Using Biologics for Ulcerative Colitis: Doctor Q&A

Editor

Ulcerative Colitis (UC) is a complicated inflammatory bowel disease (IBD) condition. There are a wide array of treatments and lifestyle changes required for UC. One such treatment option is biologics. Dr. Constance A. Pietrzak, a gastroenterologist at Advocate Medical Group in Chicago, explains what you should know before considering this IBD treatment option.

How do biologics work to treat UC?

In ulcerative colitis (UC), biologics work by blocking the immune response. They act on specific targets which play a role in increasing or decreasing inflammation that are lacking, not working, or in excess in the gut lining, rather than suppressing the entire immune system. These targets include tumor necrosis factor (TNF)-alpha, interleukins, adhesion molecules, colony-stimulating factors, and others.  Biologics can increase the anti-inflammatory response, thereby improving disease.

Which biologics are available to treat UC?

Infliximab and recently adalimumab, TNF-alpha inhibitors, are approved for treatment and maintenance of remission for moderate to severe UC that does not respond well to more conventional treatments.  Vedolizumab, an integrin receptor antagonist, can be used to treat moderate to severe UC unresponsive to infliximab, immunomodulators, or in those who remain steroid-dependent. Golimumab, another TNF-alpha inhibitor, is approved for those with moderate to severe UC who are steroid-dependent or failure to respond to other UC treatment options, such as 5-ASA’s or immunomodulators.

When should someone consider using biologics?

Patients with active UC are usually treated first with conventional therapies, including 5-ASA’s, corticosteroids, and immunomodulators. If patients with moderate to severe active UC do not respond to these conventional therapies, or steroids cannot be stopped, then biologics are used to induce and/or maintain remission.

What is the usual duration for taking biologics?

Typically, once a biologic is started, it is continued indefinitely. When disease is well-controlled on a regimen, then it is recommended that such a regimen be continued.  Patients who used infliximab, discontinued the medication, and required it again, were found to have diminished response the second time around due to formation of antibodies.

Recently, the concept of de-escalating therapy, where patients on combination therapy are taken off one of these medications, has been studied, particularly in Crohn’s disease. The key is to monitor various clinical factors and for the patient to remain on at least one of the therapies. Stopping all therapy, despite being clinically in remission is not advised.

How effective are biologics in treating UC?

Conventional therapies have had limited efficacy in treating moderate to severe UC, requiring more advanced treatment and even surgery. The use of biologics in treating UC has revolutionized our capabilities in successfully treating UC and achieving mucosal healing.  Clinical response has been shown in up to 60 percent with the use of biologics.  At this time, only a few biologics are approved to treat UC compared to Crohn’s disease. However, these agents are extremely effective in inducing and maintaining remission in patients with moderate to severe UC who have tried using other immunosuppressive therapies.

Do biologics have certain advantages over other treatment options?

The major advantage of biologics over other therapies is their efficacy and, therefore, preventing the need for colectomy surgery. Twenty to 40 percent of patients with UC do not respond to conventional therapies. Another advantage is that these medications are targeted to very specific parts of the immune response, rather than suppressing the entire immune system, resulting in fewer major side effects.

Who should not take biologics?

Caution should be taken in patients with certain medical conditions. Those with a history of tuberculosis (TB) or have been exposed to TB should undergo testing for the disease. If positive, treatment for TB should be started prior to starting biologics. People with uncontrolled heart failure should not use biologics.  People with active infections, certain neurological disorders (multiple sclerosis or autoimmune neurological disorders), or untreated cancers (lymphoma, malignant melanoma, renal cell carcinoma, and lung cancer) should not be started on biologics. Also, patients who are already immunosuppressed for any underlying medical conditions should not use biologics.

Any other advice or information you’d give about biologics?

Biologics are extremely safe and effective medications used to treat moderate to severe UC that is unresponsive to conventional therapies.  It is very important that you work with your doctor when taking these medications and keep them informed of any symptoms you experience, either related to your UC or potential side effects of the medications.  Prior to taking these medications, it is encouraged that you have an extensive discussion with your physician regarding any testing that needs to be completed (TB, Hepatitis B and C viruses), possible side effects from biologics, and potential risk for side effects. Doing so will put you at great ease with starting biologics and also place you in control of your health. It is imperative that you do not stop these medications on your own.  If you do, only restart them with the guidance of your doctor.