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Review
. 2025 Aug 7;31(29):107745.
doi: 10.3748/wjg.v31.i29.107745.

Positioning and sequencing of advanced therapies in inflammatory bowel disease: A guide for clinical practice

Marcello Imbrizi  1 , Matheus F C Azevedo  2 , Julio P Baima  3 , Natália S F Queiroz  4 , Rogério S Parra  5 , Sandro D C Ferreira  6 , Ligia Y Sassaki  3 , Julio Maria F Chebli  7
Affiliations
Review

Positioning and sequencing of advanced therapies in inflammatory bowel disease: A guide for clinical practice

Marcello Imbrizi et al. World J Gastroenterol. .

Abstract

Over the past decade, the therapeutic armamentarium for inflammatory bowel disease (IBD) has substantially expanded with the incorporation of multiple classes of advanced therapies. Currently, in addition to tumor necrosis factor-α inhibitors, the therapeutic arsenal for IBD includes anti-integrin agents, interleukin (IL)-12/23p40 and IL-23p19 antibodies, Janus kinase inhibitors, and sphingosine 1-phosphate receptor modulators. Although advances in IBD pharmacotherapy have enabled disease remission and improved control of intestinal inflammation in many individuals previously considered clinically 'intractable', they have also increased the complexity of decision-making related to the initial positioning and sequencing of therapies in the heterogeneous clinical presentations of IBD. Until molecular and genetic markers capable of predicting therapeutic responses become available in practice, the choice of initial and subsequent therapy in individuals with IBD is based on factors including disease severity, phenotype, risk of complications, comorbidities, extraintestinal manifestations, and the balance between efficacy, safety, convenience, and access. This review explores the factors that influence treatment decisions regarding initial therapy selection and sequencing across IBD scenarios, offering practical tips for personalizing therapy based on the safety and efficacy of advanced treatments and the individual's risk of disease- or therapy-related adverse outcomes.

Keywords: Advanced therapy; Biologic agents; Biologics; Crohn's disease; Inflammatory bowel disease; Janus kinase inhibitors; Sequencing; Treatment strategy; Ulcerative colitis.

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Conflict of interest statement

Conflict-of-interest statement: Imbrizi M has received fees for serving as a speaker and/or an advisory board member for Abbvie, Ferring, Janssen, Nestle, Pfizer and Takeda; Azevedo MFC has received fees for serving as a speaker and/or an advisory board member for Abbvie, Janssen and Takeda; Baima JP has received fees for serving as a speaker and/or an advisory board member for Janssen and AbbVie; Queiroz NSF has served as a speaker and advisory board member of Janssen, Takeda and Abbvie; Parra RS has received fees for serving as a speaker and/or an advisory board member for Takeda, Janssen, AbbVie, Ferring and Pfizer; Ferreira SDC has received fees for serving as a speaker and/or an advisory board member for Janssen, Takeda, and Pfizer; Sassaki LY has received fees for serving as a speaker and/or an advisory board member for Janssen and AbbVie; Chebli JMF has received fees for serving as a speaker and/or an advisory board member for Takeda, Janssen, AbbVie, Abbott, and Sandoz.

Figures

Figure 1
Figure 1
Considerations in positioning and sequencing advanced therapies in inflammatory bowel disease. IBD: Inflammatory bowel disease. Image created with BioRender.
Figure 2
Figure 2
Factors beyond clinical phenotype and disease activity that guide therapy selection. JAK: Janus kinase. Image created with BioRender.
Figure 3
Figure 3
Inflammatory bowel disease treatment guide: Preferred, alternative, and avoidable medications by patient profile. EIM: Extraintestinal manifestation; HF: Heart failure; NYHA: New York Heart Association; TNF: Tumoral necrosis factor; S1P: Sphingosine 1-phosphate; JAK: Janus kinase; PsA: Psoriatic arthritis; PsO: Psoriasis. Image created with BioRender.
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