What happens if I develop herpes zoster while taking Rinvoq (upadacitinib)?

Management of Herpes Zoster While Taking Rinvoq (Upadacitinib)

Risk and Occurrence

If you develop herpes zoster (shingles) while taking Rinvoq (upadacitinib), you should temporarily interrupt Rinvoq treatment until the herpes zoster episode resolves. 1

• Herpes zoster reactivation is a known risk with Janus kinase inhibitors (JAKi) like Rinvoq, with incidence rates 3-4 times higher than placebo in Western countries and up to 9 times higher in Japan and Korea 2
• The risk of herpes zoster appears to be dose-dependent, with higher doses of upadacitinib associated with greater risk 3, 4
• Multidermatomal herpes zoster is specifically listed as an opportunistic infection reported with Rinvoq in the FDA label 1

Immediate Management Steps

When herpes zoster develops while on Rinvoq:

1. Temporarily discontinue Rinvoq treatment 1

   • The FDA label explicitly states: "If a patient develops herpes zoster, consider temporarily interrupting RINVOQ/RINVOQ LQ until the episode resolves" 1

2. Seek prompt medical evaluation 5, 6

   • Undergo complete diagnostic testing appropriate for an immunocompromised patient 1

3. Initiate antiviral therapy 5

   • For uncomplicated herpes zoster: oral acyclovir or valacyclovir 5
   • For disseminated or invasive herpes zoster: intravenous acyclovir 5, 7
   • Start treatment as soon as possible after diagnosis 5

Treatment Course

• Antiviral therapy should be continued until all lesions have scabbed 5
• Monitor for complete healing of lesions before considering resuming Rinvoq 5, 1
• Rinvoq may be resumed once the herpes zoster infection is controlled 1
• In severe cases of disseminated herpes zoster, longer-term suppressive therapy with valacyclovir may be considered 7

Potential Complications

• Post-herpetic neuralgia may develop in approximately 6.9% of first herpes zoster events in rheumatoid arthritis patients taking JAKi 8
• Immunocompromised patients may develop chronic ulcerations with persistent viral replication 6
• Secondary bacterial and fungal superinfections can occur, particularly in immunocompromised hosts 6

Prevention After Recovery

• Consider recombinant zoster vaccine (Shingrix) after recovery to prevent future episodes 5, 4
• The safety of the inactivated zoster vaccine (Shingrix) has been suggested in a small open-label study, though efficacy data in JAKi-treated patients is limited 2
• Recombinant zoster vaccination should be highly considered for all adult patients prior to starting JAKi therapy 4

Risk Factors for Herpes Zoster on JAKi

Be aware of factors that increase your risk of herpes zoster while on Rinvoq:

• Age (older patients have higher risk) 2
• Female gender 2
• Prednisolone >7.5 mg per day 2
• Prior history of infection or hospitalization 2
• Higher doses of JAKi medication 3, 4
• Japanese or Korean ethnicity (significantly higher rates observed) 2

Important Considerations

• Recurrent herpes zoster can occur in a small proportion of patients after the first episode 2, 8
• The median time to resolution of first herpes zoster events in JAKi-treated patients is approximately 20-22 days 8
• Subsequent herpes zoster events typically resolve more quickly than first episodes (median 11-15 days) 8

Remember that while herpes zoster is a significant concern with Rinvoq therapy, proper management with temporary medication interruption and appropriate antiviral treatment typically leads to resolution in most cases 8.