S4932 Case Report: Management of Upadacitinib Induced Anemia in a Patient With Ulcerative Colitis

Introduction: Upadacitinib (UPA) is a Janus Kinase inhibitor currently approved for moderate to severe ulcerative colitis (UC). Drug-induced anemia with hemoglobin (hgb) levels less than 8 grams per deciliter (g/dL) is an adverse event that has been observed in Janus Kinase clinical trials. The current prescribing recommendation for those who experience anemia related to UPA is to stop treatment, noting that the anemia is generally reversible. However, there is little known about the safety and success of resuming UPA in such patients. We present a case of UPA-associated anemia in a patient with UC who achieved successful re-initiation of therapy without recurrent anemia while maintaining clinical remission. Case Description/Methods: A 55-year-old woman with moderate to severe UC started on UPA 45 mg daily after failure to control her disease with adalimumab and infliximab. Despite a rapid improvement of bowel habit, within 1 month her hgb dropped from 13.2 g/dl to 8.7 g/dl. UPA was held and workup revealed normal iron studies, normal upper endoscopy and video capsule endoscopy, along with a colonoscopy showing improved colitis with no bleeding source. Further work-up by hematology revealed no alternative etiology. As the patient’s bowel complaints resumed and the hgb improved to 10.7 g/dl, UPA was re-initiated at 30 mg daily. Several weeks after resuming UPA the patient recaptured clinical remission, her hgb rose to 12.0 g/dl and remains normal at 3-month follow-up. Discussion: UC is a debilitating disease with significant morbidity. While several therapies exist for treatment of UC, UPA is among the most effective. As anemia is one of the most reported adverse events related to UPA, it is imperative to develop an effective management strategy that balances the needs of medication efficacy and safety. Our case demonstrates a patient whose severe anemia was successfully corrected, then maintained with resumption of UPA at a lower dose while achieving a successful response to therapy. Our case suggests that patients who develop drug-induced anemia on induction dosing of UPA can be considered for re-initiation of therapy at a lower dose following recovery of hgb in the appropriate clinical setting.