Kinase Inhibitors: Baricitinib and Other Janus Kinase Inhibitors, and Bruton’s Tyrosine Kinase Inhibitors
Last Updated: February 11, 2021
Janus Kinase Inhibitors
The kinase inhibitors are proposed as treatments for COVID-19 because they can prevent phosphorylation of key proteins involved in the signal transduction that leads to immune activation and inflammation (e.g., the cellular response to proinflammatory cytokines such as interleukin [IL]-6).1 Janus kinase (JAK) inhibitors interfere with phosphorylation of signal transducer and activator of transcription (STAT) proteins2,3 that are involved in vital cellular functions, including signaling, growth, and survival.
Immunosuppression induced by this class of drugs could potentially reduce the inflammation and associated immunopathologies observed in patients with COVID-19. Additionally, JAK inhibitors, particularly baricitinib, have theoretical direct antiviral activity through interference with viral endocytosis, potentially preventing entry into and infection of susceptible cells.4
- There are insufficient data for the COVID-19 Treatment Guidelines Panel (the Panel) to recommend either for or against the use of baricitinib in combination with remdesivir for the treatment of COVID-19 in hospitalized patients, when corticosteroids can be used.
- In the rare circumstance when corticosteroids cannot be used, the Panel recommends baricitinib in combination with remdesivir for the treatment of COVID-19 in hospitalized, non-intubated patients who require oxygen supplementation (BIIa).
- The Panel recommends against the use of baricitinib without remdesivir, except in a clinical trial (AIII).
- There are insufficient data for the Panel to recommend either for or against the use of baricitinib in combination with corticosteroids for the treatment of COVID-19. Because both baricitinib and corticosteroids are potent immunosuppressants, there is potential for an additive risk of infection.
- The Panel recommends against the use of JAK inhibitors other than baricitinib for the treatment of COVID-19, except in a clinical trial (AIII).
The Panel’s recommendations for the use of baricitinib are based on data from the Adaptive COVID-19 Treatment Trial 2 (ACTT-2), a multinational, randomized, placebo-controlled trial of baricitinib use in hospitalized patients with COVID-19 pneumonia (see below for a full description of the ACTT-2 data for baricitinib). Participants (n = 1,033) were randomized 1:1 to oral baricitinib 4 mg or placebo, for up to 14 days, in combination with intravenous (IV) remdesivir, for up to 10 days. Participants who received baricitinib had a shorter time to clinical recovery than those who received placebo (median recovery time of 7 vs. 8 days, respectively). This treatment effect was most pronounced among those who required high-flow oxygen or non-invasive ventilation but were not on invasive mechanical ventilation. The difference in mortality between the treatment groups was not statistically significant.5
Corticosteroids have established efficacy in the treatment of severe and critical COVID-19 pneumonia (see the Therapeutic Management and Corticosteroids sections). The Panel’s recommendations for the use of baricitinib are based on data for the benefit of corticosteroids and the uncertain clinical impact of the modest difference in time to recovery between the placebo-treated and baricitinib-treated patients in the ACTT-2 trial. The Panel also considered the infrequent use of corticosteroids in the ACTT-2 trial, given that patients receiving corticosteroids for the treatment of COVID-19 at study entry were excluded.
On November 19, 2020, the Food and Drug Administration (FDA) issued an Emergency Use Authorization (EUA) for the use of baricitinib in combination with remdesivir in hospitalized adults and children aged ≥2 years with COVID-19 who require supplemental oxygen, invasive mechanical ventilation, or extracorporeal membrane oxygenation (ECMO).6
The issuance of an EUA does not constitute FDA approval. An EUA indicates that a product may be effective in treating a serious or life-threatening disease or condition. FDA approval occurs when a product has been determined to provide benefits that outweigh its known and potential risks for the intended population.
Monitoring , Adverse Effects, and Drug-Drug Interactions
Most of the data on adverse effects of JAK inhibitors refer to chronic use of the agents. Adverse effects include infections (typically respiratory and urinary tract infections) and the reactivation of herpes viruses. Additional toxicities include myelosuppression and transaminase elevations. In addition, there may be a slightly higher risk of thrombotic events and gastrointestinal perforation in patients who receive JAK inhibitors.
Complete blood count with differential, liver function tests, and kidney function tests should be obtained in all patients before baricitinib is administered and during treatment as clinically indicated. Screening for viral hepatitis and tuberculosis should be considered. Considering its immunosuppressive effects, all patients receiving baricitinib should also be monitored for new infections.
The ACTT-2 study evaluated oral baricitinib 4 mg once daily;5 however, the standard dosage of baricitinib for FDA-approved indications is 2 mg once daily. Baricitinib use is not recommended in patients with impaired hepatic or renal function (estimated GFR <60 mL/min/1.73 m2).7 There are limited clinical data on the use of baricitinib in combination with strong organic anion transporter 3 inhibitors, and, in general, coadministration is not advised.7,8
Considerations in Pregnancy
There is a paucity of data on the use of JAK inhibitors in pregnancy. As small molecule-drugs, JAK inhibitors are likely to pass through the placenta, and therefore fetal risk cannot be ruled out.9 Decisions about the administration of JAK inhibitors must include shared decision-making with the pregnant individual, considering potential maternal benefit and fetal risks. Factors that may weigh into the decision-making process include maternal COVID-19 severity, comorbidities, and gestational age. When the benefits outweigh the risks, use of JAK inhibitors may be considered.
Considerations in Children
An EUA has been issued for the use of baricitinib in combination with remdesivir in hospitalized adults and children aged ≥2 years with COVID-19 who require supplemental oxygen, invasive mechanical ventilation, or ECMO. The safety and efficacy of baricitinib or other JAK inhibitors has not been evaluated in pediatric patients with COVID-19, and data on the use of the drugs in children with other conditions are extremely limited. Thus, there are insufficient data to recommend either for or against the use of baricitinib in combination with remdesivir for the treatment of COVID-19 in hospitalized children when corticosteroids cannot be used. Use of JAK inhibitors other than baricitinib for the treatment of COVID-19 in pediatric patients is not recommended, except in a clinical trial.
Baricitinib is an oral JAK inhibitor that is selective for JAK1 and JAK2 and FDA approved for the treatment of rheumatoid arthritis.7 Baricitinib can modulate downstream inflammatory responses via JAK1/JAK2 inhibition and has exhibited dose-dependent inhibition of IL-6-induced STAT3 phosphorylation.10 Baricitinib has postulated antiviral effects by blocking severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) from entering and infecting lung cells.11 Baricitinib reduced inflammation and lung pathology in macaques infected with SARS-CoV-2 but an antiviral effect was not confirmed.12
Clinical Data for COVID-19
The multicenter, randomized, double-blind ACTT-2 trial compared (1:1 allocation) oral baricitinib 4 mg daily (for up to 14 days or until hospital discharge) versus placebo, both given in combination with IV remdesivir (for 10 days or until hospital discharge). The trial included 1,033 patients hospitalized with moderate to severe COVID-19. The primary endpoint was time to recovery, which was defined as reaching Category 1 (not hospitalized, no limitations), Category 2 (not hospitalized, with limitations), or Category 3 (hospitalized, no active medical problems) on an eight-category ordinal scale within 28 days of treatment initiation. Patients who were using a medication off-label as a specific treatment for COVID-19, including corticosteroids, at study entry were excluded from the trial. In the overall cohort, the median time to recovery was shorter in the baricitinib plus remdesivir arm (7 days) than in the placebo plus remdesivir arm (8 days) (rate ratio for recovery 1.16; 95% CI, 1.01–1.32; P = 0.03). In subgroup analyses according to disease severity, the difference in time to recovery was greatest among the participants who required high-flow oxygen or non-invasive ventilation (10 vs. 18 days for the baricitinib and placebo recipients, respectively; rate ratio for recovery 1.51; 95% CI, 1.10–2.08). However, the treatment effect within this subgroup should be interpreted with caution given the relatively small sample size. Within the subgroup of patients on invasive mechanical ventilation or ECMO at study entry, it was not possible to estimate the median time to recovery within the first 28 days following treatment initiation, and there was no evidence of benefit with baricitinib use (rate ratio for recovery 1.08; 95% CI, 0.59–1.97). Improvement across ordinal categories at Day 15 was a key secondary endpoint, and again baricitinib demonstrated a significant benefit only in the subgroup of patients requiring high-flow oxygen or non-invasive ventilation (OR 2.3; 95% CI, 1.4–3.7). Mortality by 28 days was lower in the baricitinib arm than in the placebo arm, but the difference was not statistically significant (OR 0.65; 95% CI, 0.39–1.09). There was no evidence that the risk of serious adverse events or new infections was higher in the baricitinib arm than in the placebo arm (16% vs. 20% for adverse events and 6% vs. 11% for new infections in the baricitinib and placebo arms, respectively).5
Even though the use of corticosteroids for the treatment of COVID-19 was prohibited at study entry, the protocol allowed for the adjunctive use of corticosteroids at the discretion of the treating provider for the treatment of standard medical indications (e.g., asthma exacerbation, acute respiratory distress syndrome, chronic obstructive pulmonary disease). During the study, 10.9% of the patients in the baricitinib group and 12.9% in the placebo group were prescribed corticosteroids. Overall, the incidence of serious or non-serious infections was lower in the baricitinib group (30 patients [6%]) than in the placebo group (57 patients [11%]) (RD -5; 95% CI, -9 to -2). There were no statistically significant differences between the baricitinib and placebo arms in the frequency of pulmonary embolism (5 vs. 2 patients, respectively) or deep vein thrombosis (11 vs. 9 patients, respectively).
Preliminary results of this study suggest that baricitinib improves time to recovery in patients who require supplemental oxygen but not invasive mechanical ventilation. However, a key limitation of the study is the inability to evaluate the treatment effect of baricitinib in addition to, or in comparison to, corticosteroids used as standard treatment for severe or critical COVID-19 pneumonia.
Please check ClinicalTrials.gov for the latest information on studies of baricitinib and COVID-19.
Ruxolitinib is an oral JAK inhibitor selective for JAK1 and JAK2 that is currently approved for myelofibrosis, polycythemia vera, and acute graft-versus-host disease.13 Like baricitinib, it can modulate downstream inflammatory responses via JAK1/JAK2 inhibition and has exhibited dose-dependent inhibition of IL-6-induced STAT3 phosphorylation.10 Ruxolitinib also has postulated antiviral effects by blocking SARS-CoV-2 from entering and infecting lung cells.11
Clinical Data for COVID-19
A small, single-blind, randomized, controlled Phase 2 trial in patients with COVID-19 in China compared ruxolitinib 5 mg orally twice daily (n = 20) with placebo (administered as vitamin C 100 mg; n = 21), both given in combination with SOC therapy. The median age of the patients was 63 years. There were no significant demographic differences between the two arms. Treatment with ruxolitinib was associated with a nonsignificant reduction in the median time to clinical improvement (12 days for ruxolitinib vs. 15 days for placebo; P = 0.15), defined as a two-point improvement on a seven-category ordinal scale or as hospital discharge. There was no difference between the groups in the median time to discharge (17 days for ruxolitinib vs. 16 days for placebo; P = 0.94). More patients in the ruxolitinib group than in the placebo group had radiographic improvement on computed tomography scans of the chest at Day 14 (90% for ruxolitinib vs. 61.9% for placebo; P = 0.05) and a shorter time to recovery from initial lymphopenia (5 days for ruxolitinib vs. 8 days for placebo; P = 0.03), when it was present. The use of ruxolitinib was not associated with an increased risk of adverse events or mortality (no deaths in the ruxolitinib arm vs. three deaths [14% of patients] in the control arm). Despite the theoretical antiviral properties of JAK inhibitors, there was no significant difference in the time to viral clearance among the patients who had detectable viral loads at the time of randomization to ruxolitinib treatment (n = 8) or placebo (n = 9). Limitations of this study include the small sample size, the exclusion of ventilated patients at study entry, and the concomitant use of antivirals and steroids by 70% of the patients.14
Please check ClinicalTrials.gov for the latest information on studies of ruxolitinib and COVID-19.
Tofacitinib is the prototypical JAK inhibitor, predominantly selective for JAK1 and JAK3, with modest activity against JAK2, and, as such, can block signaling from gamma-chain cytokines (e.g., IL-2, IL-4) and gp 130 proteins (e.g., IL-6, IL-11, interferons). It is an oral agent first approved by the FDA for the treatment of rheumatoid arthritis and has been shown to decrease levels of IL-6 in patients with this disease.15 Tofacitinib is also FDA approved for the treatment of psoriatic arthritis, juvenile idiopathic arthritis, and ulcerative colitis.16
Clinical Data for COVID-19
There are no clinical data on the use of tofacitinib to treat COVID-19.
Considerations in Pregnancy
Pregnancy registries provide some outcome data on tofacitinib used during pregnancy for other conditions (e.g., ulcerative colitis, rheumatoid arthritis, psoriasis). Among the 33 cases reported, pregnancy outcomes were similar to those among the general pregnant population.17-19
Please check ClinicalTrials.gov for the latest information on studies of tofacitinib and COVID-19.
Bruton's Tyrosine Kinase Inhibitors
Bruton’s tyrosine kinase (BTK) is a signaling molecule of the B-cell antigen receptor and cytokine receptor pathways.
- The Panel recommends against the use of BTK inhibitors for the treatment of COVID-19, except in a clinical trial (AIII).
Acalabrutinib is a second-generation, oral BTK inhibitor that is FDA approved to treat B-cell malignancies (i.e., chronic lymphocytic leukemia/small lymphocytic lymphoma, mantle cell lymphoma). It has a better toxicity profile than first-generation BTK inhibitors (e.g., ibrutinib) because of less off-target activity for other kinases.20 Acalabrutinib is proposed for use in patients with COVID-19 because it can modulate signaling that promotes inflammation.
Clinical Data for COVID-19
Data regarding acalabrutinib are limited to the results from a retrospective case series of 19 patients with severe COVID-19.21 Evaluation of the data to discern any clinical benefit is limited by the study’s small sample size and lack of a control group.
Please check ClinicalTrials.gov for the latest information on studies of acalabrutinib and COVID-19.
Ibrutinib is a first-generation BTK inhibitor that is FDA approved to treat various B-cell malignancies22 and to prevent chronic graft-versus-host disease in stem cell transplant recipients.23 Based on results from a small case series, ibrutinib has been theorized to reduce inflammation and protect against ensuing lung injury in patients with COVID-19.24
Clinical Data for COVID-19
Data regarding ibrutinib are limited to those from an uncontrolled, retrospective case series of six patients with COVID-19 who were receiving the drug for a condition other than COVID-19.24 Evaluation of the data for any clinical benefit is limited by the series’ small sample size and lack of a control group.
Please check ClinicalTrials.gov for the latest information on studies of ibrutinib and COVID-19.
Zanubrutinib is a second-generation, oral BTK inhibitor that is FDA approved to treat mantle cell lymphoma.25 It has been shown to have fewer toxicities than first-generation BTK inhibitors (e.g., ibrutinib) because of less off-target activity for other kinases.26 Zanubrutinib is proposed to benefit patients with COVID-19 by modulating signaling that promotes inflammation.
Clinical Data for COVID-19
There are no clinical data on the use of zanubrutinib to treat COVID-19.
Please check ClinicalTrials.gov for the latest information on studies of zanubrutinib and COVID-19.
Adverse Effects and Monitoring
Hemorrhage and cardiac arrhythmia have occurred in patients who received BTK inhibitors.
Considerations in Pregnancy
There is a paucity of data on human pregnancy and BTK inhibitor use. In animal studies, acalabrutinib and ibrutinib in doses exceeding the therapeutic human dose were associated with interference with embryofetal development.22,27 Based on these data, use of BTK inhibitors that occurs during organogenesis may be associated with fetal malformations. The impact of use later in pregnancy is unknown. Risks of use should be balanced against potential benefits.
Considerations in Children
The safety and efficacy of BTK inhibitors have not been evaluated in pediatric patients with COVID-19, and data on the use of the drugs in children with other conditions are extremely limited. Use of BTK inhibitors for the treatment of COVID-19 in pediatric patients is not recommended, except in a clinical trial.
- Zhang W, Zhao Y, Zhang F, et al. The use of anti-inflammatory drugs in the treatment of people with severe coronavirus disease 2019 (COVID-19): the perspectives of clinical immunologists from China. Clin Immunol. 2020;214:108393. Available at: https://www.ncbi.nlm.nih.gov/pubmed/32222466.
- Babon JJ, Lucet IS, Murphy JM, Nicola NA, Varghese LN. The molecular regulation of Janus kinase (JAK) activation. Biochem J. 2014;462(1):1-13. Available at: https://www.ncbi.nlm.nih.gov/pubmed/25057888.
- Bousoik E, Montazeri Aliabadi H. "Do we know jack" about JAK? A closer look at JAK/STAT signaling pathway. Front Oncol. 2018;8:287. Available at: https://www.ncbi.nlm.nih.gov/pubmed/30109213.
- Stebbing J, Phelan A, Griffin I, et al. COVID-19: combining antiviral and anti-inflammatory treatments. Lancet Infect Dis. 2020;20(4):400-402. Available at: https://www.ncbi.nlm.nih.gov/pubmed/32113509.
- Kalil AC, Patterson TF, Mehta AK, et al. Baricitinib plus remdesivir for hospitalized adults with COVID-19. N Engl J Med. 2020;Published online ahead of print. Available at: https://pubmed.ncbi.nlm.nih.gov/33306283/.
- Food and Drug Administration. Fact sheet for healthcare providers: emergency use authorization (EUA) of baricitinib. 2020. Available at: https://www.fda.gov/media/143823/download. Accessed December 11, 2020.
- Baricitinib (Olumiant) [package insert]. Food and Drug Administration. 2019. Available at: https://www.accessdata.fda.gov/drugsatfda_docs/label/2019/207924s001lbl.pdf.
- Posada MM, Cannady EA, Payne CD, et al. Prediction of transporter-mediated drug-drug interactions for baricitinib. Clin Transl Sci. 2017;10(6):509-519. Available at: https://www.ncbi.nlm.nih.gov/pubmed/28749581.
- Sammaritano LR, Bermas BL, Chakravarty EE, et al. 2020 American College of Rheumatology guideline for the management of reproductive health in rheumatic and musculoskeletal diseases. Arthritis Rheumatol. 2020;72(4):529-556. Available at: https://www.ncbi.nlm.nih.gov/pubmed/32090480.
- McInnes IB, Byers NL, Higgs RE, et al. Comparison of baricitinib, upadacitinib, and tofacitinib mediated regulation of cytokine signaling in human leukocyte subpopulations. Arthritis Res Ther. 2019;21(1):183. Available at: https://www.ncbi.nlm.nih.gov/pubmed/31375130.
- Richardson P, Griffin I, Tucker C, et al. Baricitinib as potential treatment for 2019-nCoV acute respiratory disease. Lancet. 2020;395(10223):e30-e31. Available at: https://www.ncbi.nlm.nih.gov/pubmed/32032529.
- Hoang TN, Pino M, Boddapati AK, et al. Baricitinib treatment resolves lower-airway macrophage inflammation and neutrophil recruitment in SARS-CoV-2-infected rhesus macaques. Cell. 2020. Available at: https://www.ncbi.nlm.nih.gov/pubmed/33278358.
- Ruxolitinib (JAKAFI) [package insert]. 2020. Available at: https://www.jakafi.com/pdf/prescribing-information.pdf. Accessed: May 28, 2020.
- Cao Y, Wei J, Zou L, et al. Ruxolitinib in treatment of severe coronavirus disease 2019 (COVID-19): A multicenter, single-blind, randomized controlled trial. J Allergy Clin Immunol. 2020. Available at: https://www.ncbi.nlm.nih.gov/pubmed/32470486.
- Migita K, Izumi Y, Jiuchi Y, et al. Effects of Janus kinase inhibitor tofacitinib on circulating serum amyloid A and interleukin-6 during treatment for rheumatoid arthritis. Clin Exp Immunol. 2014;175(2):208-214. Available at: https://www.ncbi.nlm.nih.gov/pubmed/24665995.
- Tofacitinib (Xeljanz) [package insert]. Food and Drug Administration. 2019. Available at: https://www.accessdata.fda.gov/drugsatfda_docs/label/2019/203214s024,208246s010lbl.pdf.
- Clowse ME, Feldman SR, Isaacs JD, et al. Pregnancy outcomes in the tofacitinib safety databases for rheumatoid arthritis and psoriasis. Drug Saf. 2016;39(8):755-762. Available at: https://www.ncbi.nlm.nih.gov/pubmed/27282428.
- Mahadevan U, Dubinsky MC, Su C, et al. Outcomes of pregnancies with maternal/paternal exposure in the tofacitinib safety databases for ulcerative colitis. Inflamm Bowel Dis. 2018;24(12):2494-2500. Available at: https://www.ncbi.nlm.nih.gov/pubmed/29982686.
- Wieringa JW, van der Woude CJ. Effect of biologicals and JAK inhibitors during pregnancy on health-related outcomes in children of women with inflammatory bowel disease. Best Pract Res Clin Gastroenterol. 2020;44-45:101665. Available at: https://www.ncbi.nlm.nih.gov/pubmed/32359679.
- Owen C, Berinstein NL, Christofides A, Sehn LH. Review of Bruton tyrosine kinase inhibitors for the treatment of relapsed or refractory mantle cell lymphoma. Curr Oncol. 2019;26(2):e233-e240. Available at: https://www.ncbi.nlm.nih.gov/pubmed/31043832.
- Roschewski M, Lionakis MS, Sharman JP, et al. Inhibition of Bruton tyrosine kinase in patients with severe COVID-19. Sci Immunol. 2020;5(48). Available at: https://www.ncbi.nlm.nih.gov/pubmed/32503877.
- Ibrutinib (Imbruvica) [package insert]. Food and Drug Administration. 2015. Available at: https://www.accessdata.fda.gov/drugsatfda_docs/label/2015/205552s002lbl.pdf.
- Food and Drug Administration. FDA expands ibrutinib indications to chronic GVHD. 2017. Available at: https://www.fda.gov/drugs/resources-information-approved-drugs/fda-expands-ibrutinib-indications-chronic-gvhd. Accessed February 1, 2021.
- Treon SP, Castillo JJ, Skarbnik AP, et al. The BTK inhibitor ibrutinib may protect against pulmonary injury in COVID-19-infected patients. Blood. 2020;135(21):1912-1915. Available at: https://www.ncbi.nlm.nih.gov/pubmed/32302379.
- Zanubrutinib (Brukinsa) [package insert]. Food and Drug Administration. 2019. Available at: https://www.accessdata.fda.gov/drugsatfda_docs/label/2019/213217s000lbl.pdf.
- Tam C, Grigg AP, Opat S, et al. The BTK inhibitor, Bgb-3111, is safe, tolerable, and highly active in patients with relapsed/refractory B-cell malignancies: initial report of a Phase 1 first-in-human trial. Blood. 2015;126(23):832. Available at: https://ashpublications.org/blood/article/126/23/832/136525/The-BTK-Inhibitor-Bgb-3111-Is-Safe-Tolerable-and.
- Acalabrutinib (Calquence) [package insert]. Food and Drug Administration. 2017. Available at: https://www.accessdata.fda.gov/drugsatfda_docs/label/2017/210259s000lbl.pdf.