Dr Cross discusses factors to consider in using anti-integrins and anti-tumor necrosis factor therapeutics in managing inflammatory bowel disease, which he discussed at the recent AIBD regional meeting.

Raymond Cross, MD, is a professor of medicine and director of the Inflammatory Bowel Disease Program at the University of Maryland School of Medicine in Baltimore, Maryland.

TRANSCRIPT:

Hello, everyone. I'm Raymond Cross. I'm a professor of medicine and director of the IBD program at the University of Maryland School of Medicine. I want to go over the highlights of my recent presentation at the regional Advances in IBD. I went over the optimal use of integrins and anti-TNFs for the management of IBD.

One of the key aspects of my presentation is helping providers think about key factors before starting any biologic therapy including anti-integrin and anti-TNF. First, has infection been excluded, such as C. difficile?

This is a really important second point— does the patient have active disease confirmed by biomarkers or an endoscopy? This is a critical point before you start treatment, how severe the patient's symptoms are. This may play a role in deciding between the 2 agents as to which would work faster. Does the patient have risk factors for severe disease course or how many risk factors—so for your higher-risk patient for disabling Crohn's or colectomy you're going to go to a biologic like 1 of these 2 much sooner.

Are there complications present, does the patient have a stricture or internal penetrating complication? There's patients in reality are best served in surgery in coming up with a postoperative monitoring strategy, and potentially using a biologic to prevent recurrence.

Lastly, are there any special considerations that you need to think about that will impact your choice of treatment? Is it a woman of child-bearing age or a woman who's pregnant? Are there extraintestinal manifestations present? Is the patient of advanced age or frail, or have comorbid conditions that would tailor your treatment?

Lastly, are there any insurance barriers that are going to weigh in on what you're going to get, particularly a sub-q medicine versus an intravenous medicine?

In my presentation, I've summarized the data for you. Generally, we know that anti-TNFs and vedolizumab are effective for both ulcerative colitis and inflammatory Crohn's. I highlight inflammatory Crohn's because we know therapies don't work as well for complicated disease.

Vedolizumab, no one would argue it has a better safety signal than anti-TNF. Our network meta-analyses have demonstrated the highest effect sizes for infliximab for ulcerative colitis, and infliximab or adalimumab for bio-naive patients with Crohn's. Real-world studies and randomized trials have demonstrated a superiority of vedolizumab over anti-TNF for UC and anti-TNF for Crohn's.

How do I position these agents in clinical practice? This may be the most important set of take-home messages.

For the less sick ambulatory patient, I pick the safest mechanism action first. In this case, comparing integrin and anti-TNF, that will be vedolizumab, particularly for the ulcerative colitis patient. A sicker ambulatory patient who's bridging going into the emergency room or hospital, I choose an anti-TNF particularly, infliximab for UC. In patients with extraintestinal symptoms, I choose an anti-TNF and in my older, frail patient with comorbid conditions or recent cancer, I choose vedolizumab.

Hopefully, you tuned into my presentation and you find this summary helpful.

We'll see you at the next Advances in IBD.