Prioritization in inflammatory bowel disease therapy

ABSTRACT

Introduction

Most guidelines for IBD still recommend step-by-step therapy with initially classic drugs such aminosalicylates (in ulcerative colitis) or steroids but avoid prioritizing certain biological drugs and JAK inhibitors in the complicated course. This review provides an aid to pending therapy decisions.

Areas covered

In this review, we analyze the evidence for Crohn’s disease as well as ulcerative colitis in order to optimize and ‘personalize’ the choice of therapy, especially in difficult cases. The relevant publications in Pubmed were identified in a continuous literature review with the key words ‘Crohn´s disease’ and ‘ulcerative colitis.’

Expert opinion

Based on this complex data set following standard therapies steroid-refractory Crohn´s disease should preferentially be treated with combined infliximab plus azathioprine or risankizumab, in second line after their failure with ustekinumab or adalimumab. In steroid-refractory ulcerative colitis infliximab plus azathioprine or upadacitinib should be preferred in first line, filgotinib, tofacitinib or ustekinumab in second line. A steroid-dependent course in both diseases requires azathioprine or vedolizumab, in second line infliximab or Janus kinase inhibitors. The conclusions drawn from these complex data may be helpful for individual decision making in daily clinical practice.

KEYWORDS:

• Crohn´s disease
• ulcerative colitis
• therapy
• biologicals
• JAK-inhibitors

Article highlights

• Most guidelines covering inflammatory bowel diseases do not systematically prioritize therapeutic options but rather provide a list of drugs potentially useful in certain clinical situations and indications.

• Although the evidence is complex with only few head-to-head studies, systematic meta-analyses and real-world studies allow appropriate prioritization, both in Crohn´s disease and ulcerative colitis.

• The key parameter allowing rationalization of drug sequences is relative efficacy of the various therapies, with stratification into biological-naïve and -experienced patients (first line versus second-line treatment), i.e. individual drug history.

• Another important personalization is low versus high side effect risk (old age, prior infections, malignancies, and other comorbidities).

• Special considerations are required in case of extraintestinal manifestations, fistulae, or postoperative Crohn´s disease, and in pouchitis after colectomy in ulcerative colitis.

• These suggestions for prioritization are, of course, not intended as strict guidelines but flexible sequences, and will have to be revised as soon as new drugs are licensed and marketed.

Declaration of interest

KR Herrlinger has received honoraria for consulting Amgen, travel support from Janssen and speaker’s honoraria from Falk Pharma. EF Stange has received honoraria for consulting Amgen, CureVac, Dr. Falk Pharma, Janssen, Merck und Takeda and has given lectures supported by AbbVie, Dr. Falk Pharma, Ferring, Janssen and Takeda. The authors have no other relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript apart from those disclosed.

Reviewer disclosures

Peer reviewers on this manuscript have no relevant financial or other relationships to disclose.

Correction Statement

This article has been republished with minor changes. These changes do not impact the academic content of the article.

Additional information

Funding

This paper was not funded.