Effect of a Practice-wide Anti-TNF Proactive Therapeutic Drug Monitoring Program on Outcomes in Pediatric Patients With Inflammatory Bowel Disease

Inflamm Bowel Dis. 2020 May 25;izaa102. doi: 10.1093/ibd/izaa102. Online ahead of print.

John L Lyles 1, Aditi A Mulgund 2 3, Laura E Bauman 1 4, Weizhe Su 5, Lin Fei 6 7, Deepika L Chona 2, Puneet Sharma 1 7, Renee K Etter 1, Jennifer Hellmann 1 7, Lee A Denson 1 7, Phillip Minar 1 7, Dana M Dykes 1 8, Michael J Rosen 1 7


Author information

1Division of Gastroenterology, Hepatology, and Nutrition, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA.

2Department of Internal Medicine, University of Cincinnati College of Medicine, Cincinnati, OH, USA.

3Division of Gastroenterology and Hepatology, Medical College of Wisconsin Associated Hospitals, Milwaukee, WI, USA.

4Department of Pediatrics, University of California San Diego, La Jolla, CA, USA.

5Division of Statistics and Data Science, Department of Mathematical Sciences, University of Cincinnati, Cincinnati, OH, USA.

6Division of Biostatistics and Epidemiology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA.

7Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH, USA.

8GI Care for Kids, Atlanta, GA, USA.


Background: Reports on the feasibility and effectiveness of translating proactive, antitumor necrosis factor (TNF) therapeutic drug monitoring (TDM) for inflammatory bowel disease into practice-wide quality improvement (QI) are lacking. We aimed to determine whether a TDM QI program improved outcomes at a large academic pediatric gastroenterology practice.

Methods: We instituted local anti-TNF TDM practice guidelines to proactively monitor and optimize drug levels (goal >5 μg/mL). We conducted a retrospective single-center cohort analysis of patient outcomes before (pre-TDM) and after (post-TDM) guideline institution and assessed the independent effect by multivariable regression. Primary outcome was sustained clinical remission (SCR22-52), defined as physician global assessment (PGA) of inactive from 22 to 52 weeks and off corticosteroids at 52 weeks.

Results: We identified 108 pre-TDM and 206 post-TDM patients. The SCR22-52 was achieved in 42% of pre-TDM and 59% of post-TDM patients (risk difference, 17.6%; 95% CI, 5.4-29%; P = 0.004). The post-TDM group had an increased adjusted odds of achieving SCR22-52 (odds ratio, 2.03; 95% CI, 1.27-3.26; P = 0.003). The adjusted risk of developing high titer antidrug antibodies (ADAs) was lower in the post-TDM group (hazard ratio, 0.18; 95% CI, 0.09-0.35; P < 0.001). Although the risk of anti-TNF cessation for any reason was not significantly different, there was a lower adjusted risk of cessation related to any detectable ADA in the post-TDM group (hazard ratio, 0.45; 95% CI, 0.26-0.77; P = 0.003).

Conclusions: A practice-wide proactive anti-TNF TDM QI program improved key clinical outcomes at our institution, including sustained clinical remission, incidence of high titer ADA, and anti-TNF cessation related to ADA.

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