AGA Guidelines on Therapeutic Monitoring

From Healio Gastro: AGA releases guidelines on therapeutic drug monitoring in IBD

Key points from Healio Gastro for Adult Patients with IBD:

  • Reactive monitoring: for patients with a flare or active symptoms: “For patients on maintenance therapy with infliximab, adalimumab or certolizumab pegol who flare after initially responding, if trough levels are below 5 µg/mL, 7.5 µg/mL or 20 µg/mL, respectively without anti-drug antibodies or with low-titer antibodies, then it may be reasonable to try optimizing the index therapy (escalating anti-TNF agent by increasing dose, shortening interval and/or adding immunomodulator)”
  • Proactive monitoring: the guideline states that “no recommendation can be made regarding routine proactive TDM in patients with quiescent IBD being treated with anti-TNFs, as this is a critical knowledge gap in need of further study…careful and selective use of proactive TDM could be beneficial, but current evidence for its routine use is limited and its overall benefits remain uncertain”
  • Thiopurines: the guideline suggests TPMT testing of enzymatic activity or genotype before adults with IBD start treatment with thiopurines.
  • New biologics:  the guideline does not address therapeutic drug monitoring in patients treated with Entyvio (vedolizumab, Takeda) or Stelara (ustekinumab, Janssen) due to a lack of available data.

Reference: JD Feuerstein et al. Gastroenterol 2017; 153: 827-34. Technical review: NV Casteele et al. Gastroenterol 2017; 153: 835-57.

My take: Therapeutic monitoring has become widespread and is quite helpful.  My impression is that most pediatric gastroenterologists have adopted both proactive and reactive monitoring.

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Looking towards the  top of John Rock Hike, near Brevard, NC