What is the preferred treatment between golimumab and infliximab for Crohn's disease?

Infliximab vs Golimumab for Crohn's Disease

Infliximab is the preferred treatment for Crohn's disease, as it is the only anti-TNF agent with strong guideline recommendations and established efficacy for this indication, while golimumab is not approved or recommended for Crohn's disease. 1

Guideline-Based Recommendations

Infliximab for Crohn's Disease

• The European Crohn's and Colitis Organisation (ECCO) strongly recommends infliximab as both induction and maintenance therapy for moderate-to-severe Crohn's disease (strong recommendation, moderate-quality evidence for induction; strong recommendation, low-quality evidence for maintenance). 1

• Infliximab is administered intravenously at 5 mg/kg at weeks 0,2, and 6 for induction, followed by maintenance dosing every 8 weeks. 1

• The recommended TNF inhibitors specifically listed for Crohn's disease include infliximab, adalimumab, and certolizumab pegol—golimumab is notably absent from these recommendations. 1

Golimumab for Crohn's Disease

• Golimumab does not appear in any ECCO guidelines for Crohn's disease treatment, despite being mentioned as an available anti-TNF agent for inflammatory bowel disease in general literature. 2

• While golimumab is approved for ulcerative colitis, there is no guideline support or regulatory approval for its use in Crohn's disease. 2

Combination Therapy Considerations

When initiating infliximab, combination therapy with a thiopurine is strongly recommended to enhance efficacy and reduce immunogenicity (strong recommendation, moderate-quality evidence). 1

• Combination therapy should be maintained for a minimum of 6-12 months when using infliximab as maintenance therapy. 1

• After achieving long-term remission, de-escalation to infliximab monotherapy with withdrawal of thiopurines can be considered (weak recommendation, moderate-quality evidence). 1

Efficacy Data for Infliximab

• Meta-analyses demonstrate infliximab achieves clinical remission with a relative risk of 1.6 (95% CI: 1.17-2.36) compared to placebo in patients who failed conventional therapy. 1

• Infliximab is effective for both luminal disease (78% initial response rate) and fistulizing disease (52% initial response rate). 3

• Infliximab is the only drug therapy proven effective for fistulizing Crohn's disease, achieving complete fistula closure in a significant proportion of patients. 4

Practical Clinical Algorithm

For a patient with moderate-to-severe Crohn's disease requiring biologic therapy:

1. First-line biologic choice: Infliximab 5 mg/kg IV at weeks 0,2, and 6 1

2. Concurrent therapy: Start thiopurine (azathioprine or 6-mercaptopurine) simultaneously to reduce immunogenicity 1

3. Maintenance dosing: Continue infliximab 5 mg/kg every 8 weeks with thiopurine for 6-12 months 1

4. Dose optimization if needed: Escalate to 10 mg/kg every 8 weeks for secondary loss of response, guided by therapeutic drug monitoring 1, 5

5. Long-term management: After sustained remission, consider withdrawing thiopurine while continuing infliximab monotherapy 1

Safety Monitoring Requirements

• Screen for tuberculosis with QuantiFERON or PPD before initiating infliximab 5, 6

• Check hepatitis B status prior to treatment 6

• Rule out active infections before each infusion 6

• Monitor for infusion reactions (occur in 3-17% of patients), which can be reduced with premedication and concurrent immunosuppressants 5, 6

Common Pitfall to Avoid

Do not consider golimumab as an alternative to infliximab for Crohn's disease—this would be off-label use without guideline support or evidence of efficacy in this specific condition. 1, 2