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Copyright ©The Author(s) 2025. Published by Baishideng Publishing Group Inc. All rights reserved.
World J Gastroenterol. Aug 7, 2025; 31(29): 107745
Published online Aug 7, 2025. doi: 10.3748/wjg.v31.i29.107745
Positioning and sequencing of advanced therapies in inflammatory bowel disease: A guide for clinical practice
Marcello Imbrizi, Matheus F C Azevedo, Julio P Baima, Natália S F Queiroz, Rogério S Parra, Sandro D C Ferreira, Ligia Y Sassaki, Julio Maria F Chebli
Marcello Imbrizi, Division of Gastroenterology, School of Medical Sciences, University of Campinas, Campinas 13083-970, São Paulo, Brazil
Matheus F C Azevedo, Department of Gastroenterology, University of São Paulo, School of Medicine, São Paulo 01246-000, São Paulo, Brazil
Julio P Baima, Ligia Y Sassaki, Department of Internal Medicine, São Paulo State University, Medical School, Botucatu 18618-686, São Paulo, Brazil
Natália S F Queiroz, CMO Solare Educa Hub, São Paulo 04003-020, São Paulo, Brazil
Rogério S Parra, Department of Surgery and Anatomy, Ribeirão Preto Medical School, University of São Paulo, Ribeirão Preto 14048-900, São Paulo, Brazil
Sandro D C Ferreira, Department of Medicine, Ribeirão Preto Medical School, University of São Paulo, Ribeirao Preto 14048-900, São Paulo, Brazil
Julio Maria F Chebli, Division of Gastroenterology, Department of Medicine, University Hospital of the Federal University of Juiz de Fora, University of Juiz de Fora School of Medicine, Juiz de Fora 36036-247, Minas Gerais, Brazil
Author contributions: Imbrizi M, Azevedo MFC, Baima JP, Queiroz NSF, Parra RS, Ferreira SDC, Sassaki LY, and Chebli JMF contributed to the conception and design of the study, acquisition of data, drafting of the article, and making critical revisions related to the important intellectual content of the manuscript; All the authors approved for the final version of the article to be published.
Conflict-of-interest statement: Imbrizi M has received fees for serving as a speaker and/or an advisory board member for Abbvie, Ferring, Janssen, Nestle, Pfizer and Takeda; Azevedo MFC has received fees for serving as a speaker and/or an advisory board member for Abbvie, Janssen and Takeda; Baima JP has received fees for serving as a speaker and/or an advisory board member for Janssen and AbbVie; Queiroz NSF has served as a speaker and advisory board member of Janssen, Takeda and Abbvie; Parra RS has received fees for serving as a speaker and/or an advisory board member for Takeda, Janssen, AbbVie, Ferring and Pfizer; Ferreira SDC has received fees for serving as a speaker and/or an advisory board member for Janssen, Takeda, and Pfizer; Sassaki LY has received fees for serving as a speaker and/or an advisory board member for Janssen and AbbVie; Chebli JMF has received fees for serving as a speaker and/or an advisory board member for Takeda, Janssen, AbbVie, Abbott, and Sandoz.
Open Access: This article is an open-access article that was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution NonCommercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: https://creativecommons.org/Licenses/by-nc/4.0/
Corresponding author: Julio Maria F Chebli, MD, PhD, Adjunct Associate Professor, Senior Researcher, Division of Gastroenterology, Department of Medicine, University Hospital of the Federal University of Juiz de Fora, University of Juiz de Fora School of Medicine, Maria José Leal Street, 296, Juiz de Fora 36036-247, Minas Gerais, Brazil. julio.chebli@ufjf.br
Received: March 30, 2025
Revised: June 3, 2025
Accepted: July 11, 2025
Published online: August 7, 2025
Processing time: 130 Days and 6.2 Hours
Abstract

Over the past decade, the therapeutic armamentarium for inflammatory bowel disease (IBD) has substantially expanded with the incorporation of multiple classes of advanced therapies. Currently, in addition to tumor necrosis factor-α inhibitors, the therapeutic arsenal for IBD includes anti-integrin agents, interleukin (IL)-12/23p40 and IL-23p19 antibodies, Janus kinase inhibitors, and sphingosine 1-phosphate receptor modulators. Although advances in IBD pharmacotherapy have enabled disease remission and improved control of intestinal inflammation in many individuals previously considered clinically 'intractable', they have also increased the complexity of decision-making related to the initial positioning and sequencing of therapies in the heterogeneous clinical presentations of IBD. Until molecular and genetic markers capable of predicting therapeutic responses become available in practice, the choice of initial and subsequent therapy in individuals with IBD is based on factors including disease severity, phenotype, risk of complications, comorbidities, extraintestinal manifestations, and the balance between efficacy, safety, convenience, and access. This review explores the factors that influence treatment decisions regarding initial therapy selection and sequencing across IBD scenarios, offering practical tips for personalizing therapy based on the safety and efficacy of advanced treatments and the individual's risk of disease- or therapy-related adverse outcomes.

Keywords: Inflammatory bowel disease; Crohn's disease; Ulcerative colitis; Advanced therapy; Biologics; Sequencing; Treatment strategy; Janus kinase inhibitors; Biologic agents

Core Tip: One of the key challenges clinicians face in managing individuals with inflammatory bowel disease (IBD) is determining which advanced therapy to initiate and how to sequence treatments when needed. In the absence of readily available molecular markers, these decisions, although often complex, are guided by patient- and disease-specific factors, including disease severity, phenotype, complication risk, comorbidities, extraintestinal manifestations, the balance between drug efficacy and safety, convenience, and treatment access. In this review, we examine the various considerations influencing therapeutic decision-making in different IBD clinical contexts and offer practical tips to support more personalized approaches based on the individual's clinical profile.