Ustekinumab

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# Overview
Ustekinumab is a monoclonal antibody that is FDA approved for the {{{indicationType}}} of moderate to severe plaque psoriasis (Ps), active psoriatic arthritis (PsA).   Common adverse reactions include nasopharyngitis, upper respiratory tract infection, headache, and fatigue.

# Adult Indications and Dosage

## FDA-Labeled Indications and Dosage (Adult)
- Dosing Information
- For patients weighing 100 kg (220 lbs), the recommended dose is 45 mg initially and 4 weeks later, followed by 45 mg every 12 weeks.
- For patients weighing >100 kg (220 lbs), the recommended dose is 90 mg initially and 4 weeks later, followed by 90 mg every 12 weeks.
- Dosing Information
- The recommended dose is 45 mg initially and 4 weeks later, followed by 45 mg every 12 weeks.
- For patients with co-existent moderate-to-severe plaque psoriasis weighing >100 kg (220 lbs), the recommended dose is 90 mg initially and 4 weeks later, followed by 90 mg every 12 weeks.

## Off-Label Use and Dosage (Adult)

### Guideline-Supported Use
There is limited information regarding Off-Label Guideline-Supported Use of Ustekinumab in adult patients.

### NonGuideline-Supported Use
- Dosing Information
- Ustekinumab 6 mg/kg IV

# Pediatric Indications and Dosage

## FDA-Labeled Indications and Dosage (Pediatric)
There is limited information regarding FDA-Labeled Use of Ustekinumab in pediatric patients.

## Off-Label Use and Dosage (Pediatric)

### Guideline-Supported Use
There is limited information regarding Off-Label Guideline-Supported Use of Ustekinumab in pediatric patients.

### NonGuideline-Supported Use
There is limited information regarding Off-Label NonGuideline-Supported Use of Ustekinumab in pediatric patients.

# Contraindications
- Clinically significant hypersensitivity to ustekinumab or to any of the excipients.

# Warnings

### Precautions
- Infections
- STELARA may increase the risk of infections and reactivation of latent infections. Serious bacterial, fungal, and viral infections were observed in subjects receiving STELARA.
- STELARA should not be given to patients with any clinically important active infection. STELARA should not be administered until the infection resolves or is adequately treated. Instruct patients to seek medical advice if signs or symptoms suggestive of an infection occur. Exercise caution when considering the use of STELARA in patients with a chronic infection or a history of recurrent infection.
- Serious infections requiring hospitalization occurred in the psoriasis and psoriatic arthritis development programs. In the psoriasis program, serious infections included diverticulitis, cellulitis, pneumonia, appendicitis, cholecystitis, sepsis, osteomyelitis, viral infections, gastroenteritis and urinary tract infections. In the psoriatic arthritis program, serious infections included cholecystitis.
- Theoretical Risk for Vulnerability to Particular Infections
- Individuals genetically deficient in IL-12/IL-23 are particularly vulnerable to disseminated infections from mycobacteria (including nontuberculous, environmental mycobacteria), salmonella (including nontyphi strains), and Bacillus Calmette-Guerin (BCG) vaccinations. Serious infections and fatal outcomes have been reported in such patients.
- It is not known whether patients with pharmacologic blockade of IL-12/IL-23 from treatment with STELARA will be susceptible to these types of infections. Appropriate diagnostic testing should be considered, e.g., tissue culture, stool culture, as dictated by clinical circumstances.
- Pre-treatment Evaluation for Tuberculosis
- Evaluate patients for tuberculosis infection prior to initiating treatment with STELARA.
- Do not administer STELARA to patients with active tuberculosis. Initiate treatment of latent tuberculosis prior to administering STELARA. Consider anti-tuberculosis therapy prior to initiation of STELARA in patients with a past history of latent or active tuberculosis in whom an adequate course of treatment cannot be confirmed. Patients receiving STELARA should be monitored closely for signs and symptoms of active tuberculosis during and after treatment.
- Malignancies
- STELARA is an immunosuppressant and may increase the risk of malignancy. Malignancies were reported among subjects who received STELARA in clinical studies. In rodent models, inhibition of IL-12/IL-23p40 increased the risk of malignancy.
- The safety of STELARA has not been evaluated in patients who have a history of malignancy or who have a known malignancy.
- There have been post marketing reports of the rapid appearance of multiple cutaneous squamous cell carcinomas in patients receiving STELARA who had pre-existing risk factors for developing non-melanoma skin cancer. All patients receiving STELARA should be monitored for the appearance of non-melanoma skin cancer. Patients greater than 60 years of age, those with a medical history of prolonged immunosuppressant therapy and those with a history of PUVA treatment should be followed closely.
- Hypersensitivity Reactions
- Hypersensitivity reactions, including anaphylaxis and angioedema, have been reported post-marketing. If an anaphylactic or other clinically significant hypersensitivity reaction occurs, institute appropriate therapy and discontinue STELARA.
- Reversible Posterior Leukoencephalopathy Syndrome
- One case of reversible posterior leukoencephalopathy syndrome (RPLS) was observed in the clinical trial safety databases for psoriasis and psoriatic arthritis. The subject, who had received 12 doses of STELARA over approximately two years, presented with headache, seizures and confusion. No additional STELARA injections were administered and the subject fully recovered with appropriate treatment..
- RPLS is a neurological disorder, which is not caused by demyelination or a known infectious agent. RPLS can present with headache, seizures, confusion and visual disturbances. Conditions with which it has been associated include preeclampsia, eclampsia, acute hypertension, cytotoxic agents and immunosuppressive therapy. Fatal outcomes have been reported.
- If RPLS is suspected, administer appropriate treatment and discontinue STELARA.
- Immunizations
- Prior to initiating therapy with STELARA, patients should receive all immunizations appropriate for age as recommended by current immunization guidelines. Patients being treated with STELARA should not receive live vaccines. BCG vaccines should not be given during treatment with STELARA or for one year prior to initiating treatment or one year following discontinuation of treatment. Caution is advised when administering live vaccines to household contacts of patients receiving STELARA because of the potential risk for shedding from the household contact and transmission to patient.
- Non-live vaccinations received during a course of STELARA may not elicit an immune response sufficient to prevent disease.
- Concomitant Therapies
- In psoriasis studies the safety of STELARA in combination with other immunosuppressive agents or phototherapy has not been evaluated. In psoriatic arthritis studies, concomitant MTX use did not appear to influence the safety or efficacy of STELARA. Ultraviolet-induced skin cancers developed earlier and more frequently in mice genetically manipulated to be deficient in both IL-12 and IL-23 or IL-12 alone.

# Adverse Reactions

## Clinical Trials Experience
- Because clinical trials are conducted under widely varying conditions, adverse reaction rates observed in the clinical trials of a drug cannot be directly compared to rates in the clinical trials of another drug and may not reflect the rates observed in practice.
- Psoriasis Clinical Studies
- The safety data reflect exposure to STELARA in 3117 psoriasis subjects, including 2414 exposed for at least 6 months, 1855 exposed for at least one year, 1653 exposed for at least two years, 1569 exposed for at least three years, 1482 exposed for at least four years and 838 exposed for at least five years.
- Table 1 summarizes the adverse reactions that occurred at a rate of at least 1% and at a higher rate in the STELARA groups than the placebo group during the placebo-controlled period of Ps STUDY 1 and Ps STUDY 2
- Adverse reactions that occurred at rates less than 1% in the controlled period of Ps STUDIES 1 and 2 through week 12 included: cellulitis, herpes zoster, diverticulitis and certain injection site reactions (pain, swelling, pruritus, induration, hemorrhage, bruising, and irritation).
- One case of RPLS occurred during clinical trials.
- Infections
- In the placebo-controlled period of clinical studies of psoriasis subjects (average follow-up of 12.6 weeks for placebo-treated subjects and 13.4 weeks for STELARA-treated subjects), 27% of STELARA-treated subjects reported infections (1.39 per subject-year of follow-up) compared with 24% of placebo-treated subjects (1.21 per subject-year of follow-up). Serious infections occurred in 0.3% of STELARA-treated subjects (0.01 per subject-year of follow-up) and in 0.4% of placebo-treated subjects (0.02 per subject-year of follow-up).
- In the controlled and non-controlled portions of psoriasis clinical trials (median follow up of 3.2 years), representing 8998 subject-years of exposure, 72.3% of STELARA-treated subjects reported infections (0.87 per subject-years of follow-up). Serious infections were reported in 2.8% of subjects (0.01 per subject-years of follow-up).
- Malignancies
- In the controlled and non-controlled portions of psoriasis clinical trials (median follow up of 3.2 years, representing 8998 subject-years of exposure), 1.7% of STELARA-treated subjects reported malignancies excluding non-melanoma skin cancers (0.60 per hundred subject-years of follow-up). Non-melanoma skin cancer was reported in 1.5% of STELARA-treated subjects (0.52 per hundred subject-years of follow-up). The most frequently observed malignancies other than non-melanoma skin cancer during the clinical trials were: prostate, melanoma, colorectal and breast. Malignancies other than non-melanoma skin cancer in STELARA-treated patients during the controlled and uncontrolled portions of studies were similar in type and number to what would be expected in the general U.S. population according to the SEER database (adjusted for age, gender and race).1
- Psoriatic Arthritis Clinical Studies
- The safety of STELARA was assessed in 927 patients in two randomized, double-blind, placebo-controlled studies in adult patients with active psoriatic arthritis (PsA). The overall safety profile of STELARA in patients with PsA was consistent with the safety profile seen in psoriasis clinical studies. A higher incidence of arthralgia, nausea, and dental infections was observed in STELARA-treated patients when compared with placebo-treated patients (3% vs. 1% for arthralgia and 3% vs. 1% for nausea; 1% vs. 0.6% for dental infections) in the placebo-controlled portions of the PsA clinical trials.
- Immunogenicity
- Approximately 6% of patients treated with STELARA in psoriasis and psoriatic arthritis clinical studies developed antibodies to ustekinumab, which were generally low-titer. No apparent association between the development of antibodies to ustekinumab and the development of injection site reactions was seen. No ustekinumab-related serious hypersensitivity reactions were observed in psoriasis and psoriatic arthritis clinical trials. In psoriasis studies, the majority of patients who were positive for antibodies to ustekinumab had neutralizing antibodies.
- The data above reflect the percentage of subjects whose test results were positive for antibodies to ustekinumab and are highly dependent on the sensitivity and specificity of the assay. Additionally, the observed incidence of antibody positivity in an assay may be influenced by several factors, including sample handling, timing of sample collection, concomitant medications and underlying disease. For these reasons, comparison of the incidence of antibodies to ustekinumab with the incidence of antibodies to other products may be misleading.

## Postmarketing Experience
- Adverse reactions have been reported during post-approval use with STELARA. Because these reactions are reported voluntarily from a population of uncertain size, it is not always possible to reliably estimate their frequency or establish a causal relationship to STELARA exposure.
- Immune system disorders: Serious hypersensitivity reactions (including anaphylaxis and angioedema), other hypersensitivity reactions (including rash and urticaria).
- Skin reactions: Pustular psoriasis, erythrodermic psoriasis.

# Drug Interactions
- Concomitant Therapies
- In psoriasis studies the safety of STELARA in combination with immunosuppressive agents or phototherapy has not been evaluated. In psoriatic arthritis studies, concomitant MTX use did not appear to influence the safety or efficacy of STELARA.
- CYP450 Substrates
- The formation of CYP450 enzymes can be altered by increased levels of certain cytokines (e.g., IL-1, IL-6, IL-10, TNF, IFN) during chronic inflammation. Thus, STELARA, an antagonist of IL-12 and IL-23, could normalize the formation of CYP450 enzymes. Upon initiation of STELARA in patients who are receiving concomitant CYP450 substrates, particularly those with a narrow therapeutic index, monitoring for therapeutic effect (e.g., for warfarin) or drug concentration (e.g., for cyclosporine) should be considered and the individual dose of the drug adjusted as needed.
- Allergen Immunotherapy
- STELARA has not been evaluated in patients who have undergone allergy immunotherapy. STELARA may decrease the protective effect of allergen immunotherapy (decrease tolerance) which may increase the risk of an allergic reaction to a dose of allergen immunotherapy. Therefore, caution should be exercised in patients receiving or who have received allergen immunotherapy, particularly for anaphylaxis.

# Use in Specific Populations

### Pregnancy
Pregnancy Category (FDA):
- Pregnancy Category B
- There is a pregnancy registry that monitors pregnancy outcomes in women exposed to STELARA during pregnancy. Patients should be encouraged to enroll by calling 1-877-311-8972.
- There are no adequate and well controlled studies of STELARA in pregnant women. Developmental toxicity studies conducted with monkeys found no evidence of harm to the fetus due to ustekinumab. STELARA should be used during pregnancy only if the potential benefit justifies the potential risk to the fetus.
- Ustekinumab was tested in two embryo-fetal development toxicity studies with cynomolgus monkeys. No teratogenic effects or other adverse developmental effects were observed in fetuses from pregnant monkeys that were administered ustekinumab during the period of organogenesis either twice weekly via subcutaneous injections or weekly by intravenous injections at doses up to 45 times the maximum recommended human dose (MRHD) (on a mg/kg basis at a maternal dose of 45 mg/kg).
- In a combined embryo-fetal development and pre- and post-natal development toxicity study, pregnant cynomolgus monkeys were administered subcutaneous doses of ustekinumab twice weekly up to 45 times the MRHD (on a mg/kg basis at a maternal dose of 45 mg/kg) from the beginning of organogenesis to Day 33 after delivery. Neonatal deaths occurred in the offspring of one monkey administered ustekinumab at 22.5 mg/kg and one monkey dosed at 45 mg/kg. No ustekinumab-related effects on functional, morphological, or immunological development were observed in the neonates from birth through six months of age.
Pregnancy Category (AUS):
- Australian Drug Evaluation Committee (ADEC) Pregnancy Category
There is no Australian Drug Evaluation Committee (ADEC) guidance on usage of Ustekinumab in women who are pregnant.

### Labor and Delivery
There is no FDA guidance on use of Ustekinumab during labor and delivery.

### Nursing Mothers
- Caution should be exercised when STELARA is administered to a nursing woman. The unknown risks to the infant from gastrointestinal or systemic exposure to ustekinumab should be weighed against the known benefits of breast-feeding. Ustekinumab is excreted in the milk of lactating monkeys administered ustekinumab. IgG is excreted in human milk, so it is expected that STELARA will be present in human milk. It is not known if ustekinumab is absorbed systemically after ingestion; however, published data suggest that antibodies in breast milk do not enter the neonatal and infant circulation in substantial amounts.

### Pediatric Use
There is no FDA guidance on the use of Ustekinumab with respect to pediatric patients.

### Geriatic Use
- Of the 4031 subjects exposed to STELARA, a total of 248 were 65 years or older (183 patients with psoriasis and 65 patients with psoriatic arthritis), and 29 subjects were 75 years or older. Although no differences in safety or efficacy were observed between older and younger subjects, the number of subjects aged 65 and over is not sufficient to determine whether they respond differently from younger subjects.

### Gender
There is no FDA guidance on the use of Ustekinumab with respect to specific gender populations.

### Race
There is no FDA guidance on the use of Ustekinumab with respect to specific racial populations.

### Renal Impairment
There is no FDA guidance on the use of Ustekinumab in patients with renal impairment.

### Hepatic Impairment
There is no FDA guidance on the use of Ustekinumab in patients with hepatic impairment.

### Females of Reproductive Potential and Males
There is no FDA guidance on the use of Ustekinumab in women of reproductive potentials and males.

### Immunocompromised Patients
There is no FDA guidance one the use of Ustekinumab in patients who are immunocompromised.

# Administration and Monitoring

### Administration
- Subcutaneous

### Monitoring
There is limited information regarding Monitoring of Ustekinumab in the drug label.

# IV Compatibility
There is limited information regarding IV Compatibility of Ustekinumab in the drug label.

# Overdosage

## Acute Overdose

### Signs and Symptoms
- Single doses up to 6 mg/kg intravenously have been administered in clinical studies without dose-limiting toxicity.

### Management
- In case of overdosage, it is recommended that the patient be monitored for any signs or symptoms of adverse reactions or effects and appropriate symptomatic treatment be instituted immediately.

## Chronic Overdose
There is limited information regarding Chronic Overdose of Ustekinumab in the drug label.

# Pharmacology

## Mechanism of Action
- Ustekinumab is a human IgG1 monoclonal antibody that binds with specificity to the p40 protein subunit used by both the IL-12 and IL-23 cytokines. IL-12 and IL-23 are naturally occurring cytokines that are involved in inflammatory and immune responses, such as natural killer cell activation and CD4+ T-cell differentiation and activation. In in vitro models, ustekinumab was shown to disrupt IL-12 and IL-23 mediated signaling and cytokine cascades by disrupting the interaction of these cytokines with a shared cell-surface receptor chain, IL-12R1.

## Structure
- STELARA is a human IgG1 monoclonal antibody against the p40 subunit of the IL-12 and IL-23 cytokines. Using DNA recombinant technology, STELARA is produced in a well characterized recombinant cell line and is purified using standard bio-processing technology. The manufacturing process contains steps for the clearance of viruses. STELARA is comprised of 1326 amino acids and has an estimated molecular mass that ranges from 148,079 to 149,690 Daltons.
- STELARA, for subcutaneous use, is available as: 45 mg of ustekinumab in 0.5 mL and 90 mg of ustekinumab in 1 mL. STELARA is supplied as a sterile solution in a single-use prefilled syringe with a 27 gauge fixed 12 inch needle, or a single-use 2 mL Type I glass vial with a coated stopper. The syringe is fitted with a passive needle guard and a needle cover that is manufactured using a dry natural rubber (a derivative of latex).
- Each 45 mg ustekinumab prefilled syringe also contains: L-histidine and L-histidine monohydrochloride monohydrate (0.5 mg), Polysorbate 80 (0.02 mg), and sucrose (38 mg) to fill to a final volume of 0.5 mL.
- Each 90 mg ustekinumab prefilled syringe also contains: L-histidine and L-histidine monohydrochloride monohydrate (1 mg), Polysorbate 80 (0.04 mg), and sucrose (76 mg) to fill to a final volume of 1 mL.
- Each 45 mg ustekinumab vial also contains: L-histidine and L-histidine monohydrochloride monohydrate (0.5 mg), Polysorbate 80 (0.02 mg), and sucrose (38 mg) to fill to a final volume of 0.5 mL.
- Each 90 mg ustekinumab vial also contains: L-histidine and L-histidine monohydrochloride monohydrate (1 mg), Polysorbate 80 (0.04 mg), and sucrose (76 mg) to fill to a final volume of 1 mL.
- The STELARA solution is colorless to slightly yellow in appearance and has a pH of 5.76.3. STELARA does not contain preservatives.

## Pharmacodynamics
- In a small exploratory study, a decrease was observed in the expression of mRNA of its molecular targets IL-12 and IL-23 in lesional skin biopsies measured at baseline and up to two weeks post-treatment in subjects with psoriasis.

## Pharmacokinetics
- Absorption
- In subjects with psoriasis, the median time to reach the maximum serum concentration (Tmax) was 13.5 days and 7 days, respectively, after a single subcutaneous administration of 45 mg (N=22) and 90 mg (N=24) of ustekinumab. In healthy subjects (N=30), the median Tmax value (8.5 days) following a single subcutaneous administration of 90 mg of ustekinumab was comparable to that observed in subjects with psoriasis. Following multiple subcutaneous doses of STELARA, the steady-state serum concentrations of ustekinumab were achieved by Week 28. The mean (SD) steady-state trough serum concentration ranged from 0.31  0.33 mcg/mL (45 mg) to 0.64  0.64 mcg/mL (90 mg). There was no apparent accumulation in serum ustekinumab concentration over time when given subcutaneously every 12 weeks.
- Distribution
- Following subcutaneous administration of 45 mg (N=18) and 90 mg (N=21) of ustekinumab to subjects with psoriasis, the mean (SD) apparent volume of distribution during the terminal phase (Vz/F) was 161  65 mL/kg and 179  85 mL/kg, respectively. The mean (SD) volume of distribution during the terminal phase (Vz) following a single intravenous administration to subjects with psoriasis ranged from 56.1  6.5 to 82.1  23.6 mL/kg.
- Metabolism
- The metabolic pathway of ustekinumab has not been characterized. As a human IgG1 monoclonal antibody ustekinumab is expected to be degraded into small peptides and amino acids via catabolic pathways in the same manner as endogenous IgG.
- Elimination
- The mean (SD) systemic clearance (CL) following a single intravenous administration of ustekinumab to subjects with psoriasis ranged from 1.90  0.28 to 2.22  0.63 mL/day/kg. The mean (SD) half-life ranged from 14.9  4.6 to 45.6  80.2 days across all psoriasis studies following intravenous and subcutaneous administration.
- Weight
- When given the same dose, subjects with psoriasis or psoriatic arthritis weighing >100 kg had lower median serum ustekinumab concentrations compared with those subjects weighing 100 kg. The median trough serum concentrations of ustekinumab in subjects of higher weight (>100 kg) in the 90 mg group were comparable to those in subjects of lower weight (100 kg) in the 45 mg group.
- Hepatic and Renal Impairment
- No pharmacokinetic data are available in patients with hepatic or renal impairment.
- Elderly
- A population pharmacokinetic analysis (N=106/1937 subjects greater than or equal to 65 years old) was performed to evaluate the effect of age on the pharmacokinetics of ustekinumab. There were no apparent changes in pharmacokinetic parameters (clearance and volume of distribution) in subjects older than 65 years old.
- Drug-Drug Interactions
- The effects of IL-12 or IL-23 on the regulation of CYP450 enzymes were evaluated in an in vitro study using human hepatocytes, which showed that IL-12 and/or IL-23 at levels of 10 ng/mL did not alter human CYP450 enzyme activities (CYP1A2, 2B6, 2C9, 2C19, 2D6, or 3A4). However, the clinical relevance of in vitro data has not been established.
- Population pharmacokinetic data analyses indicated that the clearance of ustekinumab was not impacted by concomitant MTX, NSAIDs, and oral corticosteroids, or prior exposure to anti-TNF agents in patients with psoriatic arthritis.

## Nonclinical Toxicology
- Animal studies have not been conducted to evaluate the carcinogenic or mutagenic potential of STELARA. Published literature showed that administration of murine IL-12 caused an anti-tumor effect in mice that contained transplanted tumors and IL-12/IL-23p40 knockout mice or mice treated with anti-IL-12/IL-23p40 antibody had decreased host defense to tumors. Mice genetically manipulated to be deficient in both IL-12 and IL-23 or IL-12 alone developed UV-induced skin cancers earlier and more frequently compared to wild-type mice. The relevance of these experimental findings in mouse models for malignancy risk in humans is unknown.
- No effects on fertility were observed in male cynomolgus monkeys that were administered ustekinumab at subcutaneous doses up to 45 mg/kg twice weekly (45 times the MRHD on a mg/kg basis) prior to and during the mating period. However, fertility and pregnancy outcomes were not evaluated in mated females.
- No effects on fertility were observed in female mice that were administered an analogous IL-12/IL-23p40 antibody by subcutaneous administration at doses up to 50 mg/kg, twice weekly, prior to and during early pregnancy.
- In a 26-week toxicology study, one out of 10 monkeys subcutaneously administered 45 mg/kg ustekinumab twice weekly for 26 weeks had a bacterial infection.

# Clinical Studies
- Psoriasis
- Two multicenter, randomized, double-blind, placebo-controlled studies (Ps STUDY 1 and Ps STUDY 2) enrolled a total of 1996 subjects 18 years of age and older with plaque psoriasis who had a minimum body surface area involvement of 10%, and Psoriasis Area and Severity Index (PASI) score 12, and who were candidates for phototherapy or systemic therapy. Subjects with guttate, erythrodermic, or pustular psoriasis were excluded from the studies.
- Ps STUDY 1 enrolled 766 subjects and Ps STUDY 2 enrolled 1230 subjects. The studies had the same design through Week 28. In both studies, subjects were randomized in equal proportion to placebo, 45 mg or 90 mg of STELARA. Subjects randomized to STELARA received 45 mg or 90 mg doses, regardless of weight, at Weeks 0, 4, and 16. Subjects randomized to receive placebo at Weeks 0 and 4 crossed over to receive STELARA (either 45 mg or 90 mg) at Weeks 12 and 16.
- In both studies, the endpoints were the proportion of subjects who achieved at least a 75% reduction in PASI score (PASI 75) from baseline to Week 12 and treatment success (cleared or minimal) on the Physician's Global Assessment (PGA). The PGA is a 6-category scale ranging from 0 (cleared) to 5 (severe) that indicates the physician's overall assessment of psoriasis focusing on plaque thickness/induration, erythema, and scaling.
- In both studies, subjects in all treatment groups had a median baseline PASI score ranging from approximately 17 to 18. Baseline PGA score was marked or severe in 44% of subjects in Ps STUDY 1 and 40% of subjects in Ps STUDY 2. Approximately two-thirds of all subjects had received prior phototherapy, 69% had received either prior conventional systemic or biologic therapy for the treatment of psoriasis, with 56% receiving prior conventional systemic therapy and 43% receiving prior biologic therapy. A total of 28% of study subjects had a history of psoriatic arthritis.
- Clinical Response
- The results of Ps STUDY 1 and Ps STUDY 2 are presented in Table 2 below.
- Examination of age, gender, and race subgroups did not identify differences in response to STELARA among these subgroups.
- In subjects who weighed 100 kg, response rates were similar with both the 45 mg and 90 mg doses; however, in subjects who weighed >100 kg, higher response rates were seen with 90 mg dosing compared with 45 mg dosing (Table 3 below).
- Subjects in Ps STUDY 1 who were PASI 75 responders at both Weeks 28 and 40 were re-randomized at Week 40 to either continued dosing of STELARA (STELARA at Week 40) or to withdrawal of therapy (placebo at Week 40). At Week 52, 89% (144/162) of subjects re-randomized to STELARA treatment were PASI 75 responders compared with 63% (100/159) of subjects re-randomized to placebo (treatment withdrawal after Week 28 dose). The median time to loss of PASI 75 response among the subjects randomized to treatment withdrawal was 16 weeks.
- Psoriatic Arthritis
- The safety and efficacy of STELARA was assessed in 927 patients (PsA STUDY 1, n=615; PsA STUDY 2, n=312), in two randomized, double-blind, placebo-controlled studies in adult patients 18 years of age and older with active PsA (5 swollen joints and 5 tender joints) despite non-steroidal anti-inflammatory (NSAID) or disease modifying antirheumatic (DMARD) therapy. Patients in these studies had a diagnosis of PsA for at least 6 months. Patients with each subtype of PsA were enrolled, including polyarticular arthritis with the absence of rheumatoid nodules (39%), spondylitis with peripheral arthritis (28%), asymmetric peripheral arthritis (21%), distal interphalangeal involvement (12%) and arthritis mutilans (0.5%). Over 70% and 40% of the patients, respectively, had enthesitis and dactylitis at baseline.
- Patients were randomized to receive treatment with STELARA 45 mg, 90 mg, or placebo subcutaneously at Weeks 0 and 4 followed by every 12 weeks (q12w) dosing. Approximately 50% of patients continued on stable doses of MTX (25 mg/week). The primary endpoint was the percentage of patients achieving ACR 20 response at Week 24.
- In PsA STUDY 1 and PsA STUDY 2, 80% and 86% of the patients, respectively, had been previously treated with DMARDs. In PsA STUDY 1, previous treatment with anti-tumor necrosis factor (TNF)- agent was not allowed. In PsA STUDY 2, 58% (n=180) of the patients had been previously treated with an anti-TNF agent, of whom over 70% had discontinued their anti-TNF treatment for lack of efficacy or intolerance at any time.
- Clinical Response
- In both studies, a greater proportion of patients achieved ACR 20, ACR 50 and PASI 75 response in the STELARA 45 mg and 90 mg groups compared to placebo at Week 24 (see Table 4). ACR 70 responses were also higher in the STELARA 45 mg and 90 mg groups, although the difference was only numerical (p=NS) in Study 2. Responses were similar in patients regardless of prior TNF exposure.
- The percent of patients achieving ACR 20 responses by visit is shown in Figure 1.
- Figure 1: Percent of patients achieving ACR 20 response through Week 24
- The results of the components of the ACR response criteria are shown in Table 5.
- An improvement in enthesitis and dactylitis scores was observed in each STELARA group compared with placebo at Week 24.
- Physical Function
- STELARA treated patients showed improvement in physical function compared to patients treated with placebo as assessed by HAQ-DI at Week 24. In both studies, the proportion of HAQ-DI responders (0.3 improvement in HAQ-DI score) was greater in the STELARA 45 mg and 90 mg groups compared to placebo at Week 24.

# How Supplied
- STELARA does not contain preservatives. STELARA is available in single-use prefilled syringes or single-use vials containing 45 mg or 90 mg of ustekinumab. Each prefilled syringe is equipped with a needle safety guard.
- The NDC number for the 45 mg prefilled syringe is 57894-060-03.
- The NDC number for the 90 mg prefilled syringe is 57894-061-03.
- The NDC number for the 45 mg vial is 57894-060-02.
- The NDC number for the 90 mg vial is 57894-061-02.
- Storage and Stability
- STELARA vials and prefilled syringes must be refrigerated at 2oC to 8oC (36oF to 46oF). Store STELARA vials upright. Keep the product in the original carton to protect from light until the time of use. Do not freeze. Do not shake. STELARA does not contain a preservative; discard any unused portion.

## Storage
There is limited information regarding Ustekinumab Storage in the drug label.

# Images

## Drug Images

## Package and Label Display Panel

# Patient Counseling Information
- Instruct patients to read the Medication Guide before starting STELARA therapy and to reread the Medication Guide each time the prescription is renewed.
- Infections
- Inform patients that STELARA may lower the ability of their immune system to fight infections. Instruct patients of the importance of communicating any history of infections to the doctor, and contacting their doctor if they develop any symptoms of infection.
- Malignancies
- Patients should be counseled about the risk of malignancies while receiving STELARA.
- Allergic Reactions
- Advise patients to seek immediate medical attention if they experience any symptoms of serious allergic reactions.
- Instruction on Injection Technique
- The first self-injection should be performed under the supervision of a qualified healthcare professional. If a patient or caregiver is to administer STELARA, he/she should be instructed in injection techniques and their ability to inject subcutaneously should be assessed to ensure the proper administration of STELARA.
- Patients should be instructed to inject the full amount of STELARA according to the directions provided in the Medication Guide and Instructions for Use. The needle cover on the prefilled syringe contains dry natural rubber (a derivative of latex), which may cause allergic reactions in individuals sensitive to latex.
- Needles and syringes should be disposed of in a puncture-resistant container. Patients or caregivers should be instructed in the technique of proper syringe and needle disposal, and be advised not to reuse these items.

# Precautions with Alcohol
- Alcohol-Ustekinumab interaction has not been established. Talk to your doctor about the effects of taking alcohol with this medication.

# Brand Names
- Stelara

# Look-Alike Drug Names
There is limited information regarding Ustekinumab Look-Alike Drug Names in the drug label.

# Drug Shortage Status

# Price