Can I prescribe a short‑term bridge refill of upadacitinib (Rinvoq) at the prior high dose for an adult patient with ulcerative colitis who has been off the medication for two weeks because her gastroenterologist left practice?

Bridge Prescription of Upadacitinib for Ulcerative Colitis

Yes, you should prescribe a short-term bridge refill of upadacitinib at the prior high dose (45 mg daily if she was on induction, or 15-30 mg daily if she was on maintenance) to prevent disease flare while she establishes care with a new gastroenterologist, as abrupt discontinuation after two weeks significantly increases the risk of disease relapse and complications. 1

Immediate Clinical Assessment

Before prescribing, verify the following critical details:

• Confirm her current disease status: Ask about rectal bleeding, stool frequency, urgency, and abdominal pain to assess if she's experiencing a flare after the two-week gap 1
• Determine which dose she was taking: Induction therapy uses 45 mg once daily for 8-16 weeks, while maintenance therapy uses either 15 mg or 30 mg once daily 1, 2
• Review her cardiovascular risk factors: Age ≥65 years, current or former smoker, history of cardiovascular disease, or cancer history are relative contraindications for JAK inhibitors 1
• Check for venous thromboembolism (VTE) risk factors: Prior VTE, thrombophilia, prolonged immobility, or active malignancy 1, 3

Prescribing Algorithm

If She Was on Maintenance Therapy (15 mg or 30 mg daily):

• Prescribe a 30-day supply at her previous maintenance dose (either 15 mg or 30 mg once daily) 1, 4
• This provides adequate time for her to establish care with a new gastroenterologist while maintaining disease control 4
• The 30 mg maintenance dose showed superior efficacy (53.6% clinical remission) compared to 15 mg (40.4%) at 52 weeks 4

If She Was on Induction Therapy (45 mg daily):

• Determine how long she had been on 45 mg before the gap: If less than 8 weeks total, prescribe 45 mg once daily to complete the standard 8-week induction 2
• If she had 8-16 weeks of induction already: Transition to maintenance dosing at 30 mg once daily, as continuing 45 mg beyond 16 weeks is not recommended due to safety concerns 5, 3
• Do not prescribe 45 mg for more than 16 weeks total under any circumstances 5, 3

Safety Monitoring Requirements

Order the following labs before or immediately after prescribing:

• Complete blood count (CBC): Monitor for neutropenia (occurs in 5.5-8.7 events per 100 patient-years) and lymphopenia 4, 3
• Hepatic function panel: Hepatic disorders occur in 9.2-17.0 events per 100 patient-years with upadacitinib 4
• Creatine phosphokinase (CPK): Elevations occur in 8.0-10.1 events per 100 patient-years 4
• Lipid panel: JAK inhibitors can cause hyperlipidemia 1

Critical Safety Warnings to Communicate

Counsel the patient on these specific adverse events:

• Herpes zoster risk: Occurs in 6.0-7.3 events per 100 patient-years; consider vaccination if not previously vaccinated 4
• VTE and cardiovascular events: While rare (0.5-1.0 events per 100 patient-years), instruct her to seek immediate care for leg swelling, chest pain, or dyspnea 4, 3
• Serious infections: Report fever, persistent cough, or signs of infection immediately 3
• Avoid live vaccines while on upadacitinib 1

Transition Plan

Structure the bridge prescription with clear next steps:

• Prescribe exactly 30 days (not 90 days) to ensure she establishes gastroenterology care promptly 1
• Document in the prescription: "Bridge therapy pending gastroenterology follow-up. Patient's prior gastroenterologist left practice unexpectedly." 1
• Provide referrals: Give her names of at least 2-3 gastroenterologists accepting new patients who manage inflammatory bowel disease 1
• Schedule follow-up: Have her return to you in 2-4 weeks if she hasn't secured gastroenterology care, to reassess disease activity and lab results 3

Common Pitfalls to Avoid

• Do not refuse to prescribe: A two-week gap already places her at significant risk for disease flare, and further delay could precipitate acute severe ulcerative colitis requiring hospitalization 1, 6
• Do not reduce the dose arbitrarily: Maintain her established dose unless safety concerns dictate otherwise, as dose reduction can trigger loss of response 4
• Do not prescribe 45 mg indefinitely: This induction dose should never be continued beyond 16 weeks total due to increased adverse event rates 5, 3, 7
• Do not skip cardiovascular risk assessment: The FDA and European Medicine Agency specifically warn against JAK inhibitor use in high-risk cardiovascular patients 1

When to Withhold the Prescription

Absolute contraindications requiring immediate gastroenterology consultation instead of bridge prescribing:

• Active serious infection or recent serious infection within 4 weeks 3
• Absolute neutrophil count <1000/μL or platelets <50,000/μL 3
• Recent VTE (within 3 months) without anticoagulation 1, 3
• Active malignancy (except non-melanoma skin cancer adequately treated) 1
• Pregnancy or breastfeeding: JAK inhibitors are contraindicated 1

The American Gastroenterological Association strongly recommends upadacitinib for moderate-to-severe ulcerative colitis, with high-certainty evidence supporting its efficacy 1. Your bridge prescription maintains continuity of this evidence-based therapy while preventing potentially serious disease complications from treatment interruption.