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Optimising anti-TNF treatment using biosimilars

Biosimilar Efficacy & Safety

Read time: 40 mins
Last updated:6th Dec 2022
Published:7th Aug 2020

Disease Burden and Comorbidities

Immune-mediated inflammatory diseases (IMID) are associated with a high disease burden, and significantly impaired quality of life (QoL)30.

This section explores how comorbidities and undertreatment contribute to the overall high disease burden across gastroenterological, rheumatological, and dermatological conditions.

Inflammatory bowel disease: burden and comorbidities


Dr Nick Kennedy (Consultant Gastroenterologist, Royal Devon and Exeter NHS Foundation Trust; Honorary Clinical Senior Lecturer, University of Exeter Medical School, UK) describes the common symptoms of inflammatory bowel disease, and extraintestinal manifestations. Learn how treatment and surgery can impact on patients.

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Figure 3. Comorbidities in inflammatory bowel disease (Adapted31). COPD, chronic obstructive pulmonary disease.

The burden of disease in inflammatory bowel disease (IBD) patients can be wide-ranging and variable due to the chronic and unpredictable nature of the disease. The symptoms of IBD are often painful and associated with social stigma, leading some individuals to develop complications, such as bowel control, bowel urgency, pain management, or fatigue32.

Longer-term concerns such as treatment options, the prospect of surgery, the development of cancer, and the personal financial burden due to reduced working hours (absenteeism), all contribute to the significant psychosocial burden of the disease, and the well-documented decrease in the QoL when compared to healthy individuals33.

Rates of anxiety and depression are higher in patients with IBD compared to healthy controls (anxiety; 19.1% vs. 9.6%, depression; 21.2% vs. 13.4%, respectively)33. This is also true for children with IBD, where higher rates of depressive and anxiety disorders are found compared to children with other chronic diseases and it typically correlates with disease activity34. Further, the effect of proinflammatory cytokines on the brain, sleep disturbance, and corticosteroids are thought to contribute to the overall decrease in mental health34.

IBD can also have a significant impact on young patients because of the effects on their growth and bone health, micronutrient deficiencies, and colon cancer risk34. For instance, 40% of children with CD will show growth failure, with 19% achieving a height 8 cm shorter than expected. This stunted growth is multifactorial; but the use of corticosteroids and cytokine-induced growth hormone resistance have been implicated. Bone metabolism abnormalities are also an issue, and factors such as malnutrition, delayed puberty, decreased physical activity, and malabsorption contribute. However, chronic inflammation itself may exert the most profound effects placing patients at risk of fracture as they age. Chronic inflammation is also a contributing factor to the increased risk of developing colon cancer, highlighting the importance of effective and timely treatment to combat chronic inflammation, and ensure children with IBD achieve optimum adult bone mass, reduce the risk of colon cancer, and reduce the overall burden of disease35.

Other comorbidities have been associated with IBD activity such as coronary artery disease, where there is an increased risk in IBD patients compared with controls (Figure 3). Importantly, the classic risk factors such as hypertension, diabetes, dyslipidaemia, and obesity were not related to this increase, but to an increase in white blood cell counts, and a possible association with IBD activity31

Metabolic syndrome and IBD have also been linked with similarities in inadequate immune response and chronic inflammation31. It has also been shown that fatigue, although multifactorial, increases in prevalence with increased disease activity. Patients with active disease report higher rates of fatigue (60–80%) than patients in clinical remission (20–40%), and it has been suggested that proinflammatory cytokines can act on the brain inducing symptoms that resemble sickness behaviour. Fatigue is a common complaint among patients, with a large negative impact on QoL and therefore it is very important to manage this comorbidity effectively31.

With such links between increased disease activity and chronic inflammation, to an increase in the burden of disease, reduced QoL, and the prevalence of comorbidities (especially in younger patients), timely and effective disease control is paramount.

Rheumatic disease: burden and comorbidities

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Seizing the window of opportunity 


Dr Nick Kennedy (Consultant Gastroenterologist, Royal Devon and Exeter NHS Foundation Trust; Honorary Clinical Senior Lecturer, University of Exeter Medical School, UK) reviews the importance of patient risk stratification, access to effective treatments, multidisciplinary teamwork, and patient communication.

Earlier access to tumour necrosis factor alpha inhibitor (anti-TNF) treatment could reduce disease burden and improve quality of life (QoL). Is early adoption of biosimilars in clinical practice the answer?

The underuse of biologics is an issue in gastroenterology, rheumatology, and dermatology, despite the evidence that biologics offer effective treatment in all indications55. For example, patterns of biologic prescribing for Crohn’s disease (CD) in Europe vary from 8–33%, similar variations were seen for rheumatoid arthritis (RA), and only 20% of patients with moderate-to-severe plaque psoriasis (PsO) were prescribed biologics in Europe and North America55. The reasons for underuse are complex and country specific; however, in countries where biologics are less affordable, eligibility criteria tend to be more restrictive, and the most common reason for dermatologists to not initiate or maintain a biologic is cost4.

Cost-savings from the introduction of biosimilars therefore offer improved patient access, and in turn, improved clinical outcomes. Moreover, there is increasing evidence that introducing biologics at an earlier disease stage can help avoid costly care associated with immune-mediated inflammatory diseases (IMID), such as hospitalisations or surgery, providing further long-term savings4.

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Biosimilars Publication Digests

Read or download recent research on biosimilars in rheumatoid arthritis (RA) inflammatory bowel disease (IBD).

Continue to read or download graphical summaries of anti-TNFs in RA or IBD

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