Treatment of Ulcerative Colitis with Biologic Agents

First-Line Therapy Selection

For biologic-naïve patients with moderate-to-severe ulcerative colitis, the American Gastroenterological Association (AGA) suggests using infliximab or vedolizumab over adalimumab 3
Higher efficacy medications, including infliximab and vedolizumab, are preferred over lower efficacy options like adalimumab for biologic-naïve patients with moderate-to-severe UC 1, 2
Infliximab appears superior to vedolizumab, adalimumab, ustekinumab, and ozanimod in biologic-naïve patients 3
All biologic agents (infliximab, adalimumab, golimumab, vedolizumab, tofacitinib, ustekinumab) are effective compared to placebo for induction and maintenance of remission 4

Vedolizumab demonstrates a 32% lower risk of serious infections compared to TNF antagonists in patients with UC 1
JAK inhibitors (tofacitinib, upadacitinib) have restricted use in biologic-naïve patients and should be used with caution in patients with cardiovascular risk factors 1, 2

In patients with primary failure to an anti-TNF therapy, vedolizumab is strongly recommended over switching to another anti-TNF therapy 5, 6
For patients who have failed anti-TNF therapy, vedolizumab is strongly recommended to induce complete corticosteroid-free remission, according to the American Gastroenterological Association (AGA) 7
In patients with secondary failure to an anti-TNF therapy, switching to another anti-TNF therapy or vedolizumab is recommended based on therapeutic drug monitoring results 5, 6
In biologic-exposed patients, particularly after TNF antagonist failure, upadacitinib, tofacitinib, and ustekinumab appear superior to vedolizumab 8

Vedolizumab has demonstrated significant efficacy for both induction and maintenance of remission in patients with moderate to severe ulcerative colitis, according to the American Gastroenterological Association (AGA) 7
In a head-to-head trial comparing vedolizumab vs adalimumab, clinical remission rates were significantly higher in vedolizumab-treated patients (34.2% vs 24.3%) 7

Patients should be evaluated for lack of symptomatic response to anti-TNF induction therapy in 8-12 weeks to determine the need to modify therapy 5, 6
For vedolizumab, assessment of response should occur between 8-14 weeks after initiation 5, 6, 7
In patients with suboptimal response to anti-TNF induction therapy, dose intensification is recommended 5, 6
Therapeutic drug monitoring should inform dose optimization for patients with UC on anti-TNF therapy 5, 6

When starting anti-TNF therapy, it is recommended to combine it with a thiopurine or methotrexate rather than using it as monotherapy 5, 6
For vedolizumab, concomitant treatment with immunomodulators does not substantially affect its efficacy, according to the European Crohn’s and Colitis Organisation (ECCO) 9