Article Text
Abstract
Patients starting adalimumab (ADA) receive ‘standard’ or ‘accelerated’ dosing. Guidelines on selecting patients for the accelerated regimen are lacking.1 2
Our departmental database was used to identify 32 IBD patients treated with ADA between 2013 and 2021. The mean age at ADA commencement was 12.8 years. 22 patients had a diagnosis of ulcerative colitis (UC), and 10 had Crohn’s disease (CD). The mean interval between diagnosis and starting ADA was 3.1 years (range = 4 months - 8 years).
29/32 received a second immunomodulator drug in addition to ADA, usually azathioprine (26/32). 29/32 had previously been treated with infliximab (IFX). Reasons for switching included primary lack of response (12/32); adverse reaction (7/32) and loss of response due to anti IFX antibodies (7/32). No significant adverse reactions to ADA occurred in this cohort.
Faecal calprotectin (FCP) levels were available for all patients both at baseline (before starting ADA) and after induction, and paediatric ulcerative colitis activity index (PUCAI) and paediatric Crohn disease activity index (PCDAI) scores were available for 31/32.
Patients were grouped (table 1) according to whether they remained on their starting dose (Group A), or increased their dose because of disappointing clinical response plus low or intermediate serum levels (<8μg/mL)3, (Group B).
28/32 received standard induction doses of adalimumab. Serum levels were checked 12 weeks after induction. The mean post induction serum ADA level of the accelerated regimen group was 5.98μg/mL. Of the 4 accelerated induction patients, only two continued on ADA at the time of data collection, one on an increased dose.
Baseline FCP was similar in both groups, although Group B had higher mean DAI scores (table 2). FCP and DAI scores fell after induction for Group A (p=0.027 and 0.5), and after dose increase for Group B (p=0.17 and 0.002).
In conclusion, a high proportion (47%) of IBD patients required dose escalation. Patients with higher DAI scores at induction could benefit from higher starting doses.
References
Martine A, et al. Anti-TNF in children and adolescents. Int J Mol Sci. 2019 May 23;20(10):2529.
Fumery M, et al. Efficacy and safety of adalimumab. J Pediatr Gastroenterol Nutr. 2015 Jun;60(6):744–8.
Zittan E, et al. Higher adalimumab drug levels are associated with mucosal healing. J Crohns Colitis. 2016 May;10(5):510–5.