IBD

Virtual clinic increases anti‐TNF dose intensification success in Crohn’s disease


Dr Mark Ward

A virtual IBD clinic model of care involving a multidisciplinary team delivers better outcomes for patients who are losing response to biologic therapy, clinicians at the Alfred Hospital in Melbourne have shown.

When compared to standard outpatient clinic care the virtual clinic model doubled the number of patients undergoing appropriate dose intensification of anti‐TNF therapy and tripled the rate of tight‐disease monitoring, according to a study led by Dr Ashish Srinivashan of Austin Health.

The virtual clinic model of care was run on a four-weekly basis and involved a team including a gastroenterologist, IBD nurse, clinical pharmacist and an admin assistant. Patients were referred to the virtual clinic from two outpatient IBD clinics to undergo baseline investigations, including anti‐TNF trough levels, to confirm loss of response and appropriateness of dose intensification.

Approved patients then underwent dose intensified anti‐TNF therapy with infliximab and adalimumab for six months and subsequently underwent noninvasive disease re‐assessment as part of a treat‐to‐target model.

In a review of outcomes for 149 patients, there were higher rates of treatment success in the virtual clinic cohort of 69 patients compared to 80 in a standard outpatient clinic model (60.9% vs 35.0%, P < 0.002). Management via the virtual clinic was also associated with shorter time to treatment success (log rank test, P < 0.001) and was the strongest, independent predictor of treatment success.

Rates of appropriate dose intensification were twice as high with the virtual clinic model than the conventional model (82.6% vs 40.0%, P < 0.001), and there were also significantly better rates for biomarker remission, tight‐disease monitoring (84.1% vs 28.8%, P < 0.001) and treatment de‐escalation (21.3% vs 10.0%, P = 0.027) with the virtual clinic model.

The virtual clinic approach was also also associated with a longer median time to treatment escalation failure, defined as the need for surgery and/or biologic discontinuation across the virtual clinic cohort.

Writing in Alimentary Pharmacology and Therapeutics, the study investigators attributed the success of the virtual clinic approach to several factors, including having a multidisciplinary forum to support challenging therapeutic decisions via consensus and provided the operational support to execute and monitor the outcomes of these decisions.

“In a typical outpatient clinic one has very limited time to assess and manage a complicated sick IBD patient. More tests are often needed, which requires further appointments, and a delay in delivering effective treatment,” said study co-author Dr Mark Ward of Alfred Health.

“The virtual clinic helps get around this; we can make decisions, supported by the results of non-invasive tests and therapeutic drug monitoring. This facilitates a ‘treat-to-target approach’ that is, healing the bowel, rather than relying on symptoms alone,” he said.

“We’ve found through the virtual clinics a more collegiate, collaborative approach has really fostered relationships between health care providers, increased data sharing and delivered a greater capacity to personalise and be consistent in our approach to the patients’ care,” Dr Ward said.

The virtual clinic‐led model of care also succeeded by having a consistent process of proactive scheduling of disease reassessment following dose intensification to evaluate the outcome of the therapeutic intervention.

“Taken together, these observations suggest that the virtual clinic performs better than standard outpatient care as a model of care to optimally co‐ordinate the use of anti‐TNF trough levels and objective markers of disease activity in order to improve clinical outcomes and defer treatment failure.

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