Letter: comparative efficacy of biological therapy in patients with ulcerative colitis.

Abstract

SIRS We read, with great interest, the recent article titled ‘Systematic review with network meta-analysis: the efficacy of anti-tumour necrosis factor-alpha (TNF) agents for the treatment of ulcerative colitis (UC)” by Stidham and colleagues. In their Bayesian network meta-analysis, they compared the relative efficacy of different anti-TNF agents in induction and maintenance of clinical remission and response in patients with UC. They included all patients, regardless of previous anti-TNF exposure status in their analysis, did not report comparative efficacy for mucosal healing and did not include all biological agents (such as vedolizumab [VEDO]) studied for UC. We have performed a network meta-analysis of all approved (and likely to be approved) biological agents for the treatment of UC, in a subset of biological-na€ive patients. Through a systematic literature search, we identified two additional studies on the efficacy of vedolizumab in UC. 4 We abstracted data on induction of clinical remission and mucosal healing (Mayo endoscopy subscore 0 or 1, Baron score 0), in a subset of first-time users of biologicals. We performed an indirect treatment comparison network meta-analysis using Lumley’s network regression model. Our results are summarised in Table 1. On indirect comparison of nine trials, no single agent was superior to others. Anti-TNF agents were comparable to VEDO for both induction of clinical remission and mucosal healing. Although patients on infliximab (IFX) were twice as likely to achieve induction of remission as those on adalimumab (ADA) [Odds ratio (OR), 1.88; 95% Confidence interval (CI), 0.76–4.65], this difference was not statistically significant (P = 0.17). A nonsignificant trend was observed suggesting that IFX may be more efficacious than ADA in inducing mucosal healing (OR, 2.04; 95% CI, 0.97–4.27, P = 0.06). Due to differences in trial design, indirect treatment comparison of these agents for maintenance of remission had limited validity. Hence, similar to observations by Stidham and colleagues, we observed that IFX, ADA, GLM and VEDO had comparable efficacy, with no agent being clearly superior to others, in first-time biological users.