Which biologics are you comfortable combining with vedolizumab for spondyloarthritis or psoriatic arthritis patients in the setting of well-controlled inflammatory bowel disease?

Historically, rheumatologists have been hesitant to combine biologics in our patients, based largely on trials from 20 years ago that found an increased risk of serious infections when combining a TNF inhibitors and an IL1 inhibitor, or abatacept and another biologic. With the availability of newer biologics, including IL17 and IL23 inhibitors, which appear to have a lower independent risk of serious infections, rheumatologists, including myself, have been more willing to consider combination therapy when necessary to control disease activity. Vedolizumab, a relatively gut-specific agent with less systemic impact, is a particularly appealing agent to use in combination with other biologics. While I do not do so frequently, I’ve combined it ...

I agree with Dr. @Dr. First Last’s thoughtful answer. However, it should be noted that rare cases of IBD onset and exacerbation have been reported, especially in the setting of psoriasis and psoriatic arthritis, in patients on IL-17 inhibitors. This highlights the need to be vigilant and to select patients appropriately when treating this population with IL-17 inhibitors. On the other hand, IL-23 inhibitors have shown efficacy in IBD, both Crohn’s disease and ulcerative colitis.

I did want to add that IL-23 inhibitors, while effective in psoriatic arthritis, have failed in the treatment of ankylosing spondylitis. Exploratory data from PsA patients with axial symptoms suggests that there may be some symptomatic improvement but this needs to ...