Treatment for Cutaneous Herpes Zoster While on Tofacitinib
Temporarily discontinue tofacitinib immediately and initiate antiviral therapy with valacyclovir 1 gram three times daily for 7 days, starting treatment as soon as possible and ideally within 48-72 hours of rash onset. 1, 2
Immediate Management Algorithm
Step 1: Discontinue Tofacitinib
- Stop tofacitinib treatment immediately upon diagnosis of herpes zoster and do not restart until the episode completely resolves. 1
- The mechanism underlying increased herpes zoster risk with JAK inhibitors involves blocking interferon pathways, which are critical for viral immunity. 1
- Most patients in clinical trials had tofacitinib temporarily discontinued during herpes zoster episodes, with the majority able to resume treatment after resolution. 3
Step 2: Initiate Antiviral Therapy
- Start valacyclovir 1 gram orally three times daily for 7 days, beginning within 48-72 hours of rash onset for maximum efficacy. 2, 4
- Alternative antivirals include acyclovir or famciclovir, though valacyclovir offers superior bioavailability and less frequent dosing. 4
- Most patients (>90%) in tofacitinib clinical trials received antiviral treatment within 3 days of herpes zoster onset. 3
Step 3: Monitor for Complications
- Assess for signs of disseminated disease, multidermatomal involvement (≥3 adjacent or ≥2 nonadjacent dermatomes), or visceral involvement. 4, 3
- If dissemination, encephalitis, or severe disease occurs, switch to intravenous acyclovir and do not restart tofacitinib. 4, 5
- Monitor for post-herpetic neuralgia development, which occurred in 6.9% of first herpes zoster events in tofacitinib-treated rheumatoid arthritis patients. 3
When to Restart Tofacitinib
Timing of Reinitiation
- Resume tofacitinib only after complete resolution of all cutaneous lesions and symptoms, typically 15-22 days after onset. 3
- In clinical trials, median time to resolution was 22 days for first events, with 97.6% of episodes resolving completely. 3
- Concurrent antiviral treatment allows for earlier tofacitinib reinitiation once antiviral therapy has been started and acute symptoms are controlled. 1
Consider Antiviral Prophylaxis
- For patients who develop recurrent herpes zoster (second episode), strongly consider long-term antiviral prophylaxis with valacyclovir when restarting tofacitinib. 1, 5
- In one case report, a patient successfully continued tofacitinib with concurrent valacyclovir prophylaxis for 2 years after herpes zoster meningitis, without recurrence. 5
- Recurrent events occurred in 8.0% of rheumatoid arthritis patients and 2.8% of psoriatic arthritis patients on tofacitinib. 3
Long-Term Prevention Strategy
Vaccination After Recovery
- Administer the 2-dose Shingrix (recombinant zoster vaccine) series once the acute episode has fully resolved, waiting at least 2 months after symptom resolution. 1, 6
- Shingrix should have been given before starting tofacitinib, but vaccination after an episode still provides protection against future recurrences. 6, 7
- After completing Shingrix vaccination, antiviral prophylaxis can be discontinued. 5
Critical Clinical Pitfalls to Avoid
- Never continue tofacitinib during active herpes zoster, as JAK inhibition impairs interferon-mediated viral clearance and increases risk of severe complications. 1
- Do not delay antiviral therapy beyond 72 hours of rash onset, as efficacy diminishes significantly after this window. 2, 4
- Do not assume a single herpes zoster episode provides protection—8% of patients on tofacitinib develop recurrent episodes. 3
- Do not restart tofacitinib without ensuring complete lesion crusting and resolution, as premature reinitiation may prolong the episode. 3
- Do not use live-attenuated Zostavax vaccine in patients on or planning to resume tofacitinib—only Shingrix is appropriate. 1, 6