Combination of biologicals and small molecules in the treatment of extra intestinal manifestations due to inflammatory bowel disease

Extraintestinal Manifestations (EIM) of Inflammatory Bowel Disease (IBD) consist of inflammatory processes in patients with IBD outside the Gastrointestinal Tract (GIT). They are present in more than 50% of patients with IBD and their pathogenesis is an extension/translocation of the intestinal inflammatory response or an event perpetuated by IBD with the same genetic propensity as the underlying disease. There are several EIMs, which can affect different tissues, however, some are the most prevalent, such as: peripheral arthritis types 1 and 2, sacroilitis, ankylosing spondylitis (osteomuscular), erythema nodosum, psoriasis and pyoderma gangrenosum (dermatological), scleritis, episcleritis and uveitis (ocular) among others in different parts of the body [1]. The most effective treatment used today for severe EIMs are corticosteroids and immunobiological drugs, such as Infliximab (IFX), Adalinumab (ADA), Ustekinumab (UST), Vedolizumab (VDZ) and Tofacitinib (TOFA) [2,14]. According to the literature, all of them can lead to clinical remission in the affected patient. The treatment of EIM is of fundamental importance, as in addition to avoiding complications, it can improve the quality of life of patients [17], avoiding absence from work [15,16]. Furthermore, there is a lack of articles in the literature that present treatment algorithms for EIM in IBD as there is controversy in the comparison between the available drugs, as well as guidance on pharmacological associations between these drugs [18]. There is also difficulty in accessing the combination of these drugs, due to the high cost and lack of coverage by public health systems, leading to judicialization [19]. The aim of this study is to discuss these difficulties by presenting the journey of a patient, suffering from UC with failure of 2 biologicals and presenting multiple EIM [20,23].