From the Guidelines
For infliximab-resistant immunotherapy-related colitis, the best treatment is vedolizumab, typically administered at 300 mg intravenously at weeks 0,2, and 6, followed by every 8 weeks thereafter. This recommendation is based on the most recent and highest quality study available, which suggests that vedolizumab may be effective in the setting of infliximab-resistant inflammation of the small intestine and colon 1.
Key Considerations
- Vedolizumab works by specifically targeting gut inflammation through α4β7 integrin inhibition, which blocks T-cell trafficking to the intestinal mucosa without systemic immunosuppression.
- This targeted approach makes it particularly suitable for immune checkpoint inhibitor-induced colitis that hasn't responded to infliximab, which works through TNF-α inhibition.
- Close monitoring with regular clinical assessments and endoscopic evaluation is necessary to assess treatment response and guide therapy duration.
Alternative Options
- If vedolizumab is not effective, alternative options include ustekinumab (initial IV dose of ~6 mg/kg followed by 90 mg subcutaneously every 8 weeks) or tofacitinib (10 mg orally twice daily for induction, then 5 mg twice daily for maintenance) 1.
- These treatments should be used alongside corticosteroids, which can be gradually tapered as symptoms improve.
- Supportive care including fluid and electrolyte management is essential.
Important Notes
- The decision to choose one biologic therapy over the other should be based on other risk factors, including the underlying malignancy and comorbidities, risk of infection, expected duration of treatment, and other concurrent immune-related adverse events 1.
- Infliximab should be avoided in patients with underlying hematologic malignancies, and used with caution in patients with underlying severe congestive heart failure 1.
From the Research
Treatment Options for Infliximab Resistant Immunotherapy Related Colitis
- Infliximab is a commonly used treatment for immunotherapy-related colitis, but some patients may be resistant to this treatment 2.
- For patients with infliximab-resistant immunotherapy-related colitis, dose escalation of infliximab may be a viable treatment option 2.
- Vedolizumab is another treatment option that can be used for patients with ulcerative colitis, and its effectiveness has been compared to infliximab in several studies 3, 4.
- A study comparing the efficacy and safety of infliximab and vedolizumab in patients with inflammatory bowel disease found that infliximab had better efficacy in the induction phase, but similar efficacy during the maintenance phase 3.
- Another study found that infliximab-first and vedolizumab-first treatment strategies had comparable long-term effectiveness and safety outcomes in biologic-naïve patients with ulcerative colitis 4.
Predictors of Treatment Outcome
- Severe endoscopic lesions have been identified as a predictor of short- and long-term colectomy in patients with severe corticosteroid-refractory ulcerative colitis treated with infliximab 5.
- High CRP values have also been associated with an increased risk of colectomy in these patients 5.
- The effectiveness of infliximab dose escalation in patients with refractory immunotherapy-related colitis may depend on various factors, including the severity of the disease and the patient's response to initial treatment 2.
Safety and Efficacy of Treatment Options
- Infliximab has been shown to be an effective and safe rescue therapy for severe corticosteroid-refractory ulcerative colitis, with a low rate of adverse events 5.
- Vedolizumab has also been found to be safe and effective in patients with ulcerative colitis, with a similar safety profile to infliximab 3, 4.
- The infection rate was higher in infliximab for Crohn's disease and higher in vedolizumab when treating patients with ulcerative colitis 3.