Advanced therapies in inflammatory bowel disease: Special considerations

Abstract

Traditionally, there has been apprehension about using advanced IBD therapies in the setting of a history of malignancy. Data increasingly suggest that the risk of recurrence is not increased with anti-tumor necrosis factor (anti-TNF) use when a previous solid organ cancer or non-melanoma skin cancer (NMSC) has been adequately treated. However, avoidance is recommended in patients with a history of melanoma, lymphoma, or metastatic malignancy. Vedolizumab provides an appealing option given its gut selectivity, but caution is advised in those with a history of gastrointestinal (GI) cancers. A signal for malignancy risk associated with ustekinumab in either IBD or psoriasis/psoriatic arthritis (PSOLAR) clinical trial data has not been identified. Limited data regarding malignancy risk exist for tofacitinib; however, the possibility of an increased risk of NMSC and lymphoma has been raised by clinical trial data. The management of IBD in the setting of a current cancer may be more challenging and is influenced by the severity of IBD activity, the cancer therapy, and the individual’s overall prognosis and quality of life. In the setting of cytotoxic chemotherapy use, cessation of IBD immunosuppression (excluding gut-selective agents such as vedolizumab for non-GI cancers) is generally recommended and indeed may not be required given the potential benefit of cytotoxic chemotherapy for IBD activity. Timing of the resumption of IBD therapy following completion of therapy requires consideration on an individual basis.