About to try a third biologic. And question about flare management.

I started Humira for my ulcerative colitis last year and I never saw any benefit. Bloodwork showed it was present above the desired threshold and I hadn’t developed antibodies, but it still didn’t work. I switched to Stelara and just recently had a flex sig after I started flaring after coming off budesonide. The stelara didn’t work either, as inflammation was unchanged. I’m now going to switch to Entyvio. I know everyone reacts differently to the biologics but how many biologics have people gone through before finding one that worked for them? I’m starting to worry I may just not find one that works for me.

I’m also wondering what medications others use to manage flare symptoms. I have been prescribed Bentyl and another antispasmodic I can’t recall, as well as budesonide. The Bentyl and the other antispasmodic are minimally helpful. Budesonide does the trick every time, but that’s obviously not a long term answer. I’m wondering what other medications others have used successfully to treat flare symptoms.

Before the recent flex sig, I was having my usual flare symptoms, diarrhea and waxing and waning abdominal pain, and then I did the usual liquid diet for a day before the procedure and two fleet enemas ahead of the flex sig. Interestingly, I haven’t had any flare symptoms since. It could just be a coincidence, and the flare passed on its own; I’ve never had one that didn’t subside. Is it possible any of that prep could have helped somehow?

If you had no response to Humira, despite having sufficient levels and no antibodies, that means you would be considered a "primary non-responder" to anti-TNF medications.

That means that Remicade is unlikely to work either, since it's another anti-TNF medication.

And since you also didn't get a good response to Stelara, that means that the odds of Entyvio working for your aren't very good either.

The recommendation for the next med class to try would be the JAK inhibitors like Rinvoq.

At what dose of budesonide do you need to be on to get relief? The full 9mg? What if you stay on 6mg or even 3mg? Is that enough? You're right that steroids aren't a good long term solution, but budesonide is less bad than prednisone, and the lower the dose of budesonide, the better. If you can get by on 3mg or 6mg for a while as you wait for another drug to help, that's probably not terribly risky.

Humira and Remicade are anti-TNFs. They block the action of the "help" signal TNF-alpha that is sent out by the bowel tissue.

You are correct that Stelara and Entyvio are no in the same class of biologics.

Stelara is an anti-IL 12 and anti-IL 23 antibody. It works in the thymus to prevent immature lymphocytes from maturing/developing into certain types of damaging t-cells.

Entyvio an integrin blocker. It works in the junction of the blood vessel and the bowel tissue. It prevents those t cells (mature lymphocytes) that have left the thymus and are circulating in the bloodstream from leaving the blood vessel and entering the bowel tissue.

When an anti-TNF doesn't work at all for a person, Entyvio is less likely to work, and the suggestion is to try Stelara (or the similar Skyrizi). If an ant-TNF AND Stelara don't work, then it's even less likely that Entyvio will work.

In that case, the next thing to try is usually the JAK inhibitors, because their method of action is dissimilar.

Unfortunately, yes, I would say it's a poor choice - unless there are other medical concerns I'm not aware of.

Entyvio might work for you, but studies show the odds aren't very good.

If you have some other medical conditions - such as heart disease, stroke history or high risk factors - then the JAK inhibitors may be too risky for you.

But if you don't have any other conditions that would make JAK inhibitors too risky, then they are the appropriate next option for you to try. Given your history, they have a much higher chance of helping than Entyvio does.