Modern Advanced Therapies for Inflammatory Bowel Diseases: Practical Considerations and Positioning

The therapeutic armamentarium for management of inflammatory bowel diseases has expanded dramatically in the last 5 years, with the introduction of several medications with different mechanisms of action. These include the oral small molecule drugs Janus kinase inhibitors (including upadacitinib approved for Crohn's disease and ulcerative colitis [UC], and tofacitinib, approved for UC) and sphingosphine 1-phosphate receptor modulators (ozanimod and etrasimod, both approved for UC), and biologic agents, such as selective interleukin-23 antagonists (risankizumab approved for Crohn's disease, and mirikizumab approved for UC). The efficacy and safety of these therapies vary. In this review, we discuss practical use of these newer advanced therapies focusing on real-world effectiveness and safety data, dosing and monitoring considerations, and special situations for their use, such as pregnancy, comorbid immune-mediated disease, use in hospitalized patients with acute severe UC, and in the perioperative setting. We also propose our approach to positioning these therapies in clinical practice, relying on careful integration of the medication's comparative effectiveness and safety in the context of an individual patient's risk of disease- and treatment-related complications and preferences.