Positioning existing and emerging anticytokines and anti-integrins in patients with inflammatory bowel disease (IBD) for the optimum outcome requires careful consideration of comorbidities, severity of disease, and individualized needs of patients, according to David Rubin, MD, who presented at the virtual Advances in Inflammatory Bowel Disease (AIBD) 2020 regional meeting today.

David T. Rubin, MD, is the Joseph B. Kirsner Professor of Medicine and chief of the Section of Gastroenterology, Hepatology and Nutrition at the University of Chicago.

He noted that deciding which medication to use when initiating treatment depends in part on disease activity—how sick the patient is now—as opposed to disease severity—which includes prognostic indicators. Efficacy and safety of medication options, comorbidities, and individual patient considerations all must be factored into determining the medication to use at the outset. Dr Rubin noted that for most patients with IBD, the first drug works best, although this way be attributable to artifacts of clinical trials and to the severity of disease in treatment naive patients, as well as the potential for developing antidrug antibodies when an initial TNF inhibitor does not work well.

Dr Rubin recommended the use of organ-selective therapies before systemic therapies, such as topical rectal therapy before systemic therapy in distal colitis; budesonide before systemic corticosteroids; and vedolizumab before systemically active immunosuppressants.

He supported combining therapies based on patient responses and disease activity, such as using anti-tumor necrosis factor (TNF) medications with immunomodulator (IMMs) and with antibiotics in cases of perianal disease.

When treating patients with ulcerative colitis (UC), Dr Rubin suggested that combination therapy be considered for all patients using anti-TNF medications. He noted that when using infliximab as initial therapy, physicians should combine it with a thiopurine. For patients with Crohn disease, combination therapy with infliximab has been more effective than either infliximab or thiopurines as monotherapy. Anti-TNFs are recommended for patients with Crohn disease and steroid- or thiopurine-resistant or methotrexate-refractory disease.

Data indicates that patients with Crohn disease who begin therapy with anti-TNFs earlier have better outcomes, are less likely to need surgery, and the cost of care is reduced by earlier administration of TNF inhibitors, Dr Rubin noted; however, he cautioned, more drug is not necessarily better. He cited research indicating that high doses of anti-TNFs did not prevent colectomy in patients with ulcerative colitis. 

For patients with moderate to severe UC, Rubin stated, the anti-integrin vedolizumab is used for induction and maintenance of remission, in some cases with the addition of a calcineurin inhibitor induction. For Crohn disease, vedolizumab may be used with or without an IMM for moderate to severe disease, while natalizumab is indicated for induction of response/remission and maintenance.

Comparative effectiveness studies indicate that anti-TNF therapies—primarily infliximab—combined with IMMs show the best results for treating IBD. However, Rubin noted, infliximab alone better predicts remission than combination therapy.

Overall, Rubin recommended that when selecting therapeutic regimens for patients with IBD, gastroenterologists should weigh the patients’ comorbidities; consider combination therapies beyond anti-TNF with IMMs, depending on the patient’s condition and needs; be smart about determining the reasons for lack of response; and make thoughtful choices about adding a second therapeutic agent and why it may be needed.

—Rebecca Mashaw

Reference:

Rubin DT. Positioning current and emerging anticytokines and anti-integrins in IBD management. Talk presented at: Advances in Inflammatory Bowel Disease 2020 regional meeting; June 27, 2020; virtual.