What is upadacitinib?
Upadacitinib (brand name Rinvoq) is a medication used to treat rheumatoid arthritis, psoriatic arthritis, ankylosing spondylitis, atopic dermatitis, ulcerative colitis, and Crohn’s disease. Unlike biologic medications that are given by injection, upadacitinib is a pill taken by mouth once daily — a significant advantage for patients who prefer to avoid injections.
How it works
Upadacitinib is a selective JAK1 inhibitor — it belongs to a class of medications called JAK inhibitors (or “JAKinibs”). While biologics are large proteins that work outside the cell to block specific inflammatory signals, JAK inhibitors are small molecules that work inside the cell. They block enzymes called Janus kinases (JAKs) that relay inflammatory signals from the cell surface to the cell’s nucleus. By selectively targeting JAK1, upadacitinib reduces the activity of multiple inflammatory pathways simultaneously.
How to take it
- For rheumatoid arthritis: 15 mg once daily
- For other conditions: 15 mg or 30 mg once daily, depending on the indication
Take the tablet at roughly the same time each day, with or without food. Swallow it whole — do not crush, split, or chew it.
What to expect when starting
Upadacitinib can work faster than many biologics. Some patients notice improvement within 2 weeks, with significant improvement typically by 6 to 8 weeks. Because it is a pill that is rapidly absorbed, it reaches therapeutic levels quickly.
Side effects to watch for
Common side effects include:
- Upper respiratory infections
- Nausea
- Acne
- Elevated liver enzymes
- Elevated CPK (a muscle enzyme)
- Elevated cholesterol
- Herpes zoster (shingles) reactivation — the Shingrix vaccine is strongly recommended before starting treatment
FDA Boxed Warning: The FDA requires a boxed warning on all JAK inhibitors. This is based on a large safety study (ORAL Surveillance) of a different JAK inhibitor (tofacitinib) in rheumatoid arthritis patients over age 50 with at least one cardiovascular risk factor. That study found increased risks of serious cardiovascular events, certain cancers, blood clots, and death compared to TNF inhibitor biologics.
What this means for you: These risks were primarily observed in older patients with pre-existing cardiovascular risk factors (smoking, high blood pressure, diabetes, high cholesterol). The boxed warning applies to the entire JAK inhibitor class as a precaution. Your rheumatologist has assessed your individual risk profile and determined that the benefits of this medication are likely to outweigh the risks in your case. If you have concerns, discuss them openly — understanding your personal risk factors is important.
Required screening before starting
Your rheumatologist will order the following before you begin:
- Tuberculosis (TB) testing
- Hepatitis B and hepatitis C screening
- Complete blood count (CBC)
- Lipid panel (cholesterol levels)
- Liver function tests (LFTs)
- Shingrix vaccination — strongly recommended if you have not already received it
Lab monitoring
Because upadacitinib can affect blood counts, liver function, and cholesterol, your rheumatologist will monitor labs on a regular schedule:
- 4 weeks after starting
- 8 weeks after starting
- Every 3 months thereafter
This monitoring helps catch any changes early so your treatment plan can be adjusted if needed.
Things to avoid
- Live vaccines — should not be given while on upadacitinib
- Strong CYP3A4 inhibitors — certain medications can interact with upadacitinib and require dose adjustment. Always tell your rheumatologist and pharmacist about all medications you take, including over-the-counter drugs and supplements.
- Other biologics or JAK inhibitors — upadacitinib cannot be combined with other biologic medications or other JAK inhibitors
- Pregnancy — upadacitinib is not safe during pregnancy and must be stopped before conception. If you are planning a pregnancy, discuss this with your rheumatologist well in advance.
Frequently asked questions
Is a pill really as effective as an injection? Yes. JAK inhibitors have demonstrated strong efficacy across multiple conditions in large clinical trials. For many patients, they work as well as — or in some cases faster than — biologic injections.
Should I be worried about the boxed warning? It is reasonable to take the warning seriously, but context matters. The study that prompted the warning involved older patients with existing cardiovascular risk factors using a different JAK inhibitor. Your rheumatologist has evaluated your individual risk and determined that this medication is appropriate for you. All medications carry some risk — the key is whether the benefits outweigh the risks in your specific situation.
Why is the shingles vaccine recommended? JAK inhibitors can increase the risk of herpes zoster (shingles) reactivation. The Shingrix vaccine significantly reduces this risk. Ideally, complete the vaccine series before starting upadacitinib.
What if I miss a dose? Take the missed dose as soon as you remember on the same day. If it is already the next day, skip the missed dose and take your regular dose. Do not double up.
How long will I need to take this medication? Upadacitinib is typically a long-term treatment. Your rheumatologist will periodically reassess whether it remains the best option for you.
This handout is for informational purposes only and does not replace the advice of your rheumatologist. Always discuss your specific medical situation, including all medications and health conditions, with your provider before starting or changing any treatment.