Comment on: [10 years of biologic use patterns in patients with inflammatory bowel disease: treatment persistence,switching and dose intensification – a nationwide population-based study]

We read with interest the recently published study by Koo et al., ¹ which assessed the real-world effectiveness of different biological therapies and suggested an optimum treatment sequence. In this study, ustekinumab was shown to have superior persistence as the first-line treatment of Crohn’s disease but this was associated with the highest degree of dose optimization. Importantly, when exploring the persistence of a medication, intricacies such as drug levels, antibody formation and the granularity regarding clinical, endoscopic and histological remission are lacking. This often means that persistence is a surrogate marker but not definitive of what defines thriving on a medication.

We commend the authors on this extensive study and provides us valuable insight into real world prescribing and outcomes related to it. Crucially, when considering biologic sequencing, finding a consensus on optimum sequencing remains challenging. The relative paucity of head-to-head data^2,3 means we are often left with indirect comparisons such as network-meta-analysis ⁴ and retrospective studies, with only few studies comparing different biologics together. Furthermore, variable endpoints and the lack of long-term extension data make sequencing biological therapies difficult.

Most importantly, as published data in regard to optimal sequencing lacks consensus, we believe the choice of the right sequence is much more nuanced involving many pre-defined patient factors and patient preferences. Until we know more about mechanisms that drive an individual’s inflammatory process, being prescriptive about the optimum drug sequence we believe is still a long way off.