What is the recommended dose of Epuris (generic name) for a patient with acne taking Rinvoq (upadacitinib)?

Recommended Epuris (Isotretinoin) Dosing for Patients with Acne Secondary to Rinvoq (Upadacitinib)

For patients with acne secondary to Rinvoq (upadacitinib) therapy, the recommended starting dose of Epuris (isotretinoin) is 0.25-0.4 mg/kg/day, which is lower than the standard dosing used for conventional acne.

Understanding Upadacitinib-Associated Acne

Acne is one of the most common cutaneous adverse effects of JAK inhibitors like Rinvoq (upadacitinib) used in atopic dermatitis treatment:

• Occurs in a dose-dependent manner with upadacitinib, affecting up to 15.2% of patients on 30 mg daily dose and 9.8% on 15 mg daily dose 1
• Typically mild to moderate in severity, with inflammatory papules being the most common morphology 2
• Usually appears on the face, with variable onset time (mean 135.4 days after starting upadacitinib) 2
• Higher incidence in younger patients, females, and non-White patients 1

Isotretinoin Dosing Considerations

Initial Dosing

• Start with 0.25-0.4 mg/kg/day of isotretinoin for patients with acne secondary to upadacitinib 3
• This lower dosing regimen is appropriate because:
  • The acne is medication-induced rather than conventional acne
  • Lower doses minimize side effects while maintaining efficacy 3
  • Most upadacitinib-associated acne cases are mild to moderate in severity 1, 2

Duration and Monitoring

• Continue treatment for 15-20 weeks, adjusting based on clinical response
• Monitor liver function tests and lipid panel every 2-3 months 3
• For female patients of childbearing potential, mandatory pregnancy testing is required due to severe teratogenic effects 3

Management Algorithm

1. Confirm acne is related to upadacitinib therapy

   • Typically appears within 1-16 weeks after starting Rinvoq
   • Presents as inflammatory papules primarily on the face 2

2. Assess acne severity

   • Mild to moderate: Consider topical treatments first (benzoyl peroxide, topical antibiotics, topical retinoids)
   • Moderate to severe: Proceed with oral isotretinoin

3. Initiate isotretinoin therapy

   • Calculate dose based on patient weight (0.25-0.4 mg/kg/day)
   • Divide into twice daily administration with food

4. Monitor for response and side effects

   • Evaluate improvement at 4-week intervals
   • Adjust dose if needed based on clinical response and tolerability
   • Continue until significant improvement is achieved (typically 15-20 weeks)

Special Considerations

• Pregnancy prevention: Absolute contraindication in pregnancy; mandatory contraception required for female patients of childbearing potential 3
• Drug interactions: No significant interactions between isotretinoin and upadacitinib have been reported
• Laboratory monitoring: More frequent monitoring of lipids may be warranted as both medications can affect lipid profiles 3

Alternative Approaches

If isotretinoin is contraindicated or not tolerated:

• Topical retinoids combined with benzoyl peroxide as first-line therapy 4
• For female patients, hormonal therapy with combined oral contraceptives may be considered 4
• Topical antibiotics with benzoyl peroxide for inflammatory lesions 4

Most cases of upadacitinib-associated acne (40-47%) require no intervention or can be managed with topical therapies alone 1. However, for moderate to severe cases that impact quality of life, the lower-dose isotretinoin regimen offers an effective treatment option with minimized side effects.