Alternatives to Infliximab in Inflammatory Bowel Disease
Introduction to Alternative Therapies
- The American Gastroenterological Association (AGA) suggests using ustekinumab or tofacitinib as first-line alternatives to infliximab for ulcerative colitis, with vedolizumab reserved for patients prioritizing safety over efficacy 1.
Primary Alternatives for Ulcerative Colitis
- Ustekinumab or tofacitinib are the preferred alternatives when infliximab is contraindicated, particularly in patients who would have been infliximab-naïve, due to their superior efficacy for induction of remission 1, 2, 3.
- Vedolizumab represents a reasonable alternative for patients who place higher value on medication safety and lower value on relative efficacy, particularly those with less severe disease 1, 2.
Alternatives for Crohn's Disease
- Adalimumab is FDA-approved for Crohn's disease and represents the primary alternative TNF antagonist 5, 6, 7.
- Ustekinumab is approved for moderately to severely active Crohn's disease, particularly in patients with inadequate response or intolerance to TNF inhibitors 5, 6, 7.
- Upadacitinib has been approved in some countries for adults with moderately to severely active Crohn's disease who have had inadequate response or intolerance to one or more TNF inhibitors 5, 6, 7.
Critical Contraindications to Consider
- IL-17 inhibitors are absolutely contraindicated in patients with active IBD as they have been shown to exacerbate Crohn's disease in clinical trials 5, 6, 7, 8.
- Etanercept is not approved for either Crohn's disease or ulcerative colitis and should not be used as an alternative 5, 6, 7.
Special Populations
- Monoclonal antibody TNF inhibitors are strongly recommended over other biologics or JAK inhibitors for patients with both axSpA and IBD 5, 6, 7.
- Monoclonal antibody TNF inhibitors are conditionally recommended over other biologics for patients with axSpA and recurrent/refractory uveitis 5, 6, 7.