Is it appropriate to use upadacitinib (Rinvoq) for an 84‑year‑old man with severe atopic dermatitis when dupilumab (Dupixent) is unavailable?

Upadacitinib for an 84-Year-Old Man with Severe Atopic Dermatitis

Upadacitinib can be used in this 84-year-old patient with severe atopic dermatitis when dupilumab is unavailable, but proceed with extreme caution given the significantly elevated risks of serious adverse events in elderly patients, particularly those over 65 years with cardiovascular risk factors.

Critical Age-Related Safety Concerns

The FDA label for upadacitinib (Rinvoq) contains multiple boxed warnings that are particularly relevant for elderly patients 1:

• Blood clots (DVT/PE) occur more frequently in patients ≥50 years with at least one cardiovascular risk factor - this 84-year-old patient is at substantially elevated baseline risk
• Malignancy risk is concentrated in older patients: In RA trials, almost all malignancies occurred in patients ≥53 years, with lung cancer being most common in the tofacitinib (pan-JAK inhibitor) group 2
• Serious infections, including opportunistic infections and herpes zoster, are more common in elderly patients
• Major adverse cardiovascular events (MACE) including heart attack and stroke carry increased risk

When Upadacitinib Is Indicated

Upadacitinib is FDA-approved for adults and children ≥12 years with refractory moderate-to-severe atopic dermatitis whose disease is not adequately controlled with other systemic drugs including biologics, or when use of those therapies is inadvisable 1. This patient meets these criteria if dupilumab is truly unavailable.

Pre-Treatment Risk Assessment Required

Before initiating treatment, you must evaluate 2, 1:

Cardiovascular risk factors:

• Current or past smoking history
• History of heart attack, stroke, or other cardiovascular disease
• Hypertension, diabetes, hyperlipidemia

Infection screening:

• Active infections (absolute contraindication)
• History of recurrent infections
• Tuberculosis screening
• Hepatitis B/C screening
• Vaccination status (complete Shingrix series ideally 3-4 weeks before starting)

Organ function:

• Renal function: For severe renal impairment (CrCl <30 mL/min), maximum dose is 15 mg daily 2
• Hepatic function: Avoid in severe hepatic disease (Child-Pugh C) 2
• Baseline labs: CBC, liver enzymes, lipid panel, CPK

Malignancy history:

• Prior or current malignancies (relative contraindication)

GI risk factors:

• History of diverticulitis or GI ulcers (increased perforation risk, especially with concurrent NSAIDs/corticosteroids) 1

Dosing Strategy for Elderly Patients

Given the age and risk profile:

• Start with 15 mg daily rather than 30 mg to minimize adverse events, despite 30 mg showing superior efficacy in head-to-head trials 3, 4
• Real-world data shows both 15 mg and 30 mg achieve significant improvements, with 77.8% achieving EASI-75 at week 16 5
• The 15 mg dose may provide a better risk-benefit balance in this high-risk elderly patient

Monitoring Protocol

Baseline and ongoing laboratory monitoring 1:

• CBC with differential (check neutrophils, lymphocytes, hemoglobin)
• Liver enzymes
• Lipid panel at 12 weeks and as needed
• Renal function
• CPK levels

Clinical monitoring:

• Signs of infection (especially herpes zoster, herpes simplex)
• Cardiovascular symptoms (chest pain, shortness of breath)
• DVT/PE symptoms (leg swelling/pain, sudden chest pain, dyspnea)
• GI symptoms (abdominal pain, fever, nausea)

Expected Efficacy

If treatment proceeds, upadacitinib demonstrates:

• Rapid itch improvement as early as day 2 4
• EASI-75 response in 71% by week 16 (30 mg dose) 3
• Superior efficacy to dupilumab across all body regions 6
• Sustained responses through 52+ weeks 5

Alternative Considerations

The 2025 AAD guidelines recommend newer agents like lebrikizumab or nemolizumab as alternatives 7, though these may also have limited availability. Topical therapies (tapinarof cream, roflumilast cream) combined with traditional topical corticosteroids may be safer first-line options for elderly patients before escalating to systemic JAK inhibitors 7.

Bottom Line Decision Algorithm

1. If cardiovascular risk factors present (smoking, prior MI/stroke, age >65): Consider alternative systemic therapies first; if upadacitinib is the only option, use 15 mg with intensive monitoring
2. If malignancy history: Avoid upadacitinib; pursue other options
3. If no major contraindications but age >80: Start 15 mg with close monitoring every 4 weeks initially
4. Discontinue immediately if signs of infection, thrombosis, or cardiovascular events occur

The International Eczema Council guidance emphasizes that while JAK inhibitors are effective, the boxed warnings regarding thrombosis and malignancy in elderly patients must be carefully weighed 2. In this 84-year-old patient, the decision to use upadacitinib should only proceed if the severe atopic dermatitis is significantly impairing quality of life and no safer alternatives exist.