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Interventions based on therapeutic drug monitoring in patients with inflammatory bowel disease and loss of response to anti-TNF agents

Interventions based on therapeutic drug monitoring in patients with inflammatory bowel disease and loss of response to anti-TNF agents
Anti-drug antibody (ADAb) Drug trough concentration*
Inadequate (subtherapeutic) Adequate (therapeutic)
Undetectable Non immune-mediated pharmacokinetic failure:
  • Escalate dose of index drug
Mechanistic failure:
  • Switch to drug out of classΔ
Detectable Immune-mediated pharmacokinetic failure:
  • If low level ADAb: escalate dose of index drug
  • If high level ADAb: switch to drug in class◊
Mechanistic failure:
  • Switch to drug out of class
Refer to UpToDate for additional discussion on therapeutic drug monitoring.
* Target drug trough concentration: infliximab ≥5 mcg/mL; adalimumab ≥7.5 mcg/mL; certolizumab pegol ≥20 mcg/mL.
¶ Dose can be escalated by either shortening dosing interval or increasing drug dose.
Δ An alternative is to escalate anti-TNF dose, especially for patients in clinical remission but with endoscopic disease activity.
◊ In addition to switching to a drug in class, some patients may also benefit from adding an immunomodulator.
Original table modified for this publication. From: Vande Casteele N, Herfarth H, Katz J, et al. American Gastroenterological Association Institute Technical Review on the Role of Therapeutic Drug Monitoring in the Management of Inflammatory Bowel Diseases. Gastroenterology 2017; 153:835. Table used with the permission of Elsevier Inc. All rights reserved.
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