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Sarah M., 34

Mirae Phenotype · Treatment failure / active, not responding

Provisional L3 · B1 Patchy inflammation Granulomas No perianal disease 1 prior anti‑TNF
EHR · CRP 14.2 ↑ Mirae · HBI 9

Hello Dr. Wilks!

Sarah is 34 with ileocolonic, inflammatory Crohn’s on adalimumab 40 mg every two weeks since 2022. She was in clinical and biochemical remission through the spring. Over the last six weeks that has changed. On Tuesday she told me she missed two doses in August while moving house, so the most likely explanation is low drug exposure rather than a passing bad stretch.

CRP and HBI · 12 months

CRP 14.2 ↑

0 8 16 Mesalamine stopped Nov Jan Mar May Jul Sep
CRP mg/L HBI ULN 5 Medication

What has changed

  • CRP 2.4 → 6.8 → 14.2 mg/L across the last three draws, the first time above the reference range in 18 months. Haemoglobin has drifted from 13.1 to 11.9 g/dL.
  • In the app, stool frequency has doubled to six a day and pain has risen from 2 to 6 out of 10. Her HBI from check-ins has moved from 3 to 9. Fatigue began a week before the CRP rise.
  • Her watch shows resting heart rate up 9 bpm, HRV down about a third and sleep down 1.5 hours over four weeks.
  • No prescribed changes since mesalamine was stopped in February as planned. No steroid courses. Two adalimumab doses missed in August, reported in the app on Tuesday; she has been on schedule since September.

Worth asking her

  • Confirm she has been back on schedule since September, and ask about new injection-site reactions.
  • Fevers, recent antibiotics, travel or sick contacts? Infection is not yet excluded.
  • Nocturnal symptoms or blood in the stool? Neither has been logged, worth confirming.
  • Any NSAID use for the abdominal pain?

What Sarah wants from this visit

  • “Do I need to change my medication?”
  • “Can I still travel to Lisbon in October?”
  • Fatigue is affecting work; she asked whether it is the disease or the drug.

From her check-ins this week. She has a flight booked for 14 October.

Suggested next steps

  • Adalimumab trough and anti-drug antibodies first: after a treatment gap, low exposure versus immunogenicity decides whether she can stay on the drug. AGA Guideline
  • Stool C. difficile and culture, plus fecal calprotectin, to confirm active inflammation before any change. ECCO Guidelines
  • Ileocolonoscopy or MR enterography if the result would change your choice, given ileocolonic disease. ACG Guideline

The goal is to get her back into remission on a drug that worked for three years, if the results allow it. The options depend on the trough and antibody result, and I can walk through them for her phenotype whenever you like.

Still needs your review

  • Infection has not been excluded: no stool studies since 2024.
  • No endoscopic or imaging assessment since the 2023 index colonoscopy.
  • Antibody status is unknown, so re-induction cannot yet be ruled in or out.
Walk me through the options once the trough and antibodies are back.

Three results, three different paths.AGA Guideline

  • Low trough, no antibodies: under-exposure, and the most likely result after two missed doses. Re-induction or weekly adalimumab is reasonable before switching, and keeps her on a drug that worked.AGA Guideline
  • Antibodies present: immunogenic failure, which a treatment gap makes more likely. For her phenotype (treatment failure on a first anti‑TNF, ileocolonic, no perianal disease) an out-of-class switch to ustekinumab or risankizumab is the best-supported move.SEAVUE · LancetSEQUENCE · NEJM
  • Adequate trough, active inflammation: mechanistic failure. Switch class rather than to a second anti‑TNF.ACG GuidelineECCO Guidelines

If you do switch class, risankizumab showed higher endoscopic remission than ustekinumab in SEQUENCE.SEQUENCE · NEJM Either fits her Lisbon trip: neither needs infusion visits after induction.

What would change this assessment?

Three things I have not been able to confirm from her data.

  • A positive C. difficile or culture would make this an infection on top of stable disease, not loss of response. Treat that first.ECCO Guidelines
  • Nocturnal symptoms or rectal bleeding, neither logged in the app, would move endoscopy up from “if it changes your choice” to before any treatment change.ACG Guideline
  • Regular NSAID use for the pain could account for part of the CRP rise and the symptoms; worth asking directly.
Ask Mirae about Sarah…

Before you walk into the exam room, Mirae has been rounding your patients.

Mirae gathered the story.

Mirae connects your patient’s medical records, reported symptoms, and wearable data into one evolving clinical picture. See what changed between visits and how it fits their history with the context assembled for you.

Epic EHR

CRP
2.4 → 14.2
Haemoglobin
13.1 → 11.9
Adalimumab
40 mg q2w

Mirae Patient app

HBI
3 → 9
Stool frequency
3 → 6 /day
Check-ins
42

Apple Watch

HRV
48 → 31 ms
Resting HR
58 → 67
Sleep
7.1 → 5.6 h

Feb

Mesalamine stopped, as planned

Late Jul

HRV starts falling, sleep shortens

Aug

Fatigue most days, stool frequency doubles

Sep

CRP 14.2, first above range in 18 months

Mirae asked what was missing.

Mirae asks patients the follow-up questions their story raises, uncovering missed doses, new symptoms, and concerns they want addressed. Those answers become part of your assessment, giving you more time to act on what matters.

  • Questions are triggered by what changed, not sent on a schedule.
  • Answers are recorded as structured data and quoted in the assessment.
  • Patients also log the questions they want answered at the visit.
Mirae Patient

Your CRP result from Friday is higher than it has been in over a year, and nothing in your prescription changed. Have any adalimumab doses been missed or delayed in the last few months?

Yes, two while we were moving house. I’ve been back on schedule for a few weeks now.

Thanks, that helps explain it. I’ll make sure your gastroenterologist sees it before your visit. Is there anything you want to make sure gets covered?

Whether I need to change medication, and if I can still travel next month.

Mirae prepared the assessment.

Open the patient to an expert-informed assessment shaped by their disease profile, treatment history, and latest updates. Review recommended next steps, the evidence behind them, and what still needs your judgment then ask Mirae to go deeper.

Mirae Consult · Assessment

Synthesized when you open the profile
Most likely

Loss of response from low adalimumab exposure after a treatment gap. Immunogenicity possible; infection not yet excluded.

Next steps
  1. Adalimumab trough and anti-drug antibodies first: low exposure versus immunogenicity decides whether the patient can stay on the drug.AGA Guideline
  2. Stool C. difficile and culture, plus fecal calprotectin, to confirm active inflammation before any change.ECCO Guidelines
  3. Ileocolonoscopy or MR enterography if the result would change your choice.ACG Guideline
Your review
  • Infection has not been excluded: no recent stool studies.
  • No endoscopic or imaging assessment since the index colonoscopy.
  • Antibody status is unknown, so re-induction cannot yet be ruled in or out.
Patient asked
  • “Do I need to change my medication?”
  • “Can I still travel next month?”
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Clinical IBD

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  • Professor Simon Travis

    University of Oxford

    Former president of ECCO. His IBD measures and research have shaped international guidelines and everyday care.

  • Dr Alissa Walsh

    University of Oxford

    Consultant gastroenterologist and founder of Crohn’s Colitis Cure, with research in digital monitoring and patient-centred IBD care.

Start with a patient in minutes. Not a practice-wide rollout.

See what Mirae can do with a patient’s existing medical history, reported symptoms, and questions before their next visit. No practice approval, procurement, or EHR integration required.

  1. 1 Join as an individual clinician

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  2. 2 Invite a patient

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  3. 3 The patient connects their records

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  4. 4 Open their profile

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Questions about getting started.

Can I join as an individual clinician?

Yes. Individual gastroenterologists, NPs, and PAs can get free early access.

Do I need approval from my practice?

No. You join as an individual clinician and add your practice later if you want. There is no procurement, IT review, or practice-wide rollout needed to start with one patient.

Do I need an Epic or EHR integration?

No. Patients share their records themselves by signing in to their patient portal through HealthEx. Mirae works alongside your EHR without an integration project.

Can I try this with one patient tomorrow?

Yes. Once a patient has joined and connected their records, Mirae prepares an assessment from their existing history when you open their profile. Between-visit check-ins add to the picture over time, but you do not have to wait for them.

Do my patients need to join Mirae?

Yes. Patients need to sign up with Mirae for their patient-specific information to become available.

When does Mirae prepare the clinical assessment?

When you open a patient’s profile, Mirae synthesizes the available information for your review.

Is Mirae focused only on IBD?

IBD is our first clinical focus. Our broader ambition is to bring this depth of patient understanding and clinical decision support to chronic care.

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