Tofacitinib for Alopecia Areata: How long do we use it?

How long to continue Tofacitinib in Alopecia Areata?

 

A variety of treatments are available for alopecia areata. For localized (limited) AA topical steroids, steroid injections and minoxidil are still the mainstays of treatment. Treatment of advanced alopecia areata is more challenging. A variety of options are available in such cases including diphencyprone, prednisone, methotrexate and more recently tofacitinib.  

Tofacitinib in AA

We have been prescribing tofacitinib more frequently as an off label treatment for alopecia areata. The drug is surprisingly well tolerated for many, but does have potential side effects relating to long term immunosuppression. These include increased risks of infection, and concerns over possible long term cancer risks. The drug is expensive (1200-1400 USD per month). 

Lowest Dose, Shortest Time Needed

Clearly, in order to limit side effects of tofacitinib (and any drug) one should use the lowest dose possible and use it for the shortest duration possible. However, for many patients with advanced alopecia areata who are responding well tofacitinib and experiencing regrowth, any discussion of lowering the dose raises the possibility that hair loss could once again occur. The decision to taper the drug should always be carefully considered. Losing hair again can be devastating.

Some patients with advanced alopecia areata who start tofacitinib will likely need to use higher doses forever to maintain their hair density. But some patients will be able to eventually taper the dose. Some are able to taper it a bit and some are able to taper it a considerable amount and possibly even stop. However, it is less common to be in the latter group. Most patients who need to use tofacitinib in the first place have a more resistant form of hair loss that is unlikely to regrowth fully without immunosuppression.

Tapering Tofacitinib

There is no standardized formula for how to taper tofacitinib. Generally, my approach is the following.

1. Assuming a patient is using 5 mg twice daily (10 mg daily) go down to 10 mg on Monday, Wednesday and Friday and Sunday and 5 mg on Tuesday, Thursday and Saturday. This can be continued for 3 months. If there is any breakthrough hair loss, the patient returns to 10 mg daily.

2. If hair is growing fully, one can consider going down to 5 mg every day for an additional three months.

3. Thereafter, if hair growth continues to be full, we may consider 5 mg on Monday, Wednesday and Friday and no medication on the other days. A slower taper is possible if there are any concerns and this could include 5 mg daily Monday to Friday with the weekends being 'drug-free' periods.

4. Thereafter, any taper is done on a case by case basis. Many patients are not  able to taper further. However some may taper to 5 mg on Mondays and Thursdays before eventually going to one tablet weekly.

Lab Tests During a Taper

If blood tests have been stable and normal at the higher doses of tofacitinib I am generally less concerned about the patient having frequent monitoring blood tests. Nevertheless, I do feel that tests every 3-6 months is still appropriate even in a patient whose tests have been stable. I generally advise my patients to get tests for CBC, CK, cholesterol, liver function tests, creatinine, urinalysis. A repeat ECG is done every year.

Final Comments

The topic of tapering immunosuppressants is an important one in alopecia areata. Some patients are not able to taper immunosupressants at all without losing some hair. However, some patients can taper and a "go slow" approach is generally the best method. Go slow means not only taper the oral immunosuppressants slowly but given attention to how the patient's alopecia areata is treated topically. As tofacitinb is tapered, one may continue various topical (and even corticosteroid injection-based) treatments that have been performed alongside the immunosuppressive agents.  But eventually they too can be tapered in a stable patient.