“Vedolizumab showed a faster efficacy than conventional TNF-α blockers in the first-line biological treatment of ulcerative colitis (UC). The agent was particularly potent and safe in healing the intestinal mucosa, which is crucial for prognosis. Vedolizumab demonstrated the strongest effect in the first-line treatment, and it had little impact on the subsequent treatment. So, vedolizumab can be considered suitable as the first biological drug in UC treatment.”

Brian L Bressler, a professor at the University of British Columbia, Canada, said this and other remarks during his presentation on the therapy sequencing strategy in inflammatory bowel disease (IBD) at the virtual meeting of the Asian Organization for Crohn’s & Colitis (AOCC 2020) on Wednesday.

Brian L Bressler, a professor at the University of British Columbia, Canada, speaks on the therapy sequencing strategy in inflammatory bowel disease (IBD) at the virtual meeting of the Asian Organization for Crohn’s & Colitis (AOCC 2020) on Wednesday.
Brian L Bressler, a professor at the University of British Columbia, Canada, speaks on the therapy sequencing strategy in inflammatory bowel disease (IBD) at the virtual meeting of the Asian Organization for Crohn’s & Colitis (AOCC 2020) on Wednesday.

With the arrival of new agents in UC treatment, which had been limited with therapy options, physicians face greater concerns about therapy sequencing.

This year, the American Gastroenterological Association (AGA) recommended vedolizumab (brand name: Kynteles) and infliximab, instead of adalimumab and tofacitinib (brand name: Xeljanz), in UC patients who are using biological agents for the first time.

Local experts started to consider therapy sequencing as a significant issue.

Until last year, Kynteles could be used only for patients who failed in TNF-α blockers due to the limited scope of reimbursement for Kynteles.

However, this year, the government granted the expansion of reimbursement for Kynteles as the first-line treatment three years after the drug's domestic release.

Now, patients who have never used anti-TNF-α treatments can try Kynteles first.

Kynteles showed better endoscopic remission in UC patients who had never used a TNF-α blocker.

As the remission benefit was smaller in patients who had used an anti-TNF-α treatment, local UC patients have not received the full benefit of Kynteles, experts said.

At the AOCC event, Bressler emphasized that therapy sequencing emerged as an important concept in UC treatment. “The efficacy of treatment and patient prognosis may vary depending on the sequence of treatments. So, treatment should be chosen in consideration of the balance between the effectiveness and the safety,” he said.

If treatment is changed frequently due to ineffectiveness or recurrence, the scope of available therapies will shrink, he went on to say. Therefore, maintaining one therapy as long as possible is the key in UC treatment, he said.

Bressler noted that Kynteles showed different effects depending on the history of using a TNF-α blocker. When Kynteles was used as the second drug, its efficacy fell by more than half compared to that of the first treatment.

The EVOLVE real-world study showed that Kynteles as the first therapy did not affect TNF-α blockers' effect in the subsequent use.

Also, Kynteles yielded a better treatment response than adalimumab in the VARSITY study. Bressler said its safety profile was superior because it acts on the intestine only with no systemic immunosuppression.

“Vedolizumab had a rapid onset of therapeutic effect in patients who were using biological agents for the first time. It was superior to adalimumab in terms of healing intestinal mucosa and maintaining long-term effect, and did not affect the subsequent use of TNF blockers,” he said. “As new treatment options are available with various clinical evidence, it is necessary to consider the appropriate treatment sequencing for patients.”

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