Does a patient on Jakavi (Ruxolitinib) require antimicrobial prophylaxis?

From the Guidelines

Patients on Jakavi (ruxolitinib) generally do not require routine antimicrobial prophylaxis unless they have additional risk factors for infection, such as prolonged neutropenia or a history of recurrent bacterial infections, as recommended by the most recent guidelines 1. When considering antimicrobial prophylaxis for patients on Jakavi, it is essential to assess their individual risk factors, including neutropenia, prior serious infections, concomitant use of other immunosuppressants, or underlying conditions like COPD or diabetes.

• The decision to use antimicrobial prophylaxis should be based on the patient's complete clinical picture, including disease status, comorbidities, and other medications.
• If prophylaxis is deemed necessary, options include levofloxacin, as recommended by the expert panel 1, or other fluoroquinolones, which have been shown to reduce the risk of all-cause mortality and infection-related deaths in patients with neutropenia 1.
• Regular monitoring of blood counts and vigilance for signs of infection remain essential for all patients on ruxolitinib, regardless of prophylaxis status.
• It is crucial to weigh the benefits and risks of antimicrobial prophylaxis, including the potential for increased resistance to fluoroquinolones, and to consider alternative options, such as trimethoprim-sulfamethoxazole or valacyclovir, based on the patient's specific needs and risk factors 1.

From the Research

Patient on Jakavi and Anti-Microbial Prophylaxis

• The use of Jakavi (ruxolitinib) has been associated with an increased risk of infections, including herpes zoster, bronchitis, and urinary tract infections 2.
• A systematic review and meta-analysis found that ruxolitinib was associated with a statistically significant increased risk of herpes zoster infection compared to the control group 2.
• The risk of infection with ruxolitinib is dose-dependent, and the risk is compounded by other risk factors for infection, such as age and steroid co-prescription 3.
• Herpes zoster reactivation is more common with JAK inhibitors, including ruxolitinib, compared to other targeted immune modulation, making screening for varicella exposure and vaccination in appropriate cohorts an advisable strategy 3.

Infection Risks and Management

• The infection risk associated with ruxolitinib may be clinically relevant, and well-designed studies are warranted to evaluate the risk of ruxolitinib-associated infection and to identify the most appropriate antimicrobial prophylactic strategy 2.
• Patients on ruxolitinib should be monitored for signs and symptoms of infection, and antimicrobial prophylaxis should be considered in patients at high risk of infection 2, 3.
• The use of antimicrobial prophylaxis in patients on ruxolitinib is not universally recommended, and the decision to use prophylaxis should be made on a case-by-case basis, taking into account the individual patient's risk factors and medical history 2, 3.

Ruxolitinib and Immunosuppression

• Ruxolitinib exerts immunosuppressive activity, which may increase the risk of infectious complications 2.
• The immunosuppressive effects of ruxolitinib are dose-dependent, and the risk of infection is higher at higher doses 3.
• Patients on ruxolitinib should be advised to take precautions to minimize their risk of infection, such as avoiding close contact with people who have infections and practicing good hygiene 2, 3.