Journal of Medicines Optimisation - Mar 2022

Journal of Medicines Optimisation • Volume 8 • Issue 1 • March 2022 26 severe active UC, vedolizumab can be used as a first- line option. 18 Methods This was a retrospective, single site study. An extract was downloaded from the Blueteq system for a five- month period commencing February 2020 for adult patients granted approval to commence treatment for IBD. Relevant data (patient demographics and treatment details) were imported into Excel by a member of the pharmacy team. The medical records of any patients commenced on the second line choices of vedolizumab, ustekinumab, tofacitinib were purposefully identified and reviewed. Contact was made with the lead IBD nurse if the records did not provide sufficient explanation for the treatment choice. Health Research Authority criteria about research and service evaluation were considered. This was a retrospective assessment involving no changes to the service delivered to patients, and we used the NHS Health research authority tool ( http://www.hra- decisiontools.org.uk/research/index.html ) which helped confirm that no ethical approval was required for this project. Patient data were used in accordance with local NHS hospital policy. Results Over the five-month period, 20 patients (mean age 45, 50% male) had commenced one of the named biologics - 10 indicated for Crohn’s disease and 10 for Ulcerative Colitis. There was one patient on tofacitinib, seven on ustekinumab, and 12 on vedolizumab. Usage of these biologics was as second line in 10 instances (seven after adalimumab and three after infliximab), as third line in five instances (all after sequential use of adalimumab and infliximab), as sixth line in one instance, but as first line in four instances (one for Crohn’s disease and three for UC) and these were all for vedolizumab. Of these four instances, there was evidence of MDT discussion on first line use and all had a valid reason for using the more expensive vedolizumab (Table 1). Discussion This small-scale study found that the local guideline was followed as there were valid reasons for patients commencing vedolizumab as first choice treatment and hence diverging from the agreed pathway. Our agreed guideline is fairly straightforward, not overly prescriptive and deviation is allowed if the MDT agree that it is appropriate for the patient under discussion. Of interest, the patient who received vedolizumab as sixth line therapy had sequenced through the following, all for a number of months treatment each - adalimumab, infliximab, ustekinumab, infliximab (following advice from a tertiary centre to be used at a higher dose), adalimumab, (stopped due to high levels of antibody to the drug), then vedolizumab. Advice from the Regional Medicines Optimisation Committee is that a policy adopted by a commissioner that would serve to limit patients’ access to appropriate treatments based on a number of prior treatments being attempted would be counter to the provisions of the NHS Constitution. 19 Hence, the principle of sequencing is allowed when a number of biological medicines are available for a therapeutic indication, each being supported by NICE TA Guidance. Overly prescriptive guidelines that require drugs to be used in a certain sequence with little scope for Hepatitis B patient and reduced infection risk with this drug. Lowest risk option due to pancreatitis and high risk of leukaemia or lymphomas and recent urinary infection which required admission. Infliximab contra-indicated due to previous HSV2 of natal cleft. Treatment started by tertiary centre. Table 1. Reasons for vedolizumab as first choice in four patients