One of the presentations I attended at Advances in Inflammatory Bowel Diseases (AIBD) in Orlando, Florida in December 2019 was regarding the use of 5-aminosalicylic acid (5-ASA) drugs in IBD. The talk, “Don’t Forget that 5-ASAs Also Have Side Effects: Recognizing Complications” was given by Meenakshi Bewtra, MD, MPH, PhD, Assistant Professor of Medicine at the Hospital of the University of Pennsylvania, Philadelphia.

On the face of it, this appeared to be a straightforward presentation on the adverse effects (side effects) of these medications which are used to treat ulcerative colitis. However, there was an unexpected twist!

5-ASA Drugs in IBD

5-ASAs are also called aminosalicylates and include medications such as balsalazide (Colazal, Giazo), mesalamine (Apriso, Asacol HD, Canasa, Delzicol, Lialda, Pentasa, Rowasa), olsalazine (Dipentum), and sulfasalazine (Alzulfidine). However, after addressing some of the risks of these medications, which included rare conditions such as cardiac inflammation (myocarditis and pericarditis), eosinophilic pneumonia (white cells in the lungs), and nephritis (inflammation of the kidneys), Dr Bewtra hit on the most common adverse effect, which is medication failure.

The 5-ASAs are often given as a first medication to try for treating ulcerative colitis and maintaining remission. Their use in ulcerative colitis is well documented by many studies. 5-ASAs are not approved by the Food and Drug Administration to treat Crohn’s disease, however, they are used on an off-label basis. In recent years, it has been shown that these medications have not been of the same utility in treating Crohn’s disease as in ulcerative colitis. In the most current clinical guidelines for Crohn’s disease, the American College of Gastroenterology states that “5-ASA is not recommended for maintenance of medically induced remission.”

A More Prevalent Risk

A 5-ASA drug may be given initially after a diagnosis of mild to moderate ulcerative colitis because they are effective, have been used for a long time, and may cost less than the medications in other drug classes. However, as Dr Bewtra points out, 5-ASA drugs will not work for all the patients to which they are given. Here’s the twist: when this medication failure occurs, it is common to then give another type of medication — steroids.

Patients being given steroids to control their ulcerative colitis is not unusual. However, as Dr Bewtra so elegantly stated, “Steroids are bad.” The risk of steroids is well-documented and it is generally accepted that they should be used sparingly in IBD. She stressed that patients with ulcerative colitis should be treated to target and if a 5-ASA drug isn’t working, that physicians shouldn’t be afraid to escalate therapy to another type of medication.

A few key points about 5-ASAs in IBD:

• Serious adverse events with 5-ASA drugs are rare
• Nephritis has been considered a risk of 5-ASA medication but recent reports show that it may be more closely related to inflammation from IBD
• Patients receiving a 5-ASA should have their kidney function tested regularly (at least yearly)
• A risk to consider with starting 5-ASA therapy is that it may fail and steroids may be needed
• Physicians should be on the lookout for the return of active disease and should step up therapy as appropriate
• 5-ASA drugs aren’t recommended for treating Crohn’s disease

Always consult your medical team about any questions regarding IBD or medications.

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Sources:

• Bewtra M. Don’t forget that 5-ASAs also have side effects: recognizing complications. Presented at: 2019 AIBD Meeting; December 12-14, 2019; Orlando, FL. https://www.advancesinibd.com/
• Vajravelu RK, Copelovitch L, Osterman MT, et al. Risk for chronic kidney disease in patients with inflammatory bowel diseases increases with age but is not associated with 5-aminosalicylate use. Clin Gastroenterol Hepatol. 2019;S1542-3565:31245-5. doi:10.1016/j.cgh.2019.10.043
• Lichtenstein GR, Loftus EV, Isaacs KL, Regueiro MD, Gerson LB, Sands BE. ACG Clinical Guideline: Management of Crohn’s disease in adults. Am J Gastroenterol. 2018;113:481-517. doi:10.1038/ajg.2018.27
• Lim WC, Wang Y, MacDonald JK, Hanauer S. Aminosalicylates for induction of remission or response in Crohn’s disease. Cochrane Database Syst Rev. 2016;7:CD008870. doi:10.1002/14651858.CD008870.pub2