Alopecia Areata Treatment: The Future Is Here

Advancements in our understanding of alopecia areata have led to new and emerging treatments, including the recently approved Janus kinase (JAK) inhibitors baricitinib (Olumiant) and ritlecitinib (Litfulo) for severe alopecia areata.

In this exclusive MedPage Today video, Brett King, MD, PhD, of Yale School of Medicine in New Haven, Connecticut, discusses the impact of these recently approved therapies and how it has — and will — change the treatment landscape.

Following is a transcript of his remarks:

Since the approval of baricitinib in June of last year, I would say that my practice has changed dramatically in the sense that I can now write a prescription for patients and have great assurance that they’re going to get the medicine. And that changed my practice dramatically.

Since really 2014, I’ve written hundreds and hundreds — thousands of prescriptions, if you consider people coming back — for really tofacitinib [Xeljanz] off-label for alopecia areata, and I would say probably 95% of those prescriptions were denied, which meant going through an appeal process. Now with baricitinib, I write a prescription, and I think that this was a little bit of a surprise to those of us who do this a lot, is that most of those prescriptions are covered when we’re following, in a sense, the rules. When we’re doing what insurance wants us to do, which is to prescribe the medicine for patients in a certain range of severity, insurance largely has approved baricitinib. But Eli Lilly, the maker of baricitinib, has created a program that provides the medicine for those who are privately insured, making it so that the vast majority, I mean, close to 90% or more of patients are getting it, which is really amazing.

So now, just 2 months ago, we had the approval of ritlecitinib for patients down to age 12, again with severe alopecia areata. This, in my mind, this is as big a milestone as baricitinib was a year ago, because [of] its approval down to age 12. And alopecia areata commonly affects younger patients. Even younger than age 12. But the point is we have to step to age 12 before we can step to age 6. And so having a medicine now that, fingers crossed, we’re able to write a prescription for our adolescent patients and have great assurance that they’re going to get it, again it’s really been a big change and it’s really kind of shifted the way we walk into clinic and see patients.

In the pipeline is deuruxolitinib, which we’re hopeful will be approved in the next year. I can’t state strongly enough, it’s really important to have these choices. As psoriasis has demonstrated, we can tolerate, we can make use of even 13 medicines for a disease. And alopecia areata is not that uncommon. Granted, we’re talking about treatment of severe patients or moderate to severe patients, but it’s not uncommon. And this is the thing, we’ve made, and these are anecdotal observations, but I’ve made them, my wife has made them, I’m sure that other people will make them — that failure of one JAK inhibitor does not predict failure of another one. And so again, it’s really important to have more than one, even though we’re talking about now two JAK inhibitors approved with a third one coming in the next year. It means that when we look at the clinical trial data and we see, oh, about 40% of patients succeeding over 36 to 52 weeks regardless of the clinical trial, I really think that when you consider that some patients will fail one, but succeed with another, we’re really talking about 50% or 60% of patients being able to be treated with these medicines.

Again, there are no clinical features that I’m aware of. There are no clinical features that have emerged from clinical trials that I think would make us say, “I think that you are more of a baricitinib patient over a ritlecitinib patient,” or vice versa. I think that what is going to guide decision-making for the foreseeable future is really comfort. You get comfortable using one, you know how to do the lab monitoring. You just get comfortable. And so that’s the one that you reach for.

And again, I’m kind of taking a little bit, or borrowing a little bit from psoriasis here in the sense that we learned over time there are two or three medicines in the IL [interleukin]-17 inhibition class. And again, there are three in the IL-23 inhibition class. And the truth is, I think what really motivates use of one or another is just your familiarity with that medicine.