Developments in Biologic Therapy for Crohn s Disease and Ulcerative Colitis
The widespread availability of biologic agents for the treatment of inflammatory bowel disease (IBD) is likely to alter therapeutic strategies in these conditions significantly. Currently, most countries reimburse only the anti-tumor necrosis factor (TNF) agent infliximab, but promising results with other biologic agents will certainly lead to the appearance of new biologics on our markets soon.
What Is New with Infliximab?
The most important finding with regard to infliximab therapy is the fact that regular treatment with eight weekly repeated infusions is superior to episodic administration ‘as clinically needed’ (i.e. when the patient develops relapse of symptoms) in terms of immunogenicity, but also in terms of efficacy and mucosal healing. It has been convincingly shown that the former strategy leads to a significant reduction of surgeries and hospitalizations in IBD patients.1 It has also been demonstrated that the combination of infliximab with an immunosuppressive is not beneficial in reducing immunogenicity beyond a period of six months.2 Given the recent finding that all cases of hepatosplenic lymphoma during infliximab treatment (the vast majority occurring in young male patients) were observed under combination treatment with azathioprine,3 it should be recommended to withdraw the immunosuppressive to which infliximab was added after six months of combined treatment.
The situation may be different in patients in whom infliximpab is started together with azathioprine. Here, infliximab could be considered ‘bridge therapy’ for three to six months and could then be tentatively withdrawn. Infliximab is now approved and in most European countries reimbursed for both Crohn’s disease (CD) and ulcerative colitis (UC). Its efficacy is similar in both conditions, but it must be remembered that many more alternative treatment options are available for UC than for CD: 5-aminosalicylates, cyclosporine, tacrolimus, and even proctocolectomy are all effective therapies for various severities of the disease.
