Guselkumab (Monograph)

Brand name: Tremfya
Drug class: Immunomodulatory Agents

Medically reviewed by Drugs.com on Feb 10, 2025. Written by ASHP.

Introduction

Inhibitor of interleukin-23 (IL-23), a proinflammatory cytokine; a recombinant human IgG₁λ monoclonal antibody directed against the p19 subunit of IL-23.

Uses for Guselkumab

Plaque Psoriasis

Management of moderate to severe plaque psoriasis in adults who are candidates for phototherapy or systemic therapy.

Guidelines generally support use of IL-23 inhibitors as monotherapy for moderate to severe psoriasis.

Recommendations for use and selection of psoriasis therapies vary based on patient age, disease characteristics (e.g., severity, location, presence of psoriatic arthritis), and comorbidities (e.g., inflammatory bowel disease).

Psoriatic Arthritis

Management of active psoriatic arthritis in adults; may be used alone or in combination with a conventional disease-modifying antirheumatic drug (DMARD; e.g., methotrexate).

Disease-modifying treatments for psoriatic arthritis include oral small molecules (e.g., methotrexate, sulfasalazine, cyclosporine, leflunomide, apremilast), biologic DMARDs (e.g., TNF blocking agents, secukinumab, ixekizumab, ustekinumab, brodalumab, abatacept), and/or targeted synthetic DMARDs (e.g., tofacitinib).

Guidelines from the American College of Rheumatology and the National Psoriasis Foundation for management of psoriatic arthritis were last updated in 2018. Guselkumab is not included in these guidelines; however, current evidence suggests that the drug may provide an additional therapeutic option.

Recommendations for use and selection of disease-modifying therapies in psoriatic arthritis vary based on the presence of certain disease characteristics (e.g., psoriatic spondylitis/axial disease, enthesitis) and comorbidities (e.g., inflammatory bowel disease, diabetes).

Ulcerative Colitis

Management of adults with moderately to severely active ulcerative colitis.

Guselkumab Dosage and Administration

General

Pretreatment Screening

Evaluate for tuberculosis infection prior to initiation of guselkumab; start antimycobacterial therapy if indicated.
Administer all age-appropriate vaccines according to current immunization guidelines.

Patient Monitoring

Monitor closely for signs or symptoms of infection or active tuberculosis during and after treatment with guselkumab.

Other General Considerations

Guselkumab may be used alone or in combination with conventional DMARDs for the treatment of psoriatic arthritis.

Administration

Administer by sub-Q injection or IV infusion, dependent upon indication for use.

If sub-Q dose is missed, administer missed dose as soon as possible. Thereafter, resume dosing at the regular scheduled time.

Sub-Q Administration

Available as single-dose prefilled syringes, single-dose prefilled pens, and single-dose prefilled autoinjectors.

Administer by sub-Q injection into the thigh, lower abdomen, or upper arm; do not administer abdominal injections within 2 inches of the umbilicus. Use thigh (the preferred site) or abdomen for self-administration; upper arm may be used if administered by a caregiver or clinician. Avoid injections into areas where the skin is tender, bruised, red, hard, thick, or scaly. Do not inject into psoriatic lesions.

Allow prefilled syringe, pen, or autoinjector to sit at room temperature inside the carton for at least 30 minutes prior to injection without removing the needle cap; do not warm the drug in any other way (e.g., microwave, hot water). Do not shake the injection.

Intended for use under the supervision of a clinician, but may be self-administered if clinician determines the patient and/or caregiver is competent to safely administer the drug after appropriate subcutaneous training.

IV Administration

Withdraw and discard 20 mL from a 250 mL infusion bag containing 0.9% sodium chloride injection. Subsequently, withdraw 20 mL from the vial of guselkumab and add to the 250 mL infusion bag for a final concentration of 0.8 mg/mL. Gently mix diluted solution and discard any remaining solution in the guselkumab vial. Visually inspect diluted solution for particulate matter and discoloration prior to infusion; do not administer solution if it is discolored, cloudy, or contains large particles. Only infuse guselkumab using an infusion set with an in-line, sterile, non-pyrogenic, low protein binding filter (0.2 micrometer pore size). Do not infuse in the same IV line with other medications. Complete infusion within 10 hours after dilution.

Rate of Administration

Infuse over at least 1 hour.

Dosage

Adults

Plaque Psoriasis

Sub-Q

100 mg at weeks 0 and 4, followed by 100 mg every 8 weeks.

Psoriatic Arthritis

Sub-Q

100 mg at weeks 0 and 4, followed by 100 mg every 8 weeks.

Ulcerative Colitis

IV, then Sub-Q

Induction dosage: 200 mg by IV infusion over at least 1 hour at weeks 0, 4, and 8.

Maintenance dosage: 100 mg by sub-Q injection at week 16, and every 8 weeks thereafter, or 200 mg by sub-Q injection at week 12, and every 4 weeks thereafter.

Use lowest effective dosage to maintain therapeutic response.

Special Populations

Hepatic Impairment

Manufacturer makes no specific dosage recommendations.

Renal Impairment

Manufacturer makes no specific dosage recommendations.

Geriatric Patients

Dosage adjustment based on age not necessary.

Cautions for Guselkumab

Contraindications

Known serious hypersensitivity to guselkumab or any ingredient in the formulation.

Warnings/Precautions

Hypersensitivity Reactions

Anaphylaxis reported. If an anaphylactic or other serious allergic reaction occurs, discontinue guselkumab immediately and initiate appropriate supportive treatment.

Infectious Complications

Possible increased risk of infections. Bacterial, fungal, and viral infections, including gastroenteritis, upper respiratory tract infections, tinea infections, and herpes simplex infections, reported.

Do not use in patients with clinically important active infections. Consider risks and benefits before initiating therapy in patients with chronic infection or history of recurrent infection.

If a serious infection occurs or does not respond to standard therapy, discontinue guselkumab and closely monitor patient until infection resolves.

Evaluate all patients for active or latent tuberculosis prior to initiation of guselkumab therapy. Do not use in patients with active tuberculosis infection; when indicated, initiate appropriate antimycobacterial regimen for treatment of latent tuberculosis infection prior to guselkumab therapy. Also consider antimycobacterial therapy prior to initiation of guselkumab in patients with a history of latent or active tuberculosis in whom an adequate course of antimycobacterial treatment for these indications cannot be confirmed. Closely monitor for signs and symptoms of active tuberculosis during and after treatment.

Immunization

Complete administration of all age-appropriate vaccines recommended by current immunization guidelines before initiating guselkumab.

Avoid live vaccines during therapy.

Immunogenicity

Formation of anti-guselkumab antibodies, including neutralizing antibodies, reported; such antibodies were associated with lower trough concentrations of the drug, but generally not associated with loss of efficacy or injection site reactions.

Specific Populations

Pregnancy

Clinical data insufficient to establish a drug-associated risk of major birth defects, miscarriage, or other adverse maternal or fetal outcomes with administration during pregnancy. Potential for fetal exposure since human IgG crosses the placenta.

Pregnancy registry at 1-877-311-8972 or by visiting [Web].

Lactation

Not known whether guselkumab distributes into human milk, affects human milk production, or affects breast-fed infants.

Consider benefits of breast-feeding and importance of the drug to the woman; also consider any potential adverse effects on the breast-fed infant from the drug or underlying maternal condition.

Pediatric Use

Safety and efficacy not established.

Geriatric Use

Insufficient experience in patients ≥65 years of age to determine whether they respond differently than younger adults for each indication for use.

Hepatic Impairment

No formal studies to date.

Renal Impairment

No formal studies to date.

Common Adverse Effects

Most common adverse effects (≥1%) for plaque psoriasis and psoriatic arthritis include upper respiratory tract infection, headache, injection site reactions, arthralgia, bronchitis, diarrhea, gastroenteritis, tinea infections, herpes simplex infections.

Most common adverse effects (≥2%) with guselkumab induction for ulcerative colitis include respiratory tract infections. Most common adverse effects (≥2%) with guselkumab maintenance for ulcerative colitis include injection site reactions, arthralgia, upper respiratory tract infections.

Drug Interactions

Drugs Metabolized by Hepatic Microsomal Enzymes

Because elevated levels of certain cytokines during chronic inflammation may alter formation of CYP isoenzymes, guselkumab-induced changes in cytokine levels could normalize formation of CYP enzymes.

Interactions unlikely with substrates of CYP1A2, 2C9, 2C19, or 3A4.

Interaction potential of CYP2D6 substrates cannot be ruled out by available data.

CYP substrates: Upon initiation of guselkumab, consider monitoring for therapeutic effect or drug concentration and consider dosage adjustment of the CYP substrate as needed, especially if substrate has a narrow therapeutic index.

Vaccines

Avoid live vaccines. No data available regarding response to live or inactivated vaccines in patients receiving guselkumab.

Specific Drugs

Drug	Interaction	Comments
Caffeine	Possible effect on caffeine metabolism; because increased levels of cytokines during chronic inflammation may alter formation of CYP isoenzymes, guselkumab could normalize enzyme formation Limited data suggest no substantial effect on caffeine AUC
Conventional DMARDs (e.g., methotrexate)	No effect on guselkumab clearance
Dextromethorphan	Possible effect on dextromethorphan metabolism; because increased levels of cytokines during chronic inflammation may alter formation of CYP isoenzymes, guselkumab could normalize enzyme formation Limited data cannot rule out interaction potential
Midazolam	Possible effect on midazolam metabolism; because increased levels of cytokines during chronic inflammation may alter formation of CYP isoenzymes, guselkumab could normalize enzyme formation Limited data suggest no substantial effect on midazolam AUC
NSAIDs (aspirin, ibuprofen)	Aspirin, ibuprofen: No effect on guselkumab clearance
Omeprazole	Possible effect on omeprazole metabolism; because increased levels of cytokines during chronic inflammation may alter formation of CYP isoenzymes, guselkumab could normalize enzyme formation Limited data suggest no substantial effect on omeprazole AUC
Oral corticosteroids	No effect on guselkumab clearance
Warfarin	Possible effect on warfarin metabolism; because increased levels of cytokines during chronic inflammation may alter formation of CYP isoenzymes, guselkumab could normalize enzyme formation Limited data suggest no substantial effect on warfarin AUC	Consider monitoring therapeutic effect of warfarin and consider warfarin dosage adjustment as needed upon initiation of guselkumab

Guselkumab Pharmacokinetics

Absorption

Bioavailability

Bioavailability is approximately 49% following sub-Q administration.

Peak serum concentrations achieved by approximately 5.5 days following a single 100-mg sub-Q dose.

Pharmacokinetics are dose proportional over a sub-Q dose range of 10–300 mg.

Distribution

Extent

Not known whether distributed into human milk.

Special Populations

Volume of distribution increases with increasing body weight.

Elimination

Metabolism

Metabolic pathway not characterized.

Expected to be degraded into small peptides and amino acids via catabolic pathways in the same manner as endogenous IgG.

Half-life

15–18 days for psoriasis; 17 days for ulcerative colitis.

Special Populations

Pharmacokinetics not formally studied in renal or hepatic impairment.

Clearance increases with increasing body weight.

Age ≥65 years does not substantially alter clearance.

Stability

Storage

Parenteral

Sub-Q Injection

2–8°C. Keep in original carton and protect from light. Do not freeze.

Injection, for IV use

2-8ºC for vial.

Diluted solution may be stored at room temperature up to 25ºC for up to 10 hours; room temperature storage time initiates upon diluted solution preparation. Do not freeze diluted solution.

Actions

Binds with specificity to the p19 subunit of IL-23, a naturally occurring cytokine that stimulates production of proinflammatory cytokines, including interleukin-17 (IL-17) and interleukin-22 (IL-22). IL-17 and IL-22 contribute to chronic inflammation in patients with psoriasis.
Disrupts IL-23-mediated signaling and inhibits the release of proinflammatory cytokines and chemokines.

Advice to Patients

Provide all patients with a copy of the manufacturer's patient information (medication guide) and instructions for use with each prescription of the drug. Instruct patients to read the medication guide prior to initiation of therapy and each time the prescription is refilled.
Instruct the patient and/or caregiver regarding proper storage, dosage, and administration of guselkumab, including the use of aseptic technique, and proper disposal of needles and syringes if it is determined that the patient and/or caregiver is competent to safely administer the drug.
Advise patients to discontinue guselkumab and seek immediate medical attention if they experience symptoms of a serious allergic reaction (e.g., feeling of faintness; swelling of eyelids, face, lips, mouth, tongue, or throat; dyspnea or throat tightness; chest tightness; rash).
Possible increased susceptibility to infections. Instruct patients to promptly inform a clinician if any signs or symptoms of infection (e.g., fever, sweats, or chills; muscle aches; cough, shortness of breath, or blood in the phlegm; weight loss; warm, red, or painful sores on the body; diarrhea or stomach pain; burning upon urination or increased urination) occur.
Inform patients of the importance of reviewing vaccination status with clinician and receiving all appropriate vaccinations prior to initiation of guselkumab.
Inform patients of the importance of informing clinicians of existing or contemplated concomitant therapy, including prescription and OTC drugs, as well as any concomitant illnesses (e.g., active infection) or any history of tuberculosis or other infections.
Advise patients to inform their clinicians if they are or plan to become pregnant or plan to breast-feed. Encourage pregnant patients to register with the guselkumab pregnancy exposure registry.
Advise patients of other important precautionary information.

Additional Information

The American Society of Health-System Pharmacists, Inc. represents that the information provided in the accompanying monograph was formulated with a reasonable standard of care, and in conformity with professional standards in the field. Readers are advised that decisions regarding use of drugs are complex medical decisions requiring the independent, informed decision of an appropriate health care professional, and that the information contained in the monograph is provided for informational purposes only. The manufacturer’s labeling should be consulted for more detailed information. The American Society of Health-System Pharmacists, Inc. does not endorse or recommend the use of any drug. The information contained in the monograph is not a substitute for medical care.

Preparations

Excipients in commercially available drug preparations may have clinically important effects in some individuals; consult specific product labeling for details.

Please refer to the ASHP Drug Shortages Resource Center for information on shortages of one or more of these preparations.

Guselkumab
Routes	Dosage Forms	Strengths	Brand Names	Manufacturer
Parenteral	Injection, for subcutaneous use	100 mg/mL	Tremfya (available as single-dose prefilled pens, single-dose prefilled syringes, and a single-dose One-Press patient-controlled autoinjector)	Janssen Biotech
	Injection, for IV use	10 mg/mL	Tremfya (available as a single-dose vial)