Current approaches for optimizing the benefit of biologic therapy in ulcerative colitis

Abstract

As biologic-based medication options for ulcerative colitis expand, our understanding of their optimal use in clinical practice is advancing as well. The appropriate use of combination therapy with immunomodulators can reduce the immunogenicity of biologic agents and raise serum drug levels of the biologic. A treat-to-target strategy with objective assessments of disease activity clearly defines the goals of biologic drug treatment. Mucosal healing is an evolving treatment goal and is associated with long-term remission and reduced incidence of colectomy. Furthermore, regular reassessments and therapeutic drug monitoring can allow clinicians to make evidence-based changes in therapy. Biologic drug de-escalation or re-initiation are less well developed topics, but are emerging areas of study. We review the evidence underlying these advances and a modern approach to the use of biologic therapy in ulcerative colitis.

Keywords: biologic therapy; infliximab; mucosal healing; ulcerative colitis; vedolizumab.

Figure 1.

Proactive approach to optimization of anti-tumor necrosis factor (TNF) α therapy in ulcerative colitis. ADA, antidrug antibody.

Figure 2.

Reactive approach to the patient losing response to anti-tumor necrosis factor (TNF) therapy using therapeutic drug monitoring. ADA, antidrug antibody; IMM, immunomodulator.

Figure 3.

Chicago algorithm for restarting infliximab. Based on available evidence and modified from Baert et al. [2014]. Premedications include one dose of oral prednisone 40 mg the day before the first loading infusion and on the day of the first loading infusion, with one dose of oral diphenhydramine 25 mg and one dose of oral acetaminophen 650 mg. ATI, antibody to infliximab; IFX, infliximab.