From the Guidelines
For patients with rheumatoid arthritis who have a history of cytopenias, both Rinvoq (upadacitinib) and Tyenne (tocilizumab) should be used with caution rather than being absolutely contraindicated, as recommended by the 2019 EULAR update on rheumatoid arthritis management 1. When considering the use of these medications, it is essential to carefully monitor blood counts before and during treatment.
- For upadacitinib (Rinvoq), treatment should not be initiated in patients with significant cytopenias, and regular laboratory monitoring is necessary to promptly identify any adverse effects on blood counts.
- For tocilizumab, treatment is not recommended in patients with severe cytopenias, and similar monitoring strategies should be employed. The risk of cytopenias with these medications relates to their mechanisms of action: upadacitinib inhibits JAK pathways while tocilizumab blocks IL-6 receptors, both of which play roles in hematopoiesis, as discussed in the context of rheumatoid arthritis management 1. Alternative RA treatments like TNF inhibitors might be considered for patients with significant cytopenia history, though all immunomodulatory therapies carry some risk of hematologic effects. Regular laboratory monitoring, typically every 4-8 weeks initially, then every 3 months once stable, is crucial for the safe use of these medications in patients with a history of cytopenias, aligning with the principles of monitoring and adjusting therapy as outlined in the EULAR recommendations 1.
From the FDA Drug Label
ANC less than 500 Discontinue ACTEMRA Less than 50,000 Discontinue ACTEMRA The FDA drug label for Tocilizumab (Tyenne) provides guidance on dose adjustments and discontinuations in patients with cytopenias, including neutropenia (ANC less than 500 cells per mm3) and thrombocytopenia (platelet count less than 50,000 cells per mm3).
- In patients with a past history of cytopenias, the label recommends discontinuing Tocilizumab (Tyenne) if the patient develops severe neutropenia or thrombocytopenia.
- However, there is no direct information in the provided label regarding the use of Rinvoq (upadacitinib) in patients with a past history of cytopenias.
- Based on the available information for Tocilizumab (Tyenne), it can be inferred that caution should be exercised when using this medication in patients with a history of cytopenias.
- The decision to use Tocilizumab (Tyenne) or Rinvoq (upadacitinib) in patients with rheumatoid arthritis and a past history of cytopenias should be made on a case-by-case basis, taking into account the individual patient's risk factors and medical history 2.
From the Research
Rinvoq (Upadacitinib) and Cytopenias
- There is no direct evidence in the provided studies that Rinvoq (upadacitinib) is not recommended for use in patients with rheumatoid arthritis and a past history of cytopenias.
- However, the studies do mention that upadacitinib, like other JAK inhibitors, has labeled warnings for serious infections, herpes zoster, malignancies, major cardiovascular events, and venous thromboembolic events 3.
- One study mentions that upadacitinib was associated with increased risk of herpes zoster and creatine phosphokinase elevations compared to methotrexate and adalimumab 3.
- Another study reports that adverse events, including herpes zoster and malignancies, were observed in patients treated with upadacitinib, but the safety observations were similar to those in previous upadacitinib rheumatoid arthritis studies 4.
Tyenne (Tocilizumab) and Cytopenias
- There is no mention of Tyenne (tocilizumab) in the provided studies.
- Therefore, there is no evidence to suggest that Tyenne (tocilizumab) is not recommended for use in patients with rheumatoid arthritis and a past history of cytopenias based on the provided studies.
Use of Rinvoq (Upadacitinib) and Tyenne (Tocilizumab) in Patients with Cytopenias
- In general, patients with a history of cytopenias may require closer monitoring when treated with medications that can affect blood cell counts.
- However, without specific evidence or guidelines regarding the use of Rinvoq (upadacitinib) and Tyenne (tocilizumab) in patients with cytopenias, it is difficult to make a definitive statement about their use in this population 5, 6, 3, 4, 7.