What is the treatment for yeast infections and herpes outbreaks in patients taking Rinvoq (upadacitinib)?

Treatment of Yeast Infections and Herpes Outbreaks in Patients Taking Rinvoq (Upadacitinib)

For patients taking Rinvoq (upadacitinib) who experience yeast infections or herpes outbreaks, prompt antiviral or antifungal treatment is essential, with consideration for prophylactic therapy in patients with frequent recurrences.

Increased Risk of Infections with Rinvoq

• Janus kinase (JAK) inhibitors like upadacitinib (Rinvoq) are associated with an increased risk of herpes zoster reactivation compared to other treatments 1
• Higher doses of upadacitinib (30 mg daily) are associated with greater herpes zoster risk than lower doses (15 mg daily) 2
• The incidence rate of herpes zoster per 100 patient-years is approximately 3.0 for upadacitinib 15 mg and 5.3 for upadacitinib 30 mg 2
• Longer duration of exposure to higher doses of upadacitinib (45 mg) increases the risk of herpes zoster infections 3

Management of Herpes Outbreaks in Rinvoq Patients

Episodic Treatment for Herpes Outbreaks

• For breakthrough herpes outbreaks, initiate antiviral therapy as soon as possible at the first sign of prodrome or lesions 4
• Recommended regimens include:
  • Acyclovir 400 mg orally three times daily for 5 days 5, 4
  • Acyclovir 800 mg orally twice daily for 5 days 5, 4
  • Valacyclovir 500 mg orally twice daily for 5 days 5, 4
  • Famciclovir 125 mg orally twice daily for 5 days 4

Suppressive Therapy for Frequent Herpes Recurrences

• For patients with frequent recurrences (≥6 per year), consider suppressive therapy 4
• Recommended suppressive regimens:
  • Acyclovir 400 mg orally twice daily 5, 4
  • Valacyclovir 500 mg orally once or twice daily (use twice daily in immunocompromised patients) 5, 4
  • Famciclovir 250 mg orally twice daily 5, 4
• Suppressive therapy should be continued for the entire period of immunosuppression in high-risk patients 5

Special Considerations for Immunocompromised Patients

• Patients on Rinvoq should be considered immunocompromised and may experience more severe and longer-lasting herpes outbreaks 4
• Higher doses or longer duration of antiviral therapy may be required 4, 6
• For severe or disseminated herpes infections, intravenous acyclovir may be necessary, with subsequent oral suppressive therapy 7

Management of Yeast Infections in Rinvoq Patients

Treatment Options for Yeast Infections

• For uncomplicated vulvovaginal candidiasis:
  • Fluconazole 150 mg oral single dose 5
  • Topical azoles (clotrimazole, miconazole, etc.) for 1-7 days 5
• For complicated or recurrent yeast infections:
  • Fluconazole 150 mg every 72 hours for 3 doses, followed by weekly fluconazole for 6 months for recurrent cases 5
  • Consider longer duration of therapy (7-14 days) for severe infections 5

Preventive Measures

Vaccination

• Consider recombinant zoster vaccine (RZV) for eligible patients before starting Rinvoq therapy 5
• Note that vaccination may not provide complete protection, as cases of herpes zoster have been reported even in vaccinated patients on upadacitinib 7

Risk Factor Assessment

• Patients from Asian regions and those with a prior history of herpes zoster are at increased risk for herpes zoster while receiving upadacitinib 2
• Monitor these high-risk patients more closely and consider prophylactic antiviral therapy 2

Follow-up and Monitoring

• Evaluate treatment response within 1-2 weeks for both yeast infections and herpes outbreaks 5
• For persistent symptoms, consider:
  • Alternative antifungal/antiviral regimens 5
  • Testing for resistant strains, especially in immunocompromised patients 6
  • Temporary dose reduction or interruption of upadacitinib in severe cases 7

Important Caveats

• Topical acyclovir is substantially less effective than oral therapy for herpes infections and should be avoided 6
• Foscarnet is typically reserved for acyclovir-resistant HSV infections 5
• For severe or disseminated infections, consider temporarily discontinuing upadacitinib until the infection resolves 7
• Patients with HIV co-infection may require longer courses of therapy and closer monitoring 6