Time to say goodbye to TDM strategy in Crohn’s disease?

It may be time to abandon therapeutic drug monitoring (TDM) strategies for anti-TNF agents in patients with Crohn’s disease, according to an editorial in Gastroenterology journal.

In their article, Canadian gastroenterologists Professor Brian Bressler and Professor Hillary Steinhart say the recently published results of the SERENE CD study of adalimumab add to others showing that giving more drug to increase the serum concentrations does not improve outcomes during induction.

They note that the study showed comparable outcomes for a TDM strategy and one based on escalating dose based on clinical factors of Crohn’s disease such as in response to elevated Crohn’s Disease Activity Index or C-reactive protein.

“In adults, every prospective study (eg, TAXIT, TAILORIX, SERENE CD, and SERENE UC) that incorporated a TDM strategy has failed to demonstrate that adjusting anti–tumour necrosis factor drug dosing based on TDM improves outcomes,” they wrote.

The SERENE studies should convince us that if we are going to further improve outcomes with our existing therapies, we should study other potential predictors of response and use those to choose the appropriate drug and dosing or, when feasible, alter those variables to maximise response,” they added

Gastric ulcer risk high when starting aspirin

The increased risk of gastrointestinal bleeding with low dose aspirin is seen mostly in new users, with less risk seen among long term users, a new study has found.

A review of GI bleeding risks in two cohorts of patients from the UK (214,000) and Germany (7700) found that there was no significant association between low-dose aspirin and gastric ulcer overall observed in both cohorts.

Low-dose aspirin showed a weak association with prevalent duodenal ulcer in one cohort. However when looking only at new users of aspirin the hazard ratios for incident gastric and duodenal ulcer disease were 1.82 and 1.66 respectively in the UK cohort and 2.83 and 3.89 in the German cohort.

“The lower gastrointestinal risk observed in prevalent users [of aspirin] is presumably caused by either a physiological adaption to aspirin effects, the sick-stopper bias, or both,” the authors said

They said the greatest vigilance for GI bleeding risk was needed on initiation of low dose aspirin, whereas once low-dose aspirin therapy is started, adverse events monitoring is recommended to ensure its safe long-term use.

“Individuals already using low-dose aspirin for years, who do not experience unusual gastrointestinal symptoms, may tolerate the drug well,” they added.

Read more: Alimentary Pharmacology and Therapeutics.

GI surgeons calls for bread clip ban

Inadvertent swallowing of the plastic bread clips used to secure bread  bags is a common and overlooked cause of unexplained gastrointestinal symptoms, according to surgeons at Gold Coast University Hospital, Queensland.

The surgeons say they have had to deal with three cases in one year at their centre alone, suggesting the incidence of foreign object ingestion with bread clips is more common than reported in the literature.

The cases related to elderly people who were hospitalised for a variety of severe non-specific abdominal symptoms when bread clips became lodged in the mid jejunum, distal ileum and D1-duodenum respectively.

The surgeons said bread clips posed great challenges for diagnosis and treatment because they did not show up on x-rays and were difficult to remove by endoscopy.

They were often ingested by patients with dentures who could not sense them when chewing, and often posed a threat to gut perforation they added.

“Bread clips are not always readily identifiable depending on imaging and the management of these patients will often require a multidisciplinary approach between the surgeons, gastroenterologists and radiologists,” they wrote.

“Serious discussions regarding changes to food industry packaging practises within Australia should be considered and alternatives such as larger plastics clips or sealing tapes should be recommended,” they concluded.

Read more: Journal of Surgical Case Reports.