- Pediatric Gastroenterology
Clinical Associate Professor, Pediatrics - Gastroenterology
Board Certification: American Board of Pediatrics, Pediatric Gastroenterology (2013)
Fellowship: Cleveland Clinic Children's Pediatric Gastroenterology Dept (2012) OH
Residency: Nationwide Children's Hospital Pediatric Residency (2008) OH
Medical Education: The Ohio State University College of Medicine (2005) OH
Comparative Effectiveness of Anti-TNF in Combination with Low Dose Methotrexate vs Anti-TNF Monotherapy in Pediatric Crohn's Disease: a Pragmatic Randomized Trial.
BACKGROUND AND AIMS: Tumor Necrosis Factor inhibitors (TNFi), including infliximab and adalimumab, are a mainstay of pediatric Crohn's disease (PCD) therapy; however, non-response and loss of response is common. As combination therapy with methotrexate may improve response, we performed a multi-center, randomized, double-blind, placebo-controlled pragmatic trial to compare TNFi with oral methotrexate to TNFi monotherapy.METHODS: PCD patients initiating infliximab or adalimumab were randomized in 1:1 allocation to methotrexate or placebo and followed for 12-36 months. The primary outcome was a composite indicator of treatment failure. Secondary outcomes included anti-drug antibodies (ADA) and patient reported outcomes (PROs) of pain interference and fatigue. Adverse events (AEs) and Serious AEs (SAEs) were collected.RESULTS: Of 297 participants (mean age 13.9 years, 35% female), 156 were assigned to methotrexate (110 infliximab initiators and 46 adalimumab initiators) and 141 to placebo (102 infliximab initiators and 39 adalimumab initiators). In the overall population, time to treatment failure did not differ by study arm (HR 0.69, 95% CI 0.45-1.05). Among infliximab initiators, there were no differences between combination and monotherapy (HR 0.93, 95% CI 0.55-1.56). Among adalimumab initiators, combination therapy was associated with longer time to treatment failure (HR 0.40, 95% CI 0.19-0.81). A trend towards lower ADA development in the combination therapy arm was not significant. [(infliximab OR 0.72 (0.49-1.07); adalimumab OR 0.71 (0.24-2.07)]. No differences in PROs were observed. Combination therapy resulted in more AEs but fewer SAEs.CONCLUSIONS: Among adalimumab but not infliximab initiators, PCD patients treated with methotrexate combination therapy experienced a 2-fold reduction in treatment failure with a tolerable safety profile.
View details for DOI 10.1053/j.gastro.2023.03.224
View details for PubMedID 37004887
Clinical Practice Survey of Repeat Endoscopy in Pediatric Inflammatory Bowel Disease in North America.
Journal of pediatric gastroenterology and nutrition
OBJECTIVES: Endoscopic remission has become a standard treatment target in inflammatory bowel disease (IBD). It is unclear how widely this practice has been adopted amongst pediatric gastroenterology providers. This study determines the frequency of repeat endoscopy in pediatric IBD and evaluates for predictive baseline characteristics of providers.METHODS: We developed a cross-sectional survey which was distributed via three national email listservs to pediatric gastroenterology providers. We obtained baseline characteristics of respondents and assessed motivations and barriers for the practice of repeat endoscopy compared to none.RESULTS: 238 unique respondents completed the online survey. Response rate was 11% (238 of 2300 possible participants). The majority practice in an academic setting (77%) and reported participation in ImproveCareNow (63%). Overall, 65% of respondents perform repeat endoscopy to assess for endoscopic remission in pediatric IBD as part of routine clinical practice. 56% reported repeat endoscopy as individuals in the absence of a departmental protocol. "Symptoms are not sufficient to follow IBD patients" was reported by 82% of those who repeat endoscopy; conversely, "I perform endoscopy based on clinical, biomarker, and/or imaging trends" was reported by 81% of those who do not repeat endoscopy. The establishment of a pediatric-specific guideline was most commonly reported to change current practice, based on rank-order scoring.CONCLUSION: A majority of representative providers repeat endoscopy to assess for endoscopic remission in pediatric IBD. Fewer years in practice favored repeating endoscopy. The need for North American pediatric guidelines with pediatric-specific evidence to support the long term benefits of endoscopic remission are highlighted in this study.
View details for DOI 10.1097/MPG.0000000000003100
View details for PubMedID 33633082
Assuring Quality for Non-Hospital Based Biologic Infusions in Pediatric Inflammatory Bowel Disease: A Clinical Report from the North American Society for Pediatric Gastroenterology, Hepatology and Nutrition.
Journal of pediatric gastroenterology and nutrition
The primary aim of this Clinical Report by the North American Society for Pediatric Gastroenterology, Hepatology and Nutrition is to provide formal guidance to pediatric gastroenterologists and clinicians, health systems, and insurance payers regarding home- and office-based infusions for biologic therapies in pediatric inflammatory bowel disease (IBD). Patients in North America are increasingly denied coverage by payers based on "place of service" codes at hospital-based infusion units where the treating clinicians primarily provide care. A task force with topic expertise generated 8 best practice recommendations to ensure quality of care for pediatric patients with IBD receiving non-hospital based biologic infusions. Pragmatic considerations discussed in this report include patient safety, pediatric-trained nurse availability, care coordination, patient-centeredness, shared liability, administrative support, clinical governance, and costs of care.
View details for PubMedID 29324477
Premedication Use Before Infliximab Administration: A Cross-sectional Analysis
INFLAMMATORY BOWEL DISEASES
2017; 23 (1): 174-180
Premedications are commonly given to patients with inflammatory bowel disease before intravenous infliximab administration. We aimed to (1) describe practice variability; and (2) determine clinician rationale for premedicating patients with inflammatory bowel disease before infliximab administration.We developed a cross-sectional electronic survey after comprehensive literature review to assess practice variability and clinician rationale for premedication use before infliximab. An optional postsurvey quiz assessed clinicians' understanding of the available literature. The survey was distributed through members-only NASPGHAN and Crohn's and Colitis Foundation of America (CCFA) listservs and American Gastroenterological Association (AGA) and American College of Gastroenterology (ACG) web-based discussion boards.Three hundred seventy-nine unique respondents with a 93.3% survey completion rate comprised 331 (87%) and 45 (12%) pediatric and adult gastroenterologists. Among numerous options for premedications, acetaminophen (66%) and diphenhydramine (64%) were most often given before each infliximab infusion. Only 20% did not routinely use premedications. There was heterogeneity of premedication use between gastroenterologists within the same clinical practice. Of 328 (87%) respondents who completed the knowledge assessment quiz, only 18% identified the association of diphenhydramine use with increased reaction.There is high interpractice and intrapractice variability for premedication use before infliximab administration. Clinician rationale for premedicating patients seems to be driven by individual preference or group practice habit. Improved knowledge of the evidence may assist in decreasing overuse of premedications, particularly diphenhydramine.
View details for DOI 10.1097/MIB.0000000000001002
View details for Web of Science ID 000393897100027
View details for PubMedID 28002131
View details for PubMedCentralID PMC5180444