What is the recommended use and dosage of Rinvoq (upadacitinib) for treating rheumatoid arthritis and atopic dermatitis?

Recommended Use and Dosage of Rinvoq (Upadacitinib) for Rheumatoid Arthritis and Atopic Dermatitis

For rheumatoid arthritis, Rinvoq (upadacitinib) is recommended at 15 mg once daily, while for atopic dermatitis, treatment should start with 15 mg once daily with potential increase to 30 mg daily if needed in patients under 65 years of age. 1

Rheumatoid Arthritis (RA) Dosing and Indications

Rinvoq is indicated for moderate to severe active rheumatoid arthritis in patients who have had inadequate response to one or more conventional synthetic disease-modifying antirheumatic drugs (csDMARDs) or biologic DMARDs.

Dosage for RA:

• Adults: 15 mg once daily 1
• Can be used as monotherapy or in combination with methotrexate or other csDMARDs 2

Treatment Algorithm for RA:

1. First-line: Typically used after failure of methotrexate or other csDMARDs 2
2. When to use: When treatment target is not achieved with first csDMARD strategy and poor prognostic factors are present 2
3. Combination therapy: Can be added to existing csDMARD therapy 2

Atopic Dermatitis (AD) Dosing and Indications

Rinvoq is indicated for moderate to severe atopic dermatitis in patients who have failed other systemic therapies or when those therapies are inadvisable.

Dosage for AD:

• Adults under 65 years and adolescents ≥12 years weighing ≥40 kg:
  • Start with 15 mg once daily
  • If inadequate response, may increase to 30 mg once daily
  • Discontinue if adequate response not achieved with 30 mg dose
  • Use lowest effective dose to maintain response 1
• Adults 65 years and older: 15 mg once daily only 1

Pre-Treatment Evaluation

Before starting Rinvoq, the following evaluations should be performed 1:

• Tuberculosis (TB) screening (active and latent)
• Viral hepatitis screening
• Complete blood count
• Baseline hepatic function
• Pregnancy status verification in females of reproductive potential

Safety Considerations and Monitoring

Major Safety Concerns:

• Serious infections: Interrupt treatment if serious infection develops 3, 1
• Herpes zoster: Higher risk compared to other treatments 2, 3
• Thromboembolic events: Use with caution in patients with risk factors for venous thromboembolism 2, 3
• Cardiovascular risk: Increased risk of major adverse cardiovascular events, especially in patients over 50 with cardiovascular risk factors 3
• Malignancies: Monitor for development of malignancies 3

Laboratory Monitoring:

• Regular monitoring of complete blood count
• Liver function tests
• Lipid levels 3, 1

Dose Adjustments

Renal Impairment:

• RA: No dosage adjustment needed for any degree of renal impairment
• AD: For severe renal impairment (eGFR 15 to <30 mL/min/1.73m²), use 15 mg once daily
• Not recommended for end-stage renal disease 1

Hepatic Impairment:

• Not recommended for severe hepatic impairment (Child-Pugh C)
• No dosage adjustment needed for mild to moderate hepatic impairment 1

Drug Interactions:

• Strong CYP3A4 inhibitors:
  • For RA: No dosage adjustment needed
  • For AD: Use 15 mg once daily 1

Contraindications and Limitations of Use

• Not recommended for use in combination with other JAK inhibitors or biologic DMARDs
• Not recommended with potent immunosuppressants such as azathioprine and cyclosporine 1
• Avoid live vaccines during treatment 3
• Contraindicated in pregnancy 3

Efficacy Considerations

• In RA, upadacitinib has shown significant improvements in clinical signs and symptoms when used in combination with csDMARDs 4
• In AD, the 30 mg dose provides approximately 20% greater efficacy compared to the 15 mg dose 5
• For patients with refractory RA who had inadequate response to biologic DMARDs, both 15 mg and 30 mg doses showed significant improvements compared to placebo 6

By following these recommendations and monitoring protocols, Rinvoq can be effectively and safely used for the treatment of rheumatoid arthritis and atopic dermatitis.