Dr Abreu recaps the video presentation on choosing the right therapy for patients with ulcerative colitis, presented by Corey Siegel, MD, from Dartmouth-Hitchcock Medical Center, and by Dr Abreu on site at the American College of Gastroenterology 2021 Postgraduate Course in Las Vegas, Nevada, on October 24, 2021.

Maria Abreu, MD, is director of the Crohn’s and Colitis Center at the University of Miami School of Medicine in Miami, Florida.

TRANSCRIPT

Hi, I'm Maria Abreu. I'm at the University of Miami. I'm here at the ACG postgraduate course, and we've just finished the section on IBD. It was my honor to fill in for Corey Siegel who gave a wonderful talk on right patient, right therapy for ulcerative colitis, and he made some really very important points.

I think that in every patient that we see with ulcerative colitis, there are a lot of things that are brought into the decision making about how to pick the right therapy for that patient. It's about the patient. It's about the provider. It's also about, unfortunately or fortunately, the payer and what the insurance plan is going to allow us to give, quite honestly.

What Corey makes the point about distinguishing disease activity from disease severity, there are patients that might be very sick, but you get them better very quickly with corticosteroids and they go on to be on mesalamine.

Other patients that have worse prognoses, that have deeper ulcerations, their quality of life is very affected and have other signs that they're on a bad trajectory, those that have been on previous biologic agents, those that have recently completed steroids and are still flaring again. You can see where this is going±that we need to have a long-term plan for those patients.

Corey showed some where we have some comparative effectiveness data. We know that in a head-to-head study of vedolizumab versus adalimumab, vedo was superior to adalimumab. Corey went on to make the point that one might say, "Well, maybe if we up the dose of adalimumab, we could compensate for that." In point of fact, the SERENE study in ulcerative colitis that used very high doses of adalimumab in ulcerative colitis patients versus standard dosing didn't really show an advantage to those high doses. It's probably picking the right patient that's going to need higher dosing.

He then went on to show us some network meta-analyses so that in the absence of comparative effectiveness data, we can look across studies and see what would we pick for our patients. In that approach, it turned out that for the virgin, biologically-naive ulcerative colitis patient infliximab actually wins with respect to clinical remission as well as endoscopic remission.

Second was vedolizumab and all the other things that you're familiar with really were all about the same. Then for patients that had previously been on anti-TNF, the 2 agents actually that showed superiority were ustekinumab and tofacitinib in those types of patients. Now, these are network meta-analyses, and that my bias is that these studies still need to be done properly, which has to be done prospectively and not just in silico as these have been done.

One of the points that Corey made over and over again is there's no such thing as perfect. Sometimes, you just have to start something and see how it goes. Obviously, you're trying to make decisions based on whether that's a patient with extraintestinal manifestations or not, a low albumin or not, since we know that the biologics clear more quickly.

One of the things that he didn't have an opportunity to talk about was ozanimod, probably because it's one of the newest agents for which there really is very little comparative effectiveness data. This is an agent that works at a different mechanism for the ones that we're familiar with. It's an S1P receptor agonist. It inhibits lymphocytes exiting lymph nodes. They're not dead. They're stuck there. They're stuck on this freeway of the lymphatic system, and that has been shown to be effective in ulcerative colitis.

It's also FDA approved for multiple sclerosis, and so it seems to have a really quite good safety profile as well. We'll see how that's going to be put into our algorithm of taking care of ulcerative colitis patients and, again, what payers will pay.

I often will say to my patients these are the therapies that are available. I'd like to try for this one. If the insurance company is not going to accept it, I'm OK with this other one so that we already have a plan before they leave my office, and I've set the expectation.

Hopefully, you'll watch Corey's excellent presentation online virtually, and we'll look forward to seeing you in person another time.