Choosing Biologics and Small Molecules in 2024

The process of picking the right treatment begins with the initial evaluation of the patient, which includes defi ning the severity of the disease and prognostic factors.

For Crohn’s disease, predictors of an unfavorable course include age 40, the need for steroids in the fi rst fl are, perianal disease, upper GI lesions, ileocolonic lesions and stricturing and penetrating behavior.

Similarly, for ulcerative colitis (UC), predictors of an unfavorable course encompass younger age, female gender, extensive colitis, nonsmoking status and low serum albumin.When deciding on the right treatment in a clinical setting, there are preferences, good options, last choices (not necessarily wrong) and treatments with sparse data.

For moderate to severe luminal Crohn’s disease, the preference is given to infl iximab, adalimumab, risankizumab and ustekinumab. Upadacitinib is considered a good option, while azathioprine (?) and vedolizumab are the last choices.

In the case of perianal Crohn’s disease, infl iximab is preferred, and good options include adalimumab, vedolizumab and ustekinumab. Risankizumab and upadacitinib have sparse data on their effi cacy and safety.

For individuals with both infl ammatory arthritis and infl ammatory bowel disease (IBD), the preference is for anti-TNF medications. JAK inhibitors and ustekinumab are considered good options, while vedolizumab is the last choice. Ozanimods have sparse data on their effi cacy and safety.

Similarly, for those with both psoriasis and IBD, preferences include anti-TNF and ustekinumab. Vedolizumab is a last choice, and ozanimod and JAK inhibitors (excluding arthritis) have sparse data on their effi cacy and safety.