What is the appropriate management for a patient on Skyrizi (risankizumab) with chest pain and urinary tract infection (UTI) symptoms?

Management of Chest Pain and UTI Symptoms in a Patient on Skyrizi (Risankizumab)

Treat the UTI with empiric antibiotics based on local resistance patterns while simultaneously evaluating the chest pain as a potentially serious cardiac event, as both conditions require urgent assessment and management independent of Skyrizi therapy. 1, 2

Immediate Assessment of Chest Pain

The chest pain requires urgent evaluation regardless of the UTI symptoms, as chest pain mandates immediate assessment upon presentation. 1

• Obtain a 12-lead ECG within 5 minutes of presentation to rule out acute coronary syndrome or myocardial infarction 1
• Assess for life-threatening causes including acute coronary syndrome, pulmonary embolism, and cardiac events, as these must be excluded before attributing symptoms to infection 1
• Monitor vital signs and cardiac rhythm with continuous monitoring equipment, as unstable angina carries an 8% risk of death or myocardial infarction within 4 weeks 1

Key Consideration for Skyrizi Patients

While risankizumab (Skyrizi) is an IL-23 inhibitor used for ulcerative colitis and other inflammatory conditions, it does not have specific contraindications that would alter standard chest pain evaluation protocols. 1, 3 The chest pain evaluation should proceed according to standard cardiac protocols regardless of immunotherapy status.

Management of UTI Symptoms

Obtain a urine culture before initiating empiric antibiotic therapy, then start treatment immediately without waiting for culture results. 1, 2

First-Line Empiric Antibiotic Options

For uncomplicated UTI (if no complicating factors present):

• Nitrofurantoin or Trimethoprim-sulfamethoxazole for 3-5 days based on local resistance patterns 2
• Avoid fluoroquinolones if used in the last 6 months due to resistance risk 1, 2

If Complicated UTI Factors Present

This patient may have a complicated UTI given potential immunosuppression from Skyrizi therapy. 1, 4 Immunosuppression is a host-related factor that defines complicated UTIs. 4

For complicated UTI:

• Treatment duration: 7-14 days (not 3-5 days) 1, 4
• Broader antimicrobial coverage may be needed due to increased risk of resistant organisms 4
• Consider Ciprofloxacin or Trimethoprim-sulfamethoxazole for 7-14 days based on local resistance patterns 2

Critical Clinical Pitfall

Elderly patients with UTI frequently present with atypical symptoms including chest symptoms. 5 In one study, 28% of patients with bacteremic UTI presented with dyspnea and 24% were initially misdiagnosed with chest infection. 5 This is particularly common in patients over 70 years old. 5

• Do not assume chest pain is solely from UTI - both conditions require independent evaluation 5
• Obtain blood cultures if the patient appears systemically ill, as bacteremic UTI can present with respiratory features 5

Monitoring and Follow-Up

• Reassess symptoms after 48-72 hours of antibiotic treatment 2
• Repeat urine culture if symptoms persist despite treatment before prescribing additional antibiotics 2
• Continue cardiac monitoring until acute coronary syndrome is definitively excluded 1

Skyrizi-Specific Considerations

Risankizumab has demonstrated safety in clinical trials with no specific increased risk of UTI or cardiac events beyond baseline immunosuppression considerations. 3 However:

• Treat infections aggressively in patients on any immunosuppressive therapy 4
• Do not discontinue Skyrizi for uncomplicated UTI unless the infection becomes severe or systemic 1
• Consider the UTI as complicated due to the immunosuppressive effects of biologic therapy 4