Should a patient with active ulcerative colitis on 45mg daily of Rinvoq (upadacitinib) and 35mg daily of prednisone take a proton pump inhibitor?

Should This Patient Take a Proton Pump Inhibitor?

Yes, this patient should be started on a proton pump inhibitor (PPI) immediately given the combination of high-dose corticosteroids (35mg prednisone) and JAK inhibitor therapy (Rinvoq 45mg), which creates substantial gastrointestinal risk.

Critical Dose Concern Requiring Immediate Attention

Your patient is on 35mg of prednisone daily, which is below the standard therapeutic dose but still carries significant GI risk. The British Society of Gastroenterology guidelines clearly establish that 40mg prednisolone daily is the optimal dose for moderate to severe ulcerative colitis, with no additional benefit from higher doses and increased adverse effects above 40-60mg/day 1. However, your patient's 35mg dose still warrants GI protection, particularly given the dual immunosuppression.

Why PPI Prophylaxis is Essential in This Case

Corticosteroid-Related GI Risk

• Approximately 50% of patients on corticosteroids experience dyspepsia and other GI adverse events 2
• The combination of corticosteroid therapy with JAK inhibitors amplifies infection risk and inflammatory complications 2
• Standard practice for patients on ≥20mg prednisolone includes consideration of GI prophylaxis, particularly when combined with other immunosuppressive agents 1

Amplified Risk from Combination Therapy

• The concurrent use of upadacitinib with corticosteroids increases the rate of treatment-emergent adverse events, particularly serious infections 3
• Patients receiving corticosteroids at baseline had higher rates of serious adverse events during induction therapy with upadacitinib compared to those not receiving corticosteroids 3
• The dual immunosuppression creates a compounded risk profile that justifies prophylactic GI protection

Specific PPI Recommendation

Start omeprazole 20mg daily or equivalent PPI (lansoprazole 30mg, pantoprazole 40mg, or esomeprazole 20mg) taken in the morning before breakfast.

Duration of PPI Therapy

• Continue PPI prophylaxis throughout the entire duration of corticosteroid therapy 2
• The British Society of Gastroenterology recommends limiting concurrent corticosteroid use to the shortest duration necessary, ideally completing taper within 6-8 weeks 2
• PPI can be discontinued once prednisone is tapered below 20mg daily and the patient has been stable for at least 2 weeks

Critical Management Algorithm for This Patient

Immediate Actions (Days 1-3)

1. Start PPI prophylaxis immediately - do not delay for symptom development
2. Verify the prednisone dose is appropriate - consider whether 40mg would be more effective given active disease 1
3. Screen for latent tuberculosis and hepatitis B if not already done - mandatory before continuing JAK inhibitor therapy 2

Short-Term Monitoring (Weeks 1-2)

• Assess clinical response to corticosteroids within 2 weeks - if inadequate response, advanced therapy escalation should be considered rather than increasing steroid dose 1
• Monitor for dyspepsia, epigastric pain, or GI bleeding despite PPI therapy
• Weekly blood pressure monitoring given cardiovascular risks with upadacitinib 4

Corticosteroid Taper Strategy (Weeks 2-8)

• Begin tapering prednisone once clinical response is achieved, typically over 6-8 weeks 2
• If disease relapses during taper or patient requires >2 corticosteroid courses within a calendar year, consider adding thiopurine therapy or optimizing upadacitinib maintenance dosing 1
• Corticosteroids are not recommended for long-term maintenance - the goal is complete withdrawal 1

Common Pitfalls to Avoid

Do Not Continue High-Dose Steroids Beyond 2 Weeks Without Response

• If there is no adequate response to oral corticosteroids within 2 weeks, advanced therapy should be started rather than continuing or increasing steroids 1
• Prolonging high-dose corticosteroids beyond this timeframe increases adverse effects without improving outcomes 2

Do Not Forget Thromboprophylaxis if Hospitalized

• If this patient requires hospitalization for acute severe UC, subcutaneous low-molecular-weight heparin is mandatory unless contraindicated 4
• JAK inhibitors carry FDA warnings regarding thrombotic events, amplified by corticosteroid use 2

Monitor for Herpes Zoster

• Herpes zoster rates increase with longer duration of upadacitinib exposure, particularly at the 45mg induction dose 5
• Consider varicella zoster vaccination if patient is seronegative and can be timed appropriately around immunosuppression 1

Additional Safety Monitoring Required

• Lipid panel monitoring - JAK inhibitors increase hyperlipidemia risk 2
• Cardiovascular risk assessment - particularly important in patients >50 years, smokers, or those with cardiovascular risk factors 2
• Electrolyte monitoring - corticosteroids can cause hypokalemia, particularly problematic in active colitis 4