Influence of Safety Warnings on the Prescribing Attitude of JAK Inhibitors for Rheumatoid Arthritis in Italy
Authors: Paroli Marino , Becciolini Andrea , Lo Gullo Alberto , Parisi Simone , Bravi Elena , Andracco Romina , Nucera Valeria , Ometto Francesca , Lumetti Federica , Farina Antonella , Del Medico Patrizia , Colina Matteo , Ravagnani Viviana , Scolieri Palma , Larosa Maddalena , Priora Marta , Visalli Elisa , Addimanda Olga , Vitetta Rosetta , Volpe Alessandro , Bezzi Alessandra , Girelli Francesco , Molica Colella Aldo Biagio , Caccavale Rosalba , Di Donato Eleonora , Adorni Giuditta , Santilli Daniele , Lucchini Gianluca , Arrigoni Eugenio , Platè Ilaria , Mansueto Natalia , Ianniello Aurora , Fusaro Enrico , Ditto Maria Chiara , Bruzzese Vincenzo , Camellino Dario , Bianchi Gerolamo , Serale Francesca , Foti Rosario , Amato Giorgio , De Lucia Francesco , Dal Bosco Ylenia , Foti Roberta , Reta Massimo , Fiorenza Alessia , Rovera Guido , Marchetta Antonio , Focherini Maria Cristina , Mascella Fabio , Bernardi Simone , Sandri Gilda , Giuggioli Dilia , Salvarani Carlo , De Andres Maria Ilenia , Franchina Veronica , Molica Colella Francesco , Ferrero Giulio , Raffeiner Bernd , Ariani Alarico 
Published: July 2024

Background/Objectives: The Janus kinase inhibitors (JAKi) tofacitinib (TOFA), baricitinib (BARI), upadacitinib (UPA), and filgotinib (FILGO) are effective drugs for the treatment of rheumatoid arthritis. However, the US Food and Drug Administration (FDA) raised concerns about the safety of TOFA after its approval. This prompted the European Medicines Agency (EMA) to issue two safety warnings for limiting TOFA use, then extended a third warning to all JAKi in patients at high risk of developing serious adverse effects (SAE). These include thrombosis, major adverse cardiac events (MACE), and cancer. The purpose of this work was to analyze how the first two safety warnings from the EMA affected the prescribing of JAKi by rheumatologists in Italy. Methods: All patients with rheumatoid arthritis who had been prescribed JAKi for the first time in a 36-month period from 1 July 2019, to 30 June 2022 were considered. Data were obtained from the medical records of 29 Italian tertiary referral rheumatology centers. Patients were divided into three groups of 4 months each, depending on whether the JAKi prescription had occurred before the EMA’s first safety alert (1 July–31 October 2019, Group 1), between the first and second alerts (1 November 2019–29 February 2020, Group 2), or between the second and third alerts (1 March 2021–30 June 2021, Group 3). The percentages and absolute changes in the patients prescribed the individual JAKi were analyzed. Differences among the three groups of patients regarding demographic and clinical characteristics were also assessed. Results: A total of 864 patients were prescribed a JAKi during the entire period considered. Of these, 343 were identified in Group 1, 233 in Group 2, and 288 in Group 3. An absolute reduction of 32% was observed in the number of patients prescribed a JAKi between Group 1 and Group 2 and 16% between Group 1 and Group 3. In contrast, there was a 19% increase in the prescription of a JAKi in patients between Group 2 and Group 3. In the first group, BARI was the most prescribed drug (227 prescriptions, 66.2% of the total), followed by TOFA (115, 33.5%) and UPA (1, 0.3%). In the second group, the most prescribed JAKi was BARI (147, 63.1%), followed by TOFA (65, 27.9%) and UPA (33, 11.5%). In the third group, BARI was still the most prescribed JAKi (104 prescriptions, 36.1%), followed by UPA (89, 30.9%), FILGO (89, 21.5%), and TOFA (33, 11.5%). The number of patients prescribed TOFA decreased significantly between Group 1 and Group 2 and between Group 2 and Group 3 (p ˂ 0.01). The number of patients who were prescribed BARI decreased significantly between Group 1 and Group 2 and between Group 2 and Group 3 (p ˂ 0.01). In contrast, the number of patients prescribed UPA increased between Group 2 and Group 3 (p ˂ 0.01). Conclusions: These data suggest that the warnings issued for TOFA were followed by a reduction in total JAKi prescriptions. However, the more selective JAKi (UPA and FILGO) were perceived by prescribers as favorable in terms of the risk/benefit ratio, and their use gradually increased at the expense of the other molecules.