Oral 5‐aminosalicylic acid for maintenance of remission in ulcerative colitis New search for studies and content updated (no change to conclusions)

Abstract

Abstract Background

Oral 5‐aminosalicylic (5‐ASA) preparations were intended to avoid the adverse effects of sulfasalazine (SASP) while maintaining its therapeutic benefits. Previously, it was found that 5‐ASA drugs were more effective than placebo but had a statistically significant therapeutic inferiority relative to SASP. This updated review includes more recent studies and evaluates the effectiveness, dose‐responsiveness, and safety of 5‐ASA preparations used for maintenance of remission in quiescent ulcerative colitis.

Objectives

The primary objectives were to assess the efficacy, dose‐responsiveness and safety of oral 5‐ASA compared to placebo, SASP, or 5‐ASA comparators for maintenance of remission in quiescent ulcerative colitis. A secondary objective was to compare the efficacy and safety of once daily dosing of oral 5‐ASA with conventional (two or three times daily) dosing regimens.

Search methods

A literature search for relevant studies (inception to 9 July 2015) was performed using MEDLINE, EMBASE and the Cochrane Library. Review articles and conference proceedings were also searched to identify additional studies.

Selection criteria

Studies were accepted for analysis if they were randomized controlled trials with a minimum treatment duration of six months. Studies of oral 5‐ASA therapy for treatment of patients with quiescent ulcerative colitis compared with placebo, SASP or other 5‐ASA formulations were considered for inclusion. Studies that compared once daily 5‐ASA treatment with conventional dosing of 5‐ASA and 5‐ASA dose ranging studies were also considered for inclusion.

Data collection and analysis

The primary outcome was the failure to maintain clinical or endoscopic remission. Secondary outcomes included adherence, adverse events, withdrawals due to adverse events, and withdrawals or exclusions after entry. Trials were separated into five comparison groups: 5‐ASA versus placebo, 5‐ASA versus sulfasalazine, once daily dosing versus conventional dosing, 5‐ASA versus comparator 5‐ASA formulation, and 5‐ASA dose‐ranging. Placebo‐controlled trials were subgrouped by dosage. Once daily versus conventional dosing studies were subgrouped by formulation. 5‐ASA‐controlled trials were subgrouped by common 5‐ASA comparators (e.g. Asacol and Salofalk). Dose‐ranging studies were subgrouped by 5‐ASA formulation. We calculated the risk ratio (RR) and 95% confidence intervals (95% CI) for each outcome. Data were analyzed on an intention‐to‐treat basis.

Main results

Forty‐one studies (8928 patients) were included. The majority of included studies were rated as low risk of bias. Ten studies were rated at high risk of bias. Seven of these studies were single‐blind and three studies were open‐label. However, two open‐label studies and four of the single‐blind studies utilized investigator performed endoscopy as an endpoint, which may protect against bias. 5‐ASA was significantly superior to placebo for maintenance of clinical or endoscopic remission. Forty‐one per cent of 5‐ASA patients relapsed compared to 58% of placebo patients (7 studies, 1298 patients; RR 0.69, 95% CI 0.62 to 0.77). There was a trend towards greater efficacy with higher doses of 5‐ASA with a statistically significant benefit for the 1 to 1.9 g/day (RR 0.65; 95% CI 0.56 to 0.76) and the 2 g/day subgroups (RR 0.73, 95% CI 0.60 to 0.89). SASP was significantly superior to 5‐ASA for maintenance of remission. Forty‐eight per cent of 5‐ASA patients relapsed compared to 43% of SASP patients (12 studies, 1655 patients; RR 1.14, 95% CI 1.03 to 1.27). A GRADE analysis indicated that the overall quality of the evidence for the primary outcome for the placebo and SASP‐controlled studies was high. No statistically significant differences in efficacy or adherence were found between once daily and conventionally dosed 5‐ASA. Twenty‐nine per cent of once daily patients relapsed over 12 months compared to 31% of conventionally dosed patients (8 studies, 3127 patients; RR 0.91, 95% CI 0.82 to 1.01). Eleven per cent of patients in the once daily group failed to adhere to their medication regimen compared to 9% of patients in the conventional dosing group (6 studies, 1462 patients; RR 1.22, 95% CI 0.91 to 1.64). There does not appear to be any difference in efficacy among the various 5‐ASA formulations. Forty‐four per cent of patients in the 5‐ASA group relapsed compared to 41% of patients in the 5‐ASA comparator group (6 studies, 707 patients; RR 1.08, 95% CI 0.91 to 1.28). A pooled analysis of two studies showed no statistically significant difference in efficacy between Balsalazide 6 g and 3 g/day. Twenty‐three per cent of patients in the 6 g/day group relapsed compared to 33% of patients in the 3 g/day group (216 patients; RR 0.76; 95% CI 0.45 to 2.79). One study found Balsalazide 4 g to be superior to 2 g/day. Thirty‐seven per cent of patients in the 4 g/day Balsalazide group relapsed compared to 55% of patients in the 2 g/day group (133 patients; RR 0.66; 95% CI 0.45 to 0.97). One study found a statistically significant difference between Salofalk granules 3 g and 1.5 g/day. Twenty‐five per cent of patients in the Salofalk 3 g/day group relapsed compared to 39% of patients in the 1.5 g/day group (429 patients; RR 0.65; 95% CI 0.49 to 0.86). Common adverse events included flatulence, abdominal pain, nausea, diarrhea, headache, dyspepsia, and nasopharyngitis. There were no statistically significant differences in the incidence of adverse events between 5‐ASA and placebo, 5‐ASA and SASP, once daily and conventionally dosed 5‐ASA, 5‐ASA and comparator 5‐ASA formulations and 5‐ASA dose ranging studies. The trials that compared 5‐ASA and SASP may have been biased in favour of SASP because most trials enrolled patients known to be tolerant to SASP which may have minimized SASP‐related adverse events.

Authors' conclusions

5‐ASA was superior to placebo for maintenance therapy in ulcerative colitis. However, 5‐ASA had a statistically significant therapeutic inferiority relative to SASP. Oral 5‐ASA administered once daily is as effective and safe as conventional dosing for maintenance of remission in quiescent ulcerative colitis. There does not appear to be any difference in efficacy or safety between the various formulations of 5‐ASA. Patients with extensive ulcerative colitis or with frequent relapses may benefit from a higher dose of maintenance therapy. High dose therapy appears to be as safe as low dose and is not associated with a higher incidence of adverse events.

Author(s)

Yongjun Wang, Claire E Parker, Brian G Feagan, John K MacDonald

Abstract

Plain language summary

Oral 5‐ASA compounds for maintaining remission in ulcerative colitis 

Sulfasalazine (SASP) has been used for treating ulcerative colitis for decades. SASP is made up of 5‐aminosalicylic acid (5‐ASA) linked to a sulfur molecule. Up to a third of patients treated with SASP have reported side effects, which are thought to be related to the sulfur part of the molecule. Common side effects associated with SASP include nausea, indigestion, headache, vomiting and abdominal pain. 5‐ASA drugs were developed to avoid the side effects associated with SASP. This review includes 41 randomized trials with a total of 8928 participants. Oral 5‐ASA was found to be more effective than placebo (fake drug) for maintaining remission. Although oral 5‐ASA preparations are effective for maintaining remission in ulcerative colitis, they are no more effective than sulfasalazine (SASP) therapy. People who have become well can remain so by continuing to take either medication. There is no evidence that side effects are more frequent with one or the other medication. However, the side effects of 5‐ASA may be notably less than those associated with SASP therapy. Common side effects associated with 5‐ASA included flatulence, abdominal pain, nausea, diarrhea, headache, dyspepsia (indigestion), and nasopharyngitis (inflammation of the nasal passages). Most of the trials comparing 5‐ASA with SASP enrolled patients who were known to tolerate SASP. This may have reduced SASP‐related side effects in these trials. Male infertility is associated with SASP and not with 5‐ASA, so 5‐ASA may be preferred for patients concerned about fertility. 5‐ASA therapy is more expensive than SASP, so SASP may be the preferred option where cost is an important factor. Oral 5‐ASA administered once daily is as effective and safe as conventional dosing (two or three times daily) for maintaining remission in ulcerative colitis. There does not appear to be any difference in efficacy or safety between the various formulations of 5‐ASA. Patients with extensive ulcerative colitis or with frequent relapses may benefit from a higher dose of maintenance therapy. High dose therapy appears to be as safe as low dose and is not associated with a higher incidence of side effects.

Author(s)

Yongjun Wang, Claire E Parker, Brian G Feagan, John K MacDonald

Reviewer's Conclusions

Authors' conclusions

Implications for practice

It is clear that oral 5‐ASA preparations have yet to be proven to be more clinically beneficial than SASP. Male infertility is associated with SASP and not with 5‐ASA (Riley 1987; Kjaergaard 1989), so 5‐ASA may be preferred for patients concerned about fertility. 5‐ASA therapy is more expensive than SASP, so SASP may be the preferred option where cost is an important factor. 5‐ASA could also be offered to patients who are intolerant to SASP. Oral 5‐ASA administered once daily is as effective and safe as conventional dosing (twice or three times daily) for maintenance of remission in quiescent ulcerative colitis. Once daily dosing does not appear to enhance adherence in the clinical trial setting. There does not appear to be any difference in efficacy or safety between the various formulations of 5‐ASA. Patients with extensive ulcerative colitis or with frequent relapses may benefit from a higher dose of maintenance therapy. High dose therapy appears to be as safe as low dose and is not associated with a higher incidence of adverse events. When selecting among the various 5‐ASA formulations, physicians and patients should consider dose‐response data, adherence issues and price (Sandborn 2002a).

Implications for research

In this time of scarce research dollars, careful thought should be given prior to commissioning new trials of 5‐ASA preparations for the treatment of quiescent ulcerative colitis. Future trials comparing 5‐ASA with placebo or SASP may not be justified. There does not appear to be any difference in efficacy or safety between the various formulations of 5‐ASA. However the overall quality of the evidence from the studies examining differences in efficacy between various 5‐ASA formulations is low due to sparse data and risk of bias. Future trials should look at enhancing patient adherence with medication. Adherence to therapy is important for treatment success and may be an important predictor of relapse. Future trials could assess whether once daily dosing regimens improve adherence in the community.

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