Before worrying about positioning new and subsequent therapies in moderate to severe ulcerative colitis, plan for the patient’s first biologic drug to be “forever” – that’s the advice from Professor John Marshall .
Speaking at AGW 2019, the director of gastroenterology at Canada’s McMaster University said bio-naive patients were the most responsive.
“Protect and optimise your first choice,” he said.
“Anytime you use a biologic drug you have to be very intelligent about it and think about pharmacokinetics, for example, make sure you have the optimal dosing in your patient,” he told the limbic.
There were some patient subgroups where clearance might be more rapid.
“I think you have to be thoughtful about some of those things to make sure you have the optimal dose,” he said.
He said new drug options were making decisions more complicated but it was a fortunate position to be in.
“I think this in an area where shared decision making is very important. It’s our job as clinicians to be attuned to our patients’ priorities and preferences and they do vary among patients. Patients with the same information will make very different decisions.”
“Now we have to guide them, we have to inform them and we have to be a little more paternalistic than in the past because we have more choices but at the end of the day, our job is to understand our patient preferences in the short and the long term and act on them.”
He said the determinants of persistence with therapy included durability of efficacy, safe and tolerability, patient acceptance, reimbursement and support programs.
Professor Marshall said first line treatment was still steroids, but when they failed, the choice was between vedolizumab and available TNF inhibitors.
He said he felt there was a shift towards safety first in which case vedolizumab was nudging ahead.
Vedolizumab had also been reported to have both statistically and clinically significant advantages over adalimumab in the slightly controversial VARSITY trial, which was presented earlier this year at the ECCO Congress.
Tofacitinib was also “not off the table” despite some concern about increased risk of pulmonary embolism in patients using the JAK inhibitor for rheumatoid arthritis.
Professor Marshall said other hot topics included the imminent arrival of ustekinumab for ulcerative colitis – expected in the New Year in Canada.
Availability of a subcutaneous formulation of vedolizumab was also imminent and the flexibility of not having to attend an infusion centre should be popular with many patients.
“The model in the trials is to use two doses IV and then convert to subcut for maintenance. I think that’s an issue in Australia where travel for an infusion is prohibitive. We have the same issue in Canada. Not everybody wants to drive to an infusion centre to get IV therapy.”
He said there was also a lot of interest in combination therapy such as a calcineurin inhibitor in combination with vedolizumab.
A recent French study of 39 steroid-refractory patients, most of whom had failed a TNF inhibitor, found the combination allowed more than two thirds of patients to avoid colectomy.