Network meta-analysis to inform positioning of biologics in patients with Crohn's disease: Promise and perils.

With availability of several different classes of biologic agents with variable efficacy and safety profiles for moderate-severe Crohn's disease (CD), positioning of different agents in treatment course is an important question for clinicians. Though in an ideal world, positioning would be personalized and driven by likelihood of response to different agents based on biomarkers in individual patients, that is still far from reality, and decisions are empiric. In the absence of head-to-head trials of different medications, decisions on treatment choice and positioning are primarily based on clinician experience, opinion-based treatment algorithms, patient preference and insurance reimbursement. Understandably, in the absence of guidance, there is considerable practice variability on optimal choice of first- and second-line biologics in the treatment of patients with CD. In the absence of direct evidence from head-to-head trials, network meta-analysis can help assess comparative efficacy of several interventions and synthesize evidence across a network of randomized controlled trials. In this review, we discuss what network meta-analyses, what do they tell us about positioning different agents, and strengths and limitations of such an approach.