Introduction Traditionally gastroenterologists have individually monitored their inflammatory bowel disease (IBD) patients on thiopurine metabolite (TPM) immunomodulator (IM) therapies, (eg. azathioprine (AZA) or 6-mercaptopurine (6MP)), with 3 monthly blood tests. The uptake and effectiveness of this practice is not well understood.
Objective: We were keen to review the uptake and outcome of IM monitoring locally, and to see if we could improve it.
Method Local data on the National IBD Registry was used to identify all patients thought to be on TPM therapy. For 1 year a selected group were then offered automated blood testing in January, April, July and October. An IM cohort was created on our hospital laboratory testing and results system (ICE) to allow mass batch test generation, regardless of the consultant in charge, and thereby reduce workload. The pooled results were then reviewed by the IBD nurses. We recorded when these tests were completed and set up an alert system for patients failing to complete their monitoring assessments.
Results Of our 3462 local IBD patients, 525 were identified as being prescribed AZA or 6MP, and of these 464 patients were offered automated testing. By 2016 we had finished 1 year of data collection, and during this time only 171 (40%) completed all 4 tests, 109 (25%) completed 3, 73 (17%) completed 2, 58 (13%) completed just 1, and 53 (11.4%) had avoided all monitoring tests. We reviewed the notes of patients failing all 4 tests, and contacted them directly. It transpired that 24 had decided to stop themselves, 9 had moved away, 5 claimed their GPs were monitoring them, 2 had never been started on TGMs, 6 were lost to follow up, and 1 had fallen into remission, and 3 were stopped by Consultants because of intolerances. There were also 3 patients who were advised to stop because of side effects; 2 with leucopenia and 1 with pancytopenia.
Conclusion Routine 3 monthly IM testing is commonly performed throughout UK and can be costly and time consuming. Improvements were made in our local IM Service, through mass automated batch testing and a pooled monitoring system, but the actual patient uptake was still a little disappointing. Non-compliance with TPM therapy is common, and can lead to flares, complications, recurrent courses of steroids and treatment escalation. 184 (40%) patients completed less than half their tests, with total non-compliance being seen in 5%. When patients were directly challenged about their total non-compliance with IM monitoring 45% admitted not taking their TPM therapy. Whilst regular testing did pick up 3 patients with side effects, further work will be needed to assess the effectiveness of this practice.
Disclosure of Interest None Declared
- Inflammatory Bowel Disease
- service development
- service evaluation