Positioning of old and new biologicals and small molecules in the treatment of inflammatory bowel diseases

Table 2 Biologic agents which have demonstrated efficacy in inflammatory bowel diseases and rheumatology

	Mechanism of action	UC	CD	2Fistulization	Ankylosing Spondylitis	Psoriasis
Anti-TNF
1Infliximab[20,22,51,119]	Chimeric monoclonal antibody	x	x	x	x	x
Adalimumab[26,28,54,120,121]	Fully human monoclonal antibody	x	x	x	x	x
Certolizumab[31,122,123]	Pegylated humanized monoclonal antibody Fab' fragment		x	+/-	x	x
Golimumab[57,122,124]	Fully human monoclonal antibody	x			x	x
Anti-integrin
4Natalizumab[39]	Chimeric monoclonal antibody against α4 integrin		x
3Vedolizumab[46,96]	Chimeric monoclonal antibody against α4β7 integrin	x	x	+/-
Ustekinumab[50,125,126]	Fully human monoclonal antibody against P40 sub-unit of IL-12 and IL-23		x	+/-	x	x

¹Infliximab is the only biologic which has been evaluated to be an effective ‘rescue’ agent. Evidence is lacking for the remaining biologics;

²Improvement in fistulizing disease was evaluated as a primary outcome only in infliximab. Efficacy was otherwise determined indirectly from secondary outcomes, subgroup analyses and small scale studies for the remaining biologics;

³Consider the use of vedolizumab as a first-line biologic agent in patients at high risk for infectious complications. Vedolizumab has a slower onset of action (approximately 6-8 wk) as compared to alternate biologics;

⁴Use of natalizumab is contraindicated if the patient is JC virus antibody positive due to the risk of progressive multifocal leukoencephalopathy. UD: Ulcerative colitis; CD: Crohn’s disease.