Transcript
Dr. Mesinkovska:We're not going to talk about the JAK inhibitors without revisiting something that Dr. Kindred brought up before, so I'm going to throw it to Dr. Senna, and that is the box warning. I always say when we sit across from patients, our job as doctors is not to give it, not to push it, but to be transparent about it and talk about the box warnings. Dr. Senna, when a patient says, "But these JAK inhibitors, the doctor that sent me, they said you are the only one that gives it, they don't prescribe this," and they just come with the angst from the JAKs." Guide us through your discussion when it comes to the box warning.
Dr. Senna:So the first thing is we don't have time in our busy clinics to sit here and go through it in the detail that we want. So a gift has been that the National Alopecia Areata Foundation has webinars online. And I did one on safety and monitoring. I know Britt Craiglow has done one on JAK inhibitor use in kids. And in my safety and monitoring one, I actually go through exactly where the black box warning comes from, the New England Journal of Medicine paper and rheumatoid arthritis patients. And I show them the numbers of the percentages of... So I give a brief overview of that and what to expect, and I say, "Please go home and watch this 30-minute video. It goes into detail with visuals and everything of how I think about the black box warning, how we monitor for this, what the side effect rates are. Go home and watch this. And then when you come back, you can ask me questions or write to me through the portal if you have follow-up questions." And that has been incredibly helpful.
And then the other thing that I do is I have a checklist that I go through. So today I was screening a woman for potentially a JAK inhibitor, and nothing in her record, but in fact, when she was 20, she had an unprovoked clot in her right upper extremity, and her mom had a history of clotting, but they had no known gene... Well, if I didn't go through my little checklist paper that I have that I have circle yes or no quickly to make sure I'm not missing anything, I would've missed that. So there are certain things like a history of an unprovoked clot that gives me a lot of pause. Current smoker gives me a lot of pause. But sometimes if it's like “patient has well-controlled diabetes,” I say to them, "That's a risk factor. You might be more at risk of a major adverse cardiac event than someone who does not have this risk factor, but this risk is still very low."
Dr. Mesinkovska:So what did you do, for example, with the patient that had that on the checklist? What do you do?
Dr. Senna:So for her... I don't routinely do this, but for someone with a history like that and a family history, I'm going to probably do a thrombotic workup. If that's negative, then I'm going to say, "Listen, it's negative, but you have this history of clot. You could be at greater risk," and have a shared decision making around that.
Dr. Mesinkovska:So you're better than me. I'll be like, "Let me send you to hem-onc. They're the experts."
Dr. Kindred:To get clearance.
Dr. Mesinkovska:Yeah. Let me just get you clearance.
Dr. Senna:You could do that too. You could do that too. It's just then you're waiting another year by the time you get them into hem-onc and that's the issue.
Dr. Mesinkovska:You know me, I'm like chicken when it comes to that stuff. Dr. Kindred, the box warnings we discussed, has either of you encountered any box warning side effects in any of your patients? I know you...
Dr. Kindred:And that's the thing, and I prescribe a ton of JAKs and I have yet to see one of those come to fruition. And when patients with the clotting history, when I send the onc to get clearance, onc is giving them clearance. And when I talk to rheumatology, they're prescribing. And I look at the clinical trials, there are patients in clinical trials that were smokers and had risk factors, et cetera. And then there was a study that really convinced me if these patients, if I really share the data and the patients want it, I'll still monitor them, we're not cavalier, but it shows that if you really look at the data, it came down to patients 65 and older who were smokers. Even if they had a cardiovascular risk factor, but it really came down to 65 and older and smoker, two risk factors.
And sometimes it's population based. So based on the hem-onc in my area, the rheumatologists in my area for the patient who is a smoker, et cetera, I definitely share that there's a risk, but I still have the patients on a JAK. And I've been prescribing for five years now. Oh no, since 2017. And I just haven't seen it. So I wonder how much of this is background...
Dr. Mesinkovska:How about patients that are over 65? Because for the past year on a lot of podiums I keep hearing it as a controversy. There's reservations. So thoughts from both of you, Dr. Senna?
Dr. Senna:I mean, the closer I get to 65, I don't want people to be withholding medications from me. So I mean, in all seriousness though, we know that certain cancers, prostate cancer, breast cancer, with every decade of life, the risk of developing something like that goes up. So I have a frank conversation with my patients. If they don't have other risk factors that are really concerning and it's just the age thing that's holding me back, I explain to them the potential malignancy risk and I talk to them about the fact that, as long as you're up to date with their age-related screening, then I'm OK and that they continue to do whatever's recommended for age-related screening. I'm OK with it.
Dr. Mesinkovska:That's good because I had a patient in office the other day saying, "I'm in my 50s and I read all this about the patients and everything." And I was like, "Let me look at the day before in my hair clinic, what were the ages of people I had on JAK inhibitors?" And it was 62, 67, 72, and 79. I was like, "Oh Lord."
Dr. Kindred:No, that's fine. My very first patient in 2017 was 72. So our patients who have been on it, on a JAK for a while, they are aging and in asking, "Do you want to come off?" The answer is no. So I don't... Just weigh the factors. Again, over 65 and a smoker, that's when I have some hesitation based on the data. Based on the data. And not the initial data that was just cardiovascular... Not an initial, but just on people going back and re-analyzing that data, for me it's 65 and older and a smoker. That combination is where then I have hesitation.
