Journal of Medicines Optimisation - Mar 2022

Journal of Medicines Optimisation • Volume 8 • Issue 1 • March 2022 27 deviation may be good at controlling costs but may not be clinically appropriate as they do not allow for clinical judgement to over-ride the guideline when needed. If deviation from a guideline is tightly restricted this may increase demands on health services if patients' needs are not adequately met e.g. repeat clinic visits, poor mental health, comorbidity. The MDT approach allows for discussion of options with decisions reached by consensus not majority, helping to standardises practice across the specialty as decisions on treatment are no longer made by a single clinician. The involvement of nurses and pharmacist in the MDT allows consideration from different perspectives. A recent meta-analysis found that that either infliximab with azathioprine or adalimumab might be preferred as a first-line therapy for moderate-to- severe CD. 20 For moderate to severe UC, and depending on the outcome chosen, upadacitinib (a Janus kinase inhibitor not currently licensed for IBD) was ranked first for clinical remission, whereas infliximab was ranked first for endoscopic improvement. 21 A similar review also found upadacitinib was the best performing agent for the induction of clinical remission (the primary outcome) but the worst performing agent in terms of adverse events in patients with moderate-to-severe UC. 22 We recognise the limitations of a single centre, very small-scale study. We do not report follow up of patients in relation to any improvement in their IBD, or whether those patients receiving vedolizumab subsequently switched to an alternative biologic. These results therefore cannot be generalised to other hospitals and to other indications for these classes of medicines. Also, we chose not to evaluate whether the vedolizumab dosing regimen used was in accordance with the relevant NICE TAs as it is recognised that more intense regimens (higher doses, more frequent administration) have been used in some studies. Conclusion In this very small study, the choice of biologics IBD was in accordance with our local guideline in the majority of patients. Where deviation from the guideline occurred, this was justified on clinical grounds, These preliminary results from a very small sample size suggest the need for a larger study of the effectiveness of the guideline over a longer period. Declaration of interests The authors have no interest to declare. References 1. Lamb CA, Kennedy NA, Raine T, et al. British Society of Gastroenterology consensus guidelines on the management of inflammatory bowel disease in adults. Gut 2019;68(Suppl 3):s1-s106. Available at: https://gut.bmj.com/content/gutjnl/68/Suppl_3/s1.full.pdf 2. Hanauer SB, Feagan BG, Lichtenstein GR, et al. Maintenance infliximab for Crohn’s disease: the ACCENT I randomised trial. Lancet 2002;359:1541–9. Available from: https://www.thelancet.com/journals/lancet/article/PIIS0140- 6736(02)08512-4/fulltext 3. Hanauer SB, Sandborn WJ, Rutgeerts P, et al. Human anti- tumor necrosis factor monoclonal antibody (adalimumab) in Crohn’s disease: the CLASSIC-I trial. Gastroenterology 2006;130:323–33. Available at: https://www.gastrojournal.org/action/showPdf?pii=S0016- 5085%2805%2902315-2 4. Feagan BG, Rutgeerts P, Sands BE, et al. Vedolizumab as induction and maintenance therapy for ulcerative colitis. N Engl J Med 2013;369:699–710. Available at: https://www.nejm.org/doi/pdf/10.1056/NEJMoa1215734?arti cleTools=true 5. National Institute for Health and Care Excellence. NICE technology appraisal guidance. Available at: https://www.nice.org.uk/About/What-we-do/Our- Programmes/NICE- guidance/NICE-technology-appraisal- guidance 6. National Institute for Health and Care Excellence. Crohn’s disease: management. NICE Guideline 130. May 2019. Available at: https://www.nice.org.uk/guidance/ng129/resources/crohns- disease-management-pdf- 66141667282885 7. National Institute for Health and Care Excellence. Ulcerative colitis: management. NICE Guideline 130. May 2019. Available at: https://www.nice.org.uk/guidance/ng130/resources/ulcerati ve-colitis-management-pdf- 66141712632517 8. National Institute for Health and Care Excellence. Infliximab, adalimumab and golimumab for treating moderately to severely active ulcerative colitis after the failure of conventional therapy. NICE TA 329. February 2015. Available at: https://www.nice.org.uk/guidance/ta329 9. Torres J, Bonovas S, Doherty G, et al. ECCO Guidelines on therapeutics in Crohn’s Disease: medical treatment. J Crohn’s Colitis. 2020;14(1):4–22. Available at: https://academic.oup.com/ecco-jcc/article/14/1/4/5620479 10. Feuerstein JD, Isaacs KL, Schneider Y, et al. AGA clinical practice guidelines on the management of moderate to severe ulcerative colitis. Gastroenterology 2020;158:1450– 1461. Available at: https://www.gastrojournal.org/action/showPdf?pii=S0016- 5085%2820%2930018-4 11. Lichtenstein GR, Loftus EV, Isaacs KL, et al. ACG Clinical Guideline: Management of Crohn's Disease in Adults. Am J Gastroenterol 2018;113(4):481-517. Available at: https://journals.lww.com/ajg/Fulltext/2018/04000/ACG_Clini cal_Guideline__Management_of_ Crohn_s.10.aspx 12. Mulcahy AW, Hlavka JP, Case SR. Biosimilar cost savings in the United States: initial experience and future potential. Rand Health Q 2018;7:3. Available at: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6075809/