Upadacitinib
Also known as: Rinvoq
Upadacitinib is a once-daily tablet that works inside the cell to interrupt inflammatory signalling. It is more selective than the first generation of JAK inhibitors, and it has a broad range of approved uses. It is a strong option for some patients and the wrong choice for others, so the decision is an individual one.
Calm, careful medication review by a consultant rheumatologist.
What this medicine is
Upadacitinib is a targeted synthetic DMARD, commonly called a JAK inhibitor. Janus kinases are enzymes inside the cell that relay messages from inflammatory signals landing on the cell surface. Upadacitinib is designed to be selective for JAK1, which is intended to concentrate its effect on the pathways most involved in inflammation. It is taken by mouth as a prolonged-release tablet, which must be swallowed whole rather than crushed or split. Your prescriber sets the strength and schedule, adjusting for kidney or liver function and interacting medicines, so I do not publish dose schedules here.
Uses and context
Upadacitinib is used, where locally approved, in rheumatoid arthritis, psoriatic arthritis, axial spondyloarthritis including ankylosing spondylitis and non-radiographic disease, and it also has approvals in atopic dermatitis and inflammatory bowel disease. Licensed and locally approved indications differ between countries and between the individual JAK inhibitors, so upadacitinib, tofacitinib and baricitinib are not interchangeable. It is generally considered when a conventional DMARD such as methotrexate has not given adequate control, or cannot be used, and it can be used alone or alongside methotrexate.
How this relates to rheumatology care
Realistic benefit and timing: response tends to be quick, often within one to four weeks, with a clearer assessment at about three months. I judge it on your symptoms, joint examination, function and inflammatory markers. Its breadth is genuinely useful when arthritis coexists with skin or bowel inflammation, because one tablet may address more than one problem. The class cautions still apply to upadacitinib even though it is JAK1-selective, and the selectivity has not been shown to remove them. Regulators advise care with blood clots, major cardiovascular events and cancer, particularly in patients over sixty-five, current or former long-term smokers, and people with cardiovascular or cancer risk factors. In those patients another class is often the better choice, and in a younger patient without those risks upadacitinib can be an excellent one. Shingles is also more common with this class. Related reading includes my guides to rheumatoid arthritis, psoriatic arthritis and ankylosing spondylitis.
What safety checks may matter
Full blood count before starting and during treatment, watching neutrophils, lymphocytes and haemoglobin
Liver function tests at baseline and on follow-up
Lipid profile at baseline and rechecked after starting, since cholesterol can rise
Kidney function, with the amount adjusted by the prescriber where needed
Tuberculosis screening with chest X-ray and IGRA or Mantoux, plus hepatitis B and C screening before starting
Assessment of age, smoking history, cardiovascular risk, clot risk and cancer history before choosing this class
Vaccination review, with non-live vaccines and shingles vaccination considered before starting where available
Skin checks and age-appropriate cancer screening kept up to date
Side effects and red flags
If you have emergency symptoms such as severe allergic reaction, breathing difficulty, chest pain, stroke-like symptoms, severe abdominal pain, vomiting blood, black stools, sudden vision loss, severe infection symptoms, or severe weakness or confusion, please seek urgent medical care first rather than waiting for a WhatsApp reply.
Calf pain, swelling or tenderness in one leg, which can indicate a clot
Sudden breathlessness, chest pain or coughing blood, which can indicate a clot in the lung
Chest pain, pressure or tightness, or symptoms of stroke such as face droop, arm weakness or slurred speech
Fever, chills, a persistent cough, night sweats or any sign of serious infection
A painful blistering rash in a band, which may be shingles
Severe abdominal pain with fever, which needs urgent assessment
Facial or tongue swelling, or another sign of a severe allergic reaction
Things worth knowing day to day
Swallow the prolonged-release tablet whole. Do not crush, split or chew it.
Infection precautions: pause the tablets during a significant infection or fever and contact me. Report any painful blistering rash promptly, as shingles is more common with this class.
Avoid live vaccines while on upadacitinib. Non-live vaccines are encouraged, and shingles vaccination is best considered before starting.
Do not smoke. Smoking adds to both the cardiovascular and the clot risk that already need weighing with this class.
Tell me about any personal or family history of blood clots, heart attack, stroke or cancer, and about hormone treatments or long periods of immobility such as long-haul flights.
Tell any surgeon or dentist that you take upadacitinib. It is usually paused around major surgery and restarted once healing is secure and there is no infection.
Common effects include upper respiratory infections, acne, headache, nausea, raised cholesterol, raised muscle enzymes and mild blood count changes.
Upadacitinib must be avoided in pregnancy and breastfeeding, and effective contraception is advised during treatment and for a period afterwards. If you are planning a family, tell me early so we can move to a more suitable option in good time.
Do not start new medicines without checking, as strong inhibitors or inducers of certain liver enzymes change upadacitinib levels.
Questions patients often ask me about this medicine
Speak with me
If upadacitinib has been suggested for you, or you want to understand where a JAK inhibitor sits among your options, please message my clinic. Risk and benefit are individual, and I will weigh them with you honestly.
Other medications used in rheumatology care
This page is for general education only and does not replace medical advice. Please consult a qualified healthcare professional for diagnosis and treatment. Do not start, stop, or change any medicine without advice from your doctor.