Esophagus to Small Intestine
Gut. 2023;72(2):264–74
Efficacy of biological therapies and small molecules in induction and maintenance of remission in luminal Crohn’s disease: Systematic review and network meta-analysis
Objective: There are numerous biological therapies and small molecules licensed for luminal Crohn’s disease (CD), but these are often studied in placebo-controlled trials, meaning relative efficacy is uncertain. The authors examined this in a network meta-analysis.
Design: They searched the literature to July 1, 2022, judging efficacy according to induction of clinical remission, clinical response and maintenance of clinical remission, and according to previous exposure or non-exposure to biologics. They used a random effects model and reported data as pooled relative risks (RRs) with 95% confidence intervals (CIs), ranking drugs according to p-score.
Results: 25 induction of remission trials (8720 patients) were identified. Based on failure to achieve clinical remission, infliximab 5 mg/kg ranked first versus placebo (RR = 0.67, 95% CI: 0.56–0.79, p-score 0.95), with risankizumab 600 mg second and upadacitinib 45 mg once daily third. However, risankizumab 600 mg ranked first for clinical remission in biologic-naive (RR = 0.66, 95% CI: 0.52–0.85, p-score 0.78) and in biologic-exposed patients (RR = 0.74, 95% CI: 0.67–0.82, p-score 0.92). In 15 maintenance of remission trials (4016 patients), based on relapse of disease activity, upadacitinib 30 mg once daily ranked first (RR = 0.61, 95% CI: 0.52–0.72, p-score 0.93) with adalimumab 40 mg weekly second, and infliximab 10 mg/kg 8-weekly third. Adalimumab 40 mg weekly ranked first in biologic-naive patients (RR = 0.59, 95% CI: 0.48–0.73, p-score 0.86), and vedolizumab 108 mg 2-weekly first in biologic-exposed (RR = 0.70, 95% CI: 0.57–0.86, p-score 0.82).
Conclusion: In a network meta-analysis, infliximab 5 mg/kg ranked first for induction of clinical remission in all patients with luminal Crohn’s disease, but risankizumab 600 mg was first in biologic-naive and biologic-exposed patients. Upadacitinib 30 mg once daily ranked first for maintenance of remission.