What is the treatment plan for a patient on Rinvoq (upadacitinib) with a positive Quantiferon (QFT) test result?

Management of Positive QuantiFERON in a Patient on Rinvoq (Upadacitinib)

You must screen for active tuberculosis disease immediately with chest radiograph and symptom assessment, then initiate latent TB treatment before continuing or starting the JAK inhibitor, as JAK inhibitors like Rinvoq carry similar TB reactivation risk to anti-TNF agents. 1, 2

Immediate Evaluation Steps

Rule Out Active TB Disease First

• Obtain a chest radiograph immediately to exclude active pulmonary tuberculosis before diagnosing latent TB infection (LTBI). 3, 2

• Perform detailed symptom review specifically asking about:

  • Fever and night sweats 3
  • Unintentional weight loss 3
  • Chronic cough and hemoptysis 3
  • Fatigue 3

• If any TB symptoms are present, obtain sputum samples for AFB smear and mycobacterial culture to definitively exclude active disease before starting any single-drug LTBI treatment. 3, 2

Critical Safety Point

Never initiate single-drug LTBI treatment until active TB is definitively excluded, as treating active TB with a single agent will lead to drug resistance. 2

Treatment Decision Algorithm

If Active TB is Excluded and Patient is Asymptomatic:

Initiate LTBI treatment before continuing Rinvoq, as patients on immunosuppressive therapy including JAK inhibitors are high-priority candidates for LTBI treatment. 1, 2

Recommended LTBI Treatment Regimens:

Choose one of the following evidence-based regimens:

• Rifapentine plus isoniazid once weekly for 12 weeks (requires directly observed therapy) - this is the shortest regimen 2
• Rifampin 10 mg/kg (maximum 600 mg) daily for 4 months 2
• Isoniazid 5 mg/kg (maximum 300 mg) daily for 9 months (or alternatively 6 months) 2
• Isoniazid plus rifampin daily for 3-4 months 2

Special Considerations for Patients on Rinvoq

Why Treatment is Essential:

Patients receiving immunosuppressive therapy, including JAK inhibitors like Rinvoq, have increased risk of TB reactivation similar to anti-TNF agents, making them high-priority for LTBI treatment. 1, 2

Timing of Rinvoq:

While guidelines focus primarily on anti-TNF agents, the British Society of Gastroenterology recommends screening and treating LTBI before starting biologic or immunosuppressive therapy. 1 Apply this same principle to JAK inhibitors given their similar immunosuppressive mechanism.

Monitoring During LTBI Treatment

• Perform monthly clinical assessment for all patients, educating them about hepatitis symptoms (nausea, vomiting, abdominal pain, dark urine, jaundice). 2
• Obtain baseline and periodic liver function tests if the patient has risk factors including concurrent immunosuppressive medication use. 2

Important Caveats

Do Not Repeat QuantiFERON Testing:

QuantiFERON tests typically remain positive even after successful LTBI treatment and should not be used to monitor treatment response, as the test indicates immunologic memory but does not distinguish between treated versus untreated infection. 3, 4, 5

If Patient Previously Completed LTBI Treatment:

If this patient has documentation of prior completed LTBI treatment, retreatment is not needed unless:

• Documented recent close contact with an active TB case 3
• New high-risk exposure that wasn't present during initial treatment 3
• The current immunosuppression with Rinvoq represents new immunosuppression that wasn't present during initial treatment 3

In such cases, the persistent positive QuantiFERON simply reflects immunologic memory and does not indicate treatment failure or need for retreatment. 3