Abstract
BACKGROUND: Risankizumab and guselkumab are two leading interleukin-23 (IL-23) inhibitors for treating immune-mediated inflammatory diseases. While effective, a direct comparison of their real-world safety profiles is lacking. Understanding the distinct differences in their adverse event (AE) profiles is crucial for clinicians to make appropriate treatment decisions. RESEARCH DESIGN AND METHODS: We conducted a disproportionality analysis on post-marketing data obtained from the FDA Adverse Event Reporting System (FAERS) database from Q3 2017 to Q2 2025 to detect and compare the AE signals of guselkumab and risankizumab. RESULTS: A total of 22,470 and 48,141 AE reports for guselkumab and risankizumab, respectively, were analyzed. The analysis revealed markedly different safety profiles. Risankizumab showed significant signals for skin cancer (particularly in patients ≥65 years), intestinal obstruction, and other newly identified serious events such as myocardial infarction and cerebrovascular accident. In contrast, guselkumab's primary signals were dominated by medication management issues like "product dose omission issue" and "accidental exposure to product," which correlated with reports of decreased therapeutic effect. Unique, unlabeled signals for guselkumab included a different spectrum of AEs, such as Hodgkin's disease, pemphigoid, and autoimmune thyroiditis. Furthermore, the median time-to-onset was significantly shorter for guselkumab (62 days) compared to risankizumab (168 days). CONCLUSION: Guselkumab and risankizumab exhibit divergent real-world safety profiles, challenging the notion of a uniform class effect. Clinicians should be vigilant for malignancies and serious systemic events with risankizumab, particularly in the elderly, while prioritizing patient education for guselkumab to prevent administration errors. These findings support individualized treatment strategies to minimize drug-specific risks.