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Medicine Matters rheumatology

So this is the third JAK inhibitor that's kind of coming onto the market-- already on the market for rheumatoid arthritis. And they're testing this in two different Phase 3 clinical trials in psoriatic arthritis. So at EULAR this year they report both trials at the same time.

So key take home messages from these trials for rheumatologists is that, A, there's a new therapy that works pretty well in psoriatic arthritis. It actually looks really good, particularly a side by side with adalimumab. One kind of unexpected findings was that this JAK inhibitor actually works pretty well for the skin in these psoriatic arthritis patients. So that was unexpected in that the previous JAK inhibitor tofacitinib that was tested in psoriasis. You need much higher doses for those more severe patients.

And then in the trials for psoriatic arthritis, you kind of saw something similar. That it works for psoriasis, but wasn't very powerful. And here upadacitinib next to adalimumab, we see that it worked actually just as well or better than adalimumab, which is surprising. Because we think of adalimumab being one of the really good skin drugs, particularly among the TNF inhibitors.

One of the strengths of these studies is they included adalimumab as a side by side comparison. They also did kind of a dose ranging study, which was helpful and kind of understanding how the doses might impact response rates as well as adverse events. So you did see some more adverse events with that higher dose there.

Some of the limitations is that with all these randomized clinical trials in psoriatic arthritis that are used to differentiate the drug from placebo, these patients are not necessarily represented by our clinical patient population. They tend to have much higher disease levels, a baseline with average tender and swollen joint counts of 20 and 12, respectively.

So really high disease patient populations overall. So it makes it look like they change a lot better. So that's just something to keep in mind when kind of estimating response rates in clinical practice is that we don't know what this looks like in clinical practice yet.

That's always a really difficult question, especially since we have so many treatments. So I think it's a good option for patients who want oral therapies. We use to say that JAK inhibitors probably aren't so good for people with more severe psoriasis, and I think this actually changes that concept, that maybe it will work pretty well in patients with more severe psoriasis. So it doesn't kind of cut you out of that patient population.

We also have axial data, so we know works well in axial disease and we're just waiting for that Phase 3 study to finish but the Phase 2 looks really strong. So I think this does work across the board in most of the disease features. I think we still have to get more safety data as these studies continue through 52 weeks and the long term extension studies. So there's still more to learn here from a safety perspective, particularly the 15 versus 30 milligrams and kind of what will come to market.

So I'm not exactly sure. It's just really hard to say where things fit in the spectrum, but it's certainly another treatment option for patients with psoriatic arthritis, which we actually do really need still.

I'd really like to see a head to head study as well as maybe a switching study. So they didn't really kind of interesting study in RA where they looked at upa[dacitinib] versus adalimumab and switching back and forth, when you're not doing one, switch it to the other and so on.

So I think that was a really interesting study. But I'd really like to see it in clinical practice and have kind of real world maybe pragmatic trials or head to head trials that show us where this does fit. That's the kind of data that actually shows you where drugs fit.