Esophagus to Small Intestine
N Engl J Med. 2023;388(21):1966–80
Upadacitinib induction and maintenance therapy for Crohn’s disease
Background: Upadacitinib, an oral selective Janus kinase (JAK) inhibitor, is under investigation for the treatment of Crohn’s disease.
Methods: In 2 phase 3 induction trials (U-EXCEL and U-EXCEED), the authors randomly assigned patients with moderate-to-severe Crohn’s disease to receive 45 mg of upadacitinib or placebo (2:1 ratio) once daily for 12 weeks. Patients who had a clinical response to upadacitinib induction therapy were randomly assigned in the U-ENDURE maintenance trial to receive 15 mg of upadacitinib, 30 mg of upadacitinib, or placebo (1:1:1 ratio) once daily for 52 weeks. The primary end points for induction (week 12) and maintenance (week 52) were clinical remission (defined as a Crohn’s Disease Activity Index score of < 150 [range, 0–600, with higher scores indicating more severe disease activity]) and endoscopic response (defined as a decrease in the Simple Endoscopic Score for Crohn’s Disease [SES-CD; range, 0–56, with higher scores indicating more severe disease] of > 50% from baseline of the induction trial [or for patients with an SES-CD of 4 at baseline, a decrease of ≥ 2 points from baseline]).
Results: A total of 526 patients underwent randomization in U-EXCEL, 495 in U-EXCEED, and 502 in U-ENDURE. A significantly higher percentage of patients who received 45 mg upadacitinib than those who received placebo had clinical remission (in U-EXCEL, 49.5% vs. 29.1%; in U-EXCEED, 38.9% vs. 21.1%) and an endoscopic response (in U-EXCEL, 45.5% vs. 13.1%; in U-EXCEED, 34.6% vs. 3.5%; p < 0.001 for all comparisons). At week 52 in U-ENDURE, a higher percentage of patients had clinical remission with 15 mg upadacitinib (37.3%) or 30 mg upadacitinib (47.6%) than with placebo (15.1%), and a higher percentage had an endoscopic response with 15 mg upadacitinib (27.6%) or 30 mg upadacitinib (40.1%) than with placebo (7.3%) (p < 0.001 for all comparisons). Herpes zoster infections occurred more frequently in the 45-mg and 30-mg upadacitinib groups than in the respective placebo groups, and hepatic disorders and neutropenia were more frequent in the 30-mg upadacitinib group than in the other maintenance groups. Gastrointestinal perforations developed in 4 patients who received 45 mg upadacitinib and in 1 patient each who received 30 mg or 15 mg upadacitinib.
Conclusions: Upadacitinib induction and maintenance treatment was superior to placebo in patients with moderate-to-severe Crohn’s disease.