What is the preferred treatment between anti-TNF (Tumor Necrosis Factor) agents and Entyvio (vedolizumab) for ulcerative colitis?

Treatment Selection Between Anti-TNF Agents and Vedolizumab for Ulcerative Colitis

For patients with moderate-to-severe ulcerative colitis, vedolizumab is recommended over anti-TNF agents, particularly in patients who have failed prior anti-TNF therapy, due to its superior efficacy and better safety profile.

First-Line Therapy Selection

Biologic-Naïve Patients

• For biologic-naïve patients with moderate-to-severe UC, higher efficacy medications including infliximab and vedolizumab are preferred over lower efficacy options like adalimumab 1
• Infliximab appears superior to vedolizumab, adalimumab, ustekinumab, and ozanimod in biologic-naïve patients 1
• The AGA suggests using infliximab or vedolizumab over adalimumab for biologic-naïve patients with UC 1
• All biologic agents (infliximab, adalimumab, golimumab, vedolizumab, tofacitinib, ustekinumab) are effective compared to placebo for induction and maintenance of remission 1

Safety Considerations

• Vedolizumab demonstrates a 32% lower risk of serious infections compared to TNF antagonists in patients with UC 1
• Vedolizumab has a more favorable safety profile than anti-TNF therapy due to its gut-selective mechanism of action 2
• JAK inhibitors (tofacitinib, upadacitinib) have restricted use in biologic-naïve patients and should be used with caution in patients with cardiovascular risk factors 1

After Anti-TNF Failure

Primary Anti-TNF Failure

• In patients with primary failure to an anti-TNF therapy, vedolizumab is strongly recommended over switching to another anti-TNF therapy 1
• For patients who have failed anti-TNF therapy, vedolizumab is strongly recommended to induce complete corticosteroid-free remission 3

Secondary Anti-TNF Failure

• In patients with secondary failure to an anti-TNF therapy, switching to another anti-TNF therapy or vedolizumab is recommended based on therapeutic drug monitoring results 1
• After failure of a first subcutaneous anti-TNF agent (adalimumab or golimumab), patients treated with vedolizumab achieved higher clinical remission rates (49%) compared to those treated with infliximab (26%) 4
• In biologic-exposed patients, particularly after TNF antagonist failure, upadacitinib, tofacitinib, and ustekinumab appear superior to vedolizumab 1

Efficacy Considerations

Induction of Remission

• Vedolizumab has demonstrated significant efficacy for both induction and maintenance of remission in patients with moderate to severe ulcerative colitis 3
• In a head-to-head trial comparing vedolizumab vs adalimumab, clinical remission rates were significantly higher in vedolizumab-treated patients (34.2% vs 24.3%) 3
• The kinetic of response with vedolizumab appears to be slower compared to anti-TNF-alpha antibodies 2

Maintenance of Remission

• Vedolizumab shows deep and sustained remission in patients initially responding to induction therapy with a lower loss of efficacy in long-term treatment compared to anti-TNF therapy 2
• In patients who respond to vedolizumab induction, continued vedolizumab therapy is strongly recommended to maintain complete corticosteroid-free remission 1

Monitoring and Assessment

• Patients should be evaluated for lack of symptomatic response to anti-TNF induction therapy in 8-12 weeks to determine the need to modify therapy 1
• For vedolizumab, assessment of response should occur between 8-14 weeks after initiation 1, 3
• In patients with suboptimal response to anti-TNF induction therapy, dose intensification is recommended 1
• Therapeutic drug monitoring should inform dose optimization for patients with UC on anti-TNF therapy 1

Combination Therapy Considerations

• When starting anti-TNF therapy, it is recommended to combine it with a thiopurine or methotrexate rather than using it as monotherapy 1
• For vedolizumab, concomitant treatment with immunomodulators does not substantially affect its efficacy 1

Clinical Decision Algorithm

1. For biologic-naïve patients:

   • First choice: Infliximab (especially if rapid response needed) 1
   • Alternative: Vedolizumab (if infection risk is a concern) 1, 2

2. For patients with prior anti-TNF failure:

   • Primary failure: Vedolizumab 1, 3
   • Secondary failure: Consider upadacitinib, tofacitinib, or ustekinumab over vedolizumab 1

3. For patients with high risk of infections or malignancies:

   • Vedolizumab is preferred due to its gut-selective mechanism and lower infection risk 1, 2

4. For maintenance therapy after successful induction:

   • Continue the same agent that achieved induction 1
   • Vedolizumab may offer better long-term persistence with less loss of efficacy 2