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Does Missing a Dose of a JAK Inhibitor Reduce the Effectiveness?

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Published on March 29, 2016

Viewer Cindy in this Ask the Expert segment asks Dr. Naval Daver, â??Can the effectiveness of ruxolitinib (Jakafi) be impacted by missing doses?â?? Listen as Dr. Daver the long-term efficacy of this treatment and reviews the potential impact of missing a dose.

The Ask the Expert series is sponsored through an educational grant to the Patient Empowerment Network from Incyte Corporation.

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Transcript | Does Missing a Dose of a JAK Inhibitor Reduce the Effectiveness?

Please remember the opinions expressed on Patient Power are not necessarily the views of our sponsors, contributors, partners or Patient Power. Our discussions are not a substitute for seeking medical advice or care from your own doctor. That’s how you’ll get care that’s most appropriate for you.      

Andrew Schorr:  

Dr. Daver, here’s a question we got from Cindy.  Cindy writes, I’m on ruxolitinib (Jakafi) for ET and have had some issues with insurance and/or pharmacy, so I’ve had to miss some doses.  Can the effectivity or effectiveness of Jakafi be impacted by missing doses? 

Dr. Daver:             

Yeah, so I think the long-term efficacy is not really lost if you miss a few doses, and I’m talking about up to four or five days.  Although, what we have seen in some patients, and this is variable, some patients are very sensitive to continuous administration of the JAK inhibitor.  So we’ve seen some people where even two to three days, if we stop their treatment, their spleen stops coming back.  

In almost all those cases, as soon we reinitiate the Jakafi, it goes back down.  But we usually do not want to interrupt it if possible.  Now, if there’s no way out of it and you have to stop it, what I would recommend is try your best to restart is as soon as possible.  And in most cases, if it’s a small delay, less than seven days or eight days, you’ll be able to recapture a response. Although you may start actually feeling, even in those seven days, some of your symptoms coming back.

But there [are] no studies showing now that the long-term efficacy is negatively affected.  But it’s not a study we want to do.  So, in general, we tell our patients take it as frequently as possible.  If you, for whatever reason, you don’t have the pills or what, whenever you get them resume them.  When you resume them, you resume at the same dose and same schedule, so we do not try to make up the missed doses, and then you continue. 

Andrew Schorr:                  

I have a question related to taking Jakafi or ruxolitinib for a myelofibrosis patient.  I’ve heard that if you miss doses or run out, that you have a likelihood of some, I think I heard the term, some sort of cytokine storm?  So tell us about that for myelofibrosis patients.

Dr. Daver:             

Yeah, so it’s really—we call it a rebound or cytokine.  We really don’t see a cytokine storm, because now with these newer therapies we’re seeing some true cytokine storms, which are very aggressive.  Those are more usually terms referred for CAR-T cells, where you can really get a huge cytokine and can put people in the ICU, cause pulmonary failure.  What we see with Jakafi, and again it’s not common, but it is one of the reasons we are very hesitant even in patients, for example, who are admitted with infection to the hospital.  

We will always say do not stop the Jakafi.  And this is actually something that in the community happens very frequently.  So patients will be admitted for pneumonia, and the physician knee-jerk will be to stop Jakafi for eight days. And then they call, and they say the spleen is big, and he’s feeling bad.

So in the rebound, the main symptoms you will see is the spleen comes back up.  There can be fever, chills, pruritis, loss of appetite, nausea, vomiting—basically everything that we see when the patient initially presented.  And in some cases, you’re right, it can be even more severe, because the pressure has been taken off, and all those cytokines are just—and the activation comes in aggressively.

So very important that even under admission, unless it’s a really life-threatening infection or ICU stay, we really are hesitant to stop.  You can treat the pneumonia, the urinary tract infection, whatever, but continue the JAK inhibitor. 

Please remember the opinions expressed on Patient Power are not necessarily the views of our sponsors, contributors, partners or Patient Power. Our discussions are not a substitute for seeking medical advice or care from your own doctor. That’s how you’ll get care that’s most appropriate for you. 

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