Biological Agents for Moderately to Severely Active Ulcerative Colitis A Systematic Review and Network Meta-analysis

Background: Biological agents are emerging treatment options for the management of ulcerative colitis (UC). Purpose: To assess the comparative efficacy and harm of biological agents in adult patients with moderately to severely active UC who are naive to biological agents. Data Sources: MEDLINE, EMBASE, and Cochrane Library from inception through December 2013, without language restrictions, and ClinicalTrials.gov, European Medicines Agency, and U. S. Food and Drug Administration Web sites. Study Selection: Randomized, placebo-controlled or head-to-head trials assessing biological agents as induction or maintenance therapy for moderately to severely active UC. Data Extraction: Two reviewers independently abstracted study data and outcomes and rated each trial's risk of bias. Data Synthesis: There were no head-to-head trials. There were 7 double-blind, placebo-controlled trials that were rated as low risk of bias and showed that all biological agents (adalimumab, golimumab, infliximab, and vedolizumab) resulted in more clinical responses, clinical remissions, and mucosal healings than placebo for induction therapy. The results of network meta-analysis suggested that infliximab is more effective to induce clinical response (odds ratio, 2.36 [95% credible interval, 1.22 to 4.63]) and mucosal healing (odds ratio, 2.02 [95% credible interval, 1.13 to 3.59]) than adalimumab. No other indirect comparison reached statistical significance. For maintenance, 6 double-blind, placebo-controlled trials that were rated high risk of bias showed that all biological agents have greater clinical efficacy than placebo. The occurrence of adverse events was not different between biological agents and placebo. Limitation: Few trials, no head-to-head comparisons, and inadequate follow-up in maintenance trials. Conclusion: Biological agents are effective treatments for UC, but head-to-head trials are warranted to establish the best therapeutic option.