From the Guidelines
Rinvoq (upadacitinib) should be held during treatment for herpes zoster to minimize the risk of worsening the infection or delaying healing. This recommendation is based on the fact that upadacitinib is a JAK inhibitor, which can suppress parts of the immune system and increase the risk of serious and opportunistic infections, including herpes zoster 1. The guidelines for the management of atopic dermatitis in adults with phototherapy and systemic therapies recommend vaccinating for shingles before initiating a JAK inhibitor, particularly for older patients, to reduce the risk of herpes zoster 1. Additionally, the medication toxicity and monitoring guidance for JAK inhibitors, including upadacitinib, recommends screening for hepatitis B virus infection, hepatitis C virus infection, and latent TB before initiation, as well as monitoring for leukopenia, herpes zoster, and other potential toxicities 1. Given the potential risks associated with continuing upadacitinib during an active shingles infection, it is recommended to temporarily discontinue the medication until the infection resolves with appropriate antiviral treatment, such as valacyclovir 1g three times daily for 7-10 days. The decision to restart upadacitinib should be made on a case-by-case basis, taking into account the individual patient's situation and the risk of worsening the infection or delaying healing. Key considerations for managing patients with herpes zoster while on upadacitinib include:
- Temporarily discontinuing upadacitinib during active shingles infection
- Initiating antiviral treatment, such as valacyclovir, as soon as possible
- Monitoring for potential toxicities and adjusting treatment as needed
- Restarting upadacitinib only when the shingles lesions have crusted over and are healing, as determined by the healthcare provider.
From the FDA Drug Label
If a patient develops herpes zoster, consider temporarily interrupting RINVOQ/RINVOQ LQ until the episode resolves.
Yes, Rinvoq (upadacitinib) should be held during treatment for herpes zoster, as the label recommends temporarily interrupting the medication until the episode resolves 2 2.
From the Research
Herpes Zoster and Upadacitinib Treatment
- Herpes zoster (HZ) is a known risk associated with upadacitinib treatment, as reported in several studies 3, 4, 5, 6.
- The risk of HZ is increased in patients taking upadacitinib, particularly in high-risk populations such as the elderly 3.
- Discontinuation of upadacitinib has been reported in cases of HZ, including disseminated HZ 4.
- The decision to hold upadacitinib during treatment for HZ should be based on individual patient risk factors and the severity of the HZ infection.
Upadacitinib Treatment and Immune Response
- Upadacitinib is a Janus kinase (JAK)1-selective inhibitor that affects the immune response 7, 5, 6.
- Continuous treatment with upadacitinib is suggested to maintain skin clearance and antipruritic effects in patients with atopic dermatitis 7.
- However, the immune suppressive effects of upadacitinib may increase the risk of HZ and other infections 3, 4.
Clinical Considerations
- Patients taking upadacitinib should be monitored for signs and symptoms of HZ, particularly if they are at high risk for the infection 3, 4.
- The benefits and risks of continuing upadacitinib treatment during HZ infection should be carefully weighed on a case-by-case basis.
- Alternative treatment options, such as antiviral therapy, may be necessary for patients who develop HZ while taking upadacitinib 4.