Hoe kan het opvolgen van serumspiegels van - UZ Leuven

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Hoe kan het opvolgen van serumspiegels van biologische geneesmiddelen bijdragen tot een betere zorg van de patient Prof. Ann Gils Laboratorium therapeutische and diagnostische antilichamen Department Farmaceutische & Farmacologische Wetenschappen, KU Leuven Leuven , 28 april 2016

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Inflammatory diseases

Inflammatory bowel diseases

• Crohn’s disease • Ulcerative colitis

Rheumatological diseases

• Spondyloarthritis • Rheumatoid arthritis • Psoriatic arthritis

Dermatological diseases

• Plaque psoriasis

2

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Concept: elevated Tumor Necrosis Factor alpha (TNF) concentrations at the sites of inflammation drive disease pathology Therapeutic goal: removal of excess TNF from sites of inflammation

Development of anti-TNF biologicals 3

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anti-TNF biologicals

4

Tracey D. et al., Pharm & Ther 2008; 117: 244-79

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Inflammatory bowel diseases Surgery Biological Agents Immunomodulators 5-ASA Corticosteroids

step-up therapy is used

30.000 patients in Belgium

 Flemish inheritance study for Crohn’s and colitis (VLECC)” registry, a biobank collecting serum, DNA and clinical characteristics of IBD patients followed at UZ Leuven has been established since 1997  The biobank prospectively collects serial serum samples of patients with IBD and healthy controls that gave informed consent to participate in this study.  4141 patients with IBD and 4790 healthy controls have been included 5

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Biologicals to treat IBD + murine CDR

infliximab (Remicade® Remsima® Inflectra®) I.V. 5 mg/kg w0, w2, w6, q8w UC & CD

S.C. 160 mg (w0) 80 mg (w2) 40 mg (eow) UC & CD

vedolizumab (Entyvio®)

golimumab (Simponi ®)

adalimumab (Humira ®)

S.C. 200 mg (w0) 100 mg (w2) 50/100 mg (q4w) UC

I.V. 300 mg w0, w2, w6, q8w UC & CD Targets α4β7 integrin

Target tumor necrosis factor-α = anti-TNF 6

EPAR Remicade, EPAR Remsima, EPAR Inflectra, EPAR Humira, EPAR Simponi, EPAR Entyvio

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Vedolizumab: a NEW target  Humanized monoclonal antibody  Modified Fc part to increase half-life

 Inhibits interaction between 47 integrin on lymphocytes and principal ligand mucosal addressin cell adhesion molecule protein-1 (MADCAM-1) on endothelial cells  Highly selective adhesion molecule antagonist that blocks lymphocyte migration to inflamed areas of the gut  Recognizes only the 47 heterodimer and not the individual 4 or 7 monomers

+ murine CDR

vedolizumab (Entyvio®) I.V. 300 mg w0, w2, w6, q8w UC & CD Targets α4β7 integrin [email protected]

Number of patients with IBD at UZ Leuven treated with + murine CDR

infliximab (Remicade® Remsima® Inflectra®) n = 1995

vedolizumab (Entyvio®)

golimumab (Simponi ®)

adalimumab (Humira ®) n = 1138

n = 43

n = 198

8

EPAR Remicade, EPAR Remsima, EPAR Inflectra, EPAR Humira, EPAR Simponi, EPAR Entyvio

[email protected]

Treatment of IBD with anti-TNF Anti-TNF standard dose

Clinical effect is evaluated after initiation of treatment (INDUCTION)

insufficient or no response (up to 40% primary non-responders)

Expected response (primary responders) an interindividual variability in clinical response is observed

During MAINTENANCE

Secondary loss of response is observed in 23-42% of patients 9

Ben-Horin S et al., Autoimmune Rev. 2014

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Current treatment strategies

IBD patients not responding to conventional systemic therapies

* Based on physician’s preference ** Based on clinical symptoms

Selecting a biological* Treatment decision during follow-up**:

Good response

Poor response

Treatment continuation

Increase dose Switch to biological with same mechanism of action Switch to biological with different mechanism of action

10

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Pharmacokinetics/Pharmacodynamics Pharmacodynamics

Pharmacokinetics

Drug dose

EXPOSURE

Drug concentration

RESPONSE

Inflammation

Is there an association between concentration and effect?

11

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Pharmacodynamics Which effect can be measured?  Biological response

 CRP (baseline, during treatment) (CD)  Albumin

 Clinical response (UC + CD):

• complete = absence of diarrhoea and blood

• partial = clinical improvement but still persistent rectal blood loss

 Clinical remission (UC + CD)

• Absence of clinical symptoms

 Endoscopic response (UC)

• Mayo subscore of 0 or 1 (baseline, during treatment) 12

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Association between infliximab concentration and clinical and biological respons  In CD patients evaluable for mucosal healing (n=123), trough serum infliximab concentration at week 30 of 3.0 μg/mL or greater and CRP normalization were associated significantly with mucosal healing at week 26. (Reinisch W et al., Clin Gastro Hepatol 2015)  There is a significant difference between serum infliximab levels in patients with IBD in remission, compared with those who relapse (n=3483). A trough threshold during maintenance > 2 µg/ml is associated with a greater probability of clinical remission and mucosal healing. (Moore C et al., JCC 2016)

13

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Association between adalimumab concentration and clinical and biological respons  A cut-off drug level of 5.85 μg/mL (n = 71) yielded optimal sensitivity, specificity and positive likelihood ratio for remission prediction. (Mazor Y et al., APT 2014)  The median trough level of adalimumab was higher in patients in clinical remission (6.02 μg/mL) (n = 40). An absence of mucosal healing was associated with trough levels of adalimumab less than 4.9 μg/mL. (Roblin X et al., Clin Gastroenterol Hepatol 2015)

14

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Association between golimumab concentration and clinical and biological respons  Median serum golimumab concentration was significantly higher in partial clinical responders than in non-responders (n=21): 10.0 µg/ml versus 7.4 µg/ml at week 2 and 5.1 µg/ml versus 2.1 µg/ml at week 6 (Detrez I et al., JCC 2016)

15

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Pharmacokinetics/Pharmacodynamics

Pharmacokinetics EXPOSURE

Drug

Pharmacodynamics RESPONSE

Drug concentration

Therapeutic window : Infliximab: 3-7 µg/ml Adalimumab: 5-10 µg/ml 16

Inflammation

Yes, there is an association between concentration and effect for  infliximab  adalimumab  golimumab  vedolizumab [email protected]

Pharmacokinetics/Pharmacodynamics

Pharmacokinetics EXPOSURE

Drug

Absorption Distribution Elimination

Pharmacodynamics RESPONSE

Drug concentration

What determines drug serum concentration?

17

Inflammation

Yes, there is an association between concentration and effect for  infliximab  adalimumab  golimumab  Vedolizumab [email protected]

Pharmacokinetics: absorption infliximab (IFX) and vedolizumab (VEDO) intravenous route  Complete systemic availability F = 100% (IFX & VEDO)  Rapid delivery of the biopharmaceutical to the systemic circulation Tmax = within min after end of infusion  Achievement of high concentrations Cmax > 100 µg/ml

adalimumab (ADM) and golimumab (GOM) subcutaneous route  Systemic absorption: convective transport through lymphatic vessels to peripheral lymp nodes F = 64% (ADM); 51% (GOM)  slow delivery of the biopharmaceutical to the systemic circulation Tmax = 2-8 days  Achievement of low-moderate concentrations Cmax < 10 µg/ml

EPAR Remicade, EPAR Remsima, EPAR Inflectra, EPAR Humira, EPAR Simponi, EPAR Entyvio; Ordas I [email protected] et al., Clin Pharmacol Ther 2012; Dreesen E et al., Current Drug Targets 2016

Pharmacokinetics: Distribution Extravasation/distribution

systemic circulation (central compartment)

 Limited diffusion due to high molecular weight and high polarity

Target tissues (peripheral compartment)

VD = in the order of 0.1L/kg body weight which equals extracellular fluid volume

 Predominant mechanism for extravasation is convective transport

distribution

In-tissue distribution slow

 Limited diffusion due to high molecular weight and high polarity

Mould D et al., Biodrugs 2010; Glassman P et al J Clin Pharm 2015, Yarur et al Gut 2015, Dreesen et al 2016 Current Drug Targets

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Pharmacokinetics: Elimination No hepatic nor renal elimination

Primary route of antibody clearance: intracellulair enzymatic degradation after receptor-mediated, target-mediated or fluid phase endocytosis in cells of the reticuloendothelial system  receptor-mediated: binding of Fc part to FcɣR I, II and III  target-mediated: binding of Fab part to tmTNF  fluid phase endocytosis or pinocytose

Clearance of therapeutic antibodies: between 6.3 mL/h (VEDO) to 17.6 mL/h (IFX) T1/2 : between 7 days (IFX) to 22 days (VEDO)  Protein-losing enteropathy reported for infliximab

Wang W et al., Clin Pharmacol Ther 2008; Parikh A et al., 2012; Brandse J et al., Gastroenterology 2015

EPAR Remicade, EPAR Remsima, EPAR Inflectra, EPAR Humira, EPAR Simponi, EPAR Entyvio [email protected]

Pharmacokinetics: exposure to the drug

Drug

Drug concentration

Pharmacokinetic parameters of biopharmaceuticals are highly variable, depending on e.g.  drug  dose (weight)  dosage regimen  bioavailability  binding to receptors  kinetics of receptor internalization  kinetics of intracellulair catabolism  target load (disease activity)  protein losing enteropathy, ... 21

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Pharmacokinetics: exposure to the drug Drug dose

Drug concentration unknown

Therapeutic drug monitoring (TDM): measures concentration of the drug:  When to measure?  How to measure? 22

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Therapeutic Drug Monitoring: When to measure IV administration (IFX, VEDO) :  peak conc: 2h after infusion  Intermediate conc: 4w after infusion  Trough conc: just before next infusion SC administration (ADM, GOM) : Adapted from Tracey D. et al., Pharm & Ther 2008; 117: 244-79.

 peak conc: 2-8 days

infliximab = yellow line, adalimumab = green line

 (Trough) conc: just before next injection

TDM is mainly based on trough concentrations 23

Adapted from Tracey D. et al., Pharm & Ther 2008; 117: 244-79.

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Therapeutic Drug Monitoring: How to measure TNF coated Colorimetric reaction MA-IFX6B7HRP

IFX TNF

MA/MA combination Colorimetric reaction MA-IFX-2 IFX MA-IFX-1

• infliximab, adalimumab: TNF coated ELISA is used: CE-labelled kit (apDia)

Van Stappen T et al., TDM 2015; Bian S et al., JPBA 2016; Detrez I et al., JCC 2016; Gils A et al., submitted

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Therapeutic Drug Monitoring: How to measure Colorimetric reaction MA-IFX6B7HRP

INFLIXIMAB

IFX TNF

Kit from apDia  TNF coated  Serum is applied (1/100 or 1/400)  Bound infliximab (IFX) is detected using conjugate developed at KU Leuven1  MA-IFX6B7-HRP for IFX (Remicade, Remsima, Inflectra)2  Drug itself (IFX) is used as calibrator (0 ng/ml to 120 ng/ml); min detection 1 ng/ml  Measurable range = 0,5 to 12 µg/ml when using 1/100 dilution  Measurable range = 2 to 48 µg/ml when using 1/400 dilution  Kit contains two control samples (3 µg/ml and 7 µg/ml when applying 1/100)  Good trough concentrations during maintenance: within 3-7 µg/ml3 1Van

2015

Stappen T et al., TDM 2015; 2Gils et al., IBD 2016 in press, 3Vande Casteele et al., Gastroenterology

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Therapeutic Drug Monitoring: How to measure Colorimetric reaction

ADALIMUMAB

MA-ADM40D8-HRP ADM

Kit from apDia

TNF

 TNF coated  Serum is applied (1/100 or 1/400)  Bound adalimumab (ADM) is detected using conjugate developed at KU Leuven1  MA-ADM40D8-HRP for ADM (Humira)  Drug itself (ADM) is used as calibrator (0 ng/ml to 120 ng/ml): min detection 1 ng/ml  Measurable range = 0,5 to 12 µg/ml when using 1/100 dilution  Measurable range = 2 to 48 µg/ml when using 1/400 dilution  Kit contains two control samples (3 µg/ml and 7 µg/ml when applying 1/100)  Good trough concentrations during maintenance: above 5 µg/ml2 1Bian

S et al., JPBA 2016; 2Mazor et al., APT2014

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Therapeutic Drug Monitoring: How to measure MA/MA combination Colorimetric reaction

Colorimetric reaction MA- VEDO-2

MA-GOM-2 GOM MA-GOM-1

VEDO MA-VEDO-1

• golimumab, vedolizumab: MA/MA ELISA is used

Van Stappen T et al., TDM 2015; Bian S et al., JPBA 2016; Detrez I et al., JCC 2016; Gils A et al., submitted

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Therapeutic Drug Monitoring: biosimilars  Sept 2013, EMA issued marketing autorization of a biosimilar of Remicade, CT-P13, to two applicants, Celltrion Inc. and Hospira Inc. under the trade names Remsima and Inflectra, respectively.  Both drugs are manufactured by Celltrion InC.  Due to intrinsic complexity and manufacturing dependency, a biosimilar cannot be seen as an exact copy of its orginator product  For approval EMA requires extensive in vitro and in vivo nonclinical and clinical comparability studies which demonstrate comparable quality, safety, and efficacy and the absence of clinical relevant differences as compared with those of the originator product

Van Stappen T et al., TDM 2015; Gils A et al., IBD 2016 in press

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Therapeutic Drug Monitoring: biosimilars  Approval of Remsima and Inflectra implies that all major physicochemical characteristics and biological activities of the biosimilar were shown to be comparable to those of Remicade  Significant differences in fucosylation have been observed but EMA concluded that these differences do not have an impact on the clinical properties Can the same assay be used to measure Remicade, Remsima and Inflectra?

Van Stappen T et al., TDM 2015; Gils A et al., IBD 2016

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Therapeutic Drug Monitoring: biosimilars

 Quantification of biosimilars

Colorimetric reaction

MA-IFX6B7-HRP IFX TNF

Determination of concentrations of Remicade, Remsima and Inflectra using infliximab ELISA kit (apDia) Concentrations are expressed as mean ± SD (n = 3) µg/mL infliximab. Nominal concentration

Remicade

Remsima

Inflectra

1

1.0 ± 0.1

1.0 ± 0.1

1.0 ± 0.1

7

6.6 ± 0.3

6.8 ± 0.5

7.4 ± 0.1

(µg/mL) 3 10

2.7 ± 0.1 10.5 ± 0.4

2.8 ± 0.1 10.1 ± 0.9

2.9 ± 0.2

Concentrations are expressed as mean ± SD (n = 3) µg/mL infliximab. Van Stappen et al., TDM 2015; Gils A et al., IBD 2016

10.2 ± 0.6

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Therapeutic Drug Monitoring: infliximab Enzyme-linked immunosorbent assay Radio-immunoassay Homogeneous mobility shift assay

• •

Requires multiple samples at a time Lacks speed

• •

Very expensive Not for routine measurements

• •

Safety  specialized laboratories Lacks speed

Development of rapid point-of-care assay for infliximab quantification (In collaboration with R-Biopharm AG, Darmstadt, Germany) Lateral flow-based assay

Gold nanoparticle Anti-tag antibody

TNF tag

Infliximab

MA-IFX6B7

Test line

31

Van Stappen T et al., presented at ECCO 2016 and DDW 2016, paper submitted

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Therapeutic Drug Monitoring: infliximab

Collect blood sample

Diluted sample Solution B Solution A

Analyze result

= Mixture

Application of Mixture

Adjust dosing regimen or continue treatment?

Prepare serum (15 min)

Van Stappen T et al., presented at ECCO 2016 and DDW 2016, paper submitted

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Therapeutic Drug Monitoring: infliximab

Analytical validation of the new rapid lateral flow-based assay for infliximab quantification (Pearson r = 0.95, ICC = 0.95 for samples taken during induction; Pearson r = 0.92, ICC = 0.87 for samples taken during maintenance) Gold nanoparticle HRP

Anti-tag antibody TNF tag

MA-IFX6B7

Infliximab

MA-IFX6B7 Test line

Infliximab

Comparison LFA with ELISA

TNF ELISA well

33

Van Stappen T et al. Ther Drug Monit, 2015; 37, 479-85 &

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Van Stappen T et al., presented at ECCO 2016 and DDW 2016, revised version of paper submitted

Therapeutic Drug Monitoring/ Pharmacokinetics

absorption distribution elimination

drug

drug concentration EXPOSURE

Immuun-mediated response

Anti-drug antibodies (ADA): Effect on elimination? [email protected]

nonneutralizing versus neutralizing ADA

35

Carrascosa JM, Actas dermisifiliogr. 2013

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The effect of (non)neutralizing ADA?

36

Carrascosa JM, Actas dermisifiliogr. 2013

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HOW TO DETECT anti-drug antibodies? Several assays available:  RIA

 cell based assay

 Homogenous mobility shift assay  bridging assay

IFX-Biotin

MA-IFX10F9 IFX

[email protected]

HOW TO DETECT anti-drug antibodies? Harmonization of anti-drug antibody titers through use of universal calibrators:  infliximab:MA-IFX10F9 (Van Stappen T et al. IBD 2015)  adalimumab: MA-ADM6A10 (Gils A et al., TDM 2014)  golimumab: MA-GOM159B8 (Detrez I et al., JCC 2016)  vedolizumab: MA-VEDO19C11 (unpublished data)

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Measurement of antibodies towards therapeutic antibodies Anti-infliximab

IFX-Biotin

MA-IFX10F9 IFX

Kit from apDia: anti-infliximab  IFX coated  Serum is applied (1/25 or 1/200)  Bound antibodies towards IFX (ATI) are detected using biotinylated IFX conjugate  Calibrator:specific Mab: MA-IFX10F91 (range 0-5 ng/ml) directed towards drug  Measurable range = 2,5 to125 ng/ml when using 1/25 dilution  Measurable range = 20 to 1000 ng/ml when using 1/200 dilution  Kit contains two control samples (9,4 ng/ml and 75 ng/ml when applying 1/25) 39 considered as high  ATI concentrations above 400 ng/ml are 1Van

Stappen T et al. IBD 2015

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HOW TO DETECT anti-drug antibodies: biosimilars?

Anti-infliximab titers* in patients treated with Remicade Patient sample 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36

*expressed

Infliximab (µg/mL) < 0.3 10.1 < 0.3 1.3 < 0.3 < 0.3 < 0.3 < 0.3 < 0.3 < 0.3 < 0.3 < 0.3 < 0.3 < 0.3 < 0.3 0.4 < 0.3 < 0.3 < 0.3 < 0.3 < 0.3 < 0.3 < 0.3 < 0.3 < 0.3 < 0.3 < 0.3 < 0.3 < 0.3 < 0.3 < 0.3 < 0.3 < 0.3 < 0.3 < 0.3 < 0.3

Anti-Remicade

Anti-Remsima

Anti- Inflectra

< 1.6 < 1.6 < 1.6 < 1.6 < 1.6 < 1.6 4 4 19 25 45 49 62 87 90 104 106 126 166 167 177 181 222 242 259 343 388 438 482 491 686 686 > 800 > 800 > 800 > 800

< 1.6 < 1.6 < 1.6 < 1.6 < 1.6 < 1.6 5 6 27 31 53 67 81 107 108 118 127 137 191 187 199 207 279 267 309 413 393 473 513 531 737 > 800 > 800 > 800 > 800 > 800

< 1.6 < 1.6 < 1.6 < 1.6 < 1.6 < 1.6 4 5 45 43 71 99 82 154 91 101 123 140 199 197 272 225 249 344 356 512 602 477 502 542 863 > 800 > 800 > 800 > 800 > 800

 Consistent positive/negative titers  Titers: highly correlate

as ng/mL MA-IFX10F9 equivalents, titers above 400 ng/ml is considered as high

Gils A et al., IBD 2016

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Measurement of antibodies towards therapeutic antibodies

IFX-Biotin

MA-IFX10F9

Drug sensitive: in presence of excess of IFX, ATI can not be detected only determine ATI when IFX is below detection limit

IFX

41 1Van

Stappen T et al. IBD 2015

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Drug-sensitive versus drug-tolerant assay No detection of ADA in presence of drug

Detection of ADA in presence of drug

Pretreatment steps: removal of excess of drug & dissociation of drug/anti-drug complex

% MA-IFX10F9 recovery

HOW TO DETECT anti-drug antibodies: Convert drug resistent in drug tolerant assay? 100 80 60 40 20 0

0

2

4

6

Infliximab (µg/mL)

8

10

Detection of 500 ng/mL MAIFX10F9 in the bridging ELISA without (dotted line) and with (dashed line) the sample pretreatment protocol in the presence of increasing concentrations of infliximab.

42 1Van

Stappen T et al. IBD 2015, Van Stappen T et al.,DTA 2016

[email protected]

Measurement of antibodies towards therapeutic antibodies

30

1600

20

600

1100 100 100 75 50 25 0

10

90 10 0 11 320 0 33 0 34 0

80

70

60

50

40

30

20

10

0

0

ADA (ng/mL)

IFX (µg/mL)

Comparison of the bridging ELISA with and without the sample pretreatment protocol for the detection of anti-drug antibodies (ADA) in two patients treated with infliximab.

Time (weeks) after IFX initiation

The infliximab concentration is presented as a dotted line with triangles indicating the date of infusion. ADA levels are represented with a dashed line (circles indicating the date of infusion) and a full line (diamonds indicating the date of infusion) for the bridging ELISA without and with the sample pretreatment protocol, respectively.

 Drug tolerant anti-infliximab antibody assay can predict formation of anti-drug antibodies providing opportunities for early treatment optimization 43 1Van

Stappen T et al. IBD 2015, Van Stappen T et al., DTA 2016

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TAKE HOME MESSAGE TDM implies more than just measuring drug concentration Patient & disease characteristics need to be combined with TDM TDM is an objective tool that can assist in treatment decisions TDM can be used in treating algorithms  to distinguish primary non-responders from patients with insufficient exposure during induction  for patients with secondary loss of response  for patients in clinical remission

44

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Acknowledgements Laboratory for Therapeutic and Diagnostic Antibodies http://pharm.kuleuven.be/biotech Leuven IBD research group http://www.ibd-kuleuven.com Prof Séverine Vermeire Prof Marc Ferrante Prof Gert Van Assche Prof Paul Rutgeerts Prof Kurt De Vlam Prof Siegfried Segaert UZ Leuven

Contact: [email protected] 45

[email protected]

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Hoe kan het opvolgen van serumspiegels van - UZ Leuven

Hoe kan het opvolgen van serumspiegels van biologische geneesmiddelen bijdragen tot een betere zorg van de patient Prof. Ann Gils Laboratorium therape...

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