Medication Ladder?

[Mehita]

Does anyone have a good link describing or depicting the med ladder? In particular, after Humira, where do things go?

It seems like after Humira it tends to be Cimzia, Entyvio, Symponi, Tysabri. Yes? No? Aside from Humira, the rest aren't pediatric approved, right?

How are y'all feeling about these new meds?

Thanks

 

[Maya142]

Typically Cimzia is after Humira and then the others in some order (whatever the doctor prefers). Our GI does not like Cimzia and anyway, M's IBD is mostly under control while her AS is most definitely not, so we went with Simponi.

Cimzia and Simponi are not approved for pediatric use but our pediatric rheumatologist has used both for a while. Our GI has used Cimzia but not Simponi before. Cimzia is in trials of Crohn's in kids (and JIA in kids). Simponi is only in trials for JIA in kids as far as I know, but is approved for UC in adults.

Simponi is a VERY easy, basically painless shot - generally given every 4 weeks but M gets it every two weeks. It does not burn like Humira.

The only other one GI's sometimes use is Stelara (IL 23/12 inhibitor) which isn't approved for Crohn's in adults yet but is in trials. I've only ever heard of a few kids on that though.

 

[Clash]

Agreed. After humira some GIs skip Cimzia especially if the kid isn't responding to anti tnf blockers. C would move to another med right now if allowed because he doesn't feel the humira does as good as the remicade and he therefore thinks it isn't worth the pain of the shot(a kid who doesn't take pain meds 2 days after surgery and doesn't want them for his joint pain). But he's early on in the humira journey so I hope he comes around to it.

 

[my little penguin]

Humira has only been approved for adult crohns/UC in the us
Humira is also approved for pediatric JIA
But not approved for pediatric crohns yet in the us ( approved in Europe)


After humira it gets fuzzy depending on your insurance and GI.
Cimizia is in trials for pediatric approval
Stelera /entivio and simponi are in any order

I don't focus on what next since it's constantly changing what's available and approved


Also in DS case when he started humira he didn't have arthritis so the ladder then is very differebt from what we consider now

 

[crohnsinct]

Mehita! You are playing our favorite game! Outguess the gi!

If remi stops working for o the gi said he would like to try humira then next up is stelara but more because of the psoriasis and psa I think.

 

[izzi'smom]

We went to tacrolimus after humira, which most docs don't use. Next was simponi, although I've since learned if remi and humi had no effect, simponi is unlikely to. We are trying entyvio next.

 

[Maya142]

Humira was quite recently approved for pediatric Crohn's MLP. It's only approved for kids over 6 though so far. For JIA I know they routinely use it for kids as young as 2 years old.

http://www.ccfa.org/news/fda-approves-humira-kids.html

 

[my little penguin]

Opps!!
It wasn't offically approved when DS started it .

 

[SupportiveMom]

Simponi came before Cimzia & entyvio for my kid, but I'm in canada and entyvio was just approved here for adults so the list is a bit different. Izzi's mom strange you said that about Simponi. Humira did nothing for D, Remicade barely anything, simponi is the only biologic that worked to achieve remission for her, even if only for a short time. Like you though Entyvio is next & our consult is on the 14th about it.

 

[Mehita]

Mehita! You are playing our favorite game! Outguess the gi!

Actually, the game is "educate the hubster". He doesn't like to talk about this stuff much, but he will read links I send him.

CCFA has short simple explanations at this link:
http://www.ccfa.org/medications-biologic-therapy.pdf

Pretty unlikely a person would do biologics and then go backward to methotrexate or Imuran, right?

And what determines "pediatric"? Is it just age? 18?

 

[Tesscorm]

Pretty unlikely a person would do biologics and then go backward to methotrexate or Imuran, right?

Curious about this too... I did ask a similar question here a while back and the answer(s) I received what that it isn't done very often but the reason may be due to insurance. Very often, insurance requires a step up progression and that means most who are moving from remicade/humira have likely already tried the immunosuppressants.

So, I'm not sure if there's any medical reason why you can't move from biologic to immunosuppressant. But, as S went straight to remicade, I have wondered if immunosuppressants would be an option for him in the future.

Maya, did your daughters move from biologic to immunosuppressant?

 

[northwesterner]

Curious about this too... I did ask a similar question here a while back and the answer(s) I received what that it isn't done very often but the reason may be due to insurance. Very often, insurance requires a step up progression and that means most who are moving from remicade/humira have likely already tried the immunosuppressants.

So, I'm not sure if there's any medical reason why you can't move from biologic to immunosuppressant. But, as S went straight to remicade, I have wondered if immunosuppressants would be an option for him in the future.

Maya, did your daughters move from biologic to immunosuppressant?

I started with Aza, not tolerated. Moved to Remicade. After many years on Remicade, it quit working, and I moved back to methotrexate (which I did not try before moving up to Remicade). It worked well for a year, but became difficult to tolerate. It is possible to go "backwards."

 

[Maya142]

Nope, we had them on biologics and then added immunomodulators. So Humira +MTX, Remicade + MTX, Remicade + Imuran etc. We're still trying to find the "magic" combination that will work for M. S is doing well on Humira + MTX.

 

[SupportiveMom]

Funny this is actually what I just asked an IBD doc at an education symposium a few weeks ago. It was a talk on combo therapy (biologics+immunosuppressives). I was told the only way that doc would ever have a patient step away from a biologic and only be on an immunosuppressive is if antibodies were developed with biologics and there were no other biologic options or if a patient was doing well after years of good scopes and remission and the patient pushed it.

 

[crohnsinct]

O's doc has said that since her last scope was pristine and she hasn't flared in 2 1/2 years he is considering her in deep stable remission. So, if she for some reason fails Remicade or develops antibodies, he would entertain the idea of moving to methotrexate alone, especially since she has already moved through puberty and is older now (almost 16).