A132 ANTI-TNF DOSE AUGMENTATION FREQUENTLY OCCURS IN THE ABSENCE OF OBJECTIVE EVIDENCE OF DISEASE ACTIVITY. (15th March 2019) - Elias, E
Abstract: Background: Anti-TNF dose is frequently increased or dosing interval shortened in IBD subjects with persistent gastrointestinal symptoms. Evidence supporting dose augmentation is of low quality and the practice imparts a significant additional cost of care. Persons with symptoms ascribed to IBD may not have evidence of ongoing inflammation and therefore would not be expected to benefit from dose augmentation. Aims: We sought to determine the extent to which clinicians routinely assessed the presence of active inflammation prior to undertaking anti-TNF dose augmentation. Methods: Medical records of all IBD patients prescribed anti-TNF therapy from 2007–2016 by 11 of 23 Manitoba gastroenterologists were reviewed and demographics, disease characteristics, and IBD treatments recorded. Patients who underwent anti-TNF dose augmentation were further reviewed for the presence of objective assessment of inflammation - including laboratory investigations (CRP, ESR, albumin, ferritin, hemoglobin, fecal calprotectin), cross-sectional abdominal imaging, and endoscopy - in the 90 days preceding dose augmentation. Results: 737 subjects receiving anti-TNF therapy were identified, of whom 197 had anti-TNF doses augmented on 269 occasions (151 CD, 46 UC). 72 subjects (51.1%) with CD had penetrating disease while 23 (50.0%) with UC had pancolitis. Mean age at diagnosis was three years younger amongst dose augmented subjects (26.3 vs 29.4 years, p=0.002), but no other significant differences in demographics, disease phenotype, or baseline lab values were found. Biochemical evidence of inflammation was assessed prior to dose augmentation on 161 of 269 occasions (59.9%). Results of these investigations were abnormal in only 32 cases (11.9%). Cross-sectional imaging was performed in 21 cases (7.8%) and revealed active disease in 20 (7.4%). Endoscopy was performed on 31 occasions (11.5%) with 26 (9.7%) revealing active disease. Overall, objective evidence of inflammation was present for 69 of 269 dose augmentation events (25.7%), no evidence of inflammation was present for 105 (39.0%), and no investigations were performed for 95 (35.3%). Conclusions: Anti-TNF dose augmentation routinely occurs in the absence of objective evidence of active inflammatory disease. This represents a target for ongoing quality improvement to optimize care of persons with IBD requiring anti-TNF based therapies given the significant economic burden of unjustified and potentially unnecessary dose augmentation. Funding Agencies: None