Adherence to adalimumab therapy in Crohn's disease: a French multicenter experience

Medication Non-Adherence in Inflammatory Bowel Disease: A Systematic Review Identifying Risk Factors and Opportunities for Intervention

Inflammatory bowel disease (IBD) is treated with medications to induce and maintain remission. However, many people with IBD do not take their prescribed treatment. Identifying factors associated with IBD medication adherence is crucial for supporting effective disease management and maintaining remission. Quantitative and qualitative studies researching IBD medication adherence between 2011 and 2023 were reviewed. In total, 36,589 participants were included in 79 studies. The associated non-adherence factors were contradictory across studies, with rates notably higher (72-79%) when measured via medication refill. Non-adherence was lower in high-quality studies using self-report measures (10.7-28.7%). The frequent modifiable non-adherence risks were a poor understanding of treatment or disease, medication accessibility and an individual's organisation and planning. Clinical variables relating to non-adherence were the treatment type, drug regime and disease activity. Depression, negative treatment beliefs/mood and anxiety increased the non-adherence likelihood. The non-modifiable factors of limited finance, younger age and female sex were also risks. Side effects were the main reason cited for IBD non-adherence in interviews. A large, contradictory set of literature exists regarding the factors underpinning IBD non-adherence, influenced by the adherence measures used. Simpler medication regimes and improved accessibility would help to improve adherence. IBD education could enhance patient knowledge and beliefs. Reminders and cues might minimise forgetting medication. Modifying risks through an adherence support intervention could improve outcomes.

Designing for medication adherence in inflammatory bowel disease: multi-disciplinary approaches for self-administrable biotherapeutics

Biotherapeutics are among the therapeutics that have revolutionized standard inflammatory bowel disease (IBD) treatment, which was previously limited to mesalamine, 5-aminosalicylic acid, corticosteroids, and classical immunosuppressants. Self-administrable biotherapeutics for IBD would enable home-based treatment and reduce the burden on medical infrastructure. Self-administration is made possible through subcutaneous injectable, oral, and rectal dosage forms. Nevertheless, the full benefits of self-administration cannot be realized without first addressing the issue of medication adherence, which remains woefully inadequate for IBD biotherapies. Some of the major barriers to medication adherence in IBD are the route of administration, frequency of administration, and undesired side effects. In this review, we identify the main physiological and engineering constraints that underlie these three barriers to adherence. We then highlight key technological and behavioral innovations-spanning multiple scientific disciplines-that can be leveraged to design novel therapies and interventions that improve adherence to self-administered IBD biotherapies.

Infliximab vs adalimumab: Points to consider when selecting anti-tumor necrosis factor agents in pediatric patients with Crohn's disease

Biologic agents with various mechanisms against Crohn's disease (CD) have been released and are widely used in clinical practice. However, two anti-tumor necrosis factor (TNF) agents, infliximab (IFX) and adalimumab (ADL), are the only biologic agents approved by the Food and Drug Administration for pediatric CD currently. Therefore, in pediatric CD, the choice of biologic agents should be made more carefully to achieve the therapeutic goal. There are currently no head-to-head trials of biologic agents in pediatric or adult CD. There is a lack of accumulated data for pediatric CD, which requires the extrapolation of adult data for the positioning of biologics in pediatric CD. From a pharmacokinetic point of view, IFX is more advantageous than ADL when the inflammatory burden is high, and ADL is expected to be advantageous over IFX in sustaining remission in the maintenance phase. Additionally, we reviewed the safety profile, immunogenicity, preference, and compliance between IFX and ADL and provide practical insights into the choice of anti-TNF therapy in pediatric CD. Careful evaluation of clinical indications and disease behavior is essential when prescribing anti-TNF agents. In addition, factors such as the efficacy of induction and maintenance of remission, safety profile, immunogenicity, patient preference, and compliance play an important role in evaluating and selecting treatment options.

How are patients' preferences for anti-TNF influenced by quality of life? A discrete choice experiment in Crohn's disease patients

BACKGROUND AND OBJECTIVE

Anti-TNFs have been shown to significantly improve the health-related quality of life (HRQoL) in Crohn's disease (CD) patients. The purpose of this study was to investigate to what extend the patients' preferences for these intravenous (IV) and subcutaneous (SC) treatments differ based on respondents' quality of life. An online discrete choice experiment (DCE) was conducted to understand patient trade-offs in treatment choice.

METHODS

Fifty-seven Crohn's disease anti-TNF naïve patients were asked to choose between two different scenarios, considering the following attributes: mode of administration (MODE), total availability for injection (TIME), speed of onset (DELAY), risk of anti-TNF administration despite a contraindication (RISK) and total monthly out-of-pocket expenses (COST). At the same time, patients completed the IBDQ-32 questionnaire. Conditional logit models without and with interaction terms were estimated to evaluate attribute weights.

RESULTS

Patients preferred to self-administer SC anti-TNF rather than have a primary care nurse do it, whereas the preference for IV route was negative. After adding interaction terms however, the IV route became preferred for patients with impaired HRQoL, this preference having decreased as HRQoL increased. Surprisingly, patients with impaired HRQoL were less willing to spend more time on treatment, and this effect diminished as HRQoL (overall and in each dimension) became higher.

CONCLUSIONS

HRQoL level changed patients' preferences for the anti-TNF treatment. The results suggest the need to optimise the management of IV infusions in the hospital and reinforce the importance of patient-reported outcome measures (PROMS) as a common practice to improve shared medical decision making.

No Difference of Adalimumab Pharmacokinetics When Dosed at 40 mg Every Week or 80 mg Every Other Week in IBD Patients in Clinical Remission After Adalimumab Dose Intensification

INTRODUCTION

The pharmacokinetic equivalence of dose intensification with adalimumab (ADA) 80 mg every other week (EOW) compared to weekly 40 mg has only been supported by modeling systems.

AIM OF THE STUDY

To compare the trough levels of ADA (TLA) and the occurrence of anti-ADA antibodies (AAA) between these two treatment regimens.

PATIENTS AND METHODS

This was a prospective study including all consecutive patients with inflammatory bowel disease (IBD) who had reached a longstanding and deep remission under treatment with ADA 40 mg once a week. In these patients, the ADA regimen was changed from 40 mg/week to 80 mg EOW. TLA and AAA levels using a drug-tolerant assay were monitored before and ten weeks after from the change in the ADA regimen and the results compared by a Wilcoxon paired test.

RESULTS

Sixty-two patients (60% CD, mean age 35 years) were included. Before and ten weeks after the changes of ADA regimen, the median TLA were (6.9 µg/mL versus 7.0 µg/mL, respectively; P = 0.34) and the AAA levels (3.4 µg/ml-eq versus 3.0 µg/ml-eq, respectively; P = 0.25.) were quite similar. Likewise, quartiles of TLA (Kendall test r = 0.91; P < 0.001) and AAA (r = 0.78; P < 0.001) did not differ before and after ADA regimen. When stratifying all the patients into 4 groups based on drug/antibody levels (immunogenic, subtherapeutic, therapeutic, or supratherapeutic), no patient needed for returning to the previous weekly regimen. In terms of acceptability, more than 60% of patients preferred an injection EOW compared once a week.

CONCLUSIONS

In IBD patients who achieved a deep clinical remission under ADA 40 mg once a week, the pharmacokinetic of ADA was similar when ADA regimen was changed to 80 mg EOW. Given the patient's preference for the latter regimen, a modification of injection regimen should be systematically proposed.

[Compliance with biologic agents: Current situation]

Despite the fact that the prognosis of chronic inflammatory disorders is improved by biological agents, compliance with those therapeutics remains imperfect. Compliance corresponds to the measurable part of the follow-up of the medical prescription by the patient, whereas adherence is related to the acceptation of the treatment by the patient. The compliance rates of biologic agents are generally higher than those of conventional therapies. Compliance can be influenced by the real or experienced efficacity of the treatment, by patient-related factors or by the patient-physician relationship. An increase of compliance is associated with an improvement of adherence. To achieve this, the physician can use educational measures such as patient education, which allows the identification of poor adherence. Such programs have been shown to improve the patient's knowledge of the disease and treatment leading to better adherence and compliance.

Patients' Online Information-Seeking Behavior Throughout Treatment: The Impact on Medication Beliefs and Medication Adherence

Research on the longitudinal impact of using the internet as an information source on patients' beliefs and medication adherence is scarce. Chronic patients (N = 107) from six hospitals were surveyed to longitudinally explore their online information seeking behavior throughout treatment (i.e., before the consultation about their newly prescribed medication in the initiation phase and after six months in the implementation phase) and how this affects their medication beliefs (concerns and necessity) and medication adherence after three weeks (T1) and six months (T2). Most patients (79%) used the internet. Patients who used the internet before the consultation reported to have more concerns about their medication at T1 and T2 compared to those who did not. Moreover, patients who used the internet throughout treatment valued their concerns higher than the necessity after six months (T2). Patients who used the internet after the consultation reported to be more non-adherent after three weeks (T1) compared to those who did not. Because of the longitudinal nature of this study, we were able to pinpoint in which treatment phase patients' online information seeking behavior is particular relevant in affecting patients' beliefs and medication adherence.

A Targeted Literature Review Examining Biologic Therapy Compliance and Persistence in Chronic Inflammatory Diseases to Identify the Associated Unmet Needs, Driving Factors, and Consequences

Chronic inflammatory diseases (CIDs) represent a substantial clinical and economic burden to patients, providers, payers and society overall. Biologics, such as tumor necrosis factor inhibitors (TNFi), have emerged as effective treatment options for patients with CIDs. However, the therapeutic potential of biologics is not always achieved in clinical practice, with results from studies examining the use of biologics in real-world settings suggesting lower levels of treatment effectiveness compared with clinical trial results. Using a targeted approach, this literature review demonstrates that compliance and persistence with biologic therapy is suboptimal and that this has implications for both clinical outcomes and treatment costs. The review identified a variety of predictors of treatment compliance and persistence, including increased age, female gender, presence of comorbidities, increased disease activity, longer disease duration, smoking, increased body mass index, higher biologic treatment dose, higher treatment cost and lower health-related quality-of-life scores. Patients often cited factors associated with medication delivery as a reason for non-compliance and non-persistence, and device-related improvements to treatment delivery were associated with higher rates of compliance and persistence. The articles identified in this review provide insights that have the potential to help guide the development of new solutions to improve disease management and optimize treatment regimens. This has the potential to benefit patients' health by improving clinical outcomes and to reduce the burden to society by limiting the economic impact of patients' disease.

FUNDING

UCB Pharma.

Nonadherence to Biologic Therapies in Inflammatory Bowel Disease

BACKGROUND

Nonadherence to medications is common with patients with inflammatory bowel disease (IBD). The aim of this study was to assess adherence to biologic medications prescribed for IBD and to identify risk factors for biologic nonadherence.

METHODS

This was a single center retrospective cohort study investigating IBD patient adherence to biologic therapies over a 2-year period from September 2014 to September 2016. Specialty pharmacy and infusion center records were obtained and a modified medication possession ratio was calculated. Patient characteristics associated with nonadherence in a univariate model were placed into a multivariate logistic regression to assess independent predictors of nonadherence.

RESULTS

Three hundred sixty-five patients met inclusion criteria; 63 patients were on vedolizumab. Three hundred and one patients (82%) had Crohn's disease. The pooled 24-month adherence rate was 66%; adherence to individual biologic therapy included vedolizumab 83%, infliximab 70%, adalimumab 57%, and certolizumab pegol 50%. Facility-administered biologics were independently associated with higher adherence than self-administered biologics (OR 2.39, 95% CI 1.50 - 3.80). Additional risk factors for nonadherence included younger age (OR 1.22, 95% CI 1.01-1.47) and noncommercial insurance (OR 1.78, 95% CI 1.01 - 3.13).

CONCLUSIONS

This is the first study to assess adherence to vedolizumab in IBD patients, which was higher than 3 other commonly prescribed biologic medications. Self-administered injections were strongly associated with biologic nonadherence. Younger age and noncommercial insurance also were associated with biologic nonadherence. Modality of administration should be taken into account when selecting a biologic agent for treatment of IBD.

Adherence rates and health care costs in Crohn's disease patients receiving certolizumab pegol with and without home health nurse assistance: results from a retrospective analysis of patient claims and home health nurse data

BACKGROUND

Patient support programs have a positive effect on adherence to therapy. Certolizumab pegol (CZP) is a tumor necrosis factor antagonist for the treatment of Crohn's disease.

OBJECTIVES

To assess, using real-world claims data, whether home health nurse assistance had an effect on patients' adherence to CZP and to measure its impact on health care use and costs.

METHODS

A retrospective analysis of medical and pharmacy claims data from the IQVIA Real-World Data Adjudicated Claims Database was conducted using data from January 1, 2007 through September 30, 2015. CZP patients with Crohn's disease were eligible to receive self-administration instructions from a nurse or nurse-administered CZP injections, or both. These services were provided by CIMplicity^®, a home health nurse program sponsored by UCB Pharma. Cohorts were based on patients with and without nurse assistance and were matched based on gender and categorical age. Adherence to CZP was determined using the medication possession ratio (MPR) and proportion of days covered (PDC). A Kaplan-Meier analysis was performed to compare time to discontinuation of CZP between the two cohorts. Multivariate regression analyses were performed, adjusting for additional covariates to compare the effect of CZP with and without nurse assistance on hospitalization and total health care costs.

RESULTS

Patients with at least 12 months of continuous enrollment post-index date were evaluated for adherence to CZP (n=276 in each cohort). The mean and median PDC and MPR values were higher with nurse assistance than without. Time to discontinuation was significantly longer in patients who received CZP with nurse assistance than without (P=0.0004). Results from the multivariate analyses showed a significant reduction in all-cause hospitalization (-55.8%; P=0.0026) and total health care costs (-14.3%; P=0.0045) with nurse assistance.

CONCLUSION

This analysis suggests that home health nurse assistance increases adherence to CZP and reduces health care costs in patients with Crohn's disease.

Optimizing Selection of Biologics in Inflammatory Bowel Disease: Development of an Online Patient Decision Aid Using Conjoint Analysis

OBJECTIVES

Recent drug approvals have increased the availability of biologic therapies for inflammatory bowel disease (IBD), making it difficult for patients with ulcerative colitis (UC) and Crohn's disease (CD) to navigate treatment options. Here we developed a conjoint analysis to examine patient decision-making surrounding biologic medicines for IBD. We used the results to create an online patient decision aid that generates a unique "preferences report" for each patient to assist with shared decision-making with their provider.

METHODS

We administered an adaptive choice-based conjoint survey to IBD patients that quantifies the relative importance of biologic attributes (e.g., efficacy, side effect profile, mode of administration, and mechanism of action) in decision making. The conjoint software determined individual patient preferences by calculating part-worth utilities for each attribute. We conducted regression analyses to determine if demographic and disease characteristics (e.g., type of IBD and severity) predicted how patients made decisions.

RESULTS

640 patients completed the survey (UC=304; CD=336). In regression analyses, demographics and IBD characteristics did not predict individual patient preferences; the main exception was IBD type. When compared to UC, CD patients were more likely to report side effect profile as most important (odds ratio (OR) 1.63, 95% confidence interval (CI) 1.16-2.30). Conversely, those with UC were more likely to value therapeutic efficacy (OR 1.41, 95% CI 1.01-2.00).

CONCLUSIONS

Biologic decision-making is highly personalized; demographic and disease characteristics poorly predict individual preferences, indicating that IBD patients are unique and difficult to statistically categorize. The online decision tool resulting from this study (www.ibdandme.org) may be used by patients to support shared decision-making and optimize personalized biologic selection with their provider.

Chronic Disease and Self-Injection: Ethnographic Investigations into the Patient Experience During Treatment

Introduction

Drug administration by self-injection provides an option to treat chronic inflammatory diseases such as rheumatoid arthritis (RA) and Crohn’s disease (CD). However, a negative self-injection experience for patients may reduce patient adherence to the recommended treatment regimen. In this study, a holistic approach was used to identify common themes along the treatment pathway and at self-injection that, if changed, could improve patient experience and treatment outcomes.

Methods

Two ethnographic studies were conducted: Field Insights CODE (FI[CODE]) examined the treatment pathway within the context of the experience of living with RA or CD, and Injection Mission 2020 (IM2020) focused on the moment of self-injection. FI(CODE) used an open ethnographic approach to interview 62 patients and 10 healthcare professionals (HCPs) from the US and UK. IM2020 included a review of over 50 injection device design information sources from the sponsor, and interviews with 9 patients, 8 HCPs, and 5 medical device designers from the US, UK, Canada, and Japan.

Results

FI(CODE) identified suboptimal treatment practices along the treatment pathway in four key areas: treatment team communication, treatment choice, patient empowerment, and treatment delivery. Patients with more treatment options and greater disease understanding were less likely to struggle with the treatment process. IM2020 demonstrated that five related components influenced the self-injection experience: delivery process, emotional state, social perception, educational level, and ritualization of the self-injection process.

Conclusion

These analyses highlight several potential areas for improvement, including aligning the device more to patients’ needs to improve treatment adherence, better accessibility to educational resources to increase patient disease understanding, and guidance to empower patients to develop an optimal personalized self-injection ritual.

Funding

UCB Pharma.

Electronic supplementary material

The online version of this article (doi:10.1007/s40744-017-0080-4) contains supplementary material, which is available to authorized users.

Some medicines used to treat long-term conditions, such as rheumatoid arthritis or Crohn’s disease, are injected under the skin. Often, patients can choose to inject medicines themselves (self-injection). This must be done correctly for the medicines to work properly. But, the training surrounding self-injection is uneven and often cannot address the fundamental problems facing all self-injecting patients.

What healthcare improvements could help patients self-inject successfully? To find out, we interviewed people living with rheumatoid arthritis or Crohn’s disease, while others were doctors, nurses, and people who design injection devices.

We found four common problems in the overall healthcare that patients received:

There were communication problems between different healthcare professionals and between healthcare professionals and patients, for example about treatment options or goals.

Each level in the healthcare system (e.g., the nurse, doctor, hospital board, health insurance company) made decisions that limited how many treatment options were presented to patients for consideration.

Patients were not empowered, as they felt they lacked personal input, information, and control in treatment decisions.

Healthcare professionals focused on disease treatment but not patient experience; they did not fully explain how to perform injections (delivery), leaving patients to figure it out by trial and error.

In addition, five factors were identified that affected patients’ experiences of self-injection:

Process of injection: minimal one-on-one instruction for self-injection left some patients anxious and more prone to mistakes.

Emotions: some patients were better than others at ‘overriding’ emotions (e.g., fear) when self-injecting.

Views on injections: there was negative social stigma around injections, but patients had greater trust in more technological, modern devices.

Education: doctors often failed to explain how to manage fear and anxiety.

Developing a ritual: patients with a ritualized routine for when, where, and how to self-inject were more confident.

If doctors and nurses can support patients by providing a greater choice of treatments and injection devices, and teaching more about self-injection, this could improve patients’ experiences and allow medications to work better. Healthcare professionals should help patients to develop their own, optimal routine for self-injection.

Risk for Overall Infection with Anti-TNF and Anti-integrin Agents Used in IBD: A Systematic Review and Meta-analysis

BACKGROUND

The overall risk for infection with contemporary biological agents in treating Crohn's disease (CD) and ulcerative colitis (UC) has not been systematically assessed.

METHODS

We performed a PubMed and Cochrane database literature search to evaluate randomized, placebo-controlled trials of biologics in treating UC and CD. Meta-analysis was performed using a DerSimonian and Laird random effects model. We determined relative risk (RR) of harm against placebo; number needed to harm (NNH) was reported when appropriate. Heterogeneity and publication bias were assessed.

RESULTS

Fourteen trials (6 UC and 8 CD) evaluating 5107 patients were included. For anti-tumor necrosis factor agents used in the treatment of UC, golimumab {NNH of 9.3, RR = 1.4 (95% confidence interval [CI], 1.04-1.8)} and pooled studies of infliximab and adalimumab (NNH = 17.2, RR = 1.2 [95% CI, 1.0-1.3]) had a statistically significant higher risk for any infection versus placebo. Risk was not significantly increased in anti-tumor necrosis factor trials in CD (RR = 1.1 [95% CI, 0.8-1.5]). By contrast, anti-integrin agents in UC (RR = 1.0 [95% CI, 0.9-1.2]) or CD (RR = 1.1 [95% CI, 0.97-1.3]) did not confer a statistically significant excess risk of infection versus placebo.

CONCLUSIONS

Anti-tumor necrosis factor therapy but not anti-integrin therapy is associated with a greater infection risk than placebo in treating UC. Neither class of therapy is associated with increased infection risk over placebo in treating CD. Our findings can help guide patient-centered discussions regarding the risk for infection with biological agents.

Medication non-adherence in adult patients affected by inflammatory bowel disease: a critical review and update of the determining factors, consequences and possible interventions

Achieving adherence to medications can be a serious challenge for patients affected by inflammatory bowel disease (IBD). Medical treatment is fundamental for inducing and maintaining remission, preventing flares and reducing the risk of colorectal cancer. Non-adherence may affect patients' quality of life resulting in unfavourable treatment outcomes, more hospitalizations and higher healthcare-related costs. Recognising and improving adherence is therefore a primary aim for the treatment of IBD. Areas covered: We critically discuss the current knowledge on medication non-adherence in adult patients affected by IBD, also mentioning a few issues concerning the paediatric and adolescent populations. In particular, we reviewed the literature focusing on the definition and detection of non-adherence, on its extent and on the possible non-modifiable and modifiable factors involved (patient-centred, therapy-related, disease-related and physician-related). Furthermore, we analysed the interventional studies performed so far. The literature review was conducted through PubMed addressing medication non-adherence in IBD, using the keywords 'adherence' and related terms and 'IBD, ulcerative colitis or Crohn's disease'. Expert commentary: Adherence to therapy for IBD is a complex yet fundamental issue that cannot be solved by addressing a single aspect only. Future studies should focus on patient-tailored and multidimensional interventions.

Loss of Response to Anti-TNFs: Definition, Epidemiology, and Management

Tumor necrosis factor-α (TNFα) antagonists have advanced the management of inflammatory bowel diseases patients leading to an improvement of patient's quality of life with the reduction of number of surgeries and hospitalizations. Despite these advances, many patients do not respond to the induction therapy (primary non-response-PNR) or lose response during the treatment (secondary loss of response-LOR). In this paper we will provide an overview of the definition, epidemiology and risk factors for PNR and LOR, as well as discuss the therapeutic options for managing LOR.

A Systematic Review of Factors Associated with Non-Adherence to Treatment for Immune-Mediated Inflammatory Diseases

BACKGROUND

Non-adherence impacts negatively on patient health outcomes and has associated economic costs. Understanding drivers of treatment adherence in immune-mediated inflammatory diseases is key for the development of effective strategies to tackle non-adherence.

OBJECTIVE

To identify factors associated with treatment non-adherence across diseases in three clinical areas: rheumatology, gastroenterology, and dermatology.

DESIGN

Systematic review.

DATA SOURCES

Articles published in PubMed, Science Direct, PsychINFO and the Cochrane Library from January 1, 1980 to February 14, 2014.

STUDY SELECTION

Studies were eligible if they included patients with a diagnosis of rheumatoid arthritis, ankylosing spondylitis, psoriatic arthritis, inflammatory bowel disease, or psoriasis and included statistics to examine associations of factors with non-adherence.

DATA EXTRACTION

Data were extracted by the first reviewer using a standardized 23-item form and verified by a second/third reviewer. Quality assessment was carried out for each study using a 16-item quality checklist.

RESULTS

73 studies were identified for inclusion in the review. Demographic or clinical factors were not consistently associated with non-adherence. Limited evidence was found for an association between non-adherence and treatment factors such as dosing frequency. Consistent associations with adherence were found for psychosocial factors, with the strongest evidence for the impact of the healthcare professional-patient relationship, perceptions of treatment concerns and depression, lower treatment self-efficacy and necessity beliefs, and practical barriers to treatment.

CONCLUSIONS

While examined in only a minority of studies, the strongest evidence found for non-adherence were psychosocial factors. Interventions designed to address these factors may be most effective in tackling treatment non-adherence.

Optimizing biological therapy in Crohn's disease

Anti-TNF therapy has revolutionized the treatment of inflammatory bowel diseases, including both Crohn's disease and ulcerative colitis. However, a significant proportion of patients does not respond to anti-TNF agents or lose response over time. Recently, therapeutic drug monitoring has gained a major role in identifying the mechanism and management of loss of response. The aim of this review article is to summarize the predictors of efficacy and outcomes, the different mechanisms of anti-TNF/biological failure in Crohn's disease and identify strategies to optimize biological treatment.

Loss of response to anti-tumor necrosis factors: what is the next step?

The management of patients with inflammatory bowel disease (IBD) presenting with loss of response (LOR) to anti-tumor necrosis factor (TNF) biologics is an increasingly encountered challenge for clinicians caring for these patients. Clinical decisions are complicated by the lack of consistent terminology and diagnostic criteria to define LOR, the myriad of causes that may give rise to symptoms mimicking LOR, and the multiplicity of possible medical interventions. Choosing the best next step is dependent first on accurate identification of the etiology of symptoms and specifically on ascertaining that IBD activity is responsible for the flares. At this point, some patients with mild symptoms may improve without any intervention, so watchful waiting should be borne in mind for these cases, at least for a limited period of time. Otherwise, dose intensification or a switch to another anti-TNF should be contemplated, and the decision may be aided by results of drug/anti-drug antibody levels. A switch to another biologic with a different mode of action should also be considered, as well as less well evidence-based options, which may nevertheless benefit some difficult patients. These include the addition of an immunomodulator to reverse immunogenicity and restore clinical response, retreatment with a previously failed anti-TNF and other experimental interventions. Before any of these is contemplated, the patient's adherence to anti-TNF therapy should be verified as it may contribute to LOR in up to 20% of patients.

Implementable strategies and exploratory considerations to reduce costs associated with anti-TNF therapy in inflammatory bowel disease

A health care system is needed where care is based on the best available evidence and is delivered reliably, efficiently, and less expensively (best care at lower cost). In gastroenterology, anti-tumor necrosis factor agents represent the most effective medical therapeutic option for patients with moderate-to-severe inflammatory bowel disease (IBD), but are very expensive and account for nearly a quarter of the cost of IBD care, representing a major area of present and future impact in direct health care costs. The ImproveCareNow Network, consisting of over 55 pediatric IBD centers, seeks ways to improve the value of care in IBD, curtailing unnecessary costs and promoting better health outcomes through systematic and incremental quality improvement initiatives. This report summarizes the key evidence to facilitate the cost-effective use of anti-tumor necrosis factor agents for patients with IBD. Our review outlines the scientific rationale for initiating cost-reducing measures in anti-tumor necrosis factor use and focuses on 3 implementable strategies and 4 exploratory considerations through practical clinical guidelines, as supported by existing evidence. Implementable strategies can be readily integrated into today's daily practice, whereas exploratory considerations can guide research to support future implementation.

Tailoring anti-TNF therapy in IBD: drug levels and disease activity

The treatment of IBD with anti-TNF agents has substantially evolved since their first introduction more than a decade ago. The robust efficacy witnessed in many patients has raised new questions pertaining to the observation of subgroups of patients who fail to respond or who lose response to these otherwise very effective drugs. Conversely, the exorbitant cost of biologic agents coupled with their efficacy in inducing lasting remission has introduced new concepts addressing the possibility of therapy cessation in some patients after deep remission has been achieved. Measuring drug and anti-drug antibody (ADA) levels which develop in some patients has emerged as a valuable tool in understanding the mechanisms responsible for some of these clinical scenarios. However, knowledge on how to use these measurements to guide clinical decisions in daily practice is still in its nascency and awaits prospective validation trials. Furthermore, as described in this Review, knowledgeable interpretation of drug and ADA test results mandates understanding the interplay between the technical profile of the assay used, the timing of the measurement in the drug cycle, assessment of disease activity, and the profoundly different pharmaco-clinical scenarios that can culminate in a similar test result.

A systematic review of economic studies on biological agents used to treat Crohn's disease

BACKGROUND

Identifying clinical scenarios that maximize the cost-effectiveness of biological treatments can lead to optimized health care cost-saving and clinical effectiveness from a society's perspective.

METHODS

Published articles between January 1995 and June 2012 were searched in PubMed, EMBASE, ABI/INFORM, Tuft's Cost-Effectiveness Analysis Registry Database, Cochrane National Health Service Economic Evaluation Database, International Pharmaceutical Abstracts, Web of Science, and Google Scholar. Studies of interest included the following: (1) cost studies, (2) economic evaluations, or (3) narrative or systematic reviews related to economic evaluations of biological treatments for moderate-to-severe Crohn's disease (CD). The primary outcomes of interest included costs associated with biological treatments and cost-effectiveness measures, including incremental cost-effectiveness ratios. A threshold of $100,000/quality-adjusted life year (£60,000/quality-adjusted life year) gained was used for treatment cost-effectiveness.

RESULTS

Thirty-eight studies were identified, including 15 economic evaluations and 23 cost studies or reviews of economic evaluations. Economic evaluations found that infliximab and adalimumab were more cost-effective than standard therapy for luminal CD when provided as an induction therapy followed by episodic therapy over 5 or more years. The cost-effectiveness of infliximab and adalimumab versus standard therapy for luminal CD was less certain when used as 1-year maintenance treatment with or without previous induction therapy. Cost studies revealed that infliximab therapy reduced health care resource utilization and cost. Older reviews were inconclusive about the cost-effectiveness of biological treatments used for CD.

CONCLUSIONS

Current evidence suggests that biological treatments may be cost-effective for CD under certain clinical scenarios. Future studies evaluating all biological treatments are needed to compare their respective benefits and costs.

Low rates of adherence for tumor necrosis factor-α inhibitors in Crohn’s disease and rheumatoid arthritis: Results of a systematic review

AIM: To investigate adherence rates in tumor necrosis factor-α (TNF-α)-inhibitors in Crohn’s disease (CD) and rheumatoid arthritis (RA) by systematic review of medical literature.

METHODS: A structured search of PubMed between 2001 and 2011 was conducted to identify publications that assessed treatment with TNF-α inhibitors providing data about adherence in CD and RA. Therapeutic agents of interest where adalimumab, infliximab and etanercept, since these are most commonly used for both diseases. Studies assessing only drug survival or continuation rates were excluded. Data describing adherence with TNF-α inhibitors were extracted for each selected study. Given the large variation between definitions of measurement of adherence, the definitions as used by the authors where used in our calculations. Data were tabulated and also presented descriptively. Sample size-weighted pooled proportions of patients adherent to therapy and their 95%CI were calculated. To compare adherence between infliximab, adalimumab and etanercept, the adherence rates where graphed alongside two axes. Possible determinants of adherence were extracted from the selected studies and tabulated using the presented OR.

RESULTS: Three studies on CD and three on RA were identified, involving a total of 8147 patients (953 CD and 7194 RA). We identified considerable variation in the definitions and methodologies of measuring adherence between studies. The calculated overall sample size-weighted pooled proportion for adherence to TNF-α inhibitors in CD was 70% (95%CI: 67%-73%) and 59% in RA (95%CI: 58%-60%). In CD the adherence rate for infliximab (72%) was highercompared to adalimumab (55%), with a relative risk of 1.61 (95%CI: 1.27-2.03), whereas in RA adherence for adalimumab (67%) was higher compared to both infliximab (48%) and etanercept (59%), with a relative risk of 1.41 (95%CI: 1.3-1.52) and 1.13 (95%CI: 1.10-1.18) respectively. In comparative studies in RA adherence to infliximab was better than etanercept and etanercept did better than adalimumab. In three studies, the most consistent factor associated with lower adherence was female gender. Results for age, immunomodulator use and prior TNF-α inhibitors use were conflicting.

CONCLUSION: One-third of both CD and RA patients treated with TNF-α inhibitors are non-adherent. Female gender was consistently identified as a negative determinant of adherence.

Optimizing anti-TNF treatments in inflammatory bowel disease

BACKGROUND

Failure of anti-TNF treatment in inflammatory bowel disease (IBD) patients can take on several forms, each posing distinct etio-pathogenic considerations and management dilemmas.

AIM

The aim of this study is to review the mechanisms responsible for the various forms of anti-TNF failures in IBD and to elucidate strategies for optimizing clinical efficacy.

RESULTS

Primary failures of anti-TNF induction therapy occur in up to 40% of patients in clinical trials and in 10-20% in clinical series. Longer disease duration, smoking and several genetic mutations are predisposing factors for primary failures. Curiously, primary non-response is probably not a class-effect phenomenon since switching to another anti-TNF is effective in over 50% of such patients. Secondary loss of response is also a common clinical problem with incidence ranging between 23 and 46% at 12months after anti-TNF initiation. Underlying mechanisms are often related to increased anti-TNF clearance by anti-drug antibodies, but may also include other causes for recalcitrant IBD activity as well as disorders that are unrelated to IBD itself. Astute management begins with verifying the presence of uncontrolled inflammatory IBD activity as a cause for patient's symptoms. Next, it is prudent to consider a trial of wait-and-see approach, since in some patients with mild-moderate symptoms, loss of response may resolve without alteration of therapy. If it does not, measuring anti-TNF trough levels and anti-drug antibodies may clarify the underlying mechanism in individual patients although there are still limited and conflicting data regarding the role of these measurements in guiding the choice between dose-intensification, switch to another anti-TNF or to another immuno-modulator, and the addition of an immuno-modulator as a combination therapy with the failing anti-TNF. Anti-TNF re-induction after prior drug-holiday is a distinct clinical scenario and scarce evidence suggests re-induction outcome to be dependent on the circumstances when drug-holiday was commenced. Finally, discontinuation of anti-TNF in patients with stable deep clinico-biologic and mucosal remission may be a viable option, as in these carefully selected patients the majority may enjoy long-term remission without the need for continued anti-TNF treatment.

Adherence to anti-TNF therapy in inflammatory bowel diseases: a systematic review

BACKGROUND

Nonadherence to medications may affect disease outcomes. The aim of this article was to review methods of assessment, prevalence, and predictors of nonadherence to anti-tumor necrosis factor therapy in inflammatory bowel diseases (IBD).

METHODS

Studies were identified through the electronic database of MEDLINE (up to January 2012) and the annual meetings of Digestive Disease Week, the American College of Gastroenterology, the United European Gastroenterology Week, and the European Crohn's and Colitis Organization.

RESULTS

Among 1783 citations identified, 13 studies evaluated adherence to biologics in IBD. Several methods were used to assess adherence to anti-tumor necrosis factor, including the medication possession ratio, the medication refill adherence, and the Morisky Medication Adherence Scale 8. Pooled adherence to anti-tumor necrosis factor therapy was 82.6%. Pooled adherence was 83.1% in adalimumab and 70.7% in infliximab-treated patients. Female gender, smoking, constraints related to treatment, anxiety, and moodiness were associated with nonadherence to both infliximab and adalimumab. Concomitant immunomodulator use and time since first infusion more than 18 weeks were predictors for nonadherence to infliximab . Regimen of 40 mg every other week, syringe use (versus pen), internal medicine center prescription (versus gastroenterology center prescription), retail pharmacy (versus speciality pharmacy) and new user (versus previous user) were predictors for adalimumab nonadherence.

CONCLUSIONS

More than three-quarters of patients with IBD adhere to biologics. Predictors of nonadherence include female gender, smoking, constraints related to treatment, anxiety, and moodiness. These data could be used to develop intervention studies aimed at improving adherence to biologics in IBD.

Patient adherence and efficacy of certolizumab pegol in the management of Crohn's disease

Treatment with Anti-Tumor Necrosis Factor (anti-TNF) therapy has become a mainstay of therapy for patients with CD who are unresponsive to conventional medical management. Currently there are three anti-TNFα antibodies that have been approved by the US Food and Drug Administration for the treatment of CD, namely infliximab, adalimumab and certolizumab pegol (CZP). Several double blind placebo controlled trials determined that CZP is effective as induction and maintenance treatment in adult patients with CD regardless of their prior exposure to other anti-TNFα antibodies. This review discusses the efficacy of CZP and adherence to therapy with anti-TNFα antibodies in patients with CD.

[Epidemiology, predictors and clinical aspects of loss of response to biological therapy]

In the last two decades, the treatment paradigms for Crohn's disease and ulcerative colitis have significantly changed inclusive of a continuously increasing role of biological therapy (anti TNFs). Some patients, however, experience lack or loss of response to biological treatment, and in such cases the management of patients is often empirical. In this review, the authors aim to summarize the available data regarding epidemiology and predictors of loss of response to biological therapy considering the clinical factors and the relationship between serum concentrations, antibodies against biological agents, respectively. Monitoring drug levels and antibodies is expected to play an important role in the management of loss of response (i.e. to confirm adherence, allow dose adjustment, or provide rationale for switching to another biological agent or to a different class of biological agent) in the coming years. The optimal method of detection and cut-off values are, however, not clear. In clinical practice, meticulous complex assessment of clinical symptoms, confirmation of active disease by endoscopic or radiological imaging, and excluding complications remain necessary.

The decline of anti-drug antibody titres after discontinuation of anti-TNFs: implications for predicting re-induction outcome in IBD

BACKGROUND

Anti-drug antibodies can be elicited by infliximab and adalimumab, but the rate of their decay after therapy is stopped is unknown.

AIM

To investigate the decline of anti-drug antibody titre after anti-TNF cessation, and to evaluate the clinical utility of anti-drug antibody measurement before anti-TNF re-induction.

METHODS

Inflammatory bowel disease (IBD) patients who stopped anti-TNF therapy and had measurable anti-drug antibodies were prospectively followed up by serial blood measurements of antibodies levels. The clinical outcome of a second cohort of patients who received re-induction by infliximab or adalimumab after a drug holiday >4 months was determined vis-à-vis their anti-drug antibodies status before re-induction.

RESULTS

The first cohort included 22 patients with anti-drug antibodies who were prospectively followed up after cessation of anti-TNF. Sixteen had antibodies-to-infliximab (ATI) and six had antibodies-to-adalimumab (ATA). ATI titres declined within 12 months to below detection levels in 13/16 infliximab-treated patients, whereas ATA titres became undetectable in only 2/6 adalimumab-treated patients (P = 0.04). The second cohort comprised 27 patients who resumed anti-TNFs (24 infliximab, 3 adalimumab). Of these, 3/5 patients with measurable anti-drug antibodies before re-induction experienced severe hypersensitivity reaction and/or nonresponse mandating drug-discontinuation, compared to 11/22 patients who were re-induced without measurable anti-drug antibodies (OR = 1.5, 95% CI 0.2-11, P = 0.7).

CONCLUSIONS

Antibodies to infliximab titres decline to undetectable levels within one year of cessation of infliximab in the majority of patients, whereas antibodies to adalimumab seem to persist longer after adalimumab discontinuation. Measuring antibodies to infliximab prior to infliximab re-induction is probably of little clinical utility, especially if more than a 12-month drug-holiday has elapsed.

Adalimumab for the treatment of inflammatory bowel disease

Inflammatory bowel disease (IBD) is a chronic, disabling condition with increasing prevalence throughout the world. Although the etiology of IBD is not well understood, it is characterized by a disproportionate inflammatory response in the gut that leads to tissue damage and clinical symptoms. Over the past decade, the development of biologic therapies that target the proinflammatory cytokine TNF-α in the inflammatory cascade has markedly revolutionized the treatment of IBD. Adalimumab, one of the three available anti-TNF agents, has been shown to effectively induce and maintain remission in patients with Crohn's disease. More recently, data has been published demonstrating the efficacy of adalimumab in patients with ulcerative colitis.

Review article: loss of response to anti-TNF treatments in Crohn's disease

BACKGROUND

Loss of response to anti-TNF agents in Crohn's disease is an emerging clinical problem.

AIM

To review the causes, incidence and management approach of loss of response.

METHODS

A search of medical database (PubMed) and of meetings' proceedings for definitions, causes and incidence of loss of response was carried out. Personal correspondence with principal investigators was conducted to retrieve missing data.

RESULTS

Various definitions of loss of response abound, hampering the ability to assess accurately the magnitude and management of this clinical problem. We propose to distinguish between a clinical worsening on anti-TNF treatment and a true loss of response to anti-TNFs. Accordingly, loss of response to anti-TNFs at 12 months of therapy occurs in 23-46% of patients when judged by dose intensification, or 5-13% when gauged by drug discontinuation rates. The management of loss of response should allow for a period of watchful waiting as quite often the patients' symptoms may resolve without alteration of therapy. If they do not, then identifying the correct mechanism responsible for clinical deterioration is prudent. Once symptoms are ascertained to arise from inflammatory IBD activity, drug level and antidrug antibody measurement can then help distinguish between non-adherence to therapy, immunogenicity and non-immune clearance of anti-TNF, or an un-chequered inflammation despite adequate anti-TNF levels. The latter finding may be best addressed by a switch to another class of immunomodulators, whereas a low drug level should probably be managed by dose intensification or a switch to another anti-TNF.

CONCLUSION

Studies defining how best to translate drug-level monitoring and other mechanistic considerations into clinical decisions are urgently needed.