Early Biologic Treatment for Inflammatory Bowel Disease

This rapid review updates the evidence for early biologic treatment versus conventional step-up therapy for patients with luminal Crohn disease, fistulizing Crohn disease, or ulcerative colitis. Findings are based on 4 systematic reviews, 2 randomized controlled trials, and 3 updated clinical guidelines. Luminal Crohn Disease Three systematic reviews showed that early biologic treatment, initiated within 36 months of diagnosis, significantly improved clinical remission, mucosal healing, and reduced relapse rates, surgery needs, and disease progression compared to conventional strategies. Two randomized controlled trials found that early infliximab treatment led to better remission rates, quality of life, and safety outcomes compared with conventional treatment for both adults and children with newly diagnosed moderate-to-severe Crohn disease. These results are consistent with previous evidence suggesting that early biologic drugs improve clinical benefits compared with conventional strategies. Clinical guidelines generally recommend biologic drugs as third-line treatment. One guideline targets adults and children with severe, active Crohn disease, and another focuses on children and adolescents with luminal Crohn disease regardless of severity. Of these, 1 guideline recommends first-line biologics for high-risk pediatric patients. Fistulizing Crohn Disease One guideline recommends third-line infliximab for patients with active fistulizing Crohn disease who did not respond, did not tolerate or had a contraindication to conventional therapy. First-line anti–tumour necrosis factor therapy was only recommended for children and adolescents with fistulizing perianal Crohn disease. No evidence was identified for this population. Ulcerative Colitis In 1 systematic review, early biologics were found to be associated with a higher risk of colectomy. However, these findings should be interpreted with caution as they are based on evidence from 3 observational studies. One guideline recommends infliximab as a third-line option for acute severe cases contraindicated to or clinically inappropriate with ciclosporin.