When can a geriatric patient safely restart upadacitinib (Rinvoq) after surgery?

Restarting Upadacitinib (Rinvoq) After Surgery in Geriatric Patients

Restart upadacitinib approximately 14 days after surgery once the wound shows evidence of healing, all sutures/staples are removed, there is no significant swelling, erythema, or drainage, and there is no ongoing infection at the surgical site or elsewhere. 1, 2, 1

Perioperative Management Framework

Pre-operative Withholding

• Withhold upadacitinib for at least 3 days prior to surgery 1, 2, 1
• This recommendation applies to patients with rheumatoid arthritis (RA), ankylosing spondylitis (AS), psoriatic arthritis (PsA), or juvenile idiopathic arthritis (JIA) undergoing total hip or knee arthroplasty 1, 2, 1
• The 3-day withholding period represents an update from the 2017 guideline (which recommended 7 days for tofacitinib), based on trial data demonstrating rapid disease activity increases after JAK inhibitor interruption, suggesting rapid reversal of immunosuppressive effects 1

Post-operative Restart Criteria

The decision to restart must be based on careful clinical assessment of four key factors: 1, 2, 1

1. Wound healing status: The wound must show clear evidence of healing 1, 2, 1
2. Suture/staple removal: All sutures or staples must be removed 1, 2, 1
3. Local inflammatory signs: No significant swelling, erythema, or drainage present 1, 2, 1
4. Infection status: No clinical evidence of surgical site infection or non-surgical site infection 1, 2, 1

Timing Considerations

• The typical timeframe is approximately 14 days, as normal wound closure typically requires this duration 1, 2, 1, 3, 1
• This is a conditional recommendation based on low-quality evidence, meaning individual patient factors should influence the final decision 1, 2, 1

Special Considerations for Geriatric Patients

Risk Factors Warranting Longer Withholding

Consider extending the period before restarting upadacitinib in geriatric patients with: 1

• History of severe or recurrent infections 1
• Prior prosthetic joint infection 1
• Compromised wound healing capacity
• Multiple cardiovascular risk factors (given the age-related considerations for JAK inhibitors) 4

Disease Activity Monitoring

• Rapid disease flare is possible after upadacitinib withdrawal 5
• Loss of skin clearance response can occur within 4 weeks of withdrawal in atopic dermatitis patients 5
• Trial data demonstrate rapid increases in disease activity after interrupting JAK inhibitor therapy 1
• Upon restarting, most patients recapture their previous response, with recovery typically occurring within 8 weeks 5

Important Caveats

Infection Risk Assessment

• The recommendation pertains specifically to infection risk and does not account for cardiovascular events or venous thromboembolism risk 1
• Serious infections, including pneumonia and cellulitis, have been reported with upadacitinib 6
• Higher rates of serious infections were observed in patients at higher cardiovascular risk 4

Delayed Restart Scenarios

Extend the withholding period beyond 14 days if: 1

• Wound healing complications develop
• Signs of infection emerge (surgical site or elsewhere)
• Significant wound drainage persists
• Inflammatory signs (swelling, erythema) remain present

Alternative Approach for High-Risk Patients

• In patients with history of prior severe infections or prosthetic joint infection, physicians and patients may elect longer periods without medication 1
• The conditional nature of this recommendation emphasizes the need for shared decision-making 1, 2, 1

Clinical Monitoring Upon Restart

• Monitor for herpes zoster reactivation, which appears more common with JAK inhibitors 6
• Assess for acne development, particularly in younger patients 6
• Watch for signs of viral reactivation, including hepatitis B 6
• Consider temporarily interrupting upadacitinib if herpes zoster develops 6