What should I do if I have a herpes outbreak while taking Rinvoq (upadacitinib)?

Managing Herpes Outbreak While Taking Rinvoq (Upadacitinib)

If you have a herpes outbreak while taking Rinvoq, you should temporarily interrupt Rinvoq treatment and immediately start antiviral therapy with valacyclovir 500 mg orally twice daily for 5 days or an equivalent regimen until the outbreak resolves.

Understanding the Risk

• Rinvoq (upadacitinib) is associated with an increased risk of herpes virus reactivation, including herpes zoster (shingles) and herpes simplex virus outbreaks, due to its immunosuppressive effects 1
• The FDA label for Rinvoq specifically warns about viral reactivation, including herpes virus reactivation, as a potential adverse effect 1
• JAK inhibitors like Rinvoq have been associated with higher rates of herpes zoster compared to other treatments, with higher doses carrying greater risk 2, 3

Immediate Management Steps

1. Antiviral Treatment

• Start episodic antiviral therapy immediately at the first sign of outbreak 4
• Recommended regimens include:
  • Valacyclovir 500 mg orally twice daily for 5 days 4, 5
  • Acyclovir 400 mg orally three times daily for 5 days 4, 5
  • Acyclovir 800 mg orally twice daily for 5 days 4, 5
  • Famciclovir 125 mg orally twice daily for 5 days 4, 5

2. Temporary Interruption of Rinvoq

• The FDA label recommends temporarily interrupting Rinvoq if a patient develops herpes zoster until the episode resolves 1
• This recommendation should be extended to significant herpes simplex outbreaks as well, given the similar viral reactivation mechanism 1, 6

Follow-up Management

1. Monitoring for Resolution

• Monitor for complete resolution of herpes lesions before considering restarting Rinvoq 1
• If lesions do not begin to resolve within 7-10 days of antiviral therapy, consider potential antiviral resistance (though this is rare in immunocompetent patients) 7

2. Prevention of Future Outbreaks

• For patients with frequent recurrences (≥6 episodes per year), consider daily suppressive antiviral therapy 4, 5:
  • Valacyclovir 1 g orally once daily or 500 mg orally once daily 4, 5
  • Acyclovir 400 mg orally twice daily 4, 5
  • Famciclovir 250 mg orally twice daily 4, 5

3. Consultation with Healthcare Provider

• Discuss with your healthcare provider whether:
  • Suppressive antiviral therapy is appropriate while continuing Rinvoq 4, 7
  • Dose adjustment of Rinvoq might be necessary 1
  • Alternative treatment options should be considered if herpes outbreaks become frequent or severe 1, 6

Important Precautions

• Abstain from sexual activity when lesions or prodromal symptoms are present 8, 4
• Use condoms during all sexual exposures with new or uninfected partners 8, 4
• Be aware that asymptomatic viral shedding can occur, potentially leading to transmission even without visible symptoms 8, 4
• Recognize that antiviral medications control symptoms but do not eradicate the virus or prevent all recurrences 8, 4

Special Considerations

• If you develop disseminated herpes (multiple dermatomes affected), seek immediate medical attention as this can be more serious in immunocompromised patients 6
• Consider vaccination with recombinant zoster vaccine if you are at high risk for herpes zoster, though discuss timing with your healthcare provider 9
• Patients from Asia and those with a prior history of herpes zoster may be at increased risk for reactivation while on Rinvoq 2