Maintenance Therapy for Ulcerative Colitis in Remission
For patients with ulcerative colitis in clinical remission, continue the same therapy that induced remission: oral 5-ASA at doses ≥2 g/day for those who achieved remission with 5-ASA, or biologic/immunomodulator therapy for those who required escalation beyond 5-ASA. 1, 2
First-Line Maintenance: 5-ASA Therapy
All patients with ulcerative colitis should receive lifelong maintenance therapy with 5-aminosalicylic acid (5-ASA) at doses ≥2 g/day to maintain remission, particularly those with left-sided or extensive disease. 1, 2, 3
Optimal Dosing Strategy
Higher maintenance doses (2.4 g/day) prolong remission significantly better than lower doses (1.2 g/day), with patients with extensive disease benefiting most from dose escalation. 1, 2
Once-daily dosing is as effective as divided doses and improves adherence, making it the preferred regimen. 1, 2
For patients who achieved remission with combined oral and rectal 5-ASA therapy (particularly those with left-sided disease or proctitis), continue both routes of administration to maintain remission. 1
Duration of Therapy
Lifelong maintenance with 5-ASA ≥2 g/day is recommended for all patients with ulcerative colitis. 1, 2
Discontinuing 5-ASA significantly increases relapse risk; unlike corticosteroids, no tapering is required when stopping, but cessation is generally not advised. 2
Maintenance After Biologic/Immunomodulator Escalation
For patients who required escalation beyond 5-ASA and achieved remission with biologic agents (infliximab, adalimumab, golimumab, vedolizumab) or tofacitinib, continue these agents indefinitely for maintenance. 1
Role of Concomitant 5-ASA
The AGA suggests against continuing 5-ASA in patients who are in remission on biologic agents and/or immunomodulators or tofacitinib after prior 5-ASA failure, though this recommendation is based on very low-quality evidence. 1, 2, 3
Meta-analysis shows no difference in maintaining clinical remission in TNF-α antagonist- or tofacitinib-treated patients who were versus were not on concomitant 5-ASA. 1
However, this remains an area of clinical judgment, as the evidence is indirect and does not assess systematic withdrawal of 5-ASA in biologic-treated patients. 1
Maintenance After Thiopurine Therapy
For selected patients who achieved corticosteroid-free remission with thiopurine therapy (azathioprine or 6-mercaptopurine), continue thiopurine monotherapy to maintain remission. 1, 4
- Thiopurines should not be used for induction of remission but may be considered for maintenance in steroid-dependent disease. 1
Critical Pitfalls to Avoid
Never use corticosteroids for maintenance therapy—they are ineffective for maintaining remission and their prolonged use causes significant adverse effects including osteoporosis, infection risk, and metabolic complications. 1, 3
- Corticosteroids are for induction only and must be tapered after achieving remission, typically over 8 weeks. 2, 3
Do not use methotrexate monotherapy for maintenance of remission in ulcerative colitis—it is ineffective for this indication. 1
Monitoring During Maintenance
Check fecal calprotectin every 6-12 months in patients in remission; escalate therapy if elevated (>150 mg/g) as this indicates subclinical inflammation. 2
Monitor renal function periodically in patients on mesalamine due to rare risk of interstitial nephritis. 2
Additional Considerations
The potential chemoprotective benefit of 5-ASA against colorectal cancer provides additional rationale for lifelong maintenance therapy, though recent data suggests sustained remission itself (regardless of therapy type) is protective. 1
For patients with distal disease (proctitis) who have been in remission for at least 2 years, discontinuation of medication may be reasonable, though continued therapy reduces colorectal cancer risk. 1