5-ASA Discontinuation Associated with Higher Relapse Risk in Ulcerative Colitis Patients: Study
Australia: A meta-analysis published in Inflammatory Bowel Diseases has found that ulcerative colitis patients who stop 5-aminosalicylic acid (5-ASA) monotherapy face a higher risk of relapse. However, discontinuing 5-ASA may be safe for patients with ulcerative colitis or Crohn’s disease who are also receiving immunomodulators or biologic therapy.
5-ASA, commonly known as mesalamine, has long been the first-line treatment for individuals with mild-to-moderate ulcerative colitis (UC). Its continuous use, however, comes with costs, potential side effects, and can delay escalation to more advanced therapies. For some patients, particularly those with Crohn’s disease (CD) or those already receiving immunomodulators or biologic therapy, stopping 5-ASA could be considered. Until now, the consequences of halting treatment on disease outcomes have remained unclear.
To address this, researchers led by Arteen Arzivian from Macquarie University, Sydney, conducted a systematic review and meta-analysis examining the risk of disease relapse following 5-ASA discontinuation. They searched five major databases for studies up to July 2024, ultimately including 29 studies out of over 7,200 screened. The studies were organized into six clinically relevant cohorts, allowing the team to assess relapse risk across different patient groups.
The study led to the following notable findings:
- Ulcerative colitis (UC) patients who stopped oral 5-ASA monotherapy had a 60% higher risk of relapse compared with those who continued treatment (RR 1.60).
- Discontinuation of rectal 5-ASA more than doubled the risk of relapse (RR 2.03).
- These findings emphasize the important role of 5-ASA monotherapy in maintaining remission for UC patients.
- Among patients on immunomodulators or biologics, stopping 5-ASA did not significantly increase the risk of relapse.
- Although evidence certainty was low to very low in this subgroup, monitored discontinuation of 5-ASA may be a safe strategy.
- Discontinuation in these patients could reduce medication burden without adversely affecting disease control.
The study highlights an important clinical consideration: while 5-ASA remains essential for maintaining remission in UC patients on monotherapy, its role may be less critical when combined with advanced therapies. “Discontinuation of 5-ASA monotherapy carries a clear risk for relapse, but for patients on immunomodulators or biologics, withdrawal could be a feasible approach with careful monitoring,” the authors noted.
The research provides valuable guidance for clinicians weighing the benefits and risks of continuing long-term 5-ASA therapy. It also highlights the need for individualized treatment decisions, balancing the advantages of ongoing 5-ASA use against the potential for reduced medication burden and associated side effects.
"Stopping 5-ASA monotherapy in ulcerative colitis significantly increases relapse risk, whereas its withdrawal in patients concurrently on immunomodulators or biologics appears to be largely safe. These insights may help optimize long-term management strategies for patients with inflammatory bowel diseases, allowing for more personalized and evidence-based care," the authors concluded.
Reference:
Arzivian, A., Rubin, D. T., Seow, C. H., Kerkham, A., Tran, Y., & Leong, R. W. The Risk of Relapse Associated With Discontinuation of 5-Aminosalicylates in Inflammatory Bowel Diseases: A Systematic Review and Meta-Analysis. Inflammatory Bowel Diseases. https://doi.org/10.1093/ibd/izaf277
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