Aminosalicylate withdrawal following escalation to immunomodulators or biologics in ulcerative colitis: cost saving, convenient and does not compromise efficacy

Abstract

Background Aminosalicylates are widely used in ulcerative colitis (UC) and often continued despite treatment escalation, perhaps given a lack of evidence or consensus guiding dose reduction or cessation. The aim was to compare long‐term outcomes in patients who escalated treatment and either continued or discontinued aminosalicylate therapy. Methods Consecutive patients diagnosed with UC ≥1 year prior to escalation to immunomodulator or biologic therapy while concurrently taking aminosalicylates, were compared based on discontinuation versus continuation of aminosalicylates once clinical remission was achieved (denoted as baseline). The primary endpoint was time (from baseline) to treatment failure, defined as requiring steroids, resumption of aminosalicylates or surgery. Successful discontinuation was achieved if no treatment failure occurred throughout follow‐up. The resultant cost savings per patient‐year gleaned by aminosalicylate discontinuation were calculated. Results Of 128 patients meeting inclusion criteria, 71 discontinued and 57 continued aminosalicylates post‐escalation. Median disease duration was 8.2 and 8.7 years (P = .2), time from escalation to baseline 1.8 and 2.9 years (P = .1) respectively. Post‐escalation, median time on immunomodulator was longer, yet no difference in time on biologics was observed, with successful aminosalicylate discontinuation (versus unsuccessful) (2.9 vs 1.2 years (P = .03), 0.4 vs 0.6 years (P = .8) respectively). Kaplan‐Meier survival analysis demonstrated no difference in proportion of treatment failure in the groups post‐baseline (Breslow test, P = .4), yet aminosalicylate discontinuation yielded cost savings of $AUD 2000 per patient‐year. Conclusions These real‐world data support discontinuation of aminosalicylates after achieving remission with either immunomodulator or biologic therapy in UC, at minimal risk of relapse yet enabling significant reductions in cost and tablet burden.

Letter: rationalising aminosalicylates in inflammatory bowel disease

“…Specifically, the authors have highlighted the emerging evidence in favour of withdrawal of aminosalicylates in patients with active disease and recently commenced on biologic therapy. Further to this, we have recently demonstrated in a large retrospective study that 5‐ASA therapy can also be withdrawn safely after patients have achieved remission following escalation to immunomodulators and/or biologics with significant cost savings (median $USD1500 per patient per year in reduced medication cost) 2 . Given the potential reductions in cost and the pill burden to patients, we would also advocate a trial of 5‐ASA withdrawal amongst patients achieving endoscopic or clinical remission, including those who fall in Chapman et al’s proposed high‐risk category, given that time to remission does not appear integral to the safety of treatment withdrawal.…”

Cost savings from 5‐aminosalicylate withdrawal after successful treatment escalation to immunosuppressive or anti‐TNF biologic therapy: is it worth the risk?

“…Hence, it may be argued that the continuation of aminosalicylates after successful initiation of azathioprine or a biologic agent may be superfluous and incur additional cost. In this issue, Nicolaides et al report on the cost savings using an Australian cost model of aminosalicylate withdrawal after successful therapy escalation to immunosuppressives and/or anti‐TNFs 2…”