Vedolizumab has longer persistence than infliximab as a first-line biological agent but not as a second-line biological agent in moderate-to-severe ulcerative colitis: real-world registry data from the Persistence Australian National IBD Cohort (PANIC) study

Background: The choice between infliximab (IFX) and vedolizumab (VED) as a first-line biological agent in moderate-to-severe ulcerative colitis (UC) can be difficult. Second-line vedolizumab (VED) efficacy may decline following prior infliximab (IFX) treatment failure in UC patients. However, it is not known whether second-line IFX efficacy declines after failure of first-line VED. Aims: We aimed to compare first-line and second-line persistence of IFX and VED, in particular whether second-line IFX persistence declines after failure of first-line VED. Methods: Persistence of IFX and VED was analysed from the Australian Pharmaceutical Benefits Scheme registry data as either first- or second-line treatment in UC. Propensity score matching (1:1) was conducted in the comparison of first-line treatments. Cox proportional hazard regression analysis was used to identify significant predictors and expressed as a hazard ratio (HR and 95% CI). Results: There were 420 subjects with moderate-to-severe UC who received either first-line IFX (n = 251) or VED (n = 169), with 774 patient-years of follow-up. First-line VED had significantly longer persistence than first-line IFX (>50.2 versus 22.2 months, p = 0.001). Fifty-three subjects failed first-line IFX and swapped to second-line VED (IFX -> VED group). Twenty-two subjects failed first-line VED group and swapped to second-line IFX (VED -> IFX group). First-line VED persistence was significantly longer than second-line VED (>50.2 versus 32.0 months, p = 0.03), but first-line IFX persistence was not statistically significantly different to second-line IFX (27.6 months versus > 38.6 months, p = 0.30). Immunomodulator co-therapy was significantly associated with a lower risk of nonpersistence of first-line VED (HR: 0.55, 95% CI: 0.33-0.89, p = 0.02) and IFX (HR: 0.63,95%CI: 0.33-0.92, p = 0.02). Conclusion: VED had a significantly longer persistence than IFX as first-line biological agent but does not disadvantage second-line IFX use in moderate-to-severe UC. VED after IFX is associated with significantly poorer persistence. VED, therefore, should be considered as the first-line biological agent of choice in UC.