Which ulcerative colitis biologic is also approved for treatment of rheumatoid arthritis?

TNF Antagonists (Infliximab, Adalimumab, Golimumab) Are the Ulcerative Colitis Biologics Also Approved for Rheumatoid Arthritis

Among UC biologics, infliximab, adalimumab, and golimumab are FDA-approved for both ulcerative colitis and rheumatoid arthritis, making them the optimal choice when treating both conditions simultaneously. 1

Primary Recommendation

The TNF antagonists represent the only class of UC biologics with dual FDA approval for both conditions. This makes them uniquely positioned for patients requiring treatment of both UC and RA:

• Infliximab: Approved for moderate-to-severe UC and RA
• Adalimumab: Approved for moderate-to-severe UC and RA
• Golimumab: Approved for moderate-to-severe UC and RA

All three demonstrate strong efficacy in UC, with infliximab showing superior remission rates compared to adalimumab in biologic-naïve UC patients (RR 2.10; 95% CI 1.16-3.79) 1. For UC specifically, the AGA strongly recommends using any of these TNF antagonists over no treatment (moderate quality evidence) 1.

Why Other UC Biologics Don't Work for RA

Vedolizumab is gut-selective (anti-integrin targeting α4β7) and has no systemic effect on joint inflammation—it is not approved for RA and should not be used for this indication 1.

Ustekinumab (IL-12/23 inhibitor) is approved for UC but not for RA, though it has approval for psoriatic arthritis 1.

Special Consideration: Tofacitinib (JAK Inhibitor)

Tofacitinib is approved for both UC and RA, making it another viable option. However, critical safety considerations apply:

• FDA restricts tofacitinib use in UC to patients who have failed or are intolerant to TNF antagonists 1
• In RA patients ≥50 years with cardiovascular risk factors, tofacitinib carries increased risk of pulmonary embolism and all-cause mortality at higher doses 1, 2
• For UC: induction dose is 10mg twice daily for 8 weeks; maintenance is 5mg twice daily 1
• Case reports demonstrate efficacy in UC-associated arthritis 3, 4

Use tofacitinib only after TNF antagonist failure in UC, and avoid in older RA patients with cardiovascular risk factors 1, 2.

Clinical Algorithm

For patients with both UC and RA:

1. First-line: Start with a TNF antagonist (infliximab, adalimumab, or golimumab)

   • Infliximab preferred in biologic-naïve UC patients for superior efficacy 1
   • Consider combination with immunomodulator (thiopurine or methotrexate) for enhanced efficacy in both conditions 1

2. After TNF antagonist failure: Consider tofacitinib

   • Only if patient is <50 years OR lacks cardiovascular risk factors
   • Monitor closely for thromboembolic events 2

3. Avoid: Vedolizumab (no RA efficacy), IL-17 inhibitors (may worsen IBD) 5

Important Caveats

Combination therapy considerations: The AGA suggests combining TNF antagonists with thiopurines or methotrexate over monotherapy in UC, which aligns well with RA management where combination therapy is standard 1. This dual benefit makes combination therapy particularly attractive in this population.

Monitoring requirements: TNF antagonists require screening for latent tuberculosis, hepatitis B, and monitoring for infections and malignancies—standard for both conditions.

Pregnancy planning: JAK inhibitors (tofacitinib) should be avoided in women of childbearing age contemplating pregnancy due to limited safety data 6.