Review offers better optimization, escalation paths for UC therapies
Patients with mildly-to-moderately active ulcerative colitis could benefit from different optimizations and combinations of 5-aminosalicylates and mesalazine for either induction or maintenance therapy, according to research published in The Lancet Gastroenterology and Hepatology.
Siddharth Singh, MD, of the division of gastroenterology and hepatology at the University of California San Diego, and colleagues wrote that previous research has done little to shed light on the comparative efficacy and positioning of different UC treatments.
“Despite most patients with [UC] having mild-to-moderate disease activity, practice varies considerably between inflammatory bowel disease specialists, gastroenterologists, and primary care physicians,” they wrote. “Important areas of variability include the dosing of mesalazine for induction and maintenance of remission, comparative efficacy of diazo-bonded 5-ASAs and mesalazine, role of combined oral and topical 5-ASA, and positioning of budesonide multimatrix in the management of patients with extensive mild-to-moderate [UC].”
Singh and colleagues searched the literature for randomized controlled trials of adults with left-sided or extensive UC. They included trials in which patients received treatment with oral sulfasalazine, 5-ASAs, controlled ileal-release budesonide, or budesonide multimatrix, alone or in combination with rectal 5-ASA therapy, and were compared with each other or placebo for induction or maintenance of clinical remission.
In 48 trials that focused on induction (n = 8,020), investigators found that combined oral and rectal 5-ASAs and high-dose mesalazine were ranked highest for induction of remission. Both therapies appeared superior to standard-dose mesalazine with a failure to induce remission OR of 0.41 (95% CI, 0.22–0.77) and 0.78 (95% CI, 0.66–0.93), respectively.
All the medical interventions were superior to placebo for maintenance of remission based on 28 trials that met the inclusion criteria for maintenance (n = 4,218). However, combined oral and rectal 5-ASAs and high-dose mesalazine were not superior to standard-dose mesalazine.
Singh and colleagues wrote that because many patients with mildly-to-moderately active UC are at low risk for colectomy, they are managed by varying practices, including primary care physicians and general gastroenterologists. They wrote that their findings could help provide optimal management and reduce risk for disease progression among these patients.
“Optimization of 5-ASA is often an underused approach in the management of patients with mild to moderate ulcerative colitis; at the same time, 5-ASA-based therapy is often relied on too heavily, with failure to recognize patients who might be at high risk of colectomy and might therefore benefit from early escalation to immunosuppressive therapy,” they wrote. “By informing comparative efficacy of different 5-ASA-based treatment strategies and a quantitative assessment of success of these therapies, we believe our findings can inform clinical practice and treatment guidelines.” – by Alex Young
Disclosures: Singh reports support from the ACG Junior Faculty Development Award and the Crohn’s and Colitis Foundation Career Development Award. He also reports receiving grants from Pfizer and AbbVie.