Vedolizumab—an anti-integrin agent—has a superior safety profile to tumor necrosis factor (TNF) antagonists in the management of inflammatory bowel disease (IBD) and shows potential for first-line and combination therapy, according to Brian Feagan, MD, who presented today at the 2019 Advances in Inflammatory Bowel Diseases (AIBD) Meeting.

Dr Feagan is director of clinical trials at Robarts Research Institute at Western University in London, Ontario.

He started his session by highlighting how the drug pipeline for IBD has evolved. He said that TNF antagonists are highly effective in ulcerative colitis (UC), as induction and maintenance therapy, and in Crohn disease (CD). However, some of the medications have had certain limitations.

“The limitations of the drugs [for IBD] are something we need to go over with new approaches to therapy,” he said.

For example, certain TNF therapies are associated with serious infection. However, there is no increased risk of infection associated with treatment with vedolizumab. “If you ask your rheumatology colleagues or patients with asthma or other inflammatory diseases, this is a markable advantage,” he said.

New research has opened up the possibility of using vedolizumab as a first-line medication in IBD, Dr Feagan said. “Its been said that we do not have experience using it in this sequence, and if a patient has failed therapy with a TNF antagonist, we know that vedolizumab is effective and ustekinumab is effective, but the other way around is really unknown,” he said. “The EVOLVE study presented at [United European Gastroenterology (UEG) Week] a few months ago used vedolizumab as first-line therapy with a TNF antagonist as second-line. And in both [UC and CD], it did not show there was a significant drop-off in efficacy.”

Dr Feagan also addressed the use of combination therapy in IBD. “Combination therapy, while unproven, has been helpful in my experience and is recommended in high-risk patients.”

A common misconception is the notion that combination therapy will increase the risk of infection—this is not the case, he said. “If you have greater efficacy, you reduce disease activity, reduce exposure to corticoid steroids, and then this offsets the risk,” he said.

He noted that he would treat a patient with a combination of an anti-integrin and an immunosuppressant.

“Patients with different mechanisms of action hit different pathways, so you can get true biological synergetic effects,” he said. “In my practice, if a patient has failed multiple drug therapies—and I’m choosing vedolizumab for context—I will use it in combination with an immunosuppressive drug because that patient is running out of medical options.”

—Melinda Stevens

Reference:

Feagan B. A practical approach to anti-integrins in IBD 2020. Presented at: 2019 AIBD Meeting; December 12-14, 2019; Orlando, FL.