Abstract Background Primary sclerosing cholangitis associated with inflammatory bowel disease (PSC-IBD) is frequently refractory to standard biologic therapy. Oral vancomycin (OVT) has been proposed as an immunomodulatory treatment option when biologic therapy fails, however comparative evidence remains sparse in the literature. This review pooled data to compare the efficacy of OVT against biologic therapy in PSC-IBD. Methods A systematic search of electronic databases including PubMed, EMBASE, SCOPUS and CENTRAL were conducted using two distinct search strategies to identify biologic and OVT cohorts. To minimise confounding and due to lack of data on concurrent biologic use in oral vancomycin cohorts, only OVT cohorts with 10% concurrent biologic exposure were eligible. A Bayesian random-effects binomial model was fitted on the logit scale with weakly informative priors and was used to estimate pooled remission probabilities, risk ratios (RR) and risk difference (RD) each with 95% credible intervals (CrI). Adverse events were summarised descriptively. Results Eight OVT cohorts (n = 211) and five biologic-only cohorts (n = 403) met inclusion criteria and contributed to this review. Across the studies, OVT demonstrated higher remission rates compared to biologic therapy. The pooled probability of clinical remission with OVT was 85.7% (95% CrI 72.0–95.3%), compared with 52.4% for biologics (95% CrI 28.0–80.2%) corresponding to a posterior RR of 1.76 (95% CrI 1.06–3.11) and RD of + 33.3% (95% CrI 4.9–59.9%). Endoscopic outcomes showed a similar pattern whereby OVT achieved a pooled remission rate of 73.4% (95% CrI 40.8–94.8%) versus 37.0% with biologics (95% CrI 11.1–75.8%), giving a RR of 2.52 (95% CrI 0.88–6.62) and RD of + 36.5% (95% CrI –7.3 to 71.4%). Posterior probabilities indicated a high likelihood of OVT benefit for both clinical (98.9%) and endoscopic (95.1%) remission. Between study heterogeneity was moderate to high for both clinical and endoscopic endpoints likely due to variation in definitions of outcomes, follow up, doses of drugs and importantly study design. OVT cohort reported treatment-related adverse events hence comparative analysis could not be done. Conclusion OVT was associated with substantially higher clinical and endoscopic remission rates compared to biologic therapy in PSC-IBD supported by high posterior confidence. However, the considerable between study heterogeneity and observational nature of the studies included, does warrant caution when interpreting these results. While these results are promising, large scale randomised control trials studying these outcomes are paramount in order to validate the results and guide clinical practice in this complicated patient population. Conflict of interest: Mr. Dey, Pritom: No conflict of interest Da’Costa, Jedd: No conflict of interest Bhanderi, Bhuvan: No conflict of interest Joshi, Deepak: No conflict of interest Kent, Alexandra: I have received honoraria/Consultancy/Sponsorship fees from: Lilly, AbbVie, Coloplast, J & J, Pfizer, Takeda, Tillotts, Dr Falk, Galapagos/AlfaSigma Pavlidis, Polychronis: Advisory services/ speaker fees/ conference sponsorship/ research grants: Abbvie, Alfasigma, DrFalk, J & J, Pfizer, Roche, Takeda, Teva
Dey et al. (Thu,) studied this question.
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