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Tofacitinib

Medically reviewed on September 10, 2018

Pronunciation

See also: Otezla

(toe fa SYE ti nib)

Index Terms

  • CP-690, 550
  • Tofacitinib Citrate

Dosage Forms

Excipient information presented when available (limited, particularly for generics); consult specific product labeling.

Tablet, Oral:

Xeljanz: 5 mg

Tablet Extended Release 24 Hour, Oral:

Xeljanz XR: 11 mg

Brand Names: U.S.

  • Xeljanz
  • Xeljanz XR

Pharmacologic Category

  • Antirheumatic Miscellaneous
  • Antirheumatic, Disease Modifying
  • Janus Associated Kinase Inhibitor

Pharmacology

Tofacitinib inhibits Janus kinase (JAK) enzymes, which are intracellular enzymes involved in stimulating hematopoiesis and immune cell function through a signaling pathway. In response to extracellular cytokine or growth factor signaling, JAKs activate signal transducers and activators of transcription (STATs), which regulate gene expression and intracellular activity. Inhibition of JAKs prevents cytokine- or growth factor-mediated gene expression and intracellular activity of immune cells, reduces circulating CD16/56+ natural killer cells, serum IgG, IgM, IgA, and C-reactive protein, and increases B cells.

Absorption

Oral:

Immediate release: Rapid (74%); Cmax is reduced by 32% when administered with high-fat meal, but AUC remains unchanged.

Extended release: Cmax increased by 27% and Tmax was extended by ~1 hour when administered with high-fat meal, but AUC remains unchanged.

Distribution

Vd: 87 L

Metabolism

Hepatic (70%): CYP3A4 and CYP2C19 to inactive metabolites

Excretion

Primarily urine (30%) as unchanged drug

Time to Peak

0.5 to 1 hour (immediate release); 4 hours (extended release)

Half-Life Elimination

~3 hours (immediate release); ~6 hours (extended release)

Protein Binding

~40% (predominantly to albumin)

Special Populations: Renal Function Impairment

AUC increased ~1.75- to 2.5-fold in moderate and severe renal impairment.

Special Populations: Hepatic Function Impairment

AUC and Cmax increased ~1.5-fold in moderate hepatic impairment.

Use: Labeled Indications

Psoriatic arthritis: Treatment of active psoriatic arthritis in adults who have had an inadequate response or intolerance to methotrexate or other DMARDs

Rheumatoid arthritis: Treatment of moderately- to severely-active rheumatoid arthritis (as monotherapy or in combination with methotrexate or other nonbiologic DMARDs) in adults who have had an inadequate response to, or are intolerant of, methotrexate

Ulcerative colitis: Treatment of moderately- to severely-active ulcerative colitis in adults

Limitations of use: The use of tofacitinib in combination with biologic DMARDs or with potent immunosuppressants (eg, azathioprine, cyclosporine) is not recommended.

Contraindications

There are no contraindications listed in the manufacturer's US labeling.

Canadian labeling: Hypersensitivity to tofacitinib or any component of the formulation.

Dosing: Adult

Note: When transitioning from immediate release to extended release, begin extended release the day following the last dose of 5 mg immediate release. Tofacitinib should not be used in combination with biologic DMARDs or with strong immunosuppressants, such as azathioprine, tacrolimus, or cyclosporine. Do not initiate therapy in patients with an absolute lymphocyte count <500 cells/mm3, absolute neutrophil count <1,000 cells/mm3, or hemoglobin <9 g/dL.

Psoriatic arthritis: (use in combination with nonbiologic DMARDs): Oral:

Immediate release: 5 mg twice daily

Extended release: 11 mg once daily

Rheumatoid arthritis (monotherapy or in combination with nonbiologic DMARDs): Oral:

Immediate release: 5 mg twice daily

Extended release: 11 mg once daily

Ulcerative colitis: Oral: Immediate release: 10 mg twice daily for ≥8 weeks followed by 5 or 10 mg twice daily; use lowest effective dose to maintain response. Discontinue therapy if inadequate response achieved after 4 months using 10 mg twice daily.

Dosage adjustment for concomitant therapy:

CYP3A4 inducers (eg, rifampin): Coadministration is not recommended.

Strong CYP3A4 inhibitors (eg, ketoconazole):

Immediate release: Reduce dose to 5 mg twice daily (if taking 10 mg twice daily) or 5 mg once daily (if taking 5 mg twice daily).

Extended release: Use is not recommended.

Concomitant moderate CYP3A4 inhibitors and potent CYP2C19 inhibitors (eg, fluconazole):

Immediate release: Reduce dose to 5 mg twice daily (if taking 10 mg twice daily) or 5 mg once daily (if taking 5 mg twice daily).

Extended release: Use is not recommended.

Dosing: Geriatric

Refer to adult dosing.

Dosing: Renal Impairment

Mild impairment: No dosage adjustment necessary.

Moderate to severe impairment: Reduce dose to 5 mg (immediate release) once daily. A supplemental dose after dialysis is not necessary in patients with severe impairment on dialysis. Note: Tofacitinib has not been studied in patients with baseline CrCl <40 mL/minute.

Dosing: Hepatic Impairment

Mild impairment: No dosage adjustment necessary.

Moderate impairment: Reduce dose to 5 mg (immediate release) once daily.

Severe impairment: Use is not recommended (has not been studied in patients with severe hepatic impairment or in patients with hepatitis B or hepatitis C viruses).

Dosing: Adjustment for Toxicity

Infection: If a patient develops a serious infection, interrupt treatment until the infection is controlled.

Lymphopenia (lymphocytes ≥500 cells/mm3): Maintain dose.

Lymphopenia (lymphocytes <500 cells/mm3) confirmed by repeat evaluation: Discontinue therapy.

Neutropenia (ANC >1,000 cells/mm3): Maintain dose.

Neutropenia (ANC persistently between 500 to 1,000 cells/mm3):

Immediate release: If taking 5 mg twice daily, interrupt therapy; may resume 5 mg twice daily when ANC >1,000 cells/mm3. If taking 10 mg twice daily, reduce dose to 5 mg twice daily; may resume 10 mg twice daily when ANC >1,000 cells/mm3 based on clinical response.

Extended release: Interrupt therapy; may resume 11 mg once daily when ANC >1,000 cells/mm3.

Neutropenia (ANC <500 cells/mm3): Discontinue therapy.

Anemia (hemoglobin <8 g/dL or decrease >2 g/dL): Interrupt therapy until hemoglobin values have normalized.

Anemia (hemoglobin ≥9 g/dL and decrease ≤2 g/dL): Maintain dose.

Administration

Oral: May be taken with or without food.

Extended release: Swallow tablet whole and intact; do not crush, split, or chew.

Storage

Store between 20°C and 25°C (68°F to 77°F).

Drug Interactions

Aprepitant: May increase the serum concentration of CYP3A4 Substrates (High risk with Inhibitors). Monitor therapy

Baricitinib: May enhance the adverse/toxic effect of Biologic Disease-Modifying Antirheumatic Drugs (DMARDs). Avoid combination

BCG (Intravesical): Immunosuppressants may diminish the therapeutic effect of BCG (Intravesical). Avoid combination

BCG (Intravesical): Myelosuppressive Agents may diminish the therapeutic effect of BCG (Intravesical). Avoid combination

Biologic Disease-Modifying Antirheumatic Drugs (DMARDs): May enhance the adverse/toxic effect of Tofacitinib. Avoid combination

Bosentan: May decrease the serum concentration of CYP3A4 Substrates (High risk with Inducers). Monitor therapy

Bradycardia-Causing Agents: Tofacitinib may enhance the bradycardic effect of Bradycardia-Causing Agents. Monitor therapy

Ceritinib: May increase the serum concentration of CYP3A4 Substrates (High risk with Inhibitors). Management: Use of ceritinib with a narrow therapeutic index CYP3A substrate (eg, alfentanil, cyclosporine, dihydroergotamine, ergotamine, fentanyl, pimozide, quinidine, sirolimus, tacrolimus) should be avoided when possible. Monitor therapy

Chloramphenicol (Ophthalmic): May enhance the adverse/toxic effect of Myelosuppressive Agents. Monitor therapy

CloZAPine: Myelosuppressive Agents may enhance the adverse/toxic effect of CloZAPine. Specifically, the risk for neutropenia may be increased. Monitor therapy

Coccidioides immitis Skin Test: Immunosuppressants may diminish the diagnostic effect of Coccidioides immitis Skin Test. Monitor therapy

Conivaptan: May increase the serum concentration of CYP3A4 Substrates (High risk with Inhibitors). Avoid combination

CYP3A4 Inducers (Moderate): May decrease the serum concentration of CYP3A4 Substrates (High risk with Inducers). Monitor therapy

CYP3A4 Inducers (Strong): May decrease the serum concentration of Tofacitinib. Avoid combination

CYP3A4 Inhibitors (Moderate): May decrease the metabolism of CYP3A4 Substrates (High risk with Inhibitors). Monitor therapy

CYP3A4 Inhibitors (Strong): May increase the serum concentration of Tofacitinib. Management: Tofacitinib dose reductions are recommended when combined with strong CYP3A4 inhibitors. Recommended dose adjustments vary by tofacitinib formulation and therapeutic indication. See full monograph for details. Consider therapy modification

Dabrafenib: May decrease the serum concentration of CYP3A4 Substrates (High risk with Inducers). Management: Seek alternatives to the CYP3A4 substrate when possible. If concomitant therapy cannot be avoided, monitor clinical effects of the substrate closely (particularly therapeutic effects). Consider therapy modification

Deferasirox: May decrease the serum concentration of CYP3A4 Substrates (High risk with Inducers). Monitor therapy

Deferiprone: Myelosuppressive Agents may enhance the neutropenic effect of Deferiprone. Avoid combination

Denosumab: May enhance the adverse/toxic effect of Immunosuppressants. Specifically, the risk for serious infections may be increased. Monitor therapy

Dipyrone: May enhance the adverse/toxic effect of Myelosuppressive Agents. Specifically, the risk for agranulocytosis and pancytopenia may be increased Avoid combination

Echinacea: May diminish the therapeutic effect of Immunosuppressants. Consider therapy modification

Fingolimod: Immunosuppressants may enhance the immunosuppressive effect of Fingolimod. Management: Avoid the concomitant use of fingolimod and other immunosuppressants when possible. If combined, monitor patients closely for additive immunosuppressant effects (eg, infections). Consider therapy modification

Fluconazole: May increase the serum concentration of Tofacitinib. Management: Tofacitinib dose reductions are recommended when combined with fluconazole. Recommended dose adjustments vary by tofacitinib formulation and therapeutic indication. See full monograph for details. Consider therapy modification

Fosaprepitant: May increase the serum concentration of CYP3A4 Substrates (High risk with Inhibitors). Monitor therapy

Fosnetupitant: May increase the serum concentration of CYP3A4 Substrates (High risk with Inhibitors). Monitor therapy

Fusidic Acid (Systemic): May increase the serum concentration of CYP3A4 Substrates (High risk with Inhibitors). Avoid combination

Idelalisib: May increase the serum concentration of CYP3A4 Substrates (High risk with Inhibitors). Avoid combination

Immunosuppressants: May enhance the immunosuppressive effect of Tofacitinib. Management: Concurrent use with antirheumatic doses of methotrexate or nonbiologic disease modifying antirheumatic drugs (DMARDs) is permitted, and this warning seems particularly focused on more potent immunosuppressants. Consider therapy modification

Ivosidenib: May decrease the serum concentration of CYP3A4 Substrates (High risk with Inducers). Monitor therapy

Leflunomide: Immunosuppressants may enhance the adverse/toxic effect of Leflunomide. Specifically, the risk for hematologic toxicity such as pancytopenia, agranulocytosis, and/or thrombocytopenia may be increased. Management: Consider not using a leflunomide loading dose in patients receiving other immunosuppressants. Patients receiving both leflunomide and another immunosuppressant should be monitored for bone marrow suppression at least monthly. Consider therapy modification

Methotrexate: May enhance the immunosuppressive effect of Tofacitinib. Management: Avoid the use of tofacinib in combination with potent immunosuppressive methotrexate-containing regimens. Monitor therapy

MiFEPRIStone: May increase the serum concentration of CYP3A4 Substrates (High risk with Inhibitors). Management: Minimize doses of CYP3A4 substrates, and monitor for increased concentrations/toxicity, during and 2 weeks following treatment with mifepristone. Avoid cyclosporine, dihydroergotamine, ergotamine, fentanyl, pimozide, quinidine, sirolimus, and tacrolimus. Consider therapy modification

Natalizumab: Immunosuppressants may enhance the adverse/toxic effect of Natalizumab. Specifically, the risk of concurrent infection may be increased. Avoid combination

Netupitant: May increase the serum concentration of CYP3A4 Substrates (High risk with Inhibitors). Monitor therapy

Nivolumab: Immunosuppressants may diminish the therapeutic effect of Nivolumab. Consider therapy modification

Pidotimod: Immunosuppressants may diminish the therapeutic effect of Pidotimod. Monitor therapy

Pimecrolimus: May enhance the adverse/toxic effect of Immunosuppressants. Avoid combination

Pitolisant: May decrease the serum concentration of CYP3A4 Substrates (High risk with Inducers). Management: Combined use of pitolisant with a CYP3A4 substrate that has a narrow therapeutic index should be avoided. Other CYP3A4 substrates should be monitored more closely when used with pitolisant. Consider therapy modification

Promazine: May enhance the myelosuppressive effect of Myelosuppressive Agents. Monitor therapy

Roflumilast: May enhance the immunosuppressive effect of Immunosuppressants. Consider therapy modification

Simeprevir: May increase the serum concentration of CYP3A4 Substrates (High risk with Inhibitors). Monitor therapy

Sipuleucel-T: Immunosuppressants may diminish the therapeutic effect of Sipuleucel-T. Monitor therapy

St John's Wort: May decrease the serum concentration of CYP3A4 Substrates (High risk with Inducers). Management: Consider an alternative for one of the interacting drugs. Some combinations may be specifically contraindicated. Consult appropriate manufacturer labeling. Consider therapy modification

Stiripentol: May increase the serum concentration of CYP3A4 Substrates (High risk with Inhibitors). Management: Use of stiripentol with CYP3A4 substrates that are considered to have a narrow therapeutic index should be avoided due to the increased risk for adverse effects and toxicity. Any CYP3A4 substrate used with stiripentol requires closer monitoring. Consider therapy modification

Tacrolimus (Topical): May enhance the adverse/toxic effect of Immunosuppressants. Avoid combination

Tertomotide: Immunosuppressants may diminish the therapeutic effect of Tertomotide. Monitor therapy

Trastuzumab: May enhance the neutropenic effect of Immunosuppressants. Monitor therapy

Vaccines (Inactivated): Immunosuppressants may diminish the therapeutic effect of Vaccines (Inactivated). Management: Vaccine efficacy may be reduced. Complete all age-appropriate vaccinations at least 2 weeks prior to starting an immunosuppressant. If vaccinated during immunosuppressant therapy, revaccinate at least 3 months after immunosuppressant discontinuation. Consider therapy modification

Vaccines (Live): Immunosuppressants may enhance the adverse/toxic effect of Vaccines (Live). Immunosuppressants may diminish the therapeutic effect of Vaccines (Live). Management: Avoid use of live organism vaccines with immunosuppressants; live-attenuated vaccines should not be given for at least 3 months after immunosuppressants. Avoid combination

Adverse Reactions

Incidences of adverse reactions may include unapproved dosing regimens.

>10%:

Infection: Infection (20%)

Respiratory: Nasopharyngitis (3% to 14%)

1% to 10%:

Cardiovascular: Hypertension (2%)

Central nervous system: Headache (4% to 9%)

Dermatologic: Skin rash (6%), acne vulgaris (≥2%)

Endocrine & metabolic: Increased serum cholesterol (5% to 9%)

Gastrointestinal: Diarrhea (4% to 5%), gastroenteritis (4%), nausea (4%)

Genitourinary: Urinary tract infection (2%)

Hematologic & oncologic: Anemia (4%)

Infection: Herpes zoster infection (5%; including disseminated cutaneous, meningoencephalitis, ophthalmologic)

Neuromuscular & skeletal: Increased creatine phosphokinase (3% to 7%)

Renal: Increased serum creatinine (<2%)

Respiratory: Upper respiratory tract infection (4% to 6%)

Miscellaneous: Fever (≥2%)

Frequency not defined:

Cardiovascular: Peripheral edema

Central nervous system: Fatigue, insomnia, paresthesia

Dermatologic: Erythema, pruritus, skin rash

Endocrine & metabolic: Dehydration

Gastrointestinal: Abdominal pain, diverticulitis of the gastrointestinal tract, dyspepsia, gastritis, vomiting

Hematologic & oncologic: Skin carcinoma (nonmelanoma)

Hepatic: Increased liver enzymes, liver steatosis

Infection: Opportunistic infection, serious infection, viral infection (reactivation)

Neuromuscular & skeletal: Arthralgia, joint swelling, musculoskeletal pain, tendonitis

Respiratory: Cough, dyspnea, interstitial pulmonary disease, paranasal sinus congestion

<1%, postmarketing, and/or case reports: Appendicitis, BK virus, cellulitis, cryptococcosis, cytomegalovirus disease, esophageal candidiasis, hepatotoxicity, histoplasmosis, listeriosis, lung carcinoma, lymphocytopenia, malignant melanoma, malignant neoplasm, malignant neoplasm of breast, mycobacterium infection, neutropenia, pancreatic adenocarcinoma, pneumonia, pneumonia due to Pneumocystis jirovecii, prostate carcinoma, tuberculosis

ALERT: U.S. Boxed Warning

Serious infections:

Patients treated with tofacitinib are at increased risk of developing serious infections that may lead to hospitalization or death. Most patients who developed these infections were taking concomitant immunosuppressants, such as methotrexate or corticosteroids.

If a serious infection develops, interrupt tofacitinib until the infection is controlled.

Reported infections include active tuberculosis, which may present with pulmonary or extrapulmonary disease; invasive fungal infections, including cryptococcosis and pneumocystosis, which may present with disseminated, rather than localized, disease; and bacterial, viral (including herpes zoster), and other infections due to opportunistic pathogens. Test patients for latent tuberculosis before tofacitinib use and during therapy. Initiate treatment for latent infection prior to tofacitinib use.

Carefully consider the risks and benefits of treatment with tofacitinib prior to initiating therapy in patients with chronic or recurrent infection.

Closely monitor patients for the development of signs and symptoms of infection during and after treatment with tofacitinib, including the possible development of tuberculosis in patients who tested negative for latent tuberculosis infection prior to initiating therapy.

Malignancy:

Lymphoma and other malignancies have been observed in patients treated with tofacitinib. 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.

Warnings/Precautions

Concerns related to adverse effects:

• Bone marrow suppression: Lymphocytopenia (after an initial lymphocytosis), neutropenia (<2,000 cells/mm3), and anemia have been observed with tofacitinib therapy. Lymphocyte counts <500 cells/mm3 were associated with increased incidence of treated and serious infections; avoid tofacitinib initiation in patients with lymphocytes <500 cells/mm3 at baseline. Avoid use in patients with ANC <1,000 cells/mm3 at baseline; interrupt therapy if ANC is persistently between 500 to 1,000 cells/mm3 or if ANC <500 cells/mm3 during treatment. Consider resuming tofacitinib when ANC ≥1,000 cells/mm3. Avoid tofacitinib initiation in patients with hemoglobin <9 g/dL; interrupt therapy if hemoglobin decreases >2 g/dL or if hemoglobin <8 g/dL. Monitor lymphocyte counts at baseline and every 3 months thereafter; ANC, platelet counts, and hemoglobin should be assessed at baseline, after 4 to 8 weeks of therapy, and every 3 months thereafter.

• Cardiovascular effects: A decrease in heart rate and prolonged PR interval have been reported with tofacitinib in clinical trials. Use caution in patients with baseline heart rate <60 bpm, conduction abnormalities, syncope or arrhythmia, ischemic heart disease, heart failure, or receiving concomitant therapy known to decrease heart rate or prolong the PR interval (Xeljanz Canadian product monograph).

• Gastrointestinal perforations: Use with caution in patients at increased risk for gastrointestinal perforation (eg, history of diverticulitis); perforations have been reported in clinical trials. Promptly evaluate new-onset abdominal symptoms in patients taking tofacitinib.

• Hepatotoxicity: Increased incidence of liver enzyme elevation was observed in patients taking tofacitinib compared to placebo. Routine liver function test monitoring is recommended; interrupt therapy if drug-induced liver injury is suspected.

• Infections: [US Boxed Warning]: Patients receiving tofacitinib are at increased risk for serious infections, which may result in hospitalization and/or fatality; infections often developed in patients receiving concomitant immunosuppressive agents (eg, methotrexate or corticosteroids). Active tuberculosis (pulmonary or extrapulmonary), invasive fungal (including cryptococcosis and pneumocystosis [may present as disseminated rather than local disease]) and bacterial, viral (including herpes zoster) or other opportunistic infections (including esophageal candidiasis, multidermatomal herpes zoster, cytomegalovirus infections, BK virus infection, and listeriosis) have been reported in patients receiving tofacitinib. Closely monitor patients for the development of signs/symptoms of infection during and after tofacitinib treatment. If a serious infection develops, interrupt tofacitinib until the infection is controlled. Carefully consider the risks and benefits of treatment with tofacitinib prior to initiating therapy in patients with chronic or recurrent infection. The most common serious infections reported included pneumonia, cellulitis, urinary tract infections, diverticulitis, appendicitis, and herpes zoster infections, although other serious infections may occur. Reactivation of viral infections (eg, herpes zoster) was observed in clinical trials; the incidence of chronic viral hepatitis reactivation is unknown. Screen for viral hepatitis. The risk for herpes zoster is increased with tofacitinib; patients within Asian countries appear to have a higher incidence of herpes zoster cases (Winthrop 2014). Use with caution in patients that have been exposed to tuberculosis, with a history of serious or opportunistic infection, taking concomitant immunosuppressants, with comorbid conditions that predispose them to infections (eg, diabetes), or in patients who live in or travel to/from areas of endemic mycoses (ie, blastomycosis, coccidioidomycosis, histoplasmosis). Do not initiate tofacitinib in patients with active infections, including localized infections. The risk of serious infections and opportunistic herpes zoster infections may be increased with use of higher doses. Risk of infection may be higher with increasing degrees of lymphopenia; monitor lymphocyte counts.

• Interstitial lung disease (ILD): ILD has been reported; patients developing ILD were receiving concomitant therapy associated with ILD (eg, methotrexate). Use with caution in patients with risk/history of ILD (Xeljanz Canadian product monograph).

• Lipid abnormalities: Dose dependent increases in lipid parameters (eg, total cholesterol, LDL, and HDL cholesterol) were observed in patients receiving tofacitinib; maximum lipid increases were typically seen within 6 weeks of initiation. Assess lipids 4 to 8 weeks after tofacitinib initiation and manage lipid abnormalities accordingly.

• Malignancy: [US Boxed Warning]: Lymphoma and other malignancies have been reported in patients receiving tofacitinib; Epstein Barr Virus-associated post-transplant lymphoproliferative disorder has been observed at an increased rate in renal transplant patients receiving tofacitinib and concomitant immunosuppressive medications. The most common types of malignancy observed were lung, breast, gastric, colorectal, renal cell, prostate, lymphoma, pancreatic, and malignant melanoma. The risk of malignancies, including nonmelanoma skin cancers (NMSCs), may be increased with higher doses. Consider risks versus benefits prior to use in patients with a known malignancy (other than successfully treated NMSCs) or when continuing tofacitinib in patients who develop a new malignancy. NMSCs have been reported; patients at increased risk for skin cancer should have periodic skin examinations.

• Tuberculosis: [US Boxed Warning]: Tuberculosis (pulmonary or extrapulmonary) has been reported in patients receiving tofacitinib. Patients should be evaluated for tuberculosis risk factors and active or latent infection (with a tuberculin skin test) before and during therapy. Treatment of latent tuberculosis should be initiated before use. Patients with initial negative tuberculin skin tests should receive continued monitoring for tuberculosis throughout treatment; active tuberculosis has developed in this population during treatment with tofacitinib. Use with caution in patients who have resided in regions where tuberculosis is endemic. Consider antituberculosis therapy if an adequate course of treatment cannot be confirmed in patients with a history of latent or active tuberculosis or for patients with risk factors despite negative skin test.

Disease-related concerns:

• Diabetes: Use with caution in patients with diabetes (patients with diabetes have a higher incidence of infections).

• Hepatic impairment: Use is not recommended in patients with severe hepatic impairment; dosage reduction required in patients with moderate hepatic impairment.

• Lung disease: Patients with a history of chronic lung disease or those who develop interstitial lung disease may be more prone to infections; use with caution.

• Renal impairment: Dosage reduction required in patients with moderate or severe renal impairment.

Concurrent drug therapy issues:

• Drug-drug interactions: Potentially significant interactions may exist, requiring dose or frequency adjustment, additional monitoring, and/or selection of alternative therapy. Consult drug interactions database for more detailed information.

• Immunosuppressant medications: Tofacitinib should not be administered in combination with strong immunosuppressive medications (eg, azathioprine, tacrolimus, cyclosporine) due to the risk of additive immunosuppression; such combinations have not been studied in rheumatoid arthritis.

• Biologic DMARDs: Tofacitinib should not be administered in combination with biologic DMARDs.

Special populations:

• Asian patients: Use with caution in Asian patients; an increased incidence of adverse reactions (eg, herpes zoster, opportunistic infections, decreased WBC, interstitial lung disease, increased transaminases) has been observed (Wollenhaupt 2014; Xeljanz Canadian product monograph).

• Elderly: Use with caution in elderly patients; general incidence of infection is higher in elderly.

Dosage form specific issues:

• Extended release: Use caution when administering the extended release formulation to patients with preexisting severe gastrointestinal narrowing (pathologic or iatrogenic). There have been rare reports of obstructive symptoms in patients with known strictures following ingestion of other medications which also utilize a nondeformable extended release formulation. The inert tablet shell of the extended release tablet may be noticeable in the stool (or colostomy); the active medication will have been already absorbed.

Other warnings/precautions:

• Immunizations: Immunization status should be current before initiating therapy. Live vaccines should not be given concomitantly with tofacitinib; recommended interval between receipt of live vaccines and initiation of immunosuppressive agents, such as tofacitinib, should follow current vaccination clinical guidelines. Dissemination of the vaccine strain of varicella zoster virus has been reported in a varicella virus naive patient 16 days following vaccination with Zostavax (live attenuated zoster) and 2 days after the initiation of tofacitinib.

Monitoring Parameters

Lymphocyte count (baseline and every 3 months thereafter); neutrophil/platelet counts (baseline, after 4 to 8 weeks, and every 3 months thereafter); hemoglobin (baseline, after 4 to 8 weeks, and every 3 months thereafter); lipids (4 to 8 weeks after therapy initiation and periodically); LFTs; viral hepatitis (prior to initiating therapy in accordance with clinical guidelines); signs/symptoms of infections (including tuberculosis) during and after therapy; abdominal symptoms; skin examinations (periodically, in patients at increased risk for skin cancer); heart rate and blood pressure at baseline and periodically thereafter.

Pregnancy Considerations

Outcome information following tofacitinib for rheumatoid arthritis or psoriasis in pregnancy is limited (Clowse 2016). Some guidelines recommend avoiding use in pregnant women until additional information is available (Götestam Skorpen 2016).

Data collection to monitor pregnancy and infant outcomes following exposure to tofacitinib is ongoing. Patients may enroll themselves in the Xeljanz Pregnancy Registry (877-311-8972).

Patient Education

• Discuss specific use of drug and side effects with patient as it relates to treatment. (HCAHPS: During this hospital stay, were you given any medicine that you had not taken before? Before giving you any new medicine, how often did hospital staff tell you what the medicine was for? How often did hospital staff describe possible side effects in a way you could understand?)

• Patient may experience headache, diarrhea, rhinorrhea, rhinitis, common cold symptoms, or pharyngitis. Have patient report immediately to prescriber signs of infection; signs of liver problems (dark urine, fatigue, lack of appetite, nausea, abdominal pain, light-colored stools, vomiting, or jaundice); signs of a severe pulmonary disorder (lung or breathing problems like difficulty breathing, shortness of breath, or a cough that is new or worse); mole changes; skin growths; bowel changes; night sweats; severe loss of strength and energy; severe abdominal pain; abdominal edema; nausea; vomiting; black, tarry, or bloody stools; vomiting blood; shortness of breath; muscle pain; muscle weakness; bradycardia; or abnormal heartbeat (HCAHPS).

• Educate patient about signs of a significant reaction (eg, wheezing; chest tightness; fever; itching; bad cough; blue skin color; seizures; or swelling of face, lips, tongue, or throat). Note: This is not a comprehensive list of all side effects. Patient should consult prescriber for additional questions.

Intended Use and Disclaimer: Should not be printed and given to patients. This information is intended to serve as a concise initial reference for health care professionals to use when discussing medications with a patient. You must ultimately rely on your own discretion, experience, and judgment in diagnosing, treating, and advising patients.

Further information

Always consult your healthcare provider to ensure the information displayed on this page applies to your personal circumstances.

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