Quick Shot #10 Answer
Answer: Infliximab or Ustekinumab
The patient has had two flares requiring steroids while on vedolizumab, and switching biologics is indicated. The best options are likely infliximab or ustekinumab. In a network meta-analysis of biologics for UC, infliximab was reported to be the most effective agent (Singh et al., CGH 2020). Ustekinumab is also effective for ulcerative colitis, including biologic-experienced patients, and has the advantage of a favorable safety profile for this older patient. Adalimumab would not be an optimal choice given its lower efficacy in the study noted above, as well as from the head-to-head trial with vedolizumab (VARSITY). JAK inhibitors – tofacitinib and the recently approved upadacitinib – are effective for biologic experienced patients with UC but have been positioned after anti-TNF by the FDA labeling, so would not be appropriate to use before infliximab. Shared decision making regarding potential trade offs between efficacy and safety of infliximab and ustekinumab would be the most optimal management at this time. Additionally, for patients on MediCare, ustekinumab is not well covered at this time.
- Singh S, Murad MH, Fumery M, Dulai PS, Sandborn WJ. First- and Second-Line Pharmacotherapies for Patients With Moderate to Severely Active Ulcerative Colitis: An Updated Network Meta-Analysis. Clin Gastroenterol Hepatol. 2020 Sep;18(10):2179-2191.e6. doi: 10.1016/j.cgh.2020.01.008. Epub 2020 Jan 13. PMID: 31945470; PMCID: PMC8022894.
- Sands BE, Peyrin-Biroulet L, Loftus EV Jr, Danese S, Colombel JF, Törüner M, Jonaitis L, Abhyankar B, Chen J, Rogers R, Lirio RA, Bornstein JD, Schreiber S; VARSITY Study Group. Vedolizumab versus Adalimumab for Moderate-to-Severe Ulcerative Colitis. N Engl J Med. 2019 Sep 26;381(13):1215-1226. doi: 10.1056/NEJMoa1905725. PMID: 31553834.