How to manage hypertension in a patient with ulcerative colitis on upadacitinib?

Blood Pressure Management in Ulcerative Colitis Patient on Upadacitinib

Initiate amlodipine 5 mg daily immediately for this patient with blood pressure 155/92 while on upadacitinib for ulcerative colitis. 1

Rationale for Immediate Treatment

• Blood pressure of 155/92 mmHg exceeds the treatment threshold and requires antihypertensive therapy initiation, particularly in patients on JAK inhibitors like upadacitinib which require close blood pressure monitoring. 2, 1

• Calcium channel blockers are the preferred first-line agent in this clinical scenario due to lack of drug interactions with upadacitinib and proven safety in inflammatory bowel disease patients. 1

Specific Treatment Protocol

Initial Antihypertensive Therapy

• Start amlodipine 5-10 mg once daily as the long-acting calcium channel blocker of choice, with no significant drug interactions with upadacitinib or corticosteroids. 1

• Alternative option: hydrochlorothiazide 12.5-25 mg daily if calcium channel blockers are not tolerated, though this requires careful electrolyte monitoring given the risk of hypokalemia in active colitis. 1

• Avoid ACE inhibitors or ARBs as first-line in this specific population unless calcium channel blockers and thiazide diuretics fail, as they are not the guideline-recommended first choice for UC patients on JAK inhibitors. 2, 1

Monitoring Requirements

First Month (Critical Period):

• Weekly home blood pressure monitoring is mandatory for patients with preexisting hypertension starting upadacitinib. 2, 1
• Document all readings to assess treatment response. 2

Months 1-3:

• Blood pressure checks every 3 months after treatment initiation with upadacitinib. 2, 1
• Assess for medication adherence and side effects. 2

After 3 Months:

• Monitor blood pressure every 6 months during maintenance upadacitinib therapy. 2, 1

Additional Monitoring:

• Check serum potassium closely if using thiazide diuretics, as both the diuretic and active colitis increase hypokalemia risk. 1
• Monitor for electrolyte disturbances given the patient's ulcerative colitis. 2, 1

Treatment Targets

• Target blood pressure <140/90 mmHg for long-term cardiovascular risk reduction. 2

• If blood pressure remains ≥160/100 mmHg on initial therapy, escalate treatment according to standard hypertension guidelines by adding a second agent. 2

• Consider referral to hypertension specialist if blood pressure not controlled on ≥3 antihypertensive drugs or if multiple drug intolerances develop. 2

Critical Safety Considerations for UC Patients

Cardiovascular Risk with JAK Inhibitors

• JAK inhibitors carry increased cardiovascular risk based on the ORAL surveillance study in rheumatoid arthritis, showing increased major adverse cardiac events (MACE) particularly in patients over 50 with cardiovascular risk factors. 2

• Blood pressure control is essential to mitigate this cardiovascular risk, making aggressive hypertension management particularly important in this population. 2, 1

• All adjudicated MACE events with upadacitinib occurred in patients with known cardiovascular risk factors, emphasizing the importance of risk factor modification. 3

Ulcerative Colitis-Specific Concerns

• Ensure adequate hydration and electrolyte replacement, as dehydration from active colitis may contribute to elevated blood pressure. 2, 1

• Avoid anti-diarrheal agents and opioids as they may precipitate colonic dilatation in UC patients. 2

• Thromboprophylaxis with subcutaneous low-molecular-weight heparin is mandatory in hospitalized acute severe UC patients unless contraindicated, as UC patients have 3-8 fold increased VTE risk. 2

Upadacitinib Efficacy Context

• Upadacitinib demonstrates superior efficacy for moderate-to-severe UC, with clinical remission rates of 26-34% at week 8 induction and 42-54% at week 52 maintenance therapy. 2, 4

• Rapid onset of action is seen as early as week 2, with clinical remission rates of 36% in UC patients. 5

• Real-world data confirms efficacy even in heavily pre-treated patients, with 81.5% achieving clinical remission by 8 weeks. 5

Common Pitfalls to Avoid

• Do not delay antihypertensive treatment waiting for "lifestyle modifications" in a patient already on a JAK inhibitor with known cardiovascular risks. 2, 1

• Do not use beta-blockers or heart rate-lowering agents without careful consideration, as ozanimod (another UC therapy) requires avoidance of drugs that slow heart rate or AV conduction. 2

• Do not assume hypertension will resolve after stopping upadacitinib—unlike bevacizumab-induced hypertension which typically resolves, JAK inhibitor-associated hypertension may persist. 2

• Do not overlook the need for multidisciplinary management involving both gastroenterology and cardiology/internal medicine for optimal outcomes. 2, 1