Best Practices in the Management of IBD During COVID-19 - Episode 7

Managing IBD With Anti-TNF Therapy

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Miguel Regueiro, MD: Doug, from a practical standpoint, before we get into the studies specifically, what do you tell your patients in terms of expectations for therapeutic response to an anti–TNF [tumor necrosis factor] agents?

Douglas C. Wolf, MD: I say that we want to see results much sooner than we wanted to see results 5, 10, or 20 years ago. We expect to see improvement in 4 to 6 weeks, and if we’re not seeing it, then we need to do something different, and that may be to advance therapy. With infliximab, that is starting out at a standard dose, but if someone is not improving in 2 to 4 weeks, we may escalate to 10 mg/kg from 5 mg/kg, and we may even use more advanced maintenance dosing of every 4 weeks, doing that in conjunction with therapeutic drug monitoring.

We use a similar strategy with adalimumab. If there is no benefit with standard induction dosing by week 4, I will advance to 40 mg every week rather than 40 mg every other week and get things going. At that 4- to 6-week visit, if someone is not better, then I’ll have them come back to the office. In this setting, it depends.

We can sometimes wiggle around, but the idea is to do a good reevaluation at 4 to 6 weeks and find out why it’s not working. We make sure it’s not C diff [Clostridium difficile] that was missed and make sure the patient is being compliant with therapy. In severe disease, the problem may be undertreatment, so we need to be more aggressive early. I want to see good results in 4, 6, or 8 weeks, or I may shift gears. We may change agents. We may have to reassess. It’s a similar approach in Crohn disease and ulcerative colitis.

Transcript Edited for Clarity