A virtual clinic increases anti‐TNF dose intensification success via a treat‐to‐target approach compared with standard outpatient care in Crohn’s disease

Abstract

Background: Virtual clinics represent a novel model of care in inflammatory bowel disease. Their effectiveness in promoting high quality use of biologic therapy and facilitating a treat-to-target approach is unknown. Aim:To evaluate clinical and process-driven outcomes in a virtual clinic compared to standard outpatient care amongst patients receiving intensified anti-TNF therapy for secondary loss of response. Methods:We performed a retrospective multi-centre, parallel, observational cohort study of Crohn's disease patients receiving intensified anti-TNF therapy for secondary loss of response. Objective assessments of disease activity and anti-TNF trough levels at secondary loss of response and during subsequent 6-month semesters, were compared longitudinally between virtual clinic and standard outpatient care cohorts.The primary endpoint was treatment success, with appropriateness of dose intensification, tight disease monitoring and treatment de-escalation representing secondary outcomes.Results: Of 149 patients with similar baseline characteristics, 69 were managed via a virtual clinic and 80 via standard outpatient care. There were higher rates of treatment success in the virtual clinic cohort (60.9 vs 35.0%, P < 0.002). Rates of appropriate dose intensification (82.6% vs 40.0%, P < 0.001), biomarker remission (faecal calprotectin P = 0.002), tight-disease monitoring (84.1% vs 28.8%, P < 0.001) and treatment de-escalation (21.3% vs 10.0%, P = 0.027) also favoured the virtual clinic cohort. Conclusion:This study favoured a virtual clinic-led model-of-care over standard outpatient care in facilitating treatment success as part of an effective treat-to-target approach in Crohn's disease. A virtual clinic model-of-care also improved treatment outcomes and quality of use of intensified anti-TNF therapy through processes that promoted appropriate dose intensification and tight-disease monitoring, while encouraging more frequent dose de-escalation. | 1343SRINIVASAN et Al.

Systematic review: efficacy of escalated maintenance anti‐tumour necrosis factor therapy in Crohn's disease

“…Disease duration did not affect clinical response to escalated anti‐TNF treatment in most cases 25,27,39,45 . Older age at diagnosis was associated with a better response to dose escalation in a small number of studies 47,60,66 …”

“…In two retrospective studies, patients with complicated disease were more likely to respond to escalated therapy than patients with an inflammatory phenotype 27,47 . However, in two other retrospective studies, nonstricturing nonpenetrating disease was associated with successful dose escalation 66,77 …”

“…A retrospective follow‐up study of the CALM cohort found that patients who achieved endoscopic or deep remission after 1 year of intensified treatment were significantly less likely to have disease progression, including new fistulas, strictures and hospitalisation or surgery for CD, over a median of three years 4 . In a ‘real world’ context, a retrospective study of dose‐escalated CD patients (n = 149) found that management via a virtual clinic, where there is a tendency towards a ‘tight control’ approach with regular biomarker analysis, is associated with higher rates of treatment escalation success compared to standard outpatient care ( P < 0.001) 66 …”

“…4 In a 'real world' context, a retrospective study of doseescalated CD patients (n = 149) found that management via a virtual clinic, where there is a tendency towards a 'tight control' approach with regular biomarker analysis, is associated with higher rates of treatment escalation success compared to standard outpatient care (P < 0.001). 66…”

Dialing Back M for Monoclonal: Successful De-escalation of Dose-Intensified Anti-tumor Necrosis Factor Therapy in Inflammatory Bowel Disease

“…A novel aspect to the study by Little et al is the contribution of a virtual multidisciplinary team (MDT) clinic toward facilitating clinical decision-making. As previously published by the authors, this conference, conducted on a monthly basis [12], facilitates integration of TDM with objective evaluation of disease activity in order to better inform therapeutic decisions. Non-invasive markers of disease activity, both fecal calprotectin and gastrointestinal ultrasound, were used to closely monitor disease and tailor therapy, reducing the cost, risk, and unpleasantness associated with frequent endoscopy.…”