What are the adjunct therapies for ulcerative colitis after treatment with mesalamine (5-aminosalicylic acid)?

From the Guidelines

For patients with colitis who have not responded adequately to mesalamine, biologic therapies such as infliximab or vedolizumab are recommended as adjunct therapy options. According to the AGA clinical practice guidelines on the management of moderate to severe ulcerative colitis 1, current evidence supports the use of infliximab, adalimumab, golimumab, vedolizumab, and tofacitinib for the induction and maintenance of remission in moderate-severe UC.

Key Considerations

• The guidelines suggest that infliximab and vedolizumab may be preferred first-line therapy in biologic-naïve patients, rather than standard-dose adalimumab or golimumab 1.
• Combination therapy of a biologic agent with an immunomodulator is more effective than monotherapy with either agent, though patients may opt for monotherapy due to side effects or disease severity 1.
• In patients with moderate-severe disease activity, at high risk of colectomy, biologic agents with or without an immunomodulator, or tofacitinib, should be used early rather than gradual step up therapy after failure of 5-aminosalicylates 1.

Treatment Options

• Infliximab: 5mg/kg at weeks 0,2, and 6, then every 8 weeks
• Vedolizumab: 300mg at weeks 0,2, and 6, then every 8 weeks
• Tofacitinib: 10mg twice daily for induction, 5mg twice daily for maintenance

Monitoring and Safety

• Regular monitoring for medication efficacy and side effects is essential, including blood tests for immunomodulators and pre-treatment screening for infections before starting biologics 1.

From the Research

Adjunct Therapy for Colitis after Mesalamine

• The primary goal of managing ulcerative colitis is to induce and maintain clinical remission, and mesalamine is often the first-line therapy for this purpose 2.
• For patients who are refractory to mesalamine or have more severe disease, other treatment options such as steroids, azathioprine/mercaptopurine, cyclosporine, or infliximab may be considered 2.
• Azathioprine has been shown to be effective in maintaining remission in patients with ulcerative colitis, particularly for those who have failed or cannot tolerate mesalazine or sulfasalazine 3, 4.
• Increasing the dose of mesalazine up to 4.0g/day may be safe and effective for patients who relapse under low-dose maintenance therapy 5.
• The use of azathioprine or 6-mercaptopurine as maintenance therapy may be considered for patients who require repeated courses of steroids or have failed other treatments 3, 4.

Treatment Options

• Azathioprine: may be effective for maintaining remission in patients with ulcerative colitis, but may have adverse effects such as acute pancreatitis and bone marrow suppression 3, 4.
• 6-mercaptopurine: may be effective for maintaining remission in patients with ulcerative colitis, but may have adverse effects and requires careful monitoring 4.
• Cyclosporine: may be considered for patients who have failed other treatments, but requires careful monitoring due to potential adverse effects 4.
• Infliximab: may be considered for patients with severe disease or who have failed other treatments, but requires careful monitoring due to potential adverse effects 2.

Safety and Efficacy

• Mesalamine is generally considered safe and effective for the treatment of ulcerative colitis, with serious adverse effects being rare 2, 6.
• Azathioprine and 6-mercaptopurine may have adverse effects, and patients should be carefully monitored while on these medications 3, 4.
• The efficacy and safety of these treatments should be carefully considered and individualized for each patient based on their specific needs and medical history.