JAK inhibitors

This information is for anyone with axial spondyloarthritis (axial SpA), including people with ankylosing spondylitis (AS)

JAK inhibitors are the newest class of drugs available to treat axial SpA

These drugs work by limiting the action of Janus kinase enzymes, which are involved in the inflammation that causes the symptoms of axial spondyloarthritis.

Like biologic drugs, these are ‘targeted’ therapies, which work on the immune response. Unlike the biologics, they can be taken in tablet form as they are small molecule therapies.

Have they been approved for use in the UK?

England, Wales and Northern Ireland

The National Institute for Health and Care Excellence (NICE) approved the use of the JAK inhibitor upadacitinib, also known by the brand name, Rinvoq, on 30 September 2022 for treating active ankylosing spondylitis that is not controlled well enough with conventional therapy in adults. NICE then approved upadacitinib (Rinvoq) or treating active non-radiographic axial spondyloarthritis in adults on 01 February 2023.

On 18 October 2023 NICE approved tofacitinib (Xeljanz) for treating active ankylosing spondylitis. It is only available as an option to people who have already tried anti TNF therapy or for whom it is unsuitable.

NICE guidance covers England, Wales and Northern Ireland.

Scotland

Upadacitinib (Rinvoq) has been approved by the Scottish Medicines Consortium for treating active non radiographic axial spondyloarthritis and active ankylosing spondylitis in adults who have responded inadequately to conventional therapy.

Another JAK inhibitor called tofacitinib (Xeljanz) has also been accepted for use within NHS Scotland for treating active ankylosing spondylitis in adults who have responded inadequately to conventional therapy.

Who can take them?

People diagnosed with non-radiographic axial spondyloarthritis need to have either an MRI showing current inflammation or blood tests showing raised inflammatory markers in order to qualify for upadacitinib under NICE guidance.

It is recommended only if anti TNF medication has been tried and has not been effective OR if you are unable to take anti TNF for medical reasons.

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Upadacitinib (Rinvoq)

Upadacitinib (Rinvoq) is taken as a tablet. The tablets should be swallowed whole and taken with or after food.

If you take more than the recommended dose by mistake, contact your doctor straight away. If you miss a dose, carry on with the usual dose the next day.

Upadacitinib (Rinvoq) is a long-term treatment and it’s important to keep taking taking even if it doesn’t seem to be working at first. If your symptoms improve then do keep taking it to make sure your condition remain under control.

Your doctor may decide to stop upadacitinib and try another treatment if your symptoms haven’t improved very much after 6 months.

The recommendation is that you avoid food or drink containing grapefruit while you’re on upadacitinib. Grapefruit can add to the effect of upadacitinib and therefore increase the risk of side effects.

Risks and side effects

Like any medicine, upadacitinib can cause side effects. The most common side effects are:

body aches or pain
fever or chills
headache
itching or warmth, redness, swelling or tenderness of the skin
unusual tiredness or weakness
coughs, colds, sinus infections
feeling sick (nausea).

You may also be more likely to pick up infections while you’re on upadacitinib. If you develop an infection (bacterial, viral or fungal) you should stop your upadacitinib tablets and see your GP to have the infection treated. You should also contact your rheumatology team for advice on when to restart your upadacitinib.

Do also contact your GP or your rheumatology team if you come into contact with someone who has chickenpox or shingles. These illnesses can be more severe than usual if you’re on upadacitinib, and you may need anti-viral treatment if you develop either chickenpox or shingles.

If your doctor thinks you could be at increased risk of skin cancer, they may suggest precautions such as wearing sunscreen and regularly checking your skin for new spots or changes to any freckles or moles.

Cases of blood clots have been reported in people taking upadacitinib. You should get medical help as soon as possible if you have painful swelling in a leg or arm or if you develop chest pain or shortness of breath, as these could be signs of a blood clot.

You should also tell your doctor or nurse specialist if you develop any of the following after starting upadacitinib:

a sore throat, fever, or a cough that won’t go away
unexplained bruising or bleeding
a painful rash
any new symptoms that concern you.

Tofacitinib (Xeljanz)

Tofacitinib (Xeljanz) is taken as a tablet with or without food. If you take more than the recommended dose by mistake, contact your doctor straight away. If you miss a dose, carry on with the usual dose the next day.

If you haven’t noticed any improvement in your symptoms after six months, discuss it with your doctor, who may decide to stop the tofacitinib and try another treatment for your condition.

Tofacitinib (Xeljanz) is a long-term treatment and it’s important to keep taking it, even if it doesn’t seem to be working at first. Do continue to take it if your symptoms improve, to help keep your condition controlled.

Risks and side effects

Like any medicine, tofacitinib can cause side effects. Feeling sick, having diarrhoea and headaches are fairly common when taking tofacitinib but may settle with time. Do go to your doctor if these don’t settle or if you have blood in your poo.

You may also be more likely to pick up infections while you’re on tofacitinib (Xeljanz). These aren’t usually serious and include throat, nose and chest infections, cold sores, urinary tract infections and stomach upsets. If you develop an infection (bacterial, viral or fungal) do see your GP to have the infection treated and take their advice on whether you need to stop taking your tablets until the infection has cleared.

You should also see your doctor if you develop chickenpox or shingles or come into contact with someone who has chickenpox or shingles. These may be more severe if you’re on tofacitinib (Xeljanz). You may need treatment, and you may need to stop taking tofacitinib (Xeljanz)until you’re better.

Your rheumatology team will arrange for you to have regular blood tests as some people who take tofacitinib (Xeljanz) may have a reduced white blood cell count, raised cholesterol or raised levels of liver enzymes.

Cases of blood clots have been reported in people taking tofacitinib (Xeljanz). You should get medical help as soon as possible if you have painful swelling in a leg or arm or if you develop chest pain or shortness of breath, as these could be signs of a blood clot.

Rarely, tofacitinib can cause an allergic reaction with sudden swelling, a rash or breathlessness. If you develop these symptoms, or any other severe symptoms while taking tofacitinib, you should seek medical advice straight away.