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First-Line Biologics or Small Molecules in Inflammatory Bowel Disease: a Practical Guide for the Clinician


Purpose of Review

Treating moderate-to-severe inflammatory bowel disease has become increasingly complex as the array of available biologics increases. Moreover, tofacitinib, the first small molecule approved for IBD, is available for use in ulcerative colitis. Choosing the right biologic, for the right patient, at the right time, can be a confusing and daunting task for clinicians.

Recent Findings

In this review, we summarize the evidence for first-line use of the available biologics by disease state. Special circumstances for consideration including rapidity of action, safety, comparative effectiveness, postoperative Crohn’s disease, fertility and pregnancy, and extraintestinal manifestations are discussed.


In the moderate-to-severe UC patient, vedolizumab and infliximab are preferred first-line options. In the moderate-to-severe CD patient with a penetrating phenotype or with multiple EIMs, infliximab or adalimumab are the preferred first-line agents. In the moderate-to-severe CD patient with an inflammatory phenotype, anti-TNF, vedolizumab, and ustekinumab are all reasonable options.

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Papers of particular interest, published recently, have been highlighted as: •• Of major importance

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Correspondence to David Hudesman.

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David Hudesman is a consultant for Abbvie, Janssen, Salix, Takeda, and Pfizer.

Shannon Chang is a consultant for Takeda, Oshi Health, and Pfizer.

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Chang, S., Hudesman, D. First-Line Biologics or Small Molecules in Inflammatory Bowel Disease: a Practical Guide for the Clinician. Curr Gastroenterol Rep 22, 7 (2020).

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  • Positioning biologics
  • Inflammatory bowel disease
  • Infliximab
  • Adalimumab, vedolizumab
  • Tofacitinib
  • Ustekinumab