My last session I was able to attend for AIBD 2020 focused on therapies for IBD that are beyond Anti-TNF medications. The specific sessions I attended were led by Anita Afzali, MD, MPH, FACG and Raymond Cross, MD, MS, AGAF, FACG. I wanted to attend this session because I have always found immunology fascinating and absolutely loved the classes I took on it. Kind of ironic that I was later diagnosed with IBD, right? Anyway, hearing discussions about newer biologic therapies and what is in the pipeline is encouraging as an IBD patient and a medical provider. I know many of you are on immunomodulator therapy or biologics, and there are risks and benefits to consider when starting and continuing these medications.
First, let’s do a basic intro to one way that inflammation plays a role in IBD, specifically through TNF-alpha. I love this video from Animated IBD Patient if you are more of an auditory/visual learner. TNF-alpha is only one mediator of inflammation, and that’s why we are looking at other inflammatory targets, such as interleukins (IL-), JAK pathways, leukocyte (white blood cell) trafficking and preventing adhesion of these inflammatory molecules to name a few. (I also promise this will make more sense down below :) ). It’s pretty amazing that we know some pathways to target specifically to reduce inflammation, paving the way for medicines like Remicade (infliximab), Humira (adalimumab), Stelara (ustekinumab), Entyvio (vedolizumab), Xeljanz (Tofacitinib) and others. This decreases our reliance on medicines like prednisone, which lower inflammation in a broad way and typically have more unwanted side effects.
We have to consider the limitations of our current therapies when looking at new targets - 30-40% of us will fail to have an initial response to anti-TNF therapy and up to 50% of us may lose our positive response to biologics in the first year of therapy. There is also the cost, route of administration (like if you need to go to an infusion center) and treatment related adverse events (i.e. immunosuppression, allergic reactions, etc.) that are very important to consider when looking at our current therapies and targets for the future. We do know from recent studies that patients who have never been on anti-TNF therapies do better on medications that target other specifics in the inflammatory pathway, such as Entyvio, Stelara and Xeljanz. And, as with any medication you take, from Tylenol to biologic medications, there are always risks to consider. These are the safety concerns highlighted from the talk below:
IL-12 and IL-23 inhibitors - what are our safety concerns?
Data from the PSOLAR registry showed no increased risk of:
Serious infections
Malignancy (except non-melanoma skin cancers)
Major adverse cardiac events
All-cause mortality (death)
JAK inhibitors - what are our safety concerns?
Infection - herpes zoster (shingles)
Thromboembolism/VTE - aka blood clots; this was seen in Rheumatoid Arthritis (RA) literature
All-cause mortality (death) - also seen in RA literature
Increased total cholesterol, HDL and LDL cholesterols
Cardiovascular events - this could mean heart attacks, strokes, etc.
Anti-trafficking agents, specifically S1P Receptor Modulators which prevent lymphocytes from contributing to tissue inflammation - what are our safety concerns?
Serious infection - herpes zoster (shingles), PML (progressive multifocal leukoencephalopathy)
Bradyarrhythmia and AV conduction delays - heart issues
Macular edema - visual problems
A good thing I noticed when I was looking at the study results on newer medications in the pipeline is that they all look at both clinical and endoscopic remission. This is a step in the right direction for us as IBD patients since things may look great on endoscopy or colonoscopy, but we may not feel well clinically. I hope that the clinical remission criteria look at patient-centered endpoints as well.
Portion from Positioning IBD Therapies
Going off of our information above, Dr. Cross reviewed some important goals of therapy when considering newer IBD therapies and how they affect the patient based on low- and high-risk disease, among other things. Our goals of therapy are to induce clinical remission (no IBD symptoms), avoid short- and long-term toxicity of therapy, maintain steroid-free remission, enhance quality of life, achieve mucosal healing in the gut (aka deep remission), prevent/treat complications of IBD and to decrease unnecessary health care expenditures such as ER visits and hospitalizations.
There have also been studies, such as the CALM study, that look at a “treat to target” approach for patients. This includes targets such as absence of ulceration via endoscopy/colonoscopy or other imaging modalities, and does not just rely on resolution of symptoms alone as the only target. The CALM study, which involved Crohn’s patients, found that the treat to target approach led to higher rates of mucosal healing than typical clinical management. Have specific targets to meet, including clinical remission for patients and imaged-guided remission could help streamline treatment and increase the involvement of the patient in their care.
Dr. Cross also discussed how to approach highly-effective treatments in IBD patients. This decision is based on the severity of symptoms, the inflammatory burder, risk factors for severe disease or a disabling disease course and the presence/absence of complicated Crohn’s disease. Once the decision has been made by you and your provider to initiate highly effective therapy, there are even MORE factors to consider! These include:
Is there evidence that one agent is more efficacious than another?
How severe are the patient’s symptoms?
What safety considerations are present? This could include an elderly patient, having comorbid conditions or being risk-averse.
Does the patient have a preference regarding mode of delivery? This can mean taking a medication by mouth, injection, IV infusion, etc.
What type of insurance does the patient have? I’m so glad they’re taking this into consideration! As much as providers wish they didn’t have to consider this when prescribing the therapy for patients, this is so important to keep in mind.
Does the patient have extra-intestinal manifestations of disease? This can mean things like arthritis, uveitis (eye inflammation), skin changes and others.
Are patients with a uterus/ovaries of childbearing age?
Without boring you further by reviewing studies and their data, IBD researchers are doing great work at comparing older and newer biologic therapies and how they affect patients who have never been on biologics, have failed biologics, IBD patients with extra-intestinal manifestations and how they compare in IBD patients with moderate to severe disease.
Based on studies comparing these various aspects of treatment and how newer therapies that target more specific aspects of inflammation in IBD, the decision to start highly effective therapy is one that should be made with you in mind, but with your GI provider taking your entire clinical picture and risk factors into account. The goals of treatment will be clinical remission and endoscopic improvement. Based on current data, it is recommended that IBD patients who are older, have less severe symptoms/inflammatory burden and those with comorbid conditions take a “safety first” approach - utilize ustekinumab (Stelara) or vedolizumab (Entyvio) as their data shows improvement and has the least amount of serious side effects.
For IBD patients with more severe symptoms, it is recommended to start with infliximab (Remicade) or tofacitinib (Xeljanz); however, Xeljanz should be avoided in patients with a uterus/ovaries who are of childbearing age. In IBD patients with prominent extra-intestinal manifestations, they recommend anti-TNFs, tofacitinib or ustekinumab. I know this all sounds like a lot, but know there are inflammatory-specific treatments being studied in the pipeline and that IBD researchers are comparing current treatment modalities and how they can best serve their patients with evidence-based data for treatment in conjunction with your clinical picture. As always, if you have questions about a particular treatment or side effects (anything really), always ask your GI provider. They went to school for years to be able to care for you, and they should be happy to answer any questions you have about treatment. All questions are good questions, and I hope this article was interesting and inspiring for you as you continue on your IBD journey.