Management of Positive QuantiFERON in Patients Starting or on Rinvoq
All patients with a positive QuantiFERON test must receive treatment for latent tuberculosis before or concurrent with Rinvoq initiation, with the timing determined by individual TB risk factors. 1
Mandatory Pre-Treatment Evaluation
Before starting Rinvoq, you must complete comprehensive TB screening that includes: 1
- QuantiFERON or other IGRA testing (preferred over TST in immunocompromised patients and those with BCG vaccination) 1
- Chest radiography to definitively rule out active TB—do not rely solely on negative IGRA 1
- Clinical assessment for TB risk factors 1
Critical pitfall: Never start Rinvoq in patients with untreated latent TB or active TB, as JAK inhibitors significantly increase reactivation risk. 1, 2
Risk Stratification and Treatment Timing
Low-Risk Patients (Start Rinvoq After 1 Month of LTBI Treatment)
Low-risk patients can initiate Rinvoq after completing at least 1 month of latent TB treatment. 1 Low-risk is defined as patients without: 1
- Close TB contacts
- Residence in endemic areas
- Recent immigration from high-incidence regions
- Intravenous drug use
High-Risk Patients (Complete Full LTBI Treatment First)
High-risk patients must complete the entire course of LTBI treatment before starting Rinvoq. 1 High-risk features include: 1
- Close TB contacts
- Recent immigrants from high-incidence areas
- Intravenous drug users
- Residence in endemic areas
- Underlying conditions predisposing to infection
- Concomitant corticosteroid use (particularly >15 mg prednisone equivalent daily for ≥4 weeks) 1
Recommended LTBI Treatment Regimens
The preferred regimen is rifampin 10 mg/kg/day (maximum 600 mg) for 4 months, which demonstrates equivalent efficacy to 9-month isoniazid with superior completion rates, lower cost, and better safety profile. 1
Alternative regimens include: 1
- Isoniazid for 9 months (supplement with vitamin B6)
- Rifapentine plus isoniazid once weekly for 3 months
- Rifampin/isoniazid combination for 3-4 months
Critical Drug Interactions and Monitoring
Monitor liver function tests closely when combining LTBI treatment with Rinvoq, particularly with isoniazid-containing regimens. 1 Rifampin significantly affects drug metabolism through cytochrome P450-3A4 and may interact with other immunosuppressants. 1
The FDA label mandates interrupting Rinvoq if drug-induced liver injury is suspected until this diagnosis is excluded. 2
Ongoing Monitoring During Rinvoq Therapy
Continuously monitor for TB signs and symptoms during and after Rinvoq treatment. 1, 2 Consider annual TB screening for patients with ongoing risk factors for TB exposure. 1
If a patient develops a new infection during Rinvoq treatment, perform prompt and complete diagnostic testing, initiate appropriate antimicrobial therapy, closely monitor the patient, and interrupt Rinvoq if not responding to antimicrobial therapy. 2
Management of Active TB Development
Interrupt Rinvoq immediately if active TB is diagnosed. 1, 2 Complete full antibacterial treatment with symptom resolution before considering Rinvoq reinitiation. 1
Additional Considerations
Avoid Rinvoq in patients with active, serious infections, including localized infections. 2 The FDA label specifically states that patients with latent TB should be treated with standard antimycobacterial therapy before initiating Rinvoq, and anti-TB therapy should be considered prior to initiation in patients with previously untreated latent TB or active TB in whom an adequate course of treatment cannot be confirmed. 2
Higher rates of serious infections, including tuberculosis, were reported with Rinvoq in clinical trials, with pneumonia and cellulitis being the most frequent. 2 Among opportunistic infections, tuberculosis, multidermatomal herpes zoster, oral/esophageal candidiasis, and cryptococcosis were specifically reported. 2