How to Position the Growing Number of Therapies in IBD

At the American College of Gastroenterology (ACG) annual meeting, Miguel Regueiro, MD, of the Digestive Disease and Surgery Institute at the Cleveland Clinic, discussed the immunologic basis of novel biologic therapies for inflammatory bowel disease (IBD) during the GI Pathophysiology Course.

In this video, Regueiro talks about how he utilizes different options for Crohn’s disease and ulcerative colitis in his practice.

Following is a transcript of his remarks:

I’d like to highlight one of my presentations that occurred on the first day of ACG. This was part of the ACG Pathophysiology Course where I presented the therapies for inflammatory bowel disease, both Crohn’s disease and ulcerative colitis. I went through the different mechanisms of action. This is an exciting time for IBD therapies, a lot of hope for our patients. And then I also presented a new safety pyramid, which we’ve put together over the years, and we’ve just recently updated this and published this in the IBD Journal, and I spent some time talking about that.

Part of my presentation in the ACG Pathophysiology Course was how I positioned these therapies in my own clinical practice. A few highlights include, in very severe ulcerative colitis patients admitted to the hospital, if they’ve never been on a treatment, I still use infliximab [Remicade] and I tend to use the 10-mg/kg dose. If they’ve already been on infliximab, there are now emerging data on Janus kinase inhibitors, tofacitinib [Xeljanz], and now maybe upadacitinib [Rinvoq]. I also talked about Crohn’s disease. So for the severe Crohn’s patient with perianal fistula and also very severe Crohn’s in the GI tract, I’m still using infliximab in combination with azathioprine. For everything else, moderate Crohn’s disease and moderate ulcerative colitis, I take a bit of a different approach and we have lots of therapies.

So for moderate Crohn’s disease, we have vedolizumab [Entyvio], ustekinumab [Stelara]. Now risankizumab [Tremfya]. We’re actually looking at other therapies even beyond the anti-TNF [tumor necrosis factor]. If a patient has been on a TNF inhibitor and failed that in Crohn’s, I am starting to use more and more upadacitinib. Similarly, for ulcerative colitis, we have a whole new class of therapies, the S1P [selective sphingosine-1-phosphate] molecules, ozanimod [Zeposia], and just approved etrasimod [Velsipity]. I think those are best used in the milder end of moderate ulcerative colitis as first-line therapy after a 5-ASA [5-aminosalicylate]. And then obviously we have ustekinumab, vedolizumab, the TNF inhibitors, and always upadacitinib for that group as well.

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