Rates and Benefits of Infliximab and Adalimumab Dose Escalation in Ulcerative Colitis

In clinical practice, we often see patients who lose response to anti-tumor necrosis factor (TNF) therapy over time. Infliximab and adalimumab are the most commonly used anti-TNF agents in ulcerative colitis. The doses of these medications are increased often in clinical practice; therefore, it is important to know the frequency of loss of response (LOR) with these drugs and the potential benefit of dose escalation based on available evidence.    

In this systematic review and meta-analysis, 50 studies evaluated LOR as well as dose escalation with infliximab and adalimumab. The authors sorted LOR into 3 groups:

• Treatment discontinuation 
• Treatment optimization based on dose escalation with or without treatment switch and/or medical rescue therapy (steroids/cyclosporine) and/or surgery
• Increase of disease activity per increased clinical disease activity scores and/or C-reactive protein levels and/or endoscopic disease worsening

This review showed that 10% of patients receiving infliximab and 13% receiving adalimumab had an annual LOR. The dose escalation rate was 14% for infliximab recipients, which led to clinical benefit in 72% of patients. Among adalimumab recipients, 21% had a dose increase, leading to clinical benefit in 52% of patients.