Optimizing biologic therapy for treatment of inflammatory bowel disease.

GVA Gastroenterologists need to know that biologic agents have been under study for more than 15 years now, and a lot has been learned about their benefits and risks. The anti–tumor necrosis factor (TNF) agents are currently dominating the field of biologic therapy in inflammatory bowel disease (IBD). The armamentarium is relatively small for gastroenterologists compared with that for rheumatologists who have a lot of options in terms of currently available biologic agents. Approved anti-TNF agents that are now on the market include infliximab (Remicade, Janssen Biotech), adalimumab (Humira, AbbVie), and certolizumab pegol (Cimzia, UCB). These agents have been dominating the field and will probably do so for a few more years, although new agents are coming. In addition, the anti-integrin antibody natalizumab (Tysabri, Biogen Idec) is a therapeutic option. We know that the benefits of currently available biologic agents outweigh the risks in patients with refractory Crohn’s disease and ulcerative colitis. The risks are manageable and mostly related to development of infections. There may be a potential for disease modification in the long term with these agents. The ability of biologic agents to be disease-modifying has yet to be proven prospectively, but indirect evidence suggests that the biologic agents have the capacity to modify disease. The current concerns are optimizing available biologic therapies and patient selection. Should every patient with Crohn’s disease be treated with a biologic agent? Probably not, but we have yet to discover those clear predictors of response that would help identify the patient who would most benefit from biologic therapy. We do have some indicators, though. Patients with perianal disease, extensive small bowel disease, or rectal ulcerations would be candidates for primary therapy with a biologic agent before corticosteroids or immunosuppressive agents are considered.