Modern use of 5-aminosalicylic acid compounds for ulcerative colitis

ABSTRACT

Introduction: For 30 years, 5-aminosalicylic acid (5-ASA) has been the backbone of therapeutic management in patients with ulcerative colitis (UC). In the biologic era, it still remains the treatment of choice in mild-to-moderate UC. Positioning of this therapeutic class in moderate-to-severe UC is less clear.

Areas covered: Several studies demonstrated the ability of 5-ASA to induce endoscopic remission to a similar extent as anti-TNF therapy on the moderate segment of UC. Histologic remission is achieved after induction in up to 45% of patients treated with topical 5-ASA and 30% with oral formulations. Aminosalicylates offer a favorable safety profile compared to that of immunomodulators and biologics. High-dose 5-ASA therapy may be a valuable option for patients with moderately active disease, and physicians should weigh the pros and cons of this strategy in selected patients. Whether aminosalicylates should be continued in combination with thiopurines or biologic therapy remains under debate.

Expert opinion: In the era of biologics, aminosalicylates remain the first-line therapy in patients with mild UC, and have to be considered in case of moderate UC, given their favorable risk-benefit profile. We suggest that 5-ASA should be used in moderate patients without poor prognostic factors, while biologics should be preferred otherwise.

KEYWORDS:

• 5-ASA
• aminosalicylate
• balsalazide
• biologic
• histologic healing
• inflammatory bowel disease
• mesalamine
• mesalazine
• mucosal healing
• mucosal

Article highlights

• In the biologic era, 5-ASA compounds still remain the backbone of therapeutic management in patients with mild-to-moderate UC, whether for induction or maintenance therapy.

• Aminosalicylates offer a favorable safety profile compared to that of immunomodulators and biologics, although this may be biased by the fact that patients receiving the latter therapies probably have more severe disease activity which is known to be associated with adverse outcomes.

• High-dose 5-ASA therapy may thus be a valuable option for patients with moderately active disease without poor prognostic factors, and physicians should weigh the pros and cons of this strategy in selected patients.

• Adherence to 5-ASA therapy still has to be improved, but new formulations, once-daily dosing and therapeutic education should allow to address these specific issues in the coming years.

This box summarizes key points contained in the article.

Declaration of interest

L Peyrin-Biroulet received consulting fees from Merck, AbbVie, Janssen, Genentech, Mitsubishi, Ferring, Norgine, Tillots, Vifor, Pharmacosmos, BMS, UCB-pharma, Hospira, Celltrion, Takeda, Biogaran, Boehringer Ingelheim, Lilly, Pfizer, HAC-Pharma, Index Pharmaceuticals, Amgen, Sandoz, Forward Pharma GmbH, Celgene, Biogen, Lycera, Samsung Bioepis, and lecture fees from Merck, Abbvie, Takeda, Janssen, Ferring, Norgine, Tillots, Vifor, Mitsubishi, HAC-pharma. S Danese served as a speaker, consultant, and advisory board member for Schering-Plough, AbbVie, MSD, UCB Pharma, Ferring, Cellerix, Millenium Takeda, Nycomed, Pharmacosmos, Actelion, Alphawasserman, Genentech, Grunenthal, Pfizer, AstraZeneca, Novo Nordisk, Cosmo Pharmaceuticals, Vifor and Johnson and Johnson, and Nikkiso Europe GMBH. M Nedeljkovic works for Tillotts Pharma AG (Fivasa®). The authors have no other relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript apart from those disclosed.

Reviewer disclosures

Peer reviewers on this manuscript have no relevant financial relationships or otherwise to disclose.

Additional information

Funding

This paper was funded by Tillotts Pharma AG; Switzerland.