- Fecal Incontinence
|Appropriateness of Biologics in the Management of Crohn's Disease Using RAND/UCLA Appropriateness Methodology
Weizman AV1, Nguyen GC1, Seow CH2, Targownik L3, Murthy SK4, Boland K1, Afzal NM1, Khanna R5, Jones J6, Afif W7, Halder S8, Reinglas J4, Fowler S9, Huang V1, Kaplan GG2, Melmed GY10. Inflamm Bowel Dis. 2018 Oct 19. doi: 10.1093/ibd/izy333. [Epub ahead of print]
1 Division of Gastroenterology, Department of Medicine, Mount Sinai Hospital, University of Toronto Toronto, Ontario, Canada.
2 Division of Gastroenterology and Hepatology, Department of Medicine, University of Calgary, Calgary, Alberta, Canada.
3 Division of Gastroenterology, Department of Internal Medicine, University of Manitoba, Winnipeg, Manitoba, Canada.
4 Division of Gastroenterology, Department of Medicine, University of Ottawa, Ottawa, Ontario, Canada.
5 Division of Gastroenterology, Department of Medicine, Western University, London, Ontario, Canada.
6 Division of Gastroenterology, Department of Medicine, Dalhousie University, Halifax, Nova Scotia, Canada.
7 Division of Gastroenterology, Department of Medicine, McGill University, Montreal, Quebec, Canada.
8 Division of Gastroenterology, Department of Medicine, McMaster University, Hamilton, Ontario, Canada.
9 Division of Gastroenterology, Department of Medicine, University of Saskatchewan, Saskatoon, Saskatchewan, Canada.
10 Inflammatory Bowel Disease Center, Cedars-Sinai Medical Center Los Angeles, California, USA.
BACKGROUND: 3 classes of biologics are now available for the treatment of Crohn's disease. The availability of multiple treatment options has led to questions regarding the appropriateness of each agent for a given patient. We aimed to evaluate physician preferences for the use of specific biologic agents in a variety of Crohn's disease management scenarios using the RAND/UCLA Appropriateness Methodology.METHODS: A panel consisting of members of the CINERGI group (Canadian IBD Network for Research and Growth in Quality Improvement) was assembled. A literature review was performed on factors identified as influential upon choice of biologic therapy. Clinical scenarios were developed, and panelists rated the appropriateness of biologic therapy classes in each scenario individually and again during a face-to-face meeting after moderated discussion.
RESULTS: Two hundred eighty-eight modifications of 3 clinical scenarios were rated. Factors that influenced biologic choice included perianal disease, antidrug antibody status, extraintestinal manifestations, consideration of potential pregnancy, and history of serious infection or malignancy. Anti-TNF therapy was considered appropriate in the postoperative patient. Ustekinumab and vedolizumab were considered appropriate in patients without perianal disease over the age of 65 with a history of malignancy or serious infection. The use of anti-TNF therapy was considered inappropriate in some scenarios whereby drug level was adequate and no antidrug antibody (ADA) was detectable.
CONCLUSIONS: We evaluated the appropriateness of the 3 available classes of biologics in a number of scenarios for the treatment of Crohn's disease. History of serious infection and malignancy, particularly in individuals over 65 years, and consideration of future pregnancy were patient-specific variables that impacted treatment decisions. These findings can serve as a guide for providers considering biologic therapy in patients with Crohn's disease.