progression of biologics

I am still doing a lot of information gathering before I make any decisions about how to proceed with "The Next Step"

so it seems like the SOP is:
take a tnf antagonist
when that fails
take entyvio
when that fails
hope another drug is out.

seems like one just takes a drug until it fails to take another until it fails and so on

Now - after ASAs fail, does one do remicade then humira, or vice versa, or are they mutually exclusive? Like if you take humira, develop antibodies, do you take remicade or proceed to entyvio?

oh! Fair enough! I guess I just threw that out there!

I was Dx with pancolitis in 1988.
Have been in and out of remission for 29 years.
Usually just Rowasa in addition to generic sulfasalazine worked.
Then I got switched to Lialda about 10 years ago - changed my life.
Last 3-4 years, have had to go on prednisone a few times. But then all was well.
(WORKED and ALL WAS WELL does not mean no symptoms but I could go do things and not be trapped by UC, always have symptoms)
Last summer about this time I got REALLY REALLY SICK
My gastro felt the ASAs were not longer working.
For the first time ever I had severe drug rxns to pred, sent me to the ER, but I can take pred. I think this was due to severe dehydration and malnutrition, I lost so much weight. I never been sick like that before...never!
My gastro referred me to an IBD specialist at UNC
I got functional but not better, then I began to get quite sick again in Feb 2017
Since then I have been off and on with the pred and trying different ASAs.
My new gastro said the next step is humira but not sure due to breast cancer but thinks it is okay (I am going to consult with my med onc)
My gastro feels he may be able to appeal to insurance to go straight to entyvio using the cancer card.
I am just researching a lot of clinical data and anecdotal data.
So just trying to learn if people go on humira after remicade or vice versa before they ever go on entyvio.

does this help?

The 1st line treatment is anti-inflammatory 5ASA/mesalamine. The recommendation is a daily 4.8 grams oral mesalamine, and nightly 4 grams of mesalamine through an enema. If that's not enough then the second line treatment is added to the first and both are taken.

The 2nd line treatment is immunomodulators (imuran/azathioprine/6MP). Slow acting medications taking 2-3 months to work that require routine blood monitoring. Due to those limitations, some gasteroenterologists skip over 2nd line treatment and go on to the third line of treatment (especially true of pedatric cases and severe pancolitis cases involving hospitilization).

The third line of treatment is biologics and it is often added concurrently to classes 1 and 2. Biologics are quick working and do not require blood monitoring. Tnf-alpha blocking biologics are often tried 1st (remicade, humira, or simponi) due to their longer tract-record and also they are often much easier to approve for a 1st biologic insurance (many insurance policies state entyvio can only be prescribed if you have previously failed one tnf-alpha-blocker).

Taking immunomodulators with biologics can help to prevent antibody formation (to remicade especially, and others as well). Antibodies can make a biologic less effective or cease to work entirely. Should one develop antibodies to one tnf-alpha blocker then often the dose can simply be increased to account for antibodies and the patient regains a response. If antibody concentrations are too high then one can switch between tnf-alpha blockers (say from remicade to humira) and there's no guarantee antibodies will form to the second tried (different enough molecules between them to necessitate your immune system developing new antibodies specific to each drug).

Should one entirely fail the tnf-alpha class of biologics, then other classes of biologics are available that use entirely different mechanisms of action: Entyvio (madcam1 blocker), Stelara (blocks interleukin IL-12 and IL-23), and xeljanz (jak-inhibitor). New treatments are always on the horizon but there is already many options to choose from.

about 20 percent of UC patients fail response to everything and surgery quickly finds them. We have posters who've undergone this surgery and who are loving their post-uc lives.

You can do remicade and then humira, or simponi... in whatever order you want too. Of course you need to be aware that the response rate is about 60% for remicade, and it's lower for the others, and if you do not respond to one, your chances of responding to another are much lower. I was a non-responder to all of the meds, and I ended up having surgery, which I am actually thankful for. Jumping from drug to drug and worrying about the future, my health, my ability to hold a career, wasn't my thing... There are a lot of drugs in trials that should be available soon for UC, stuff like stelara and xeljanz.