulted in no changes in AUC while peak plasma concentration was reduced by 32%

            Extended-release tablet

            • Coadministration of with a high-fat meal resulted in no changes in AUC while peak plasma concentration was increased by 27% and peak plasma time was extended by ~1 hr

            Distribution

            Protein Bound: ~40% (predominately to albumin)

            Vd: 87 L (following IV administration)

            Distributes equally between RBCs and plasma

            Metabolism

            Clearance mechanisms: ~70% hepatic metabolism and 30% renal excretion

            Primarily metabolized by CYP3A4 (accounting for ~53% of total clearance) and by CYP2C19 (accounting for ~17% of total clearance)

            Metabolites: Potency <10% of parent compound

            Elimination

            Half-life: 3 hr

            Renal clearance: 30%

            Excretion: 30% urine

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            Administration

            Oral Administration

            May take with or without food

            Extended-release tablets: Swallow whole; do not crush, split, or chew

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            Formulary

            FormularyPatient Discounts

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            Tier Description
            1 This drug is available at the lowest co-pay. Most commonly, these are generic drugs.
            2 This drug is available at a middle level co-pay. Most commonly, these are "preferred" (on formulary) brand drugs.
            3 This drug is available at a higher level co-pay. Most commonly, these are "non-preferred" brand drugs.
            4 This drug is available at a higher level co-pay. Most commonly, these are "non-preferred" brand drugs or specialty prescription products.
            5 This drug is available at a higher level co-pay. Most commonly, these are "non-preferred" brand drugs or specialty prescription products.
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            NC NOT COVERED – Drugs that are not covered by the plan.
            Code Definition
            PA Prior Authorization
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