Infliximab and upadacitinib therapy may be more efficacious than other biological and small molecule treatments for moderate to severe ulcerative colitis, according to a systematic review and meta-analysis published in Gut.

Researchers pooled the results from 28 randomized controlled trials, including over 12,500 patients, in order to rank the efficacy and safety of biological and small molecule treatments for moderate to severe ulcerative colitis. Outcomes included the likelihood of clinical remission, endoscopic improvement, and adverse events.

Upadacitinib 45 mg daily, followed by infliximab 5 mg/kg and infliximab 10 mg/kg, ranked first for likelihood to achieve clinical remission (relative risk [RR] of failure to achieve clinical remission, 0.73; 95% CI, 0.68-0.80). Adalimumab 160/160 mg, adalimumab 80/40 mg, and filgotinib 100 mg once daily were not superior to placebo.

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Endoscopic improvement was most likely with infliximab 10 mg/kg (RR of

failure to achieve endoscopic improvement, 0.61; 95% CI, 0.51-0.72), followed by upadacitinib 45 mg daily, and infliximab 5 mg/kg. Adalimumab 80/40 mg was not superior to placebo.

Upadacitinib 45 mg once daily had the highest incidence of adverse events, though the events were unlikely to lead to treatment withdrawal.

This meta-analysis was limited by possible confounding factors, as trials varied regarding concurrent immunomodulator use. Additionally, the data for upadacitinib 45 mg daily was obtained from and have not been published or properly peer-reviewed.

“[T]his systematic review and network meta-analysis has demonstrated that all biological therapies and small molecules, other than adalimumab 160/160mg, adalimumab 80/40mg and filgotinib 100mg once daily were superior to placebo for induction of remission of moderate to severe UC, and all drugs, other than adalimumab 80/40mg, were superior to placebo in terms of endoscopic improvement,” investigators concluded. “Future trials should better elucidate the impact of these drugs on long-term and corticosteroid-free clinical remission in patients with moderate to severe UC.”


Burr N, Gracie D, Black C, Ford A. Efficacy of biological therapies and small molecules in moderate to severe ulcerative colitis: systematic review and network meta-analysis. Gut. Published online December 22, 2021. doi: 10.1136/gutjnl-2021-326290