Anti-TNF Dose Augmentation Frequently Occurs in the Absence of Objective Evidence of Disease Activity: Fellows-in-Training Award (IBD Category)
Bibliographic record
Abstract
Introduction: Anti-TNF dose is frequently increased or dosing interval shortened in IBD subjects with persistent gastrointestinal symptoms. Evidence supporting dose augmentation is of low quality and the practice imparts a significant additional cost of care. Persons with symptoms ascribed to IBD may not have evidence of ongoing inflammation and therefore would not be expected to benefit from dose augmentation. We sought to determine the extent to which clinicians routinely assessed the presence of active inflammation prior to undertaking anti-TNF dose augmentation. Methods: Medical records of all IBD patients prescribed anti-TNF therapy from 2007-2016 by 8 of 23 Manitoba gastroenterologists were reviewed and demographics, disease characteristics, and IBD treatments recorded. Patients who underwent anti-TNF dose augmentation were further reviewed for the presence of objective assessment of inflammation - including laboratory investigations (CRP, ESR, albumin, ferritin, hemoglobin, fecal calprotectin), cross-sectional abdominal imaging, and endoscopy - in the 90 days preceding dose augmentation. Results: 529 subjects receiving anti-TNF therapy were identified, of whom 151 had anti-TNF doses augmented on 195 occasions (117 CD, 34 UC). 51 subjects (43.6%) with CD had penetrating disease while 16 (47.1%) with UC had pancolitis. Mean age at diagnosis was 25.5 years and 50.3% of subjects were female. There was no difference in demographics, disease phenotype, or baseline lab values between those who received dose augmentation and those who did not. Biochemical evidence of inflammation was assessed prior to dose augmentation on 134 of 195 occasions (68.7%). Results of these investigations were abnormal in only 23 cases (11.8%). Cross-sectional imaging was performed in 11 cases (5.6%) and revealed active disease in 8 (4.1%). Endoscopy was performed on 28 occasions (14.4%) with 24 (12.3%) revealing active disease. Overall, objective evidence of inflammation was present for 48 of 195 dose augmentation events (24.6%), no evidence of inflammation was present for 95 (48.7%), and no investigations were performed for 52 (26.7%). Conclusion: Anti-TNF dose augmentation routinely occurs in the absence of objective evidence of active inflammatory disease. This represents a target for ongoing quality improvement to optimize care of persons with IBD requiring anti-TNF based therapies given the significant economic burden of unjustified and potentially unnecessary dose augmentation.
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How this classification was reachedexpand
Full frame machine prediction
Teacher imitationNot calibrated prevalence, not ground truth. Human validation pending. The Gemma side is a direct model label for every work in the frame, read from the title-only record. The Codex side is a classifier learned from the 10,348 direct Codex labels and calibrated to design-weighted sample rates; fields without enough sample support carry no Codex call. Candidate is the union of the two sides; consensus is their intersection. These outputs are machine_predicted_unvalidated and are not human labels.
Distilled classifier scores by category (both heads)
| Category | Codex | Gemma |
|---|---|---|
| Metaresearch | 0.001 | 0.003 |
| Meta-epidemiology (narrow) | 0.000 | 0.000 |
| Meta-epidemiology (broad) | 0.000 | 0.000 |
| Bibliometrics | 0.001 | 0.001 |
| Science and technology studies | 0.000 | 0.000 |
| Scholarly communication | 0.000 | 0.000 |
| Open science | 0.000 | 0.000 |
| Research integrity | 0.000 | 0.000 |
| Insufficient payload (model declined to judge) | 0.005 | 0.001 |
Machine scores (provisional)
The two teacher heads of the student model, read on this work. A score orders the frame for review; it never asserts a category, and the validation status ships verbatim with every row.
Baseline scores from an immature model (maturity gate not passed, 7 training rounds). Scores rank; they never assert a category.
score_only:v0-immature-baseline · verbatim from the scoring run: score_only means the number may rank works, and no category label ships from itClassification
machine, unvalidatedMachine predicted; a candidate call from one source (direct Gemma or distilled Codex), not a consensus.
How this classification was reached, model by model and score by score, is at the end of the page under "How this classification was reached".