Impact of switching janus kinase inhibitors in the treatment of severe alopecia areata

Summary: Abstract Body: Alopecia areata (AA) is an autoimmune condition with limited treatment options for severe cases. Janus kinase inhibitors (JAKis) have improved treatment outcomes for severe AA, but data on switching between JAKis, whether due to lack of efficacy or insurance reasons, is limited. This study evaluated the impact of switching JAKis in patients with severe AA. A retrospective review was conducted on severe AA patients who switched JAKis after at least 6 months of treatment with an initial JAKi. Outcomes were assessed using Severity of Alopecia Tool (SALT) scores. Eight patients (75% female, mean age 45 years) were included, with AA duration of current episode of 6.6 years (1.5–10) and a mean baseline SALT score of 93 (70–100). Patients received their initial JAKi for an average of 24 months (6–65), including baricitinib (n=4), deuruxolitinib (n=1), ruxolitinib (n=1), and tofacitinib (n=2). Six patients switched due to lack of efficacy, and two due to insurance denial. Using SALT ≤20 as a cutoff for response, three patients (37.5%) achieved clinically meaningful improvement after switching JAKis, with a mean SALT reduction of 72. Two patients showed minimal improvement, and one showed no improvement. Notably, two patients worsened after switching JAKis due to insurance denial, despite initial improvement on tofacitinib (SALT 20, 25); their SALT scores increased to 50 and 35 after switching. Of three patients who switched to a third JAKi, none attained a SALT ≤20, though two showed some improvement. This study demonstrates that switching JAKis can benefit some severe AA patients, with 37.5% showing meaningful regrowth. Notably, two patients denied tofacitinib coverage after significant regrowth experienced worsening AA when switched due to insurance restrictions, highlighting the importance of patient advocacy in these cases. Limitations include the small sample size, retrospective design, and severity of AA at baseline. A multi-center study is underway to include a larger, more diverse population. Aubrey Martin¹, Divya Sharma¹, Carly Kreytak¹, Maryanne Senna^{1, 2} 1. Dermatology, Lahey Hospital & Medical Center, Burlington, MA, United States. 2. Dermatology, Harvard Medical School, Boston, MA, United States. Clinical Research: Epidemiology and Observational Research