Should You Consider Stacking Biologics?
If you want to try stacking a biologic with another biologic or small molecule drug, your healthcare team can help you decide on the best way forward. “As with all IBD therapy, we are always weighing the risk and the benefit,” says Philpott. “The risk of incompletely treated Crohn’s, in particular for a patient with severely destructive disease, is very real.”
Since experts don’t have much data and these drugs have a high price tag, dual therapy isn’t right for everyone, says Philpott, who believes that they should only be used with great care. “But it can give us hope and success for patients that have struggled up to now to gain control of their disease.”
Who Benefits From Biologic Stacking?
Dual therapy can offer a better chance of treatment success in some situations. “If the patient has been on numerous therapies without great success, and on their current therapy they have had a response, but not full remission, then I consider adding a second medication,” says Philpott.
Biologic stacking can also work well for people with extraintestinal manifestations (EIMs) — complications that can occur in the blood, joints, skin, eyes, kidneys, liver, and bones.
Stacking vs. Switching
“Before making any change, I take a step back and make sure we are dealing with a true active disease,” says Ali. That means using labs or endoscopy or other imaging, such as a CT or MRI scan, to confirm there is ongoing inflammation, and not an overlapping condition, such as irritable bowel syndrome (IBS), an infection, or a structural issue like a stricture.
“I tend to consider stacking when a patient is getting some benefit but not enough, or when different aspects of the disease are not controlled by one medication,” Ali says. “[W]hereas I switch therapies when the current drug is clearly not working at all. For example, if a patient with Crohn’s disease is on an anti-TNF therapy and has had some improvement in their intestinal symptoms but still has active perianal fistulas or persistent inflammation on endoscopy, I may consider adding a second agent to target a different pathway.”
“In contrast, if that same patient had no meaningful improvement at all despite adequate drug levels [in the blood], I would be more likely to switch to a different class of therapy rather than stack,” Ali says.
Barriers to Access
One aspect to think about when considering dual therapy is the cost. “Even when biologic stacking makes sense clinically, access can be a major barrier,” says Ali.
Using two advanced therapies together is often considered off-label (not approved by the U.S. Food and Drug Administration), which means insurance approval is not guaranteed, says Ali. “Prior authorizations can be complex; approvals can be inconsistent, and denials are not uncommon.”
Even when dual treatments are approved, your copay could still be high, Ali says. “At the end of the day, the best treatment plan is not just what works scientifically, but what is realistically achievable for the person sitting in front of us.”
Philpott hopes for more future studies on dual therapy to better guide how to prescribe this treatment option and provide more insurance coverage. In the meantime, it may be possible to qualify for financial assistance programs sponsored by drug manufacturers.
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