IBD is chronic lifelong disease that requires lifelong therapy. We need drugs that can maintain mucosal healing and drugs that can be used long-term with minimal safety concerns.
Conventional therapies have limited role to achieve mucosal healing in many patients. Thiopurine may not be the answer long-term especially in young or elderly patients.
Biologics have changed the way we treat IBD including Anti-TNF (Infliximab, Adalimumab, Golimumab), Anti-integrin (Vedolizumab) and Anti-IL-12/23 (Ustekinumab) and new small molecules such as JAK kinase inhibitor (Tofacitinib) and S1P Receptor Modulator (Ozanimod) that were recently FDA approved.
In Crohn’s disease, Ustekinumab showed similar efficacy to anti-TNF for induction of remission as first line. Ustekunimab had higher persistence in Crohn’s disease than Vedolizumab as first-line therapy and second-line therapy (PANIC study, AGA guidelines). Anti-TNF showed strongest evidence in perianal CD. In Ulcerative colitis, Infliximab and Vedolizumab performed the best in the induction of clinical remission as first line from network analysis, and Vedolizumab has the lowest risks of serious infections & adverse events. Ustekinumab showed similar efficacy in both bio-naïve and bio-failure UC for clinical remission and endoscopic improvement whereas Ustekinumab had higher efficacy than Vedolizumab in UC after failure of anti-TNF (network meta-analysis). Oral small molecules may change the paradigm of therapy. Ultimately, choice of drugs needs to be considered in the context of individual patient profile, risk and benefit (tuberculosis, hepatitis) cost and long term persistence.