Biologics in the management of pediatric inflammatory bowel disease: When and what to choose

Figure 1 Approach to a child with inflammatory bowel disease requiring biologics. IBD: Inflammatory bowel disease; EEN: Exclusive enteral nutrition; 5-ASA: 5-aminosalicylic acid; TB: Tuberculosis; AFB: Acid fast bacilli; HRCT: High resolution computed tomography; HBV: Hepatitis B virus; HCV: Hepatitis C virus; HIV: Human immunodeficiency virus; TNF: Tumor necrosis factor; TDM: Therapeutic drug monitoring; ADAb: Anti-drug antibody.

Figure 2 Therapeutic drug monitoring in a child on biologics. Infliximab and adalimumab are generally not abandoned unless drug concentration is ≥ 10 μg/mL. Target higher drug levels in fistulizing perianal disease. LOR: Loss of response; TDM: Therapeutic drug monitoring; IM: Immunomodulator; ¹Arrow: In those at risk of increased drug clearance.

Figure 3 Comparative safety, relative annual cost (in India) and efficacy profile of various biologics in pediatric inflammatory bowel disease. PIBD: Pediatric inflammatory bowel disease; IFX: Infliximab; ADA: Adalimumab; UST: Ustekinumab; VDZ: Vedolizumab; TOFA: Tofacitinib; CD: Crohn’s disease; UC: Ulcerative colitis; ASUC: Acute severe ulcerative colitis; (1): Response rates to biologics taken from reference[21,25,26,31,34,103]; (2): Response rates to biologics taken from reference[30,31,68]; (3): Response rates to biologics taken from reference[62]; (4): Response rates to biologics taken from reference[36]; (5): Response rates to biologics taken from reference[53,56]; (6): Response rates to biologics taken from reference[51]; (7): Response rates to biologics taken from reference[33]; (8): Response rates to biologics taken from reference[57].

Figure 4 Biologics in children with inflammatory bowel disease: Choice of therapy and future perspectives. IBD: Inflammatory bowel disease; TNFα:Tumor necrosis factor alpha; Anti-α4β7: Anti-alpha4beta7; IL: Interleukin; JAK: Janus kinase; IFX: Infliximab; HLA: Human leukocyte antigen; DTT: Dual-targeted therapy; IM: Immunomodulators; AZA: azathioprine; MTX: Methotrexate; TDM: Therapeutic drug monitoring; PIBD: Pediatric inflammatory bowel disease.