The number of inflammatory bowel disease treatment options with different mechanisms of action has exploded over the past several years. With this bounty, clinicians need to evaluate drug- and patient-related factors to determine when it’s best to reach for each agent, according to a presentation at the 2024 Expert Strategies in Endoscopy, Gastrointestinal and Liver Disorders meeting.
Sharing her insights on optimal IBD drug sequencing at the meeting, Maria T. Abreu, MD, the president of the American Gastroenterological Association and director of the Crohn’s and Colitis Center at the University of Miami Miller School of Medicine, discussed multiple patient factors she takes into account when determining the therapeutic approach for a patient with Crohn’s disease (CD) or ulcerative colitis (UC).
Clinical Characteristics of Patients
When choosing an IBD treatment, Dr. Abreu said she reviews patient comorbidities, including history of cancer, risk for infection and whether they are women of childbearing age, given the different safety profiles and contraindications of the available agents (Table). In addition, she said it is important to consider whether patients have extraintestinal manifestations of IBD or other immune-mediated conditions so you can choose an agent that has systemic versus gut-specific effects.
| Table. Choice of Biologic According to Selected Patient Characteristics | ||
| Patient factor | Drugs to reach for | Drugs to avoid |
|---|---|---|
| History of or high risk for cancer | Anti-integrin Anti–IL-23, anti–IL-12/23 | JAK inhibitors |
| High risk for infection | Anti-integrins Anti–IL-23, anti–IL-12/23 | JAK inhibitors Anti-TNFs |
| Cardiovascular risk factors | Anti-integrins Anti–IL-23, anti–IL-12/23 S1P receptor agonists | JAK inhibitors Anti-TNFs (less risk) |
| Woman of childbearing age | All monoclonal antibody biologics are safe | S1P receptor agonists JAK inhibitors |
| Extraintestinal manifestations or other immune-mediated conditions | JAK inhibitors Anti-TNFs | |
| Previous anti-TNF exposure | JAK inhibitors Anti–IL-23, anti–IL-12/23 Anti-integrins (UC) | Ustekinumab |
| Hospitalized/major impact on daily activities | Anti-TNFs JAK inhibitors | |
| IL, interleukin; JAK, Janus kinase; S1P, sphingosine-1-phosphate; TNF, tumor necrosis factor; UC, ulcerative colitis. Source: Maria Abreu, MD. | ||
For UC specifically, Dr. Abreu said she also assesses how sick the patient is, considering steroid dependence, the disease’s impact on the person’s daily life and whether they are nearing hospitalization because this can inform how important it is to prioritize a medicine that is quickly effective.
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Perhaps most importantly, Dr. Abreu said, she considers whether IBD patients were exposed previously to a biologic and if so, which one, since the efficacy of an IBD medication can depend on where it is placed in the treatment sequence, particularly if used after anti–tumor necrosis factor (TNF) agents (BMC Gastroenterol 2022;22[1]:498). “When you start with anti-TNF therapy, it could be awesome. However, one of the consequences is that if the immune system figured out a way to bypass the effect of suppressing TNF, … that’s a person who becomes refractory to the subsequent therapies,” Dr. Abreu explained.
Essentially, “in a biologic-naive patient, whether it’s UC or CD, the world is your oyster because everything is going to work,” she said. But, she added, factors such as safety concerns for certain populations, the need for systemic effects, speed of drug effect or reversal of effect, and futureproofing by choosing first-line agents that increase the likelihood that subsequent lines of therapy will be efficacious are all factors that clinicians should consider when selecting which drug to use for which patient.
Biologic-Naive Ulcerative Colitis
For the “steroid-dependent, chronically active UC patient,” Dr. Abreu recommended sphingosine 1-phosphate (S1P) receptor agonists, which “work by trapping and confusing T-cells in lymph nodes and possibly even inside lymphoid follicles in the gut.” These drugs—etrasimod (Velsipity, Pfizer) and ozanimod (Zeposia, Bristol Meyers Squibb)—are effective and do not increase the risk for infection, Dr. Abreu said, noting that “the only thing that is different between them” is that etrasimod “is more quickly reversible because it does not have long-lived metabolites.” However, she stressed that she would not use S1P receptor agonists in her patients who could become pregnant, due to teratogenicity concerns.
Miguel Regueiro, MD, the chief of the Digestive Disease Institute at Cleveland Clinic in Cleveland, told Gastroenterology & Endoscopy News that he also would avoid Janus kinase (JAK) inhibitors in this group of patients who are “pregnant or interested in becoming pregnant in the very short term.”
Another option for biologic-naive patients with UC, particularly women of childbearing age, is the anti-integrin vedolizumab (Entyvio, Takeda), Dr. Abreu said. In a head-to-head study versus adalimumab, vedolizumab showed superiority in terms of the proportion of patients who achieved clinical remission, endoscopic improvement and histologic remission (N Engl J Med 2019;381[13]:1215-1226).
Another benefit of vedolizumab, besides its strong safety, is that its use as a first-line agent does not seem to diminish the efficacy of other agents in subsequent lines of therapy, as happens when anti-TNFs are used first-line. “If you start with vedolizumab, things look OK as a second line,” Dr. Abreu said, citing a study that examined the efficacy of anti-TNFs when used first- or second-line after vedolizumab and found “no difference” in the efficacy of the anti-TNF in each scenario (J Crohns Colitis 2021;15[10]:1694-1706).
Agents that inhibit interleukin (IL)-23, including the IL-12/23 inhibitor ustekinumab (Stelara, Janssen), risankizumab (Skyrizi, AbbVie) and the recently approved mirikizumab (Omvoh, Lilly) also are “effective and very safe” first-line treatments for UC, Dr. Abreu said. Dr. Regueiro pointed out that these agents “would be a very good first choice” for patients on the more severe end of moderate.
IBD Experts Encourage Proactive Therapeutic Drug Monitoring for Anti-TNFs
Once patients have started an IBD treatment regimen, Dr. Abreu stressed the importance of therapeutic drug monitoring (TDM), as well as proactive monitoring with biochemical markers of inflammation to “optimize the drug.”
Citing examples with anti-TNFs—the agents in which TDM has been best studied—Dr. Abreu advocated for proactive monitoring over the reactive monitoring currently recommended by the American Gastroenterological Association (Gastroenterology 2017;153[3]:827-834) because of proactive monitoring’s potential “to improve response rates and prevent [secondary loss of response].”
In a study in children with IBD taking adalimumab, those who were randomized to proactive drug monitoring were more likely to achieve sustained corticosteroid-free clinical remission and dose optimization than those randomized to reactive monitoring (Gastroenterology 2019;157[4]:985-996). In another study, patients with immune-mediated conditions taking infliximab who underwent proactive TDM showed better sustained disease control than those without TDM (JAMA 2021;326[23]:2375-2384).
In terms of how to implement proactive TDM, Dr. Abreu cited a study that changed her approach to monitoring her patients taking infliximab (Inflamm Bowel Dis 2022;28[9]:1375-1385). The single-arm study of both adult and pediatric IBD patients involved checking infliximab trough levels before the second and third infusions of infliximab. The investigators found that, based on those levels, 41% and 69% of patients required accelerated dosing of the third and fourth infusions, respectively.
Based on this finding, Dr. Abreu said, she now checks infliximab trough levels before the third dose, and “if that level … is less than 20, I bring them back four weeks later to give them the fourth dose.” She explained that “by checking it before the third dose, it gives you an opportunity to intercept the fourth dose. If you discover that they have low levels before the third dose, they will never make it to fourth dose” eight weeks later. “That’s when most patients are getting immunized,” she said. “When you have zero drug at trough, it’s a recipe for immunizing your patients to infliximab.”
For the other biologics, proactive TDM may be less supported, according to Dr. Regueiro, who said he’s “not currently doing [proactive TDM] for vedolizumab or the interleukin therapies, primarily because we are still learning the data.” He added that these agents also have “very low immunogenicity, so there’s a low likelihood of antibody formation against the drug.” He explained that “if a patient is losing response, I tend to simply escalate the dose or shorten the interval.”
In UC patients with extraintestinal manifestations, Dr. Regueiro explained that “TNF inhibitors and certainly the JAK inhibitors are probably the two preferred” agents for joint arthritis and that he “tends to use TNF inhibitors or interleukin inhibitors as the first line” for skin manifestations. He said he would use this same approach in his CD patients with extraintestinal involvement.
Dr. Regueiro also said anti-TNFs, specifically infliximab, are a good first-line option for very severe UC patients who “are teetering on the need for hospitalization.”
Biologic-Exposed Ulcerative Colitis
“For someone who has already failed first-line advanced therapy [for UC], it kind of depends what they failed in terms of your choice of what to do next,” Dr. Abreu said. If patients failed an S1P receptor modulator, she recommended trying vedolizumab, an IL-23 inhibitor or infliximab. For those who failed vedolizumab, she recommended an IL-23 inhibitor or an anti-TNF. Finally, for those who failed anti-TNFs, she recommended a JAK inhibitor or, based on an extrapolation of the SEQUENCE study (N Engl J Med 2024;391[3]:213-223), risankizumab or mirikizumab (over ustekinumab).
The two JAK inhibitors approved for UC are tofacitinib (Xeljanz, Pfizer) and upadacitinib (Rinvoq, AbbVie). These agents, which work by blocking signaling to initiate cytokine production, are oral and, like anti-TNFs, may be a good option for patients who have another immune-mediated condition in addition to UC, Dr. Abreu noted. In terms of efficacy, she highlighted that “upadacitinib really blows out of the water most other therapies for IBD.” However, she cautioned that “when you have something so potently immunosuppressive, you get more toxicity.”
Biologic-Naive Crohn’s Disease
As in UC, there is generally “equipoise” regarding the first-line efficacy of the biologics available to treat CD, Dr. Abreu said, citing the head-to-head SEAVUE trial (Lancet 2022;399[10342]:2200-2211) and a network meta-analysis (Gastroenterology 2021;160[7]:2512-2556). However, she pointed to a few specific agents she would recommend for biologic-naive patients with moderate disease, including ustekinumab and risankizumab, vedolizumab and adalimumab. For patients with severe or fistulizing disease, she pointed to infliximab, as well as ustekinumab and risankizumab, as good options.
Biologic-Exposed Crohn’s Disease
In CD patients who failed a biologic, Dr. Abreu recommended trying a new mechanism of action for the second-line drug, similar to what she recommended in UC. However, she noted that when considering IL-23 inhibitors for biologic-exposed patients, clinicians need to know there is evidence showing that the efficacy of ustekinumab decreases as it is used in later lines of therapy (Am J Gastroenterol 2023;118[2]:317-328) and that risankizumab has been shown to be “clearly more endoscopically and clinically effective than ustekinumab” in patients who previously received an anti-TNF (N Engl J Med 2024;391[3]:213-223).
Dr. Abreu also recommended upadacitinib–the only JAK inhibitor approved for CD–for patients who previously failed an anti-TNF, and for biologic-exposed patients with fistulizing disease.
Dr. Abreu reported financial relationships with AbbVie, Alimentiv, Amgen, Bristol Myers Squibb, Celsius, Gilead, Janssen, Lilly, Pfizer, Prometheus, Takeda and UCB Biopharma. Dr. Regueiro reported financial relationships with AbbVie, Amgen, BMS, Boehringer Ingelheim, Celgene, Celltrion, Genentech, Gilead, Janssen, Lilly, Organon, Pfizer, Prometheus, Roche, Salix, Takeda and UCB.
This article is from the October 2024 print issue.