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Proactive drug monitoring can prevent serious IBD complications
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BOSTON – Optimizing therapeutic drug levels before the development of new symptoms can help patients with inflammatory bowel disease avoid serious complications and adverse events, according to a presentation given at the Interdisciplinary Autoimmune Summit.
Adam Cheifetz, MD, director of the Center for Inflammatory Bowel Disease at Beth Israel Deaconess Medical Center said proactive therapeutic drug monitoring (TDM) works by keeping patients’ drug concentration levels within a therapeutic window. Despite somewhat limited research about its benefits, Cheifetz said the implementation of proactive TDM should be common sense.
“I am a huge proponent of TDM, particularly proactively,” he said. “To me, it doesn’t make sense to wait until someone is failing a drug before optimizing it.”
While higher concentrations of biologics are associated with better outcomes in IBD, lower concentrations are associated with loss of response and the development of antibodies. Cheifetz argued that physicians need to target the lower part of the therapeutic window for biologics and ensure levels are high enough to prevent treatment failure. If the target for therapy is histologic remission, Cheifetz said drug concentration for a biologic like infliximab likely needs to be greater than 10.
In a study published in 2017, Cheifetz and colleagues conducted a retrospective cohort study of 153 patients who responded to infliximab and underwent either proactive or reactive TDM during maintenance therapy. They found that the proactive group experienced significantly better outcomes in treatment failure, IBD-related surgery, hospitalization, development of antibodies and serious infusion reactions.
There are some issues with proactive TDM that Cheifetz said stand as barriers against its widespread use. There is still a need for a test that’s accurate, accessible and affordable, as well as prospective data on implementation and optimal trough concentration levels.
If these barriers prevent implementation of proactive TDM, Cheifetz urged physicians to at least do reactive TDM, with a warning.
“I would say if you’re only doing it reactively, you’re probably missing the boat in a percentage of patients that when you do check them they’re going to have antibodies, and you’ve now just lost a drug,” he said. “If you have someone doing well on a drug, why not optimize it from the get go?” – by Alex Young
Disclosures: Cheifetz reports that he is a consultant for AbbVie, AMAG, Ferring, Janssen, Miraca, Pfizer, and Takeda. He also receives grant and research support from Miraca.