Abstract
To the Editor, We read with great attention the interesting case report by Lenfant et al. narrating the successful use of tofacitinib in a patient with microscopic colitis and celiac disease (1), and we would point some insights about this peculiar situation. In fact, tofacitinib depicts potential side effects, including a higher risk of malignancies, and the FDA has even issued a warning about this drug’s hazard (2). Actually, a randomized open-label trial published in the New England Journal of Medicine in 2021 found that patients with rheumatoid arthritis who took tofacitinib had a higher risk of developing cancer than those who took a tumor necrosis factor (TNF) inhibitor (3). Recently, two recent randmoized controlled trials from the ORAL Surveillance Trial and published in the Annals of the Rheumatic Diseases in 2023 also contributed to shed the light on this potential risk : that patients with rheumatoid arthritis aged > 50 with cardiovascular risk who took tofacitinib had a higher risk of developing any type of cancer than those who took a TNF inhibitor (4), and secondary stratification found that they were more likely to develop cancer if they were over the age of 65 years (5). Adding insult to injury, the maligancies are also driven by the two peculiar forms of celiac disease : seronegative and refractory celiac disease (RCD), and this risk is also increased in CD diagnosed at adulthood : particularly, elder patients are prone to present a RCD, and giving immune checkpoint therapy might increase this risk (6). In conclusion, RCD ought to be definetly ruled out before starting JAK inhibitor therapy, especially in aged population with seronegative celiac disease and microscopic colitis, two well-known conditions associated with RCD.
Reference6 articles.
1. LENFANT M, DE HERTOGH G, VERSTOCKT B. Tofacitinib for celiac disease and microscopic colitis: killing two birds with one stone. Acta Gastro-Enterol Belg. 2023;86(2):374-6.
2. FDA requires warnings about increased risk of serious heart-related events, cancer, blood clots, and death for JAK inhibitors that treat certain chronic inflammatory conditions. FDA [Internet]. 2021 Dec 6 [cited 2023 Jul 22]; Available from: https://www.fda.gov/drugs/drug-safety-and-availability/fda-requires-warnings-about-increased-risk-serious-heart-related-events-cancer-blood-clots-and-death.
3. YTTERBERG SR, BHATT DL, MIKULS TR, KOCH GG, FLEISCHMANN R, RIVAS JL, et al. Cardiovascular and Cancer Risk with Tofacitinib in Rheumatoid Arthritis. N Engl J Med. 2022 Jan 27;386(4):316-26.
4. CURTIS JR, YAMAOKA K, CHEN YH, BHATT DL, GUNAY LM, SUGIYAMA N, et al. Malignancy risk with tofacitinib versus TNF inhibitors in rheumatoid arthritis: results from the open-label, randomised controlled ORAL Surveillance trial. Ann Rheum Dis. 2023 Mar 1;82(3):331-43.
5. KRISTENSEN LE, DANESE S, YNDESTAD A, WANG C, NAGY E, MODESTO I, et al. Identification of two tofacitinib subpopulations with different relative risk versus TNF inhibitors: an analysis of the open label, randomised controlled study ORAL Surveillance. Ann Rheum Dis. 2023 Jul;82(7):901-10.