Precision-Medicine Approach Improves IBD Infliximab Outcomes

Medscape

12-05-2025

SAN DIEGO — In tough-to-treat chronic inflammatory bowel disease (IBD), a precision-medicine strategy based on patients' molecular profiles showed efficacy in guiding anti–tumor necrosis factor (anti-TNF) therapy treatment decisions to improve outcomes.
'This is the first study implementing multi-biomarker signatures in informed decisions instead of single biomarker–based trial algorithms [in IBD],' said first author Florian Tran, MD, in presenting the late-breaking study at Digestive Disease Week (DDW) 2025.
'We have now been able to demonstrate for the first time that precision medicine can be successfully applied in the context of chronic inflammatory bowel diseases, leading to improved long-term outcomes,' said Tran, a professor of pathophysiology of chronic inflammation at the Institute of Clinical Molecular Biology and Department of Internal Medicine, Kiel University and University Hospital Schleswig Holstein, Kiel, Germany.
Anti-TNF therapies can be highly effective in a range of immune-mediated inflammatory diseases, including IBD, but not all patients respond. Key singular candidates of biomarkers that could better predict a response show relatively low predictive power or a failure to replicate in independent studies.
In previous research, Tran and colleagues reported identification of early dynamic molecular changes in the blood that are more robustly predictive of responses to anti-TNF therapy.
'We have generated compelling evidence that therapy-induced changes in inflammatory pathways can reliably predict patient outcomes,' he said.
Among them are dynamic transcriptome changes that emerge early during treatment and can predict response to anti-TNF therapy, as well as clinical response trajectories that differ based on subgroups.
To further investigate the benefits of the multi-biomarker signatures collectively, as opposed to single biomarker–based algorithms, Tran and colleagues conducted the phase 3, open-label GUIDE-IBD trial, enrolling 102 adults with a confirmed diagnosis of Crohn's disease (CD) or ulcerative colitis (UC) at three German university hospitals between February 2021 and January 2024.
All patients had been assigned the anti-TNF drug infliximab for the first time.
Study participants were randomized to receive either the molecular-guided care or standard medical care, with stratifications based on diagnosis, recruiting center, and baseline corticosteroid use.
Those in the molecular group received real-time molecular assessments at baseline and weeks 2, 6, 14, and 26, which included peripheral blood samples and biopsies of known messenger ribonucleic acid–based biomarkers.
The assessments also looked at infliximab and anti-drug antibody levels.
Molecular reports were then provided through molecular medicine boards for patients in the molecular-guidance group at weeks 2, 14, 26, and 52, whereas data from the standard care group was not communicated.
Based on the biomarker data, therapy decisions were made such as adjustments to dosing, intervals, comedication, and switches in therapy.
The primary endpoint was the combined end point of disease control, defined as clinical remission (CD Activity Index < 150, partial Mayo score < 2), endoscopic remission (simplified endoscopic score for CD ≤ 4 [≤ 2 for isolated ileal disease], endoscopic Mayo score ≤ 1), or biochemical remission (CRP < 5 mg/L, fecal calprotectin < 250 mg/g).
A total of 87 patients completed the study with available primary endpoint data to week 52; there were 38 in the molecular care group and 49 in the standard care group. In each group, approximately half of the patients had CD and half had UC.
For the primary endpoint, comprehensive disease control was significantly more frequent in the molecular care group at week 52 (55.3%) than in the standard care group (26.5%), with an absolute difference of 29% ( P = .0072).
Furthermore, the secondary endpoint of the combined rate of endoscopic and clinical remission at week 52 was also higher in the molecular group (60.5%) than in the standard care group (32.7%; P = .0163).
An exploratory analysis further showed therapy switches were more common in the molecular group (47%) than in the standard care group (29%), with an increased rate of drug switching between 14 weeks and 26 weeks.
More patients in the molecular guidance group achieved comprehensive disease control (deep remission) at week 52 ( P = .0135).
'The [molecular guidance] group was more likely to switch therapies after the induction period, reducing the number of patients who are suboptimally treated under infliximab,' Tran noted.
The results underscore that 'even in the absence of a single 'magic' biomarker, precision medicine can materially improve patient outcomes by integrating complex molecular data into everyday clinical decisions, enabling more effective therapy choices and reducing unnecessary drug side effects,' he said.
Approach Pioneered in Oncology
Tran noted that the collaboration necessary for the approach was based on strategies pioneered in cancer centers, which have resulted in significant improvements in cancer therapy outcomes.
'For the first time in IBD, we have now integrated multidimensional molecular data and innovative drug-dosing models into these inflammation boards,' he said.
Key components of the intervention include a highly structured patient care process with fixed assessment timepoints, as well as 'a multidisciplinary, quality-controlled decision-making process that is meticulously documented,' he explained.
The results underscore that 'we must move away from sole physician-driven treatment decisions in IBD towards a structured expert-board model for therapy decision-making.'
Benefits in Other IBD Therapies Unclear
Commenting on the study, Ashwin N. Ananthakrishnan, MD, an associate professor of medicine with Massachusetts General Hospital, in Boston, noted that 'this approach may help optimize existing treatment early and ensure that ineffective treatments don't get dragged on.'
Importantly, however, a key limitation is that 'this does not tell you upfront whether a treatment is likely to work or what the best treatment is,' Ananthakrishnan told Medscape Medical News . 'That is a critically important unmet need in IBD.'
While doses are escalated, if needed, with infliximab and other biologic drugs, that may not be the case with other therapies, he explained.
'For other agents, such as JAK [Janus kinase] inhibitors, we actually start at a higher dose and then reduce for maintenance,' said Ananthakrishnan.
How this approach would work for these drugs or 'for drugs where blood levels are not reflective of efficacy is also not clear,' he said.