Vedolizumab vs TNF Antagonists and Long-Term Outcomes in Ulcerative Colitis

Importance: Tumor necrosis factor (TNF) antagonists and vedolizumab are the most commonly used advanced therapies for management of moderate-to-severe ulcerative colitis (UC). There are limited data evaluating long-term outcomes with a TNF antagonist-first vs vedolizumab-first treatment strategy.

Objective

To compare long-term clinical outcomes among biologic-naive patients with UC initiating infliximab or adalimumab vs vedolizumab as first-line advanced therapy. Design, setting, and participants: This Swedish nationwide population-based cohort study used linked health registers. Biologic-naive patients with UC who initiated infliximab, adalimumab, or vedolizumab between January 1, 2015, and June 30, 2021, were included and followed up until June 30, 2023, for a median of 4.3 to 5.4 years. Data analysis was conducted from April to September 2025. Exposures: Initiation of a TNF antagonist (ie, infliximab or adalimumab) or vedolizumab as first-line advanced therapy. Main outcomes and measures: The primary outcome was the incidence rate of all-cause hospitalizations (including recurrent events). Secondary outcomes included incidence rates of colectomy, corticosteroid dispensations, advanced therapy switching, and proportion of quarters spent in corticosteroid-free disease stability (defined as no oral corticosteroid dispensation, no initiation of a new advanced therapy or immunomodulator, and no hospitalization or colectomy within a 3-month period). Groups were balanced using inverse probability of treatment weighting (IPTW) accounting for disease characteristics, health care utilization, comorbidities, and medication use.