Abstract Background Monitoring of monoclonal antibody (mAb) clearance has been suggested for prediction and follow-up of treatment outcomes in patients with inflammatory bowel diseases. We investigated clearance monitoring in patients with Crohn’s disease (CD) using data from clinical trials. Methods Data from patients with moderate-to-severe CD starting infliximab (n=108; TAILORIX trial [1]) and ustekinumab (n=80; a real-life cohort study [2]) therapy were repurposed. Endoscopic remission (CD Endoscopic Index of Severity <3) was assessed at week (w)12 and w54 of infliximab therapy. Endoscopic response (≥50% reduction in Simple Endoscopic Score for CD) was assessed at w24 of ustekinumab therapy. We performed Bayesian forecasting to estimate time-varying mAb clearance using measured drug concentrations, covariates, and population pharmacokinetics models (NONMEM 7.5). A novel software tool for clearance monitoring of infliximab and ustekinumab was developed using the Shiny and mapbayr packages in R. Results Baseline demographics and clinical characteristics of the patients are summarized in Table 1. Patients achieving endoscopic remission at w12 had significantly lower infliximab clearance and higher infliximab serum trough concentrations (Ctrough) at w2 and w6 of standard 5 mg/kg infliximab induction therapy, than patients without endoscopic remission (p<0.05). During infliximab maintenance therapy (with eventual dose optimisations), patients achieving endoscopic remission at w54 had significantly lower infliximab clearance (p<0.001) but not higher infliximab Ctrough (p=0.92) than patients without endoscopic remission. Moreover, infliximab clearance during maintenance had similar discriminative ability as faecal calprotectin (area under the receiver operating characteristics curve 0.63 [95% confidence interval 0.57–0.69] vs. 0.67 [0.61–0.73], respectively) (Figure 1). Ustekinumab clearance (p<0.05), but not Ctrough, was significantly different between endoscopic responders and non-responders during standard ustekinumab induction and maintenance therapy. We developed an evidence-based interactive software tool that can predict the probability of achieving endoscopic outcomes in a clinical setting based on the estimated clearance of infliximab and ustekinumab (https://lpmx.shinyapps.io/clearance_monitoring/). Conclusion While Ctrough loses its ability to predict treatment response when doses are optimised or not administered by bodyweight, mAb clearance remains a reliable predictor. Our interactive clearance monitoring tool can forecast the chance of achieving endoscopic outcomes and distinguish between exposure-driven and mechanistic failure when patients with CD are dose-optimised.
Read full abstract