Vedolizumab-First Strategy Linked to More Corticosteroid-Free Stability in Ulcerative Colitis

A Swedish nationwide cohort study published in JAMA Network Open compared first advanced therapies in biologic-naive patients with ulcerative colitis (UC). Over as long as 5 years, patients who started vedolizumab spent more time in corticosteroid-free disease stability than those who started infliximab or adalimumab. Rates of all-cause hospitalization did not differ significantly.

The authors wrote that tumor necrosis factor (TNF) antagonists and vedolizumab are the most commonly used advanced therapies for moderate-to-severe UC, but long-term data comparing TNF antagonist–first and vedolizumab-first strategies are limited. To compare strategies rather than individual drugs, patients stayed in their original group even if they later switched therapies.

Using linked national health registers, the investigators included 3263 patients who started infliximab (n = 1393), adalimumab (n = 1583), or vedolizumab (n = 287) between January 2015 and June 2021. Median follow-up was 4.3 to 5.4 years. The groups were balanced using inverse probability of treatment weighting.

The primary outcome was all-cause hospitalization, counting repeat admissions. It did not differ significantly for infliximab vs vedolizumab (incidence rate ratio [IRR], 1.14; 95% CI, 0.91-1.43) or for adalimumab vs vedolizumab (IRR, 1.08; 95% CI, 0.86-1.35). A quarter counted as corticosteroid-free disease stability if it had no oral corticosteroid dispensing, no new advanced therapy or immunomodulator, and no hospitalization or colectomy. Patients were in stable quarters 60.0% vs 66.6% of the time for infliximab vs vedolizumab (risk ratio, 0.88; 95% CI, 0.82-0.94). For adalimumab vs vedolizumab, the figures were 66.6% vs 70.0% (risk ratio, 0.92; 95% CI, 0.87-0.98).

Rates of colectomy and serious infection did not differ significantly in either comparison. Adalimumab initiators switched advanced therapies more often (IRR, 1.21; 95% CI, 1.02-1.43). Results were broadly consistent in propensity score–matched analyses, except that UC-related hospitalization was significantly higher with infliximab in the matched comparison.

The authors described the findings as associational and hypothesis generating. They said residual confounding likely remained; for example, clinicians often choose infliximab for more severe disease. The administrative data also lacked clinical, endoscopic, and biomarker detail. They added that the findings may apply mainly to high-income countries with tax-funded health care and to patients mainly of European heritage.

Source: Singh S, Söderling J, Forss A, et al. Vedolizumab vs TNF antagonists and long-term outcomes in ulcerative colitis. JAMA Netw Open. 2026;9(9):e2636165. doi:10.1001/jamanetworkopen.2026.36165