Dose Augmentation of Tumor Necrosis Factor Inhibitors is Frequently Performed in Persons With Inflammatory Bowel Disease in the Absence of Objective Evidence of Active Inflammation.

Abstract

Antitumor necrosis factor (anti-TNF) dose augmentation is frequently utilized in the management of inflammatory bowel disease (IBD), yet the extent to which clinicians assess for objective markers of inflammation before using the strategy is unknown. To determine the incidence of anti-TNF dose augmentation and the frequency with which it is preceded by the objective assessment of IBD activity. All 23 prescribers of anti-TNF for IBD in Manitoba facilitated chart review of their adult anti-TNF users from 2005 to 2016. Time from anti-TNF initiation to dose augmentation was recorded for all previously biologic-naïve patients. The practices of 11 of 23 prescribers were audited in greater detail and the biochemical, imaging, and endoscopic investigations conducted in the 90-day preceding dose augmentation extracted. A total of 838 patients met inclusion criteria; 70.4% had Crohn's disease, whereas 29.6% had ulcerative colitis or IBD unclassified. The median duration of follow-up was 22.6 [interquartile range (IQR), 10.3-43.2] months for adalimumab and 28.4 (IQR, 10.2-59.9) months for infliximab (P=0.01). The cumulative incidence of dose augmentation at 12 months was 32.9%. Dose augmentation occurred more often in ulcerative colitis than in Crohn's disease (hazard ratio, 1.83; IQR, 1.36-2.47). Overall, 70.7% of patients underwent some form of testing to assess the inflammatory burden before dose augmentation. Objective evidence of inflammation supporting dose augmentation was documented in only 24.7% of cases. One third of previously biologic-naïve patients had anti-TNF doses increased within the first 12 months of treatment. Dose augmentation frequently occurred in the absence of objective evidence of inflammatory disease activity.