FRIDAY, NOVEMBER 7, 2014 RITZ-CARLTON HOTEL, TORONTO25

CASE-BASED WORKSHOPOptimizing Management with Anti-TNF Levels and Antibodies

You are looking after a 45-year-old male psychology professor with ulcerative pancolitis who has been on anti-TNF combination therapy with azathioprine 150 mg/d plus mesalamine 2.0 g/d since he was 30 years of age.

You have had him in your objective monitoring program over the last 10 years and he has done well with 2 minor !ares, one that responded to a short course of corticosteroids and the second, 4 years ago, that responded to a re-induction of anti-TNF. He is now on maintenance anti-TNF, azathioprine 150 mg/d and mesalamine 2 g/d.

He returns early from a 6 month sabbatical in France because he is now !aring with loss of response having 5 bowel motions daily and 50% with blood. You see him in your o"ce. Partial Mayo score is 7, indicating moderately active disease.

ARS Decision Node1. Do you have a routine monitoring strategy for your UC patients

on anti-TNF agents? Yes No

2. Do you have access to azathioprine metabolite levels?

Yes No

3. Do you use azathioprine metabolite levels to direct your care? Yes No

4. Do you have access to anti-TNF drug levels? Yes No

5. Do you use anti-TNF drug levels to direct your care? Yes No

6. Are you aware of the programs available from AbbVie and Janssen to support therapeutic drug monitoring? Yes No

On further questioning he tells you that the anti-TNF does not seem to be having the same e#ect as it did before. He feels there is only minor improvement with each dose.

ARS Decision Node7. With this history, would you set up the process for him to switch

the anti-TNF agent? Yes No

You make the decision not to switch until you have more information.

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ARS Decision Node 8. If you could only do one test at this time, which would it be?

a. Colonoscopy

b. 6TG and 6MMP levels

c. Anti-TNF antibody levels

d. Anti-TNF trough levels

You decide to obtain an anti-TNF trough level.

ARS Decision Node9. While you wait for the anti-TNF trough level, what can you do

to treat this gentleman?

a. Corticosteroids

b. Mesalamine

c. Re-induction with the anti-TNF

d. Antibiotics

e. Probiotics

Your anti-TNF level comes back at 2.0 and the antibody level as 1.3.

ARS Decision Node10. What is the correct response to these values?

a. Switch to another anti-TNF

b. Increase the dose of the current anti-TNF

c. Abandon anti-TNF and obtain o!-label vedolizumab

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FRIDAY, NOVEMBER 7, 2014 RITZ-CARLTON HOTEL, TORONTO 26