Ustekinumab

Ustekinumab (trade name Stelara) is a type of biological therapy. It works by binding to two specific proteins on cells, which in turn interferes with the function of a group of white blood cells called T cells. This modifies the activity of the immune system to reduce the inflammation that causes the symptoms of psoriatic arthritis.

Ustekinumab can be prescribed by a consultant or other clinical rheumatology specialist for adults with psoriatic arthritis. It’s a long-term treatment, so it may be up to six months before you start to notice the benefits. It can be used alone or with methotrexate.

Ustekinumab won’t be started if:

• your arthritis isn’t active
• you’re pregnant or breastfeeding
• you haven’t tried other treatments appropriate for your condition first.

Your doctor may decide not to prescribe ustekinumab if:

• you have, or have recently had, an infection
• you’ve had phototherapy treatment for psoriasis
• you’ve had injections to treat allergies.

There’s no good evidence that using ustekinumab to control your immune system increases your risk of cancer. Even so, if you’ve had cancer before, you should always let your clinical team know in case this affects decisions about your treatment.

You’ll have blood tests before treatment starts to assess your disease and whether the drug is suitable for you. Your doctor will also check if you’ve previously been exposed to tuberculosis (TB), and you may need a course of treatment for latent (asymptomatic) TB before starting ustekinumab.

You’ll be monitored regularly while taking ustekinumab, and if you’re taking other drugs alongside (such as methotrexate), you’ll also need to continue your blood tests for these.

Ustekinumab is given as an injection under the skin (subcutaneous injection) using a pre-filled syringe, avoiding areas of psoriasis. After the first dose you’ll be given another at four weeks, then every 12 weeks from then on. The prescribed dose will depend on your weight. To begin with, a nurse will usually give you the injections. But you, your partner, or another family member can also be shown how to give them.

If you have a latex allergy you should mention this to your doctor as the needle cover on the pre-filled syringe may contain latex and could cause a reaction.

If you miss a dose, ask your rheumatology team for advice on when you should have your next dose. Because it’s is a long-term treatment, it’s important to keep taking ustekinumab (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 the disease under control).

Some side-effects can happen around the time of the injection. The most common are dizziness, sore throat, joint pain, headaches, feeling sick (nausea), and soreness around the injection site. These aren’t usually serious.

Because ustekinumab affects your immune system you may be more likely to pick up infections. If you’ve any symptoms of infection (including fever, feeling tired or short of breath, persistent cough, burning when urinating or diarrhoea), or if you’re in any doubt, speak to your rheumatology team immediately. They may advise you to delay your next dose until you’re better.

Some people may have an allergic reaction with sudden swelling, a rash or breathlessness. This is very rare, but if you do develop these symptoms, or any other severe symptoms, during or soon after a dose of ustekinumab, you should seek medical advice immediately.

Reducing the risk of infection

• Try to avoid close contact with people with severe active infections.
• For advice on avoiding infection from food, visit: https://www.nhs.uk/conditions/food-poisoning/pages/prevention.aspx

You may be taking methotrexate as well as ustekinumab. However, some medicines may interact with ustekinumab. Check with your doctor before starting any new medicines, and remember to mention you’re on ustekinumab 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 take over-the-counter or herbal medicines without discussing it first with your rheumatology team.

It’s recommended that you carry a biological therapy alert card, so anyone treating you will know that you’re on ustekinumab – ask your rheumatology team for a card.

Vaccinations

It’s best to speak to your healthcare team about any vaccinations you might need before starting treatment with ustekinumab. Generally, you should avoid live vaccines while you’re on ustekinumab – these include measles, mumps, rubella, yellow fever and shingles. You should also avoid having tuberculosis (BCG) vaccination for a year after stopping treatment with ustekinumab.

Flu vaccines are fine and are usually recommended.

Having an operation

If you’re thinking about having surgery, talk this over with your rheumatology team. For most operations you’ll be advised to stop ustekinumab beforehand. You can restart when your wound is healed and there are no signs of infection.

There’s no known interaction between ustekinumab and alcohol. However, if you’re also taking methotrexate, this can interact with alcohol and affect your liver so you should keep well within the recommended limits of no more than 14 units of alcohol per week for adults – unless your doctor advises a lower limit.

If you're thinking of trying for a baby, talk to your rheumatology team in advance so that you can plan what to do with your medication.

The latest guidelines say that women can take ustekinumab while trying to become pregnant. But it's recommended that women stop taking this drug if they become pregnant.

You should be OK to breastfeed while taking ustekinumab, but the research is limited so you should discuss this with your doctor.