Case 20.2
Due to prior TNF failure, she was switched to ustekinumab. However, her MRE continued to show ongoing inflammation, so ustekinumab was re-induced, but she still had no clinical or objective signs of improvement. She was then switched to vedolizumab without response. Ultimately, she was started on tofactinib 11 mg extended release in addition to vedolizumab by her rheumatologist for management of rheumatoid arthritis and IBD.
The patient has no prior cardiac history or thromboembolic disease but she is 79 years old with hypertension and hyperlipidemia. Knowing this, what would you recommend now?
Ask rheumatology to switch from tofacitinib to off-label upadacitinib for her RA and stop vedolizumab
Given her current response to tofacitinib 11 mg daily, there is no indication to switch to upadacitinib nor is there a reason to do so from a safety perspective. However, upadacinitib did show efficacy in a phase 3 trial for Crohn’s disease presented at DDW 2022 and thus could be considered should she lose response to other therapies.
Continue tofacitinib but stop vedolizumab
Vedolizumab was not effective and should be discontinued. While ORAL surveillance data has demonstrated an increased risk for major adverse cardiovascular events (MACE) in patients undergoing treatment with a JAK inhibitor, given that she has failed nearly all other approved therapies for Crohn's disease, it is reasonable to trial tofacitinib with an indication for RA after careful discussion of risks, benefits, and alternatives.
Escalate tofacitinib to 10mg BID from 11mg daily
As she is doing well on the current dose, there is no need to escalate. She should continue on the lowest effective dose of tofacitinib, which she is on now, 11 mg daily
Re-challenge with infliximab and stop tofacitinib
As she had antibody to inflixilmab, she is high risk for having a reaction or not responding. If she is doing well on the tofacitinib, she should continue
Any of these choices is correct
As described several of these answer choices would not be correct next steps for management.