From the AGA Journals

Upadacitinib shows promise in treatment-resistant UC and Crohn’s

Understanding the efficacy, onset of action and safety of newly approved inflammatory bowel disease (IBD) therapies is difficult in the absence of real-world data as clinical trial populations are much more restrictive and typically do not reflect the patient populations seen in most IBD clinics. This single-center study by Friedberg and colleagues reports on their experience with upadacitinib use in patients with ulcerative colitis (UC) and Crohn’s disease (CD). One key finding of this study is the rapid onset of action with high rates of clinical response and remission within 2 weeks of initiation (60% and 36%) for UC and (50% and 56%) for CD. Further, these high rates of clinical response and remission were noted despite exposure to multiple prior therapies (including prior tofacitinib use), which has been a limitation with other IBD therapies.

Dr. Jill K.J. Gaidos

With the concerns for safety of tofacitinib use, another Janus kinase inhibitor, raised by the ORAL surveillance study, many patients and practitioners are concerned about the safety of upadacitinib use. This study highlighted the low rate of adverse events including no incidences of herpes zoster infection, venous thromboembolism or major adverse cardiovascular events. Acne was noted to be the most common adverse event, occurring in 22% of the study population.

Further research is needed to assess the long term clinical and endoscopic response rates as well as long-term safety assessments, however these results will facilitate conversations with patients who could potentially benefit from treatment with this new therapy.

Jill K. J. Gaidos, MD, FACG, AGAF, is associate professor of medicine, vice chief of clinical research, section of digestive diseases, Yale University, and director of clinical research, Yale Inflammatory Bowel Disease Program, New Haven, Conn.


 

FROM CLINICAL GASTROENTEROLOGY AND HEPATOLOGY

Treatment-resistant patients with active ulcerative colitis and Crohn’s disease saw high remission rates and fast response after being switched to upadacitinib, according to results from a real-world study at a Chicago treatment center.

The results suggest that upadacitinib may be an appropriate salvage treatment for patients who have failed other advanced therapies, including tofacitinib.

Dr. Scott Friedberg

For their research, published in Clinical Gastroenterology and Hepatology, Scott Friedberg, MD, and colleagues at the University of Chicago’s Inflammatory Bowel Disease Center, looked at results from 44 patients diagnosed with ulcerative colitis and 40 with Crohn’s disease, all with active luminal or perianal disease. All patients in the study had previous exposure to tumor necrosis factor inhibitors, and nearly 90% had exposure to two or more advanced therapies, including tofacitinib (n = 17), before being switched to upadacitinib.

Upadacitinib (Rinvoq, AbbVie) is the second small-molecule Janus kinase (JAK) inhibitor approved for ulcerative colitis by the Food and Drug Administration in March 2022 after tofacitinib (Xeljanz, Pfizer) in 2018. Upadacitinib received an additional indication in May 2023 as a treatment for Crohn’s disease. It selectively inhibits JAK1, while tofacitinib inhibits JAK1 and JAK3.

Among the ulcerative colitis patients in Dr. Friedberg and colleagues’ study (mean age, 39 years; 48% female), 85% had a clinical response and 82% achieved clinical remission by week 8. Of nine patients previously treated with tofacitinib, seven (78%) achieved remission at 8 weeks.

Some 76% of the Crohn’s disease patients in the study (mean age, 37 years; 53% female) saw clinical response by 8 weeks, and 71% achieved remission by that time. More than 60% of all participants who had increased fecal calprotectin and C-reactive protein levels at baseline saw normalization of these biomarkers by week 8.

Some patients saw an especially fast response, with 36% of the ulcerative colitis patients and 56% of the Crohn’s patients experiencing clinical remission by week 2.

Acne was the most common reported adverse event, occurring in 23% of patients. Only one serious adverse event, an anemia requiring hospitalization, occurred during the study.

No wash-out period occurred before starting patients on upadacitinib. There were no adverse events seen associated with this strategy, Dr. Friedberg and colleagues noted, a finding with important implications for real-world practice.

“When patients with active IBD are sick, starting a new therapy as soon as it is available is not only reasonable, it is required,” the investigators wrote. Additionally, the findings support the use of upadacitinib in ulcerative colitis patients with previous exposure to tofacitinib, as “selectivity of JAK targets may have different effectiveness profiles.”

Upadacitinib’s rapid onset “has multiple advantages,” the investigators wrote, “not only by being an option for severely active disease but also by allowing for a rapid taper or complete avoidance of corticosteroids.”

The authors noted their study’s small sample size as a key limitation. Several of Dr. Friedberg’s coauthors disclosed financial relationships with drug manufacturers, including AbbVie.

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