Upadacitinib

Upadacitinib, also known by the trade name Rinvoq, is a type of drug known as a JAK inhibitor. These drugs work by limiting the action of Janus kinase enzymes, which are involved in the inflammation that causes the symptoms of rheumatoid arthritis and some other conditions.

Upadacitinib isn’t a painkiller, but it can reduce the symptoms and limit the joint damage that could be caused by your condition. If upadacitinib works for you, your symptoms should start to improve within 2–8 weeks after you start taking it, but you may not notice the full benefit for 3–6 months.

Updacacitinib can be prescribed by a consultant rheumatologist for adults with moderate or severe rheumatoid arthritis. It can also be used to treat psoriatic arthritis.

Upadacitinib won’t be started if:

• your condition isn’t active
• you haven’t tried other treatments for your condition first
• you have an infection.

Before you’re prescribed upadacitinib, doctors may use a scoring system to assess how many of your joints are painful or swollen and how you are feeling. This helps them work out how active your arthritis is. You’ll also need blood tests before treatment starts to see whether the drug is suitable for you.

Your doctor will need to check if you’ve previously been exposed to tuberculosis (TB). Even if you don’t have symptoms, the bacteria that cause TB may still be present in the body, and you may need a course of treatment to deal with this before starting upadacitinib.

If you’ve ever had hepatitis you may need regular checks for this as upadacitinib may increase the risk of the hepatitis coming back.

Upadacitinib is usually prescribed alongside methotrexate unless there are reasons why you can’t take methotrexate. However, upadacitinib should not be used alongside other immunosuppressive or biologic drugs or other JAK inhibitors.

Upadacitinib is not recommended if you’re pregnant, planning to become pregnant or breastfeeding.

Your doctor may decide not to prescribe upadacitinib if you’ve had or have any of the following:

• shingles
• disease of the lungs, liver or kidneys
• heart problems, high blood pressure, high cholesterol, or blood clots (deep vein thrombosis or pulmonary embolism)
• stomach ulcers
• cancer.

Upadacitinib Is taken as a tablet once a day. The tablets should be swallowed whole and taken with or after food. In some circumstances, your doctor may decide to reduce the standard dose.

If you take more than the recommended dose by mistake, contact your doctor straight away. If you miss a dose, carry on with the usual dose the next day – do not double it.

Because it’s a long-term treatment, it’s important to keep taking upadacitinib (unless you have severe side effects):

• even if it doesn’t seem to be working at first
• even when your symptoms improve (to help keep your condition under control).

Your doctor may decide to stop upadacitinib and try another treatment if your symptoms haven’t improved very much after 6 months.

Most people don’t have any side effects, and for those who do, they aren’t usually serious.

You will normally need to have regular tests while you’re on upadacitinib to make sure it isn’t having any unwanted effects on your blood, liver or general health.

It’s recommended that you avoid food or drink containing grapefruit while you’re on upadacitinib. Grapefruit can add to the effect of upadacitinib and therefore increase the risk of side effects.

If you do have very bad side effects, or are worried about your symptoms, you should ask a health professional for advice.

The most common side effects are:

• body aches or pain
• fever or chills
• headache
• itching or warmth, redness, swelling or tenderness of the skin
• unusual tiredness or weakness
• coughs, colds, sinus infections
• feeling sick (nausea).

If your doctor thinks you could be at increased risk of skin cancer, they may suggest precautions such as wearing sunscreen and regularly checking your skin for new spots or changes to any freckles or moles.

Cases of blood clots have been reported in people taking upadacitinib. You should get medical help as soon as possible if you have painful swelling in a leg or arm or if you develop chest pain or shortness of breath, as these could be signs of a blood clot.

You should also tell your doctor or nurse specialist if you develop any of the following after starting upadacitinib:

• a sore throat, fever, or a cough that won’t go away
• unexplained bruising or bleeding
• a painful rash
• any new symptoms that concern you.

Contact your rheumatology team if you come into contact with someone who has chickenpox or shingles. They may suggest a blood test to check your antibody levels. These illnesses can be more severe than usual if you’re on upadacitinib, and you may need anti-viral treatment if you develop either chickenpox or shingles.

You may also be more likely to pick up other infections while you’re on upadacitinib, especially if you’re over 65, but the tips below should help reduce the risk of infections.

Tips to reduce your risk of infection

• Try to avoid close contact with people you know have an infection.
• Wash your hands regularly and carry around a small bottle of antibacterial hand gel.
• Keep your mouth clean by brushing your teeth regularly.
• Stop smoking if you’re a smoker.
• Make sure your food is stored and prepared properly.
• Try to keep your home clean and hygienic, especially the kitchen, bathroom and toilets.

If you develop an infection (bacterial, viral or fungal) you should stop your upadacitinib tablets and see your GP to have the infection treated. You should also contact your rheumatology team for advice on when to restart your upadacitinib.

It’s recommended that you carry a patient alert card so anyone treating you will know that you’re on upadacitinib.

You’ll probably be taking methotrexate as well as upadacitinib. However, some drugs may interact with upadacitinib. These include some of the drugs used to treat fungal or bacterial infections, tuberculosis, seizures or fits, and drugs that affect your immune system such as azathioprine, ciclosporin and tacrolimus.

Check with your doctor before starting any new medicines, and remember to mention you’re on upadacitinib if you’re treated by anyone other than your usual rheumatology team.

You can carry on taking non-steroidal anti-inflammatory drugs (NSAIDs) or painkillers, if needed, unless your doctor advises otherwise.

Don’t use complementary treatments, such as herbal remedies, without discussing this first with your doctor or pharmacist as some of them could interact with upadacitinib.

Vaccinations

It’s best to discuss vaccinations with your healthcare team before starting upadacitinib.

It’s usually recommended that people on upadacitinib avoid live vaccines such as measles, mumps and rubella (MMR), chickenpox and yellow fever. But sometimes a live vaccine may be necessary, so you should discuss this with your rheumatology team.

Before you start upadacitinib, your rheumatology team may suggest a blood test to check for antibodies against chickenpox. If the result is low, they may recommend vaccination against chickenpox.

If you’re offered shingles vaccination after starting upadacitinib, you should not have the live vaccine (Zostavax) but you may be able to have the non-live vaccine (Shingrix) if this is suitable for you.

It’s recommended that you have the vaccination against COVID-19, and the pneumonia and yearly flu vaccines while taking upadacitinib. These vaccines are not live, so it’s safe for you to have them.

Having an operation

If you’re thinking about having surgery, talk this over with your specialists. They may advise you to stop upadacitinib for a time before and after your operation.

There’s no need to avoid alcohol while taking upadacitinib.

Guidelines state that adults shouldn’t have more than 14 units of alcohol a week, and that these should be spread out over the course of the week. In some circumstances your doctor may advise lower limits.

You can find out more about units of alcohol at: www.drinkaware.co.uk

Because upadacitinib is a relatively new drug, we don’t yet know how it might affect pregnancy or an unborn baby.

Women who could become pregnant should use effective contraception while being treated with upadacitinib and for at least 4 weeks after stopping the treatment before trying for a baby. Tell your rheumatology team immediately if you become pregnant while you’re on upadacitinib.

We don’t yet know whether upadacitinib can pass into human breastmilk, so the current advice is not to breastfeed while taking this drug.

There’s no information currently available about whether upadacitinib might affect male or female fertility.