Targeted synthetic DMARD infection — SCE Rheumatology MCQ

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HardRheumatological PharmacologyTargeted synthetic DMARD infectionSCE Rheumatology

A 67-year-old woman taking upadacitinib for rheumatoid arthritis develops a painful vesicular rash in a thoracic dermatomal distribution. She has low-grade fever and lymphopenia. Disease activity was previously controlled. What is the most appropriate management?

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Correct answer: D — Withhold upadacitinib and treat herpes zoster promptly

Explanation lettering: B = shown as A · D = shown as B · E = shown as D · A = shown as E

Withhold upadacitinib and treat herpes zoster promptly is best because JAK inhibitors increase herpes zoster risk; suspected shingles warrants antiviral treatment and temporary interruption during significant infection. A is less suitable because methotrexate is not antiviral; B is less suitable because dose escalation increases risk; C is less suitable because live shingles vaccine is not treatment and is inappropriate during active zoster/immunosuppression; D is less suitable because continuation during active infection may worsen illness. Clinical pearl: zoster vaccination status should be reviewed before JAK inhibitor therapy where possible.

Reference: https://www.nice.org.uk/guidance/conditions-and-diseases/musculoskeletal-conditions