A Cost-Effectiveness Analysis of Alternative Disease Management Strategies in Patients with Crohn's Disease Treated with Azathioprine or 6-Mercaptopurine

Dubinsky, Marla; Reyes, Eileen; Ofman, Joshua J.; Chiou, Chiun–Fang; Wade, Sally; Sandborn, William J.

doi:10.1111/j.1572-0241.2005.41900.x

Cited by 156 publications

(123 citation statements)

References 17 publications

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“…Experience abroad has shown that AZA can be safely used in treatment of CD and UC [25][26][27] . Recently, thiopurine methyltransferase (TPMT) and its genotype have been applied in predicting the myelotoxicity and reducing the incidence of leucopenia in Europe and North America [28][29][30] .…”

Section: Discussionmentioning

confidence: 99%

Quality of care for patients with inflammatory bowel disease in East China

Zhu¹,

Cao²,

Si³

2008

WJG

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received immunomodulatory agents, and more than half of the 8 patients received a suboptimal dose of azathiopurine with no attempt to increase its dosage. CONCLUSION:The quality of care for IBD patients can be further improved. A suboptimal dose of aminosalicylate is used in treatment of patients with CD, especially in those with small intestine involved only. Topical mesalazine is inadequately used in patients with distal or left-sided colitis. Oral or intravenous steroid therapy is not used in some patients with severe IBD. Use of immunomodulatory medication is limited. Larger prospective studies are needed to investigate the quality of care for patients with IBD to establish our own evidence-based guidelines. INTRODUCTIONInflammatory bowel disease (IBD), including Crohn's disease (CD) and ulcerative colitis (UC), is a chronic disorder of the gastrointestinal tract. The prevalence of IBD is about 1.0/1000 in Western countries [1] . No large scale epidemiological investigation is available on the incidence and prevalence of IBD in China so far, but the diagnosed IBD in China has increased obviously in the past ten years [2] .A number of national and international practice guidelines for management of inflammatory bowel disease are available [3][4][5] . However, the essentials in a step-up treatment have not changed significantly. These practice guidelines are means of bringing evidence-based medicine into full play to improve IBD patient care. However, such [2] . This study was to investigate the impact of such guidelines and the quality of care for a hospital based cohort of patients with IBD from East China. MATERIALS AND METHODS SubjectsIBD patients admitted to Sir Run Run Shaw Hospital, College of Medicine, Zhejiang University, between June 2000 and June 2006, were consecutively enrolled in this study. The diagnosis of IBD was confirmed by the criteria established by Chinese Society of Gastroenterology [6] in 2000 and the guidelines issued by the Clinical Services Committee of the British Society of Gastroenterology (BSG) [3] in 2004. The patients not under the care of a gastroenterologist were excluded. Data collectionA retrospective review was performed. Clinical data on demographic information, clinical characteristics of IBD patients, as well as endoscopic, radiologic, surgical and pathological records, confirmed diagnoses, duration and severity of disease, medical therapy, were collected from the inpatient and follow-up clinic visit records and input into an IBD database. Medical therapy included use of oral aminosalicylate, topical therapy, corticosteroid agents, and use of immunomodulatory agents at admission and outpatient clinic visit. Statistical analysisVariables were expressed as mean, while categorical data such as proportion of patients receiving particular therapies and dose of medications were expressed as percentage. Association of patient gender, age, location and severity of disease with suboptimal therapy was analyzed by χ 2 test. P < 0.05 was considered statistically significant. All ...

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Section: Discussionmentioning

confidence: 99%

Quality of care for patients with inflammatory bowel disease in East China

Zhu¹,

Cao²,

Si³

2008

WJG

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“…Th is "start low go slow" strategy is unnecessary in the majority of patients with normal TPMT activity. Guiding the dosing by TPMT and thiopurine metabolite levels will lead to a faster onset of response and reduction of costs [78]. TPMT defi ciency explains approximately 25% of all the cases of myelosuppression on thiopurine treatment [60]; it does not account for all the possible factors contributing to the risk of leukopenia and does not preclude the need for continuous blood count monitoring.…”

Section: Clinical Utility Of Tpmt Assessmentmentioning

confidence: 99%

Therapeutic Drug Monitoring in Inflammatory Bowel Disease

2017

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Tumor necrosis factor (TNF)-α inhibitors and thiopurines are among the most important classes of medications utilized in the clinical management of Crohn's disease and ulcerative colitis. A signifi cant proportion of patients loses response to these agents or develops adverse eff ects during the course of the treatment. Monitoring of drug levels and anti-drug antibodies (for TNF-α inhibitors) and metabolite levels (for thiopurines) can provide valuable insight into the possible etiology of unfavorable outcomes and allow for an appropriate management strategy for these patients. Th is review summarizes the current knowledge on the clinical implications of therapeutic drug monitoring in infl ammatory bowel disease patients treated with TNF-α inhibitors and thiopurines.

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“…This strategy also expedites clinical response and may be used in combination with thiopurine methyltransferase testing, although it seems to be less cost-effective than thiopurine methyltransferase testing alone. 21 A faster response translates into a shorter course of corticosteroids, and this may be important especially in older patients. However, neither test is in common clinical usage at present.…”

Section: Immunosuppressivesmentioning

confidence: 99%

“…Normal thiopurine methyltransferase activity permits using higher doses from the onset of treatment and may reduce the time to clinical response. 21 Another strategy to optimise thiopurine dosing is the measurement of thioguanine, the main active metabolite of azathioprine. This allows faster adjustment of the dose, according to blood levels of thioguanine measured every four weeks after starting the drug, rather than having to wait three to six months to be able to assess the clinical reponse.…”

Section: Immunosuppressivesmentioning

confidence: 99%

Inflammatory Bowel Disease in Older People

Grimpen¹,

Pavli

2008

Pharmacy Practice and Res

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Inflammatory bowel disease (IBD) can affect patients of all ages. The majority of patients are diagnosed in the second or third decade of life, but a minority develop the disease at an advanced age. Diagnosis can be delayed due to the preconception that IBD mainly affects young people, and the broader spectrum of differential diagnoses in the elderly. Management and treatment options are similar to those in younger patients but adverse reactions and drug interactions may be of greater significance in the elderly. Precluding treatment with anti-tumour necrosis factor drugs on grounds of previous infection with tuberculosis or viral hepatitis, comorbidities or previous malignancy -factors often found with advanced age -can make treatment challenging. The increased risk of bowel cancer in IBD warrants regular screening, especially in the elderly as their absolute risk of cancer is higher.

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A Cost-Effectiveness Analysis of Alternative Disease Management Strategies in Patients with Crohn's Disease Treated with Azathioprine or 6-Mercaptopurine

Abstract: The addition of alternative strategies to CC may improve AZA outcomes and reduce the total cost of care for steroid treated chronically active CD patients, with TPMT being more beneficial for initial response to treatment and MM being more beneficial for sustained response to treatment.

Cited by 156 publications

References 17 publications

Quality of care for patients with inflammatory bowel disease in East China

Quality of care for patients with inflammatory bowel disease in East China

Therapeutic Drug Monitoring in Inflammatory Bowel Disease

Inflammatory Bowel Disease in Older People

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