Infliximab vs adalimumab: Points to consider when selecting anti-tumor necrosis factor agents in pediatric patients with Crohn's disease

Abstract

Biologic agents with various mechanisms against Crohn's disease (CD) have been released and are widely used in clinical practice. However, two anti-tumor necrosis factor (TNF) agents, infliximab (IFX) and adalimumab (ADL), are the only biologic agents approved by the Food and Drug Administration for pediatric CD currently. Therefore, in pediatric CD, the choice of biologic agents should be made more carefully to achieve the therapeutic goal. There are currently no head-to-head trials of biologic agents in pediatric or adult CD. There is a lack of accumulated data for pediatric CD, which requires the extrapolation of adult data for the positioning of biologics in pediatric CD. From a pharmacokinetic point of view, IFX is more advantageous than ADL when the inflammatory burden is high, and ADL is expected to be advantageous over IFX in sustaining remission in the maintenance phase. Additionally, we reviewed the safety profile, immunogenicity, preference, and compliance between IFX and ADL and provide practical insights into the choice of anti-TNF therapy in pediatric CD. Careful evaluation of clinical indications and disease behavior is essential when prescribing anti-TNF agents. In addition, factors such as the efficacy of induction and maintenance of remission, safety profile, immunogenicity, patient preference, and compliance play an important role in evaluating and selecting treatment options.

Keywords: Adalimumab; Anti-tumor necrosis factor; Crohn’s disease; Infliximab; Pediatric.

Figure 1

The pharmacokinetic profile of an intravenously or subcutaneously administered anti-tumor necrosis factor agent. A: According to a theoretical induction dosing regimen; B: According to a theoretical maintenance dosing regimen. TNF: tumor necrosis factor. Citation: Gibson DJ, Ward MG, Rentsch C, Friedman AB, Taylor KM, Sparrow MP, Gibson PR. Review article: determination of the therapeutic range for therapeutic drug monitoring of adalimumab and infliximab in patients with inflammatory bowel disease. Aliment Pharmacol Ther 2020; 51: 612-628. Copyright ©John Wiley & Sons Ltd. 2020. Published by John Wiley & Sons[31].

Figure 2

Summary flowchart of medical management of pediatric luminal Crohn’s disease and points to consider when selecting anti-tumor necrosis factor agents. TNF: Tumor necrosis factor; EEN: Exclusive enteral nutrition; IMM: Immunomodulators. Citation: van Rheenen PF, Aloi M, Assa A, Bronsky J, Escher JC, Fagerberg UL, Gasparetto M, Gerasimidis K, Griffiths A, Henderson P, Koletzko S, Kolho KL, Levine A, van Limbergen J, Martin de Carpi FJ, Navas-López VM, Oliva S, de Ridder L, Russell RK, Shouval D, Spinelli A, Turner D, Wilson D, Wine E, Ruemmele FM. The Medical Management of Paediatric Crohn's Disease: an ECCO-ESPGHAN Guideline Update. J Crohns Colitis 2020. Copyright ©Oxford University Press 2020. Published by Oxford University Press[20].