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

Bincy P. Abraham, MD, MS reviewing Savelkoul EHJ, et al. Inflamm Bowel Dis 2022 Nov 1.

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.


Comment:

This meta-analysis provides evidence that 14% of patients receiving infliximab and 21% of patients receiving adalimumab will require dose escalation in ulcerative colitis, which can lead to clinical benefit in the majority of patients but is higher with infliximab than adalimumab. From a clinical practice perspective, it is reasonable to escalate the current medical therapy dose in patients before switching treatments in order to provide maximal benefit.

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Bincy P. Abraham, MD, MS

Bio and Disclosures

Citation(s):

Savelkoul EHJ, Thomas PWA, Derikx LAAP, den Broeder N, Römkens TEH, Hoentjen F. Systematic review and meta-analysis: loss of response and need for dose escalation of infliximab and adalimumab in ulcerative colitis. Inflamm Bowel Dis 2022 Nov 1. (Epub ahead of print) (https://doi.org/10.1093/ibd/izac200)