Perspective 2023

2023 Perspective Liquid Elastase Samples To Test, or Not to Test? That is The Question… Page 10 Successful Routine Use of Quantum Blue® Therapeutic Drug Monitoring (TDM) Assays Page 12 A New Portal to Ef-FIT-ciency Page 14 Better Resource Management for Digestive Disease Pathways Page 16 In this Issue... Faecal Calprotectin - Ask Twice Page 2 CALEX Instead of Stool Pots - The Patients’ Opinion Page 4 Calprotectin Home Testing with IBDoc®: What do the patients think? Page 6 Improved Compliance for Faecal Calprotectin Page 8 Saving Hospital Resource with Direct to Patient Fulfilment for IBDoc Kits Page 9

P126 Ask Twice: The importance of a repeated faecal calprotectin testing prior to diagnostic colonoscopy in an adult inception cohort.. “During the triaging process (for the Rapid Access clinic) it became apparent that the majority of patients only had one result at the point of referral, so patients were sent a sample pot in the post and asked to bring the sample back with them to their first outpatient appointment. The median time between the GP referral and this second result was 34 days. During this project, we did not reject referrals due to the lack of a second test, but we did delay the request for a colonoscopy until the second test was available in those with a borderline initial result or the clinical history was not strongly suggestive of IBD. This was only a few days as most brought the sample along to the appointment.” The data presented in the ECCO poster showed that there were 425 patients with a single calprotectin result and 185 patients who had two calprotectin results (using BÜHLMANN fCAL turbo on Abbott Alinity analysers) and a final diagnosis between January 2021 and November 2022. There was a significant difference in the median initial calprotectin which was 949µg/g for patients who were subsequently diagnosed with IBD compared to 353µg/g for those who didn’t have IBD. If two results were available, then the difference was even more pronounced with 749µg/g for those with IBD compared to 34µg/g for those without. This data is presented in the graphs below: We are all very familiar with the use of faecal calprotectin testing to help distinguish inflammatory bowel disease (IBD) from functional disorders, and it has become a staple tool to support the clinical teams in their diagnosis and management of patients. If a negative faecal calprotectin result is obtained the cause of a patient’s symptoms is unlikely to be IBD However, calprotectin is a non-specific marker for inflammation, and so a high result may be due to something other than IBD. The literature highlights numerous other situations that can cause (usually transient) increases in the calprotectin concentration found in stool samples, for example: • Use of certain medication e.g. NSAIDs, proton pump inhibitors • Diverticulitis • Infections e.g. Salmonella, Campylobacter • Stomach/duodenal ulcers • Excessive alcohol • Cancer Basically, anything that causes an irritation/ inflammatory response in the digestive system (mouth to anus) can cause an increase in calprotectin concentrations. Whereas a negative calprotectin is a good rule out for IBD, a positive calprotectin result isn’t necessarily a cause for instant referral to secondary care. The Queen Elizabeth Hospital in Birmingham introduced a rapid access ‘Inception IBD’ clinic based on symptoms and a raised faecal calprotectin test. Dr Peter Rimmer presented their findings and some proposed changes to the pathway at the European Crohn’s and Colitis Organisation (ECCO) conference in Copenhagen earlier this year: The importance of repeated testing prior to diagnostic colonoscopy in an adult inception cohort - Comparison of first and second testing Ask Twice Dr Peter Rimmer, The Queen Elizabeth Hospital, Birmingham Author - Amanda Appleton, Senior Product Manager, Alpha Laboratories Ltd. Faecal Calprotectin Perspective 2

Supplementary graphs not presented on the poster show that 88.6% of calprotectin results fell between the first and second result in patients that subsequently had IBD excluded: It also demonstrates that 83% of patients with an increase between their first and second calprotectin test were subsequently found to have IBD. Although the overall statistics are compelling, interpretation is not always straightforward as Dr Rimmer explains: “We certainly feel that the faecal calprotectin (FCAL) is a highly accurate test but there are some inconsistencies and pitfalls, which to an extent the graph represents: • The FCAL is just a snapshot from a single time point. In acute infection it will be high but if symptoms improve and FCAL normalises then investigation isn’t needed – post infective IBS is common in this patient group. • However, IBD is also characterised by periods of relapse and remission and FCAL will fluctuate alongside this, occasionally by the time we come to investigate they may have entered a milder phase of the disease. The clinical history and duration of symptoms in these patients is important, particularly with Crohn’s disease where the symptoms can be more insidious. Z We also had a handful of patients with mild proctitis in our cohort would not have been picked up with FCAL alone as their inflammation had largely resolved by the time we saw them. • FCAL will on rare occasions fail to correlate with disease severity, in the majority of our patients that was in ileal Crohn’s disease. Again, careful attention to the clinical history is necessary and investigation required regardless of the FCAL result in those with progressive symptoms or concerning features such as weight loss.” A variety of cut-off values were assessed on the poster, and two results of >200µg/g gave the best performance overall with a 85.7 PPV% , 86.2 NPV% and a specificity of 89.5% but the sensitivity was lower than other cut-off values at 81.5%. The poster concluded that the data, in general, supports repeat FCAL testing to avoid unnecessary investigations adding to post COVID endoscopy backlogs. A cut-off of two values >200µg/g had the best overall performance but can miss a small number of IBD cases, particularly those with isolated ileitis or more indolent disease course. This cut-off should not be used in those with a marked increase between the 1st and 2nd result, where IBD is likely. Modifications to the local referral pathway are currently being determined, taking into account the data generated in the study. This will hopefully enable better use of over stretched resources which should in turn result in quicker access to those with most need. For more information on Faecal Calprotectin Testing please visit: © 2023 Copyright Alpha Laboratories Ltd. 3

? ? ? ? ? ? ? ? ? ? ? With the onset of COVID one of the big challenges faced by many hospitals was having sufficient access to biosafety cabinets for sample handling, due to the unknown infection risk from viral RNA which could be detected in the samples. Many hospitals had to prioritise which samples/tests would be performed. In the absence of spare capacity in the safety cabinets, the only way Lanarkshire could maintain their calprotectin service was to give the CALEX sample extraction device to the patients to prepare directly, rather than sending in a portion of the stool in a pot (universal tubes) for processing by the laboratory staff. Giving CALEX to patients was implemented in 2020, and seemed to work well so Lanarkshire has continued with providing CALEX for submission of samples for faecal calprotectin testing. 95% Compliance The compliance rate for the CALEX has been high at 95%, and this was reported in an article in the 2022 Leading Edge (http:// f /e-mags /Leading_ Edge_2022_Issue_1/6/index.html). Dr Ailsa Ralph has subsequently distributed two surveys amongst patients and front-line clinical staff to gain an insight into the user experience and see if there was anything that could be improved upon, and she talks here about their findings. Patient Surveys “For the survey we developed a series of closed questions with a scoring system from 1 – 5 with 1 being the best and 5 being the worst. There was also a comments section for free text at the end of the survey. The surveys were designed to try and assess how easy the CALEXwas to use, how clear the instructions were, how confident patients felt collecting their samples using the CALEX and if patients had past experience collecting faecal samples with the standard stool pots, then how did that compare with their experience using the CALEX. Patient Responses The surveys were sent with the CALEX to patients who were being asked to do a faecal calprotectin test between May 2022 to January 2023. During this time there were 6312 requests for faecal calprotectin laboratory testing. There were 59 surveys returned (although not all questions were answered in some cases – the data shown is from the responses received in each case). The results indicated that the majority of the patients found the instructions accessible and the CALEX easy to use: CALEX Instead of Stool Pots The Patients’ Opinion Ailsa Ralph, NHS Trainee Clinical Scientist Author - Amanda Appleton, Senior Product Manager, Alpha Laboratories Ltd. 4 Perspective

The next questions were aimed at trying to understand how satisfied the patients were with using the CALEX to collect the samples and what the comparison was to collecting the sample in universal tubes instead. There were 13 ‘no responses’ received for the last question regarding the comparison between the historic universal tube and current CALEX collection method which was significantly higher than the other questions. The assumption here is that the historic universal tube had not previously been used. It can be seen from the responses that the vast majority of patients found the CALEX easier, or certainly no more difficult to use to collect their stool samples into, than the traditional universal tubes and they were confident that they had completed the process correctly. 25% of the patients who responded to the survey also filled in comments. Detailed feedback is invaluable as it lets us know what went well andwhat needs improving. In broad terms, these can be categorised as follows: • Missing instructions: Z Patients reported using Google or YouTube to find out how to use the devices, and I think this suggests that we need to look at our processes for how we get the CALEX and the instructions to the patients. Z Not clear on where to return the CALEX to, and again I think this may need to be clearer on our instructions - what the patient does with the sample once it is collected. • Sample collection concerns: Z Difficulty getting the white cap off – this could be an issue for older patients or those who may have dexterity issues. However, in the main calprotectin is more often a test used for younger patients. The older age group are more likely to receive faecal immunological testing (FIT) instead. Z Difficulty getting sample into the grooves with different sample consistencies. Although there were some issues highlighted, there was also quite a lot of positive feedback which was nice to see. Healthcare Professionals A second survey was sent to front line healthcare professionals who are issuing the CALEXdevices to thepatients andprovidingadviceon their use. In themain thiswould have been secondary care professionals, but there would have been an element of primary care too. We received 13 responses back indicating that generally the CALEX were given out frequently and that they thought the instructions were clear. Some of the additional feedback that came from the healthcare professionals was that advise was often sought from patients regarding whether the buffer needed to remain in the CALEX tube and there was confusion regarding the storage requirements for the CALEX. CALEX Preferred to Sample Collection via Universal Tube The majority of patients found the CALEX devices easy to use, with accessible instructions and overall the CALEXwere rated in preference to the standard universal tubes. The feedback shows that there could be improvements in some areas on the instructions regarding sample consistency challenges and the presence of the extraction buffer. Also, in the implementation to ensure instructions accompany each CALEX device, as they are currently provided to the front line staff separately. Changes have already been made to the IFU, to address the storage condition confusion that came up during the survey, as the CALEX can now be stored at ambient, so that eliminates the concern and makes it much easier to implement going forward. We actually used the generic IFU from the website so there is no specific information regarding the return of samples and in the main this has been fine for us, but it might be worth considering a customised version with detailed return requirements if it proves to be a problemmoving forward. In the main this has been a very reassuring exercise, confirming that what we are doing is very well accepted and seems to be working for the majority of patients. This was also demonstrated in the fact that the previous audit showed a 95% compliance rate and only 6% of returned samples couldn’t be analysed (incorrect liquid level, spoiled, not labelled) showing that patients were able to follow the instructions. It has certainly made our lives a lot easier in the labs and the patients are finding it easy to use, so giving the CALEX to the patients is certainly something that we plan to continue to do.” For more information please visit: More confident that the device was used correctly. This was easier than the universal tube – it was straight forward and the instructions were clear as they also came with images to refer to. © 2023 Copyright Alpha Laboratories Ltd. 5

The demands on healthcare resources continue to escalate, with the COVID pandemic having exacerbated the existing pressures from an aging population living longer and with more complex health conditions. Changes to traditional practices are essential if healthcare services are to keep pace with the increased demands. Developments in digital App technology have the ability not only to improve the health of patients, but also to save money, through rapid optimisation of treatment. They enable early interventions through monitoring, before conditions get too serious and reduce the need for routine check-up appointments and procedures. This frees up limited resources in both pathology and the clinic. The BÜHLMANN IBDoc was the first calprotectin home test to be introduced to the market back in 2015. Since then, there have been numerous publications demonstrating the correlation of the IBDoc result from the test performed by the patient in their own home, to the results of professional laboratory analyses. More importantly there is also evidence of the correlation to the IBDoc calprotectin results to the endoscopic and histologic findings of disease status. From the clinical perspective the test undoubtedly fits the bill. Dr Pushpakaran Munuswamy, Department Lead. Gastroenterology, Basildon University Hospital introduced the IBDoc to support their IBD patients in the summer of 2020 commented that: “From my perspective I am seeing a difference already, because we can escalate treatment within a day or two of requesting the calprotectin test. Previously there was a wait of around 4 – 6 weeks or even longer depending on when the sample is taken and the capacity in the labs. Hopefully, in the future we will see the benefits of this rapid response in terms of reduced hospitalisations and clinic visits because patients have had timely interventions. It will also reduce calls to the helpline because we know the results and have been able to act quickly.” But, how do the patients feel about the changes that have been introduced? Kezia Allen Pathology project specialist conducted a survey after the IBDoc had been in use for 2 years, with around 250 patients actively using the system in Basildon. Responses to the survey were received from 22% of eligible patients with two thirds being female and a third being male. Roughly two thirds had Crohn’s disease and a third had Ulcerative colitis. The mean age of the respondents was 43 years ranging from 22 to 75 years. “Anecdotally, it seems to be the older patients that are more engaged with the home testing, and even the more senior patients which has been surprising, but maybe it is to be expected. These are the patients that have lived with the consequences of the disease for longer and are keen for things not to deteriorate.” Patients’ Experience of the IBDoc Assay Overall satisfaction with the test was high: This high level of satisfaction was also reflected in the results and aftercare with the IBDoc: Patient comments included: Calprotectin Home Testing - What do the patients think? Kezia Allen, Associate Practitioner – Clinical Trials, Basildon Hospital Having the result straight away, instead of weeks waiting, is so beneficial as you can start on the medication you require. Absolutely love it! I actually get upset when they send out a normal stool sample test and not the IBDoc. Perspective 6

Aftercare The survey showed that 94% of patients would feel satisfied with a phone consultation, rather than a face-to-face appointment, following a high result, compared to 43% who feel some level of dissatisfaction at receiving no clinical contact following a negative result. Patients know what the plan is if a high result is obtained, they will get their medication increased or switched or have further investigations so they are happier with a phone consultation. You would think a negative result would be reassuring, but possibly the worry is that with a low result they will be told nothing is wrong even though they may be feeling unwell. A low result means that the symptoms are unlikely to be caused by their IBD and need to be managed in another way. This highlights that patients do not know what to do and would still need clinical advice or better educational materials explaining the potential causes and treatments of the symptoms if they aren’t caused by IBD. The patients on the biologics verses non-biologic treatments seemed happier knowing when to use the IBDoc and knowing how to manage their condition. This is probably fairly intuitive because to get to the stage of being on biologics they have had the disease a while and it hasn’t been very easy to manage and therefore they have had to be more engaged. Improvements Some of the things that were cited by the patients that would make things easier were: • More regular contact from the IBD team, especially when starting a new treatment • More information on what causes a flare and how to control them • Access to a nutritionist/dietary advice • Better communication between the primary and secondary care providers • Access available on a wider selection of phones Fundamentally the patients seem to like the actual test, most of the points raised relate to the educational and support functions that need to underpin the adoption of new technologies. The wider selection of phones is a continuously moving goalpost as new phones are released they need to be validated for use to ensure accurate correlation to the laboratory results. This is continuous addressed but there is inevitably a delay. The Future I think it is a genuine candidate for patient self-management but we need to do more in educating patients and personalising the care that surrounds this. There are easier point of care tests than calprotectin testing, but the patients want it enough that they are prepared to do it and it works for them. Some have even changed phones so that they can use the system – this shows the level of engagement within the patient population and the desire to be able to access the new technology. Remote monitoring and patient self-management will be key to managing services going forwards, we just need to get the education aspect right. The IBDoc home testing works so well for a large number of our patients which means it can work well for most of them, we just have to get better at the support side so that patients are confident they understand the results and their condition and are beingmanaged appropriately. There is probably a lot we can learn from other chronic conditions that have been historically remotely managed like diabetes, which must also have to cope with different patient groups and different levels of engagement. Whilst this type of test will never be for everyone (let’s be honest there are some patients who will just never do a stool test regardless of where it is completed), for many this type of technology is appreciated. It has the potential to help patient engagement and support remote management and personalised care. “Using the IBDoc has increased the engagement from both the patients and the clinical team, and the speed of the results really makes a big impact in decisionmaking and patient management. It doesn’t really add more work because you save work in chasing results and additional support for patients whilst they arewaiting for results.” – Dr Pushpakaran Munuswamy Find out more at © 2023 Copyright Alpha Laboratories Ltd. 7

The IBDoc® enables faecal calprotectin testing by patients at home, using their smartphone to read the results. It facilitates remote monitoring, patient privacy, rapid implementation of appropriate treatment pathways and prioritisation of valuable resources. The IBDoc is loved by the clinical teams and patients with 85% of respondents in a recent survey preferring it to standard lab testing, and another study showing improved compliance. [Figure 1: Edwards et al. ECCO 2021 P518] Improved Compliance for Faecal Calprotectin Contact us today to see how the IBDoc can enhance your IBD service: Phone 02380 483000 or email Using the IBDoc has increased the engagement from both the patients and the clinical team, and the speed of the results really makes a big impact in decision making and patient management. Dr Pushpakaran Munuswamy from Basildon and Thurruck NHS Trust I don’t think they could have made the test any easier to be honest - if you have been offered a chance to use the IBDoc just give it a go, taking the sample isn’t a big deal and the results come through really quickly which is all that matters. Patient feedback

Saving Hospital Resources with Direct-to-Patient Fulfilment for IBDoc® Removes the additional administration required around postage of the kits to patients No stock is required to be held by the hospital Z Improves stock management Reduces storage requirements Billing is on usage Weekly reports on usage are available with tracking information Different service levels available Z Tracked 24 for urgent/flare testing Z Tracked ‘non-urgent’ for routine monitoring Contact us today to discuss your IBDoc service fulfilment needs: Email A service is being launched to enable IBDoc Calprotectin home tests to be sent direct to the patient. Some hospitals have been lucky enough to obtain administrative resource for the logistics of posting of the calprotectin home tests out to patients, but for others this task has fallen to the clinical team. The new service will alleviate the administration/resource required in packing up the kits and getting them to the post. The hospital would set up a call-off order for IBDoc kits with Alpha laboratories. When required a request would be made by the clinical team on The Alpha Portal (TAP) to send an IBDoc kit to a particular patient.

Liquid Elastase Samples To Test, or Not to Test? That is The Question… Alison Jones, Consultant Clinical Biochemist, York and Scarborough NHS Foundation Trust Author – Amanda Appleton, Senior Product Manager, Alpha Laboratories Ltd. “It is well documented that liquid/ watery stool samples should not be tested for faecal elastase due to the risk of a false low result suggesting pancreatic insufficiency (a false positive). This is not a failure of the assay – it works in exactly the same way whether the sample is formed or liquid. The challenge is more in the interpretation of the result. Is the low result due to a poorly pancreas, or is it the body’s reaction to some other pathology causing dilution of the elastase in an individual with an otherwise functioning pancreas? Although I understand the reasons, taking a hard line on samples and rejecting liquid ones isn’t overly helpful. In the main I would suggest that elastase testing comes from secondary care settings where patients are more likely to have longer term gastric issues who might never produce a more formed sample. Even if the patient does have pancreatic insufficiency, it is often associated with diarrhoea! So, is there an alternative? Alison Jones (Consultant Clinical Biochemist) from York and Scarborough NHS Foundation Trust discuss a recent audit conducted, and the recommendations that have been implemented. The reason we started the project was based on an anecdotal feeling that we were getting a lot of watery samples that weren’t being repeated despite reporting the results with comments suggesting the result may be unreliable. We retrospectively reviewed three years (2018 – 2020) of elastase results, which comprised just over 5000 tests, and 5.7% of these (288 samples) were identified as watery1. We then identified if we had received a formed sample from the same patient to try and validate the result from the liquid sample - not a technically accurate method, but the only basis we had to compare. Potential false positives There were 60 samples where we had received both a liquid and a formed stool sample within 12 months of each other. We confirmed what many people have published: Watery samples can cause a false positive result, with 71% giving a positive (<200µg/g) result with the liquid sample but a negative result (>200µg/g) from the formed sample. This means that for these patients a repeat sample is required to see if the positive result is genuine or an artifact of the composition of the sample. There were a further 87 results with values <200µg/g from liquid samples with no repeat sample received. The clinical notes from 37 of these patients were reviewed. Pancreatic Enzyme Replacement Therapy (PERT) was started in 15 patients, of which seven had surgical, imaging, histological or clinical evidence of pancreatitis, and a positive response to the PERT was noted in a further four. One patient remained symptomatic on PERT, suggesting this was an inappropriate diagnosis and treatment in this case. The potential unreliability of the faecal elastase results and/or the need for a repeat sample was only recorded in 5 of the 37 notes examined. 1 Visual flow chart of 2018-2020 review of total number of patients with watery samples 10 Perspective

Eliminating Pancreatic Insufficiency: However, we also identified that all samples that gave a negative result with the watery sample also produced a negative result with the formed sample. This means if you are able to report a result of >200µg/g on a watery sample then you are able to rule out pancreatic insufficiency as the cause of the symptoms and they don’t need to repeat it even though it wasn’t an ideal sample. In our audit, we found that 50% of watery samples gave results >200µg/g, enabling pancreatic insufficiency to be eliminated, so it is well worth processing these samples rather than rejecting and requesting a more formed sample. Mucoid Samples: The other thing we looked at in the initial review (2018 – 2020) was the impact of mucoid samples on the elastase results. There were 187 samples classified as mucoid, although the degree of mucus wasn’t noted and, as I am sure you are aware, some can be almost completely mucus whereas some are more formed with mucoid regions. We found that there wasn’t the big discrepancy in results that was observed with the liquid samples and no consistent finding of false positives (or false negatives) when results were compared with a non-mucoid sample from the same patient. We concluded that there is a much lower risk of reporting an erroneous low result from a mucoid sample compared to a watery sample. On the basis of this, we now ensure that we sample from non-mucoid regions of partially mucoid samples and do not test samples where this is not possible. As with liquid specimens, results >200ug/g are reported. However results <200ug/g from partially mucoid samples are reported but with a cautionary comment. Implementation of a New Testing Policy: We have now changed how we test and report elastase on watery samples. For a first time watery sample, if the result is above 200ug/g then this is reported, but if it is less than 200ug/g then we don’t report the result. Instead we append a comment stating that a watery sample was received and it may be unreliable, and ask for a repeat on a formed sample. This removes the possibility of an incorrect diagnosis being made on an unreliable sample. If a second watery sample is received then we will report the result in the format of a text report to ensure that the context/limitations are read rather than just the value in the results field, but to be honest we don’t get too many like this. Once this new pathway had been in place for 12 months we reaudited (May 2021 – April 2022) the data to seewhat the impact was. There were 56 samples identified as watery with values <200ug/g, and repeat samples were received from 15 of these (27%). This repeat rate is actually quite low which may imply that pancreatic insufficiency wasn’t the cause of the initial symptoms and a different diagnosis was subsequently made, or the patient just got better. Of the 15 samples provided for repeat testing, 14 were formed stools. Ten of the 15 repeat samples (67%) were found to be normal on repeat; a similar proportion to the original audit. The clinical notes from 20 patients with no repeat sample were reviewed – no reference was found to the faecal elastase test in any of the notes examined. Four patients had a previous diagnosis of pancreatic insufficiency or had a diagnosis made based on other evidence. There was no reference to PERT or pancreatic insufficiency in the remaining 16 patients, indicating that the lack of the initial reported result didn’t have a significant impact on the patient pathway. The main take home message is don’t reject watery samples for elastase testing – test them, because from our audit, you can eliminate pancreatic insufficiency in about 50% of watery samples and this will help direct patients to other diagnostic pathways.” Turbo Charge Your Faecal Testing The BÜHLMANN fCAL® turbo and fPELA assays will revolutionise your faecal calprotectin and elastase testing with a streamlined workflow.  Same CALEX® extraction for both assays: - One extraction two tests - 7 days ambient stability post extraction  CALEX® can be given to patients for sample collection - Ambient, fridge and freezer stability for a flexible return to laboratory workflow  Wide assay range provides valuable clinical insight and keeps dilutions to a minimum - Calprotectin: 20 – 2000µg/g (autodilute to 8000µg/g) - Elastase: 10 - 500µg/g  Time to first result is 10 minutes, with further results every few seconds  Protocols available for most clinical chemistry analysers - Including Abbott, Beckman, Roche, Siemens as well as stand-alone options  Calibrators, controls and reagents are all in a stable, ready to use format and they don’t need to be lot matched Contact Alpha Laboratories today to find out more. 03_Calex_Workflow_April2023.indd 1 28/02/2023 10:20:05 © 2023 Copyright Alpha Laboratories Ltd. 11

Successful Routine Use of Quantum Blue® Therapeutic Drug Monitoring (TDM) Assays in an Italian Children’s Hospital An interview with Dr. ssa Giuliana Cangemi This interview was conducted by BÜHLMANN with Dr ssa GiulianaCangami -Headof theChromatographyandMass Spectrometry Unit at the Central Laboratory of Analyses in Gaslini Intitute Pediatric Hospital in Genova, Italy. Can you introduce your organisation? In the Central Laboratory of Analyses in the Gaslini Institute Pediatric Hospital in Genova, one of the main tasks is to perform therapeutic drug monitoring (TDM). The laboratory specialises in the TDM of small molecules and for four years now, we have also been performing TDM for biologics. Most of the requests in the Central Laboratory of Analyses are coming from paediatricians. However, requests from external laboratories are also accepted and performed. It also happens that outsourced patients come to the Gaslini Institute with a prescription for the TDM tests. I would say that we had more requests from gastroenterologists when we initially started, but today rheumatologists are also keen to get TDM results for both, infliximab and adalimumab. Which technique do you use for TDM measurement and why did you choose this one? The first technique used for the TDM of the anti-TNFα such as infliximab and adalimumab was ELISA. This ELISA method was time consuming and also not economically viable when we had to perform a test including calibration and controls just for one or few patients. To avoid increasing the price of the assay, we had to wait to have enough samples to perform a batch. The price per patient was different depending on the number of patients tested per batch. This was also quite complicated to handle from an economical point of view. How did you introduce the BÜHLMANN Quantum Blue® TDM methods? Once we had been introduced to the rapid tests from BÜHLMANN Laboratories, we decided to perform a method comparison between the ELISA technique and both, Quantum Blue® Infliximab and Adalimumab rapid tests. The results were highly comparable for the trough levels between the Quantum Blue® assays and the ELISA technique, and the switch to the rapid assay was done quickly. At this time, only the rapid assays for trough levels were available and we decided to keep the ELISA method for the antibody measurement. This was not convenient, and we were ready to use the Quantum Blue® Anti-Infliximab and AntiAdalimumab as soon as they were available. As antibodies assays from the manufacturers are not standardised against each other, we did not perform a technical method comparison, but went straight for a clinical evaluation of the BÜHLMANN assays. The clinicians only require a qualitative measure of the antibodies as their need is to know whether immunisation is present or absent. Once they reviewed the good results of the evaluation, we directly switched from the ELISA to the Quantum Blue® assays and now we are using the full TDM portfolio from BÜHLMANN in our daily routine. Are there any other advantages of using the four BÜHLMANN TDM assays? Most of our patients are children, therefore the amount of blood needed to perform a test is important. The Quantum Blue® assays only request a few microlitres of blood, which is perfect for children. In addition, having the result within one hour from blood taking is an improvement in the rapid result reporting. At the beginning of the TDM measurement some time ago, we occasionally had primary non responders or secondary non responders due to treatment failure. In these cases, we had to try to quickly run a test, that was performed reactively. Today, we have screened all our patients from rheumatology The previously used ELISA method was time consuming but also not economically viable. 12 Perspective

and gastroenterology, and we are able to perform proactive monitoring thanks to the Quantum Blue® assays. Because of the quick turnaround time, we have also started to sometimes test patients just before they are discharged from the hospital and ready to go back home. However, in our daily organisation of normal routine, we have setup a specific day once a week for TDM measurements. This is really appreciated by the clinicians. They know exactly when they will get their results. Despite this test agenda, we sometimes get additional samples to be tested on another day of the week. Today, with Quantum Blue® flexibility, we have the possibility to do so, knowing exactly the costs of running only one sample per day. Which measurement algorithm do you follow? We have decided to run both serum levels and antibodies in parallel as it helps us and the clinicians to get the complete picture of the patient situation. If the serum levels are within the therapeutic window, the results are optimal and there is no need to additionally test for antibodies. Conversely, when drug is undetectable, the fact that we can measure the antibodies at the same time helps physicians to take a decision on the action needed. Would you be interested in new developments on the Quantum Blue® Reader? Today we are performing the four BÜHLMANN assays in our daily routine: Quantum Blue® Infliximab, Quantum Blue® Adalimumab, Quantum Blue® Anti-Infliximab and Quantum Blue® Anti-Adalimumab. I would say that TDM with Quantum Blue® is part of our routine use now and a very valuable tool for the clinicians to decide on dose increase or decrease, but also to support the strategy of within or in between class switch of drugs. If I would have a wish for the future, I would think that a rapid assay for the measurement of tocilizumab might be interesting for juvenile arthritis patients. We have tested an ELISA technique already but would be more interested in a rapid test. In addition, vedolizumab serum levels would be interesting and an anti-TNFCalibri method from capillary blood. For children, this would be very attractive. For more information, please visit our website: The results of the method comparison between the ELISA technique and Quantum Blue® TDM showed highly comparable trough levels. TDM with Quantum Blue® is a very valuable tool for the clinicians to decide on dose increase or decrease as well as drug class switches. © 2023 Copyright Alpha Laboratories Ltd. 13

The impact of the Faecal Immunochemical Test (FIT) on the colorectal cancer referral pathway is well documented. Having a quick and easy-to-use test, that can be directly loaded onto the automated testing platform in the laboratory makes it an ideal solution for triaging the two-week-wait pathway. However, the benefit of FIT has been tempered by the additional workload faced in logistics and sample distribution. Laboratories and service providers are having to work tirelessly to distribute kits to GPs, Clinics, and Patients, and demand is beginning to outstrip capacity. With that in mind, Alpha Laboratories has worked in conjunction with laboratories to bring you the next phase of FIT evolution that will help ease the logistics burden: The Alpha Portal (TAP). The Alpha Portal offers: • A snap-shot of FIT-Kit stock levels, lot and expiry dates • Document proofs and print-ready versions of the kit components, • Comprehensive product descriptions for each component, • A traceable ordering system which allows sites to deliver kits to any UK location, • Order reporting: run reports to highlight demand at each site, and ordering frequency. A New Portal to Ef-FIT-ciency Author – Emma Boxall, Marketing & Innovations Manager, Alpha Laboratories Ltd. 14 Perspective

Scan the QR code to see how it works. To sign up, or for more information please contact: The portal has greatly improved the FIT service at North Bristol NHS trust. It has freed up time for both lab staff and our busy stores department. Feedback from users has been overwhelmingly positive with kits usually being delivered within two working days. Previously, issues with the Trust post room and the Royal Mail service meant that deliveries could take up to a week, or even longer to arrive. The weekly report has greatly improved our ability to keep track of how many kits we are sending out to surgeries and how many we are getting back from them! TAP offers a new perspective on the distribution of sample kits: whether it’s for issuingdirect-to-patient, or for larger orders going to GPs or Clinics. It gives the user greater control over the logistics associated with FIT, and facilitates a traceable, efficient, and manageablesolutionwhichcanbescaledupanddownasrequired. The Alpha Portal has been shown to significantly improve the workflow of sample distribution in the Laboratory. With Southmead Hospital, Bristol, being one of the first to use TAP, they have reported a substantial improvement in their FIT service: This highlights that TAP works not only for the Laboratory but also benefits the clinical teams too – knowing your return rates, and being able to provide a smooth and efficient testing service, is key to supporting endoscopy resource and reducing waiting times. How it Works The named contact is assigned as the Primary Account holder: they will be the main point of contact and will dictate subsequent users’ level of access. Each user profile is grouped according to the level of access required. This will determine the number of kits they can order in a given timeframe (to help prevent overstocking) and what reports can be run. Each log-in is bespoke and orders can be tracked to the user profile. When using TAP, only kits relevant to your service are visible – so there is no chance of ordering the wrong product. There is a list of the components, the stock available, and the print-ready files should you need to review them. The stock is managed by Alpha Laboratories, and when the stock reaches “0”, the next batch of product is brought online. We monitor stock levels in the background and allocate fulfilment runs based on usage estimates. When placing the order, the list of delivery locations is prepopulated. Each site will provide us with a list of GP surgeries or locations that may require a FIT-KIT delivery – we check these through the Royal Mail software to ensure validity – and then add them to TAP. If new sites are needed, they can be quickly added by our team. Shipments are sent on a Royal Mail Tracked 48 service, or a DPD Next-Day (depending on the quantity ordered). Each shipment is traceable and comes with a Proof-of-Delivery upon request. Next Steps The Alpha Portal has been designed with you in mind. We want to ensure the FIT service is scalable and does not cause unnecessary workload at any stage. By using TAP, sites across the UK have already noticed a marked difference in the management of FIT-KIT requesting. Contact us to find out what TAP could do for your service. We continuously work to improve the solutions we offer: with that in mind, we have additional offerings in the pipeline that we hope to bring online very soon! Sign up to our newsletter to keep up to date. © 2023 Copyright Alpha Laboratories Ltd. 15

T: +44 (0)23 8048 3000 E: W: Supplied by Better Resource Management for Digestive Disease Pathways Customised FIT Kits delivered to patient ‘ready to use’ – everything the patient requires to take their sample safely at home for return to a laboratory New kit ordering portal for convenient logistics For more information, to discuss your requirements or organise an evaluation please contact: IBDoc® Home Tests. Supporting remote patient monitoring and virtual clinics Quantum Blue® for Point of Care helps triage patients in clinic giving results in a rapid time frame (15 mins) 02380 483000 • • Calprotectin Testing Make more informed clinical decisions without waiting for lab results. Faecal Immunochemical Testing Complete bespoke solutions to triage patients within the colorectal cancer pathway.