Introduction

Over the last decade, treatment options for moderate-to-severe ulcerative colitis (UC) have expanded. However, comparative studies between these agents are limited, especially among biologic naïve patients. We aimed to compare the efficacy, safety and persistence of tofacitinib and vedolizumab as the first advanced treatment for patients with UC.

Aims & Methods

Patients who received either tofacitinib or vedolizumab as their first advanced therapy for UC via the NHS Lothian health board were included. Patients aged 65 years or older were excluded. We used inverse probability of treatment weighting (IPTW). The probability of treatment assignment was calculated via logistic regression using age, gender, IBD duration, Montreal extent, CRP, concomitant corticosteroids, and partial Mayo score at drug commencement. Missing data for these variables were imputed using multivariate imputation by chained equations. Confounder-adjusted survival curves were created using Kaplan-Meier estimates weighted via IPTW. The Pepe and Fleming test was used to compare survival curves.

Results

We included 158 patients of whom 81 (51.2%) received vedolizumab and 77 (48.7%) tofacitinib. Median follow-up for patients on vedolizumab was 3.1 (1.6-4.8) years and for tofacitinib 1.5 (0.34-2.3) years. The cohort was 59.3% male with a median age of 41.1 years (31.5-51.8) and disease duration of 6.21 years (2.56-13.5). At drug commencement there were no differences in steroid prescription, partial Mayo score, CRP or faecal calprotectin.
Vedolizumab persistence was superior to tofacitinib (p=0.005). Primary non-response and secondary loss of response were 9.9% and 17.3% for vedolizumab and 23.4% and 13% for tofacitinib respectively. At week 12, steroid free clinical remission was more frequent in the vedolizumab group (69% vs 51.4%, p=0.030), Table 1.There were no differences in the frequency of adverse events (11 [13.6%] vedolizumab vs 19 [24.7%] tofacitinib, p=0.629). However, adverse events resulting in temporary discontinuation of the drug occurred in 1 (1.2%) vedolizumab versus 11 (14.3%) tofacitinib, p=0.013.

Conclusion

We found that the persistence and tolerability of vedolizumab was superior to tofacitinib in bio-naïve UC, although the rates of clinical and biomarker remission were comparable. These data may help inform positioning of advanced therapy in UC.

Disclosure

Beatriz Gros has served as consultant to Galapagos and Abbvie and as speaker for Abbvie, Jansen, Takeda, Pfizer and Galapagos. Nikolas Plevris has served as a speaker for Janssen, Takeda and Pfizer. Professor Charlie Lees has acted as a consultant to Abbvie, Janssen, Takeda, Pfizer, Galapagos, Bristol Myers Squibb, B.I., Sandoz, Novartis, GSK, Gilead, ViforPharma, Dr Falk, Trellus Health and Iterative Scopes; he has received speaking fees and travel support from Pfizer, Janssen, Abbvie, Galapagos, MSD, Takeda, Shire, Ferring, Hospira and Dr Falk. Gareth-Rhys Jones has served as a speaker for Takeda, Janssen, Abbvie, Fresnius and Ferring.

Introduction

Biologic and small-molecule therapies are widely used for ulcerative colitis (UC), but their comparative effectiveness in TNF-exposed patients remains unclear.

Aims & Methods

This study evaluates the clinical and biomarker responses to Vedolizumab, Tofacitinib, and Ustekinumab over 12 months, adjusting for baseline differences using Inverse Probability of Treatment Weighting (IPTW). A multicenter retrospective cohort of TNF-exposed UC patients treated with Vedolizumab (n = 260), Tofacitinib (n = 149), or Ustekinumab (n = 193) was analyzed. Clinical outcomes, including Partial Mayo Score (pMayo), clinical remission, and biomarker response (CRP, ESR, fecal calprotectin), were assessed at baseline (T0), 8 weeks (T1), 24 weeks (T2), and 52 weeks (T3). IPTW balanced baseline characteristics, and longitudinal changes were analyzed using a repeated-measures general linear model (GLM) with post-hoc corrections for multiple comparisons.

Results

Before IPTW, significant baseline differences existed, with Tofacitinib patients being younger (p < 0.001), more frequently female (p = 0.003), and having higher fecal calprotectin levels (p = 0.005). After IPTW, covariate balance was achieved (SMD < 0.10). pMayo scores significantly declined in all treatment groups over time (p < 0.001, η² = 0.469), with no significant main effect of therapy (p = 0.329). A minor time-by-therapy interaction (p = 0.036, η² = 0.026) indicated slight response variations but lacked clinical significance. Before IPTW, Tofacitinib showed superior pMayo improvement versus Ustekinumab (p = 0.008), but this difference lost significance post-IPTW, suggesting baseline confounding. At 52 weeks, clinical remission was highest with Tofacitinib (57%), followed by Vedolizumab (40%) and Ustekinumab (22%) (p = 0.003). Biomarker remission favored Vedolizumab (48.8%) over Tofacitinib (19.5%) and Ustekinumab (21.2%) (p = 0.002). Adverse events were rare but more frequent with Vedolizumab (p < 0.001).

Conclusion

Over 12 months, all therapies significantly improved clinical and biomarker outcomes, with no significant differences in overall pMayo reduction post-IPTW. Tofacitinib achieved the highest clinical remission, while Vedolizumab demonstrated superior biomarker response. These findings highlight the need for individualized treatment selection in TNF-exposed UC patients.

Introduction

While three JAK inhibitors are now available in Ulcerative Colitis (UC), the hierarchy of these treatments according to their effectiveness, remains to be determined.

Aims & Methods

In the JAKARTA study, we aimed to compare the effectiveness of the three available JAK inhibitors (tofacitinib/TOFA, filgotinib/FILGO and upadacitinib/UPA) in bio-exposed patients with UC.
In this retrospective multicenter study (12 centres), we included all consecutive patients with UC ≥18 years-old, partial Mayo score > 2 who had started TOFA, FILGO or UPA after receiving ≥ 1 biologic between JAN2019 and JUN2022. Acute severe UC were excluded.
Following regimen were applied for TOFA (10mg b.i.d until W8 and 5mg or 10 mg b.i.d according to physician’s judgement), FILGO (200mg q.d) and UPA (45mg q.d until W8 and 45mg, 30 mg or 15 mg q.d according to physician’s judgement).
The primary endpoint was symptomatic remission (partial Mayo score ≤ 2) without corticosteroids (CFREM) at W16. Secondary endpoints were clinical and endoscopic remission (CFREM + endoscopic Mayo score ≤ 1), histological and endoscopic mucosal improvement (HEMI) (= clinical-endoscopic and histological remission (Nancy index ≤ 1)), drug retention (treatment discontinuation-free survival using Kaplan-Meier curve), time to colectomy, time to UC-related hospitalization and secondary loss of response among patients in CFREM at W16.
All the comparisons were performed using propensity scores adjustment (IPTW).

Results

A total of 290 patients were included: 150, 79 and 61 in TOFA, FILGO, and UPA arms, respectively. The 3 groups were comparable except for higher proportion of patients with previous exposure to > 3 biologics in UPA group (p < 0.001). TOFA 10 mg b.i.d was continued until W16 in 47.0% of patients. FILGO was maintained at 200 mg in 97.5%. UPA was diminished at 30 mg and 15 mg at W8 in 55.6% and 3.3% of patients, respectively.
After IPTW, CFREM at W16 was higher in UPA (60.1%) compared to TOFA (38.9%) or FILGO groups (36.0%) (p = 0.026 and 0.016, respectively). No predictive factor of efficacy/ failure was identified with these 3 JAK inhibitors.
We failed to show any significant difference regarding clinical-endoscopic remission (UPA:16.5%, TOFA:16.5%, FILGO:12.8%) or HEMI (UPA:11.9%, TOFA: 4.4, FILGO: 12.7%) at W16.
Among patients who reduced the dose to the recommended maintenance regimen (TOFA 5 mg b.i.d and UPA 30 or 15 mg q.d) between W8 and W16, the need for dose re-escalation to the induction dose was 33.8% (27/80) for TOFA, 14.7% (5/34) for UPA30mg and 50.0 % (1/2) for UPA 15 mg. After adjustment, drug retention was longer for UPA compared to TOFA (HR = 0.38 [0.17-0.85], p = 0.019) and FILGO groups (HR = 0.17 [0.08-0.65], p < 0.001) and shorter in FILGO than in TOFA group (HR = 1.57[1.02-2.41], p = 0.038).
No difference was demonstrated in terms of time to hospitalization or surgery between the 3 groups.
Among patients achieving CFREM at W16 (regardless of the dose), secondary loss of response (symptomatic relapse) was similar for TOFA:12.8% (N=47 patients), FILGO: 19.2% (N = 26 patients) and UPA: 10.3% (N = 29 patients) (p=ns after IPTW).

Conclusion

In this real-world evidence multicenter study, UPA was the most effective JAK inhibitor in UC at short and long-term but the large use of off-label maintenance doses in current practice needs further safety investigations.

Disclosure

Consulting fees from: Abbvie, Amgen, Arena, Biocon, Biogen, Celltrion Healthcare, CTMA, Ferring, Galapagos/AlfaSigma, GutyCare/Resilience Janssen, Lilly, MSD, Nexbiome, Pfizer, Roche, Sandoz, Takeda et Tillotts
Lecture fees from : Abbvie, Amgen, Biogen, Celltrion Healthcare Galapagos/AlfaSigma, Ferring, Janssen, Lilly, Mayoli-Spindler, MSD, Nordic Pharma, Norgine, Pfizer, Roche, Takeda, Tillotts and Vifor Pharma
Research grants/fundings from: Abbvie, Celltrion Healthcare, Janssen, Lessaffre, Lilly, Pfizer, Sandoz and Takeda

Introduction

Both vedolizumab and ustekinumab can be considered for the treatment of ulcerative colitis (UC) but head-to-head trials are lacking. We aimed to compare the effectiveness of vedolizumab and ustekinumab after anti-TNF failure in UC patients.

Aims & Methods

All consecutive patients with UC treated with ustekinumab or vedolizumab after being exposed to at least one anti-TNF in 10 French centers between January 2019 and August 2022 were included retrospectively. The primary endpoint was clinical remission (Mayo score partial ≤ 2) without corticosteroid (SFCR) at week 16 (W16). Secondary endpoints were endoscopic remission (SFCR and endoscopic Mayo score ≤ 1 or fecal calprotectin < 150 µg/g), and histological healing (endoscopic remission and histological (Nancy index ≤ 1)). All the comparisons were performed using propensity score analyses (inverse probability of treatment weighting) adjusted for age, gender, smoking status, disease duration and extension, number of prior biologics or prior primary failure to biologics, the co-prescription of 5-ASA, corticosteroids or immunosuppressants, and disease severity.

Results

Among a total of 316 patients included, 165 and 151 received ustekinumab and vedolizumab, respectively. Baseline characteristics (gender, age, disease location, co-prescription of 5-ASA or corticosteroids) were similar between the two groups except for disease duration (ustekinumab, 9.3 vs vedolizumab 7.2 year; p=0.003), co-immunosuppressants (5.4% vs 20.5%, <0.001), and prior exposition to > 2 biologics (46.6% vs 5.9%, p<0.001). At W16, SFCR was respectively 40.3% and by 37.9% in the ustekinumab and vedolizumab groups (aOR = 1.10 [0.39-3.12], p=0.085). SFCR rates were 62.2% vs 53.2% (p=0.52) after one failure, 33.7% vs 44.3% (p=0.52) after two biologics and 19.1% vs 2.6% (p=0.03) after 3 biologics failure, in the ustekinumab and vedolizumab groups, respectively.
Endoscopic remission and histologic healing rates at week 16 were respectively of 17.5% vs 5.3% (aOR = 3.77 [1.25-11.36], p=0.018) and 11.1% vs 2.1% (aOR = 5.85 [1.47-23.30], p=0.012) in the groups ustekinumab and vedolizumab.

Conclusion

While no difference in terms of clinical remission was observed, ustekinumab appears to be more effective than vedolizumab to induce endoscopic and histological remission after failure of anti-TNFs in UC.

Disclosure

AbbVie, Ferring, Janssen, MSD, Takeda, Pfizer, Celgene, Biogen, Amgen, Boehringer Ingelheim, Hospira et Celltrion

Introduction

Anti-TNF agents play a significant role in the induction and maintenance therapy of moderate to severe ulcerative colitis. However, at least 30% of patients experience loss of response within the first year of treatment.

Aims & Methods

This study aims to compare Tofacitinib versus Vedolizumab in patients with ulcerative colitis in the setting of previous anti-TNF failure. We performed a systematic review in PubMed, Embase and Cochrane databases, searching for randomized and non-randomized studies comparing Tofacetinib versus Vedolizumab in this population. The primary outcome was colectomy rate. The secondary outcomes were thromboembolic event rate and infectious incidence. The odds ratio (OR) was used for binary outcomes with their respective 95% confidence interval (CI). Heterogeneity was assessed using the Cochran Q test and I² statistics.

Results

The meta-analyses included 6 studies and 2,241 patients. There was a significant difference favoring Vedolizumab in colectomy rate (OR 2.03; 95% CI 1.30 to 3.16, p=0.002; I2=0%). There were no difference in thromboembolic event rate (OR 0.90; 95% CI 0.39 to 2.06; p=0.798; I2=0%) and infection incidence (OR 0.83; 95% CI 0.56 to 1.25; p=0.378; I2=0%).

Conclusion

In patients with ulcerative colitis with prior anti-TNF failure, tofacitinib showed higher colectomy rate compared to vedolizumab, with no difference in thromboembolic and infectious events between both groups. Considering this, vedolizumab seems to be a reasonable option in this population.

References

1. Straatmijer T, Biemans V, Visschedijk MC, Hoentjen F, De Vries A, Van Bodegraven AA, et al. SUPERIOR EFFECTIVENESS OF TOFACITINIB COMPARED TO VEDOLIZUMAB IN ANTI-TNF EXPERIENCED ULCERATIVE COLITIS PATIENTS: A NATIONWIDE DUTCH REGISTRY STUDY. United Eur Gastroenterol J. 2022;10((Straatmijer T., t.straatmijer@amsterdamumc.nl; De Boer K.H.N.) Amsterdam UMC, Amsterdam, Netherlands):390–1.
2. Buisson A, Serrero M, Altwegg R, Guilmoteau T, Bouguen G, Nachury M, et al. Real-world comparison of effectiveness between tofacitinib and ustekinumab in patients with ulcerative colitis exposed to at least one anti-TNF agent: Results from the TORUS study. J Crohns Colitis. 2023;17((Buisson A.; Guilmoteau T.) CHU Clermont-Ferrand, IBD Unit, Clermont-Ferrand, France):i707.
3. Adimadhyam S, Lewis JD, Simon AL, Wolfe AE, Smith S, Hou L, et al. Real-world Evidence Comparing Tofacitinib and Vedolizumab in Anti-TNF-experienced Patients With Ulcerative Colitis. Inflamm Bowel Dis. 2024 Apr 3;30(4):554–62.
4. Hyun HK, Zhang HS, Yu J, Kang EA, Park J, Park SJ, et al. Comparative effectiveness of second-line biological therapies for ulcerative colitis and Crohn’s disease in patients with prior failure of anti-tumour necrosis factor treatment. BMC Gastroenterol. 2022 Mar 27;22(1):143.

Introduction

Janus kinase inhibitors (JAKi), including tofacitinib (TOFA, a pan-JAK inhibitor) and filgotinib (FILGO, a selective JAK1 inhibitor), represent an emerging class of orally administered agents for moderate-to-severe ulcerative colitis (UC). Comparative real-world data on their effectiveness and safety are limited.

Aims & Methods

We conducted a multicenter, real-world, propensity score-weighted cohort study using data from the Sicilian Network for Inflammatory Bowel Diseases (SN-IBD). All adult UC patients treated with TOFA or FILGO with ≥16 weeks of follow-up were included. The primary outcomes were steroid-free clinical remission and clinical response at weeks 8 and 24. Treatment persistence and adverse events were also assessed. Inverse Probability of Treatment Weighting (IPTW) was applied to adjust for baseline differences.

Results

A total of 263 patients were included (TOFA: n=171; FILGO: n=92). At week 8, steroid-free clinical remission was achieved in 53.2% of patients treated with TOFA and 43.4% of those treated with FILGO (IPTW-adjusted OR: 1.51; 95% CI: 0.88–2.61; p=0.14). Clinical response at 8 weeks was reported in 75.4% of TOFA-treated patients versus 69.6% in the FILGO group (IPTW-adjusted OR: 1.34; 95% CI: 0.73–2.46; p=0.34). At week 24, steroid-free clinical remission was observed in 58.8% of the TOFA group and 44.9% of the FILGO group (IPTW-adjusted OR: 1.37; 95% CI: 0.76–2.49; p=0.30). Clinical response rates at 24 weeks were 63.6% for TOFA and 59.0% for FILGO (IPTW-adjusted OR: 1.13; 95% CI: 0.62–2.08; p=0.69). IPTW-adjusted Kaplan–Meier and Cox proportional hazards analyses showed no statistically significant difference in the likelihood of treatment discontinuation (log-rank p=0.294; IPTW-adjusted HR for TOFA: 0.78; 95% CI: 0.49–1.25; p=0.30). Adverse event rates were 12.7 and 5.4 per 100 person-years for TOFA and FILGO, respectively, with no significant difference (p=0.152).

Conclusion

In this real-world, IPTW-based study, TOFA and FILGO were well tolerated and demonstrated comparable and high effectiveness and treatment persistence in patients with moderate-to-severe UC, supporting their use as viable oral options in routine clinical practice.

Disclosure

FSM served as an advisory board member and/or received lecture grants from AbbVie, Ferring, Galapagos, Giuliani, Janssen, Lilly, Liohealth s.r.l., Pfizer, Sandoz, Takeda Pharmaceuticals. WF served as an advisory board member and/or received lecture grants from Abbvie, MSD, Takeda, Pfizer, Biogen, Sandoz, Zambon, Ferring, Sofar. AV received lecture grants from Pfizer. MC served as an advisory board member for AbbVie, MSD, Takeda Pharmaceuticals, and received lecture grants from AbbVie, MSD, Chiesi, and Takeda Pharmaceuticals. MC served as an advisory board member for AbbVie, MSD, Takeda Pharmaceuticals, and received lecture grants from AbbVie, MSD, Chiesi, and Takeda Pharmaceuticals. FM served as an advisory board member for Janssen and Galapagos, and received lecture grants from Takeda Pharmaceuticals. SR served as an advisory board member for AbbVie, Janssen, and MSD Pharmaceuticals, and received lecture grants from AbbVie, Galapagos, Janssen, MSD, Pfizer, and Takeda Pharmaceuticals. AO served as an advisory board member for AbbVie, Ferring, Galapagos, Lilly, MSD, Janssen, Pfizer, Samsung Bioepis, and Takeda Pharmaceuticals, and received lecture grants from AbbVie, Fresenius Kabi, Galapagos, Lionheath s.r.l., MSD, Sofar, Chiesi, Janssen, Pfizer, and Takeda Pharmaceuticals. All other authors: nothing to disclose.

Introduction

Long-term VDZ outcomes in real-world cohorts have mostly focussed on 1-year follow-up, with the longest reporting outcomes at 2-years. However, most of these studies include biologic exposed patients and also report limited data on objective markers of inflammation.

Aims & Methods

We performed a retrospective, observational, cohort study. All adult UC/IBDU patients who ever received VDZ complete induction from 2014 to December 2021 were included. Baseline phenotype and follow-up data were collected via review of electronic medical records.
The primary outcome of this study was VDZ persistence. Secondary outcomes included: clinical (partial Mayo <2), biochemical (CRP <5 gr/L) and faecal biomarker (faecal calprotectin <250 µgr/gr) remission at 1,3 and 5 years; hospitalisation, steroid prescription, surgical rates; predictors of VDZ persistence; and serious adverse events.

Results

We included 290 patients (UC n=271 [93.4%], IBDU n=19 [6.6%]), median time on VDZ 27.6 months (IQR 14.4-43.2). VDZ persistence at first year was 80.7%, 64.4% at two years, 56.5% at 3 years, 49.5% at 4 years, 47.9% at 5 years and 41.5% at 6 years. Median time to discontinuation was 14.1 months (IQR 7.0-23.3 months). Reasons for drug discontinuation: 51(17.6%) primary non-response, 63 (21.7%) secondary loss of response [8 (2.8%) during the first year; 33 (11.4%) between the first and second year; 13 (4.5%) between the second and third year; 5 (1.7%) between the third and fourth year and 4 (1.4%) over the fourth year], 9 (3.1%) adverse event, 4 (1.4%) remission and 6 (2.1%) other reasons. Multivariable Cox Regression model found previous exposure to one biologic/small molecule (HR 1.52, 95% CI 1.03-2.22, p=0.033); two or more biologic/small molecule (HR 2.37, 95% CI1.37-4.09, p=0.002), steroid at baseline (HR 1.57, 95%CI 1.08-2.29, p=0.019), left-side colitis (HR 2.80, 95% CI 1.11-7.09, p=0.029), extensive colitis (HR 3.32, 95%CI 1.34-8.21, p=0.010) and disease duration ≥ 10 years (HR 0.60, 95%CI 0.43-0.86) were independent predictors for VDZ persistence (Table 1). Clinical, biochemical and faecal biomarker remission at year 1 were 171/226 (75.7%), 157/217 (72.4%) and 127/181 (70.2%); at year 3, 83/92 (90.2%), 78/91 (85.7%) and 52/59 (88.1%) and at year 5, 23/25 (92%), 23/26 (88.5%) and 15/17 (88.2%) respectively. During follow-up, steroid prescription was needed in 98 (33.8%), hospitalization 45 (15.5%) and surgery 10 (3.4%). Serious adverse events were 1.2 per 100 patient-year follow-up.

Conclusion

VDZ effectiveness is durable and its persistence is influenced by disease duration, previous exposure to biologics/small molecules, disease extension and steroids at baseline. Long-term VDZ safety is confirmed in our study.

Disclosure

Beatriz Gros has served as a speaker for Abbvie, Jansen, Takeda, Pfizer and Galapagos.
Nikolas Plevris has served as a speaker for Janssen, Takeda and Pfizer.
Professor Charlie Lees has acted as a consultant to Abbvie, Janssen, Takeda, Pfizer, Galapagos, Bristol Myers Squibb, B.I., Sandoz, Novartis, GSK, Gilead, Vifor Pharma, Dr Falk, Trellus Health and Iterative Scopes; he has received speaking fees and travel support from Pfizer, Janssen, Abbvie, Galapagos, MSD, Takeda, Shire, Ferring, Hospira, and Dr Falk.
Gareth-Rhys Jones has served as a speaker for Takeda, Janssen, Abbvie and Ferring.
Lauranne Derikx has served on advisory board for Sandoz and as a speaker for Janssen.
Colin Noble has acted as a consultant to Galapagos.
None of the other authors reported any conflicts of interest.