Ryan Ungaro, MD, on the Optimal Use of Anti-Integrins and Anti-TNFs for the Management of IBD

In this video, Ryan Ungaro, MD, discusses highlights from his presentation on the Optimal Use of Anti-Integrins and Anti-TNFs for the Management of IBD, presented during the AIBD Regional virtual conference on September 11.  

Ryan Ungaro, MD, is an assistant professor Assistant Professor of Medicine at the Icahn School of Medicine at Mt. Sinai, New York.

TRANSCRIPT

Dr. Ryan Ungaro:  Hi, my name is Ryan Ungaro. I'm an Assistant Professor of Medicine at the Icahn School of Medicine at Mt. Sinai, and I hope you enjoyed this most recent Advances in IBD Regionals, where I gave a talk on the optimal use of anti-integrins and anti-TNFs for the management of IBD.

Just as a brief recap of that session, I reviewed the data on the best positioning and use of anti-TNF and anti-integrins in both ulcerative colitis and in Crohn's disease. For anti-integrins, this would be primarily vedolizumab, although natalizumab does fall into that category, but is infrequently used now.

Then for anti-TNFs, these include the injectables adalimumab, certolizumab, and golimumab, as well as the intravenous infliximab.

Some of the high-level take-home points, number one, in ulcerative colitis, this is one of the areas where we have direct head-to-head comparison of biologics from the VARSITY trial, which compared vedolizumab compared to adalimumab for the treatment of moderate to severe ulcerative colitis.

In that head-to-head, in almost all endpoints, vedolizumab outperformed adalimumab. In ulcerative colitis, it appears that vedolizumab should be positioned early, before anti-TNFs, at least certainly adalimumab. However, interestingly, drugs such as infliximab, which are more anti-TNF intravenous, I think, can still be positioned first-line in the more severe cases.

Particularly, patients who are near hospitalization, or certainly, those who are hospitalized. An important piece of data that has emerged for the positioning of vedolizumab relative to anti-TNF medications is that anti-TNFs, prior exposure to them decreases the efficacy and effectiveness of vedolizumab.

However, the converse does not appear to be true. Patients who have vedolizumab first, and then are subsequently treated with an anti-TNF, the second-line use of anti-TNF does not appear to be associated with decreased efficacy and effectiveness if a patient had prior vedolizumab exposure.

In general, for UC, vedolizumab is positioned primarily as a first-line therapy now, particularly in moderate to severe on the more moderate side of the disease severity. Anti-TNF can be positioned second, but used first-line, depending on disease severity, particularly the more severe cases, and of course, consideration of insurance coverage.

Both vedolizumab and anti-TNF drugs, very useful in ulcerative colitis. In contrast, for Crohn's disease, we reviewed that vedolizumab, if you're using it, then you should be using it early, that the anti-integrin drugs appeared to work better in more recently diagnosed Crohn's disease, particularly the bio-naive Crohn's disease patient.

This is something where also in anti-TNF, earlier use in Crohn's disease, the better. So shorter disease duration, bio-naive. In general, vedolizumab in Crohn's disease, likely even more so than in ulcerative colitis, when you're using it after that TNF failure, tends to have a lower effectiveness.

I think in Crohn's, anti-TNF still, in most scenarios, would be preferred, although in vedolizumab, if you're using it early, in more mild to moderate disease, or in patients with specific populations of patients where safety is a primary concern, those are good scenarios where you can position vedolizumab in front of the anti-TNFs.

Of course, with all of these medications, we want to make sure that we're monitoring our therapy for both clinical and objective resolution of inflammation, and doing treat-to-target approaches, where we're consistently reevaluating on a regular basis, every three to six months, that our medications are working.

That is just the high-level synopsis, main points, from our talk on anti-TNF and anti-integrin therapies, the optimal use in IBD. We hope you enjoyed the session, this last AIBD Regionals. Thank you.