Upadacitinib (Rinvoq)
Rinvoq (upadacitinib) is a Disease Modifying Anti-Rheumatic Drug (DMARD) that’s currently used to treat rheumatoid arthritis with and without methotrexate, psoriatic arthritis, and ankylosing spondylitis.
Rinvoq works by suppressing the immune system. It belongs to a class of medications known as Janus Kinase (JAK) inhibitors.
Taking Rinvoq
Rinvoq is one of the few therapies for arthritis that is available as an oral tablet. The standard dose is 15 mg taken once every day.
Rinvoq does not work right away. It can take about 2 to 8 weeks before patients start feeling better, and it can take 3 to 6 months to feel the maximum effect of this medication. If the dose is changed, it can take 2-8 weeks to feel the effects.
The manufacturer of Rinvoq offers a support program to Canadian patients that are prescribed the medication:
Patient support program enrolment formsImportant Tests and Risks
Regular blood tests are necessary when taking Rinvoq.
Doctors will advise patients how frequently they want to run tests to make sure that the medicine isn’t affecting the kidneys, liver, blood counts, or cholesterol levels.
Testing is usually required once every 1 to 3 months.
Rinvoq can make it a bit harder for people to fight off infections.
People taking this medicine should call their doctor they have a fever, think they have an infection, or have been prescribed antibiotics to treat an infection.
Patients should coordinate with their doctor to stop treatment before any surgery. It can be re-started once things have healed and there’s no sign of infection. Most patients stop the medication a week before surgery. It can be restarted 10-14 days after the surgery as long as there is no sign of infection.
Patients should discuss all vaccinations with their doctor because some (live vaccines) are not advisable to get while taking Rinvoq.
Rinvoq may increase the risk of developing shingles. Please talk to your doctor about the shingles vaccine.
Rinvoq may increase your risk of blood clots in the legs (deep venous thrombosis or DVT) or in the lungs (pulmonary embolism or PE).
Any new leg swelling or shortness of breath should be taken seriously and reviewed by a doctor.
All patients should have a TB (tuberculosis) skin test and a chest x-ray before starting treatment.
Science
One way that cells in the body communicate with each other is with special signalling proteins called cytokines.
Cytokines are made and released by cells and drift around and until they encounter another cell and bind to a receptor on its surface.
When a cytokine binds to the surface of a cell, it passes its message to the cell’s nucleus (its “brain” or command centre) using a process called signal transduction. The nucleus responds to a signal by producing the appropriate protein or peptide that’s coded for in its DNA (this is called activation of transcription).
One of the important signal transduction pathways in the body uses an enzyme called Janus Kinase (JAK) and another molecule called Signal Transducer and Activation of Transcription (STAT) to send a signal to a cell’s nucleus.
The JAK-STAT pathway is important for sending signals related to bone marrow and immune system activation.
Rinvoq is a newer small molecule that enters a cell and binds to the ATP binding site on the enzyme Janus Kinase (JAK). In doing this, it prevents JAK from activating STAT which would then complete the process of sending its signal to the cell’s nucleus.
In rheumatoid arthritis and many other autoimmune disorders, the immune system is not functioning correctly. It attacks the joints the same way it attacks disease-causing germs.
By disrupting a key signal sending process related to immune system activation, Rinvoq interferes with the ability of immune system cells to talk with each other. When these cells can’t communicate as effectively, they have a hard time coordinating their attack on the joints. The end result is improvement in the symptoms of a patient’s arthritis.
Safety
The most common side effects of Rinvoq include include upper respiratory tract infections (common cold, sinus infections) and related symptoms. It might also cause nausea. Patients should tell their doctor if these effects are troublesome.
LESS SERIOUS side-effects include:
- Nausea, indigestion, and diarrhea
- Headaches
- Upper respiratory tract infection (nasopharyngitis)
- Cholesterol Levels – Rinvoq may increase cholesterol levels. This will be monitored through blood tests
MORE SERIOUS side-effects include:
- Infection – There have been serious and rare infections associated with the use of Rinvoq. Any infections or fevers should be taken very seriously and reviewed by a doctor
- Blood Counts – Rinvoq can cause changes in the numbers of white blood cells (which are needed to fight infection) and red blood cells (which carry oxygen)
- Liver – Rinvoq may irritate the liver. This does not usually cause symptoms but may be found on blood tests. It is uncommon and usually reversible when regularly monitored with your monthly blood tests
- Bowels – Rinvoq may increase the risk of bowel perforation. This is very rare.
- Blood Clots - Rinvoq may increase the risk of blood clots in the legs (deep venous thrombosis or DVT) or in the lungs (pulmonary embolism or PE). Any new leg swelling or shortness of breath should be taken seriously and reviewed by a doctor.
- Shingles - Rinvoq may increase your risk of developing shingles. Please talk to your doctor about the shingles vaccine.
- Cancer – Rinvoq has very rarely been associated with developing cancer. Tell your doctor if you have had cancer in the past.
How to minimize the side-effects of Rinvoq:
- Patients should take the medicine once a day, as prescribed by their doctor
- Patients should get regular blood tests as requested by their doctor to monitor for side effects, and remember to attend their appointments.
Patients should contact their doctor before intentionally missing a dose of Rinvoq. However, in the following situations, it would be advisable to stop taking the medicine and call a doctor:
- Fever
- An infection or signs of an infection
- Severe abdominal pain
- Leg swelling and/or new chest pain or shortness of breath
- Pregnancy
Patients who are about to have surgery should discuss stopping Rinvoq with their doctor.
Some medications may not be safe to take with Rinvoq including ketoconazole, fluconazole, and rifampin. Patients should always discuss all of the medications that they are taking with their doctor.
Some medications may increase the risk of infection and should not be taken with Rinvoq, including biologics, other JAK-inhibitors, and other potent immunosuppressive medications such as cyclosporine or azathioprine.
Patients taking Rinvoq should call their doctor if they feel sick and want to stop, or if they are concerned about any side effects.
Other reasons to call a doctor while taking Rinvoq include:
- Developing a fever or suspected infection
- Planning for surgery
- Becoming pregnant or planning on pregnancy
- Planning on getting any vaccinations
- New leg swelling, chest pain, or shortness of breath
- Severe abdominal pain
Anyone who becomes pregnant while taking Rinvoq should notify their doctor.
Pregnancy and medications