Pharmacological treatments for moderate-to-severe ulcerative colitis: a systematic review and Bayesian network meta-analysis

Backgrounds: To systematically compare the relative efficacy of different therapeutic agents for the induction and maintenance treatment of moderate-to-severe active ulcerative colitis (UC) in adult patients. Methods: We retrieved RCTs from PubMed, Embase, Scopus and CENTRAL (2020.1.1 − 2026.1.1). A Bayesian random-effects NMA was performed, with treatment efficacy ranked by SUCRA. (Registration No. CRD420261293873). Results: A total of 41 RCTs comprising 22,619 patients with moderate-to-severe active UC were included. Compared with placebo, JAK-STAT inhibitors (RR = 4.5, 95% CI 3.0–7.2), anti-TNF-α biologics (RR = 3.0, 95% CI 1.8–5.3), S1P receptor modulators (RR = 3.0, 95% CI 2.1–4.5), anti-IL-23 biologics (RR = 2.8, 95% CI 2.0–4.0), anti-integrin biologics (RR = 2.2, 95% CI 1.5–3.2) and anti-TL1A biologics (RR = 4.0, 95% CI 2.0–9.0) significantly improved clinical remission during the induction phase. Furthermore, JAK-STAT inhibitors, S1P receptor modulators, anti-IL-23 biologics, anti-TNF-α biologics, and anti-integrin biologics effectively maintained clinical remission. Monotherapy with 5-aminosalicylates (5-ASA) or immunomodulators did not demonstrate a significant benefit over placebo. Based on SUCRA probabilities, the top three regimens for induction of clinical remission were JAK-STAT inhibitors (91.5%), anti-TL1A biologics (82.3%), and anti-TNF-α biologics (70.1%). For the maintenance phase, the top three were JAK-STAT inhibitors (86.3%), S1P receptor modulators (80.5%), and anti-IL-23 biologics (59.4%). Conclusions: JAK-STAT inhibitors demonstrated optimal efficacy for achieving clinical remission in both the induction and maintenance phases of UC treatment. Additionally, targeted therapies, including anti-TNF-α, anti-IL-23, and S1P receptor modulators, provided substantial therapeutic benefits.