What are the steroid treatment options for a patient with active shingles who is currently on Rinvoq (upadacitinib)?

Steroid Treatment for Active Shingles in a Patient on Rinvoq

Systemic corticosteroids should generally be avoided in patients with active shingles who are on Rinvoq (upadacitinib), as the combination of JAK inhibitor immunosuppression with steroids significantly increases infection risks, particularly dissemination of varicella-zoster virus. 1

Primary Management Approach

Antiviral therapy is the cornerstone of treatment, not steroids:

• Initiate oral valacyclovir 1 gram three times daily for 7-10 days until all lesions have completely scabbed 1, 2
• Treatment should begin immediately, ideally within 48-72 hours of rash onset, though benefit exists even beyond this window 1
• Consider temporary reduction or holding Rinvoq during active shingles infection, particularly if disseminated disease develops 3

When Steroids May Be Considered (With Extreme Caution)

Short-course oral prednisone may be used only in highly selected cases:

• Severe, widespread shingles with significant inflammation where benefits outweigh substantial risks 1
• Dosing if used: Prednisone 0.5-1 mg/kg/day for 7-14 days maximum, then taper 3
• Must be given only in combination with adequate antiviral coverage (valacyclovir or acyclovir at full therapeutic doses) 1

Critical contraindications to steroids in this scenario:

• Immunocompromised state (which Rinvoq creates) increases dissemination risk 1
• Poorly controlled diabetes, as steroids worsen glycemic control 3
• History of steroid-induced complications 1

Evidence Against Routine Steroid Use

The evidence does not support steroids for preventing postherpetic neuralgia:

• Cochrane review found very low-certainty evidence that corticosteroids prevent postherpetic neuralgia (RR 0.95% CI 0.45-1.99) 4
• No significant difference in serious adverse events, but increased infection risk in immunosuppressed patients 4

Specific Risks with Rinvoq Combination

JAK inhibitors like Rinvoq substantially increase herpes zoster risk:

• Herpes zoster occurred more frequently in tofacitinib-treated patients in clinical trials 3
• Combined immunosuppression with steroids creates additive infection risk 3
• Glucocorticoids increase infection risk in dose-dependent manner, particularly when combined with immunosuppressants 3

Escalation Criteria Requiring IV Therapy

Switch to intravenous acyclovir 10 mg/kg every 8 hours if:

• Disseminated herpes zoster (multi-dermatomal or visceral involvement) develops 1
• Facial zoster with suspected CNS involvement or severe ophthalmic disease 1
• Patient shows inadequate response to oral antivirals after 3 days 1
• Continue IV therapy minimum 7-10 days and until clinical resolution 1

Alternative Pain Management Without Systemic Steroids

For acute pain management during active infection:

• Gabapentin or pregabalin for neuropathic pain 3
• Topical lidocaine patches once lesions have crusted 5
• Oral antihistamines for pruritus 3
• Avoid topical corticosteroids on active vesicular lesions as they may promote viral replication 5

Monitoring Requirements

If steroids are used despite risks:

• Monitor for signs of dissemination (new dermatomal involvement, fever, visceral symptoms) 1
• Check blood glucose in diabetic patients 3
• Ensure all lesions have scabbed before discontinuing antivirals 1, 2
• Follow-up audiometry if facial involvement to assess for complications 3

Prevention for Future Episodes

After resolution of acute infection:

• Strongly recommend recombinant zoster vaccine (Shingrix) once acute infection resolves, ideally before continuing Rinvoq 1
• Vaccination reduces recurrence risk even in patients on JAK inhibitors 1
• Consider prophylactic acyclovir 400 mg twice daily if recurrent episodes occur on Rinvoq 1