Baricitinib for RA. How should I use it?

Olumiant (Baricitinib) has recently been approved for use in Australia. We’re just waiting for it to soon come under our Pharmaceutical Benefits Scheme to allow rheumatologists in Australia to prescribed it for people with rheumatoid arthritis (RA) at a heavily subsidised price.

We have so many options for people with RA who are not adequately responding to the conventional DMARDs such as Methotrexate (our go-to DMARD), Sulphasalazine, Leflunomide and Hydroxychloroquine.

We do need these options given we don’t have the “complete” option, the medication that is uniformly successful in shutting down the disease process and gaining remission or at very least, a very low disease activity state.

I’ve previously written about a variety of biologic DMARDs. Then I discussed the exciting findings for this new oral agent, the 2nd in the line of new, oral JAK-inhibitors in this post entitled JAK inhibitors cometh, with a pivotal trial mentioned comparing it to the current market leader in RA, Adalimumab (Humira).

Given the availability, the question rheumatologists will be grappling with will be in whom, when, in what circumstance to actually use this medication?

My early thoughts on Baricitinib (my disclosure is that I do not have any personal experience using this medication):

• I think the data looks good but I think we’ll need time and clinical experience to work out where to use Olumiant. Aussie rheumatologists are very comfortable using the incumbent biologic DMARDs, especially the TNF-inhibitors due to the 15+ year experience locally and the surprisingly good safety profile over that period of time in Australia and worldwide.
• With Olumiant, there is worry regarding a possible increased risk of clots, DVT and PE, as well as the higher shingles risk.
• However, given the success of Xeljanz, the 1st JAK-inhibitor made available in Australia (link), there is clearly a market for a ONCE DAILY, ORAL tablet which is potent.  
• My current thinking is that the people I would consider for Xeljanz, would also be the people I would consider for Olumiant. 
• I think there will probably be fewer new initiations of Xeljanz while we get experience with this new once daily agent.
• As a treating philosophy, I would typically not swap from Xeljanz to Olumiant if the person is already doing well on Xeljanz, ie if there is not a clinical reason to do so.
• If the pharmaceutical company, Eli Lilly,  manages the media coverage to the public well, we might see people coming in asking for this “amazing” once daily oral treatment (we saw that effect with Xeljanz)!

As we lack the precision to predict which patient with RA will respond well to any one drug, both in terms of the effectiveness in shutting down the manifestation of RA and in the avoidance of side effects, we tend to base our decisions on educated guesswork mixed with patient preference and some intuition, and our individual biases.

I’ll update you on my experience with Olumiant later in the year.