First-line biologic therapy selection highly impacts ulcerative colitis outcomes: results from the APPETISER study

Area of Science:

• Gastroenterology
• Immunology
• Pharmacology

Background:

• Ulcerative colitis (UC) management involves selecting the initial biologic therapy.
• Two strategies exist: effectiveness-based (EBS) focusing on drug efficacy, and acceptability-based (ABS) prioritizing tolerability.
• Real-world data is crucial for comparing these strategies in active UC patients.

Purpose of the Study:

• To compare the effectiveness of EBS versus ABS as first-line biologic therapy in ulcerative colitis (UC) patients.
• To evaluate the impact of the initial biologic choice on long-term clinical remission and treatment outcomes.

Main Methods:

• Real-world data from consecutive UC patients (≥18 years) initiating first-line biologics were analyzed.
• EBS included infliximab or vedolizumab; ABS included adalimumab or golimumab.
• Corticosteroid-free clinical remission (PRO2-CFREM) was the primary endpoint, with propensity score adjustments for comparisons.

Main Results:

• The effectiveness-based strategy (EBS) group achieved significantly higher PRO2-CFREM rates over 24 months (74.2% vs. 46.6%, P<0.001).
• EBS demonstrated superior remission rates within the first 6 months (60.4% vs. 18.9%) and sustained benefits across subsequent periods.
• EBS was associated with a lower risk of first-line biologic discontinuation (aHR, 6.5; P<0.001) and a trend towards reduced colectomy risk (aHR, 4.5; P=0.068).

Conclusions:

• The initial choice of biologic therapy profoundly impacts ulcerative colitis (UC) outcomes.
• Effectiveness-based strategies are superior to acceptability-based strategies in achieving and maintaining remission.
• Prioritizing the most effective biologic as first-line therapy is recommended for optimal UC management.