Practice Patterns in the Use of Anti-Tumor Necrosis Factor Alpha Agents in the Management of Crohn's Disease: A US National Practice Survey Comparing Experts and Non-Experts

The US Food and Drug Administration currently approves three types of anti-tumor necrosis factor alpha (anti-TNF alpha) therapy for treatment of moderate to severe Crohn's disease. There are no guidelines to clarify which of the drugs may be better suited to individual clinical scenarios. We gathered national data on the prescribing pattern, comfort levels, and algorithms gastroenterologists use for management of their biologic-requiring Crohn's disease patients. An internet survey was mailed to members of the American Gastroenterology Association. Responses were separated into "non-expert" and "expert" physician groups on the basis of whether a practice consisted of > 50% of patients with inflammatory bowel disease. We compared experts with non-experts with regard to the use of the three anti-TNF agents, attitudes regarding their relative efficacy, and their experience with adverse events. Of 3,990 eligible gastroenterologists, 473 replied in full (11.9%). Sixty (12.6%) respondents met the criterion for IBD expert physician. Experts were comfortable using both immunomodulators and anti-TNF alpha therapy. Community physicians were equally comfortable prescribing 6-mercaptopurine, azathioprine, infliximab, and adalimumab, but less comfortable than experts with methotrexate (56 vs. 86%, P < 0.05) and certolizumab (68 vs. 89%, P < 0.05). Expert physicians were much more likely to have encountered adverse reactions to anti-TNF alpha therapy. Our results suggest that experts are more comfortable using a broader array of medical therapy than non-expert physicians. Although both groups had similar concerns regarding side-effects of anti-TNF alpha therapy, expert physicians were much more likely to have managed a broad range of complications in their patient population.