Proactive Vs Reactive Therapeutic Drug Monitoring of Infliximab in Crohn's Disease: A Cost-Effectiveness Analysis in a Simulated Cohort

Diana M. Negoescu, Eva A. Enns, Brooke Swanhorst, Bonnie Baumgartner, James P. Campbell, Mark T. Osterman, Konstantinos Papamichael, Adam S. Cheifetz, Byron P. Vaughn

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26 Scopus citations


Background: Therapeutic drug monitoring (TDM) is increasingly performed for Infliximab (IFX) in patients with Crohn's disease (CD). Reactive TDM is a cost-effective strategy to empiric IFX dose escalation. The cost-effectiveness of proactive TDM is unknown. The aim of this study is to assess the cost-effectiveness of proactive vs reactive TDM in a simulated population of CD patients on IFX. Methods: We developed a stochastic simulation model of CD patients on IFX and evaluated the expected health costs and outcomes of a proactive TDM strategy compared with a reactive strategy. The proactive strategy measured IFX concentration and antibody status every 6 months, or at the time of a flare, and dosed IFX to a therapeutic window. The reactive strategy only did so at the time of a flare. Results: The proactive strategy led to fewer flares than the reactive strategy. More patients stayed on IFX in the proactive vs reactive strategy (63.4% vs 58.8% at year 5). From a health sector perspective, a proactive strategy was marginally cost-effective compared with a reactive strategy (incremental cost-effectiveness ratio of $146,494 per quality-adjusted life year), assuming a 40% of the wholesale price of IFX. The results were most sensitive to risk of flaring with a low IFX concentration and the cost of IFX. Conclusions: Assuming 40% of the average wholesale acquisition cost of biologic therapies, proactive TDM for IFX is marginally cost-effective compared with a reactive TDM strategy. As the cost of infliximab decreases, a proactive monitoring strategy is more cost-effective.

Original languageEnglish (US)
Pages (from-to)103-111
Number of pages9
JournalInflammatory bowel diseases
Issue number1
StatePublished - Jan 1 2020

Bibliographical note

Funding Information:
for Advancing Translational Sciences of the National Institutes of Health Award Number KL2TR000113. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health. This project was supported by the University of Minnesota’s Undergraduate Research Opportunities Program.

Funding Information:
Supported by: KP is supported by Ruth L. Kirschstein NRSA Institutional Research Training Grant 5T32DK007760-18. EAE is supported by the National Institute of Allergy and Infectious Diseases of the National Institutes of Health under award number K25AI118476. BPV was supported by the National Center

Funding Information:
Conflicts of Interest: EAE received compensation from ViiV Health care for participation in an advisory board meeting. MTO received consultancy fees from Janssen, AbbVie, UCB, Takeda, Pfizer, Merck, and Lycera and research support from UCB. ASC received consultancy fees from AbbVie, Janssen, Takeda, Ferring, Miraca, AMAG, Arena, Samsung, Alfasigma, and Pfizer and research support from Miraca. BPV received research support from Takeda, Genentech, and Celgene and has received compensation from Janssen and AbbVie for speaking and advisory boards. DMN, BS, BB, JC, MO, and KP have no conflicts of interest to declare.

Publisher Copyright:
© 2019 Crohn's & Colitis Foundation. Published by Oxford University Press. All rights reserved. For permissions, please e-mail:


  • biologics
  • health economics
  • immunosuppression
  • inflammatory bowel disease


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