Dose Optimization of Anti-TNF Therapy for IBD

Dr Rubin gives a summary of key considerations in dose optimizing anti-TNFs for treatment of IBD. 

David Rubin, MD, is the Joseph B Kirsner Professor In Medicine, chief of Gastroenterology, Hepatology and Nutrition, and director of the Digestive Diseases Center at the University of Chicago School of Medicine.

Hi, it’s Dr David Rubin from the University of Chicago, on optimizing anti-TNF therapy. For high-risk patients, the ones I've already mentioned, who have high inflammatory burdens or high likelihood of clearance of drug too rapidly, that doing an intraloading or premaintenance drug level—so a week 6 drug level with infliximab and probably a week 4 or week 6 level with adalimumab—can actually guide you in early dose optimization and dose escalation going into maintenance with the presumption that that will prevent loss of response. I say presumption because those studies are still ongoing. But it certainly makes sense to know if the drug level is less than a certain amount early.  You're going to want to try to avoid loss of response later by increasing the dose, which we know correlates to an increased drug level subsequently.

So what are the levels? Well, you want an infliximab level of 17 or more prior to the third loading dose at week 6. And with adalimumab, it's a little less well defined, But I would say you want a level that's also more than 15 or 20 before your week 4 or week 6 loading phase and maintenance dosing.

So all in all, we've made some incredible progress thinking about how to use anti-TNFs in our patients with IBD. It is still a very important treatment option for people with Crohn's and colitis, and we should know as much as possible about how, when we choose this option, we want it to work, and we want it to last, and we've made some great progress in that area. Thank you very much.