Is maintenance therapy always necessary for patients with ulcerative colitis in remission?

-Context -Unspecified Ulcerative Rectocolitis is a chronic disease that affects between 0.5 and 24.5/10 5 inhabitants in the world. National and international clinical guidelines recommend the use of aminosalicylates (including mesalazine) as first-line therapy for induction of remission of unspecified ulcerative rectocolitis, and recommend the maintenance of these agents after remission is achieved. However, multiple daily doses required for the maintenance of disease remission compromise compliance with treatment, which is very low (between 45% and 65%). Use of mesalazina in granules (2 g sachet) once daily -Pentasa ® sachets 2 g -can enhance treatment adherence, reflecting in an improvement in patients' outcomes. Objective -To evaluate the evidence on the use of mesalazine for the maintenance of remission in patients with unspecified ulcerative rectocolitis and its effectiveness when taken once versus more than once a day. From an economic standpoint, to analyze the impact of the adoption of this dosage in Brazil's public health system, considering patients' adherence to treatment. Methods -A decision tree was developed based on the Clinical Protocol and Therapeutic Guidelines for Ulcerative Colitis, published by the Ministry of Health in the lobby SAS/MS n° 861 of November 4 th, 2002 and on the algorithms published by the Associação Brasileira de Colite Ulcerativa e Doença de Crohn, aiming to get the cost-effectiveness of mesalazine once daily in granules compared with mesalazine twice daily in tablets. ResultsThe use of mesalazine increases the chances of remission induction and maintenance when compared to placebo, and higher doses are associated with greater chance of success without increasing the risk of adverse events. Conclusion -The use of a single daily dose in the maintenance of remission is effective and related to higher patient compliance when compared to the multiple daily dose regimens, with lower costs.

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“…According to a study by Ardizzone et al (2) , the rate of return for maintenance therapy was 26% per year.…”

Section: Failure In Remissionmentioning

confidence: 99%

Decision Tree Construction and Cost-Effectiveness Analysis of Treatment of Ulcerative Colitis With Pentasa®mesalazine 2 G Sachet

Nishikawa

Paladini

Delfini

et al. 2013

Arq. Gastroenterol.

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“…Although the study of Dissanayake and Truelove [56] suggested that maintenance therapy with 5-ASA should be continued indefinitely, a recent trial by Ardizzone et al [57] found that patients who had maintained their remission on 5-ASA for at least 2 years had no greater risk of relapse if they were randomized to placebo than when they remained on 5-ASA.…”

Section: Maintenance Therapy In Ulcerative Colitismentioning

confidence: 99%

Medical Therapy of Inflammatory Bowel Disease

Rutgeerts

1998

Digestion

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In the past years the advances in therapy of IBD have been characterized mainly by the more widespread use of immunosuppression. Especially azathioprine is currently used in Crohn’s disease with methotrexate as the second-line immunosuppressive drug. Cyclosporin may become a drug of choice to treat severe ulcerative colitis but its effect in the long term is probably insufficient. Topically acting glucocorticosteroids have emerged as a valuable safer alternative to standard glucocorticosteroids (GCS) in right ileocolonic Crohn’s disease but GCS have no role in maintenance therapy. The most significant development in recent years is the introduction of immunomodulatory treatments using cytokines and anticytokines. The first data show that anti-TNF monoclonal antibodies, especially cA2, not only may result in rapid control of active Crohn’s disease but also achieve rapid tissue healing. Repeated administration of cA2 maintains remission. Immunomodulation therapy creates great expectations since early reset of the immunostat might be able to control inflammation in the long term. Safety will be a key issue.

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“…Ardizzone et al [61] in a placebo-controlled study evaluated if a maintenance treatment is always necessary according to the length of remission. Patients with longer remission (62 years) showed no differences in the incidence of relapse with or without mesalazine treatment (relapse rate of 18% in the mesalazine group vs. 26% in the placebo group).…”

Section: Maintenance Of Remissionmentioning

confidence: 99%

Standard Treatment of Ulcerative Colitis

Gionchetti

Rizzello

Habal

et al. 2003

Dig Dis

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Ulcerative colitis (UC) is an idiopathic, chronic inflammation of the colon which may present with a range of mild to severe symptoms. The disease may be localized to the rectum or can be more extensive and involve the left side of the colon or the whole colon. Treatment in UC is directed towards inducing and maintaining remission of symptoms and mucosal inflammation. The key parameters to be assessed for the most appropriate treatment are the severity and extent of the inflammation. Meta-analyses of published trials have shown that topical treatment with 5-aminosalicylic acid (5-ASA) is the treatment of choice in active distal mild-to-moderate UC. Oral aminosalicylates are effective in both distal and extensive mild-to-moderate disease, but in distal disease, the rates of remission are lower than those obtained with topical 5-ASA. New steroids, such as budesonide and beclomethasone dipropionate (BDP), administered as enemas, constitute an alternative to 5-ASA therapy. In some studies, these have been shown to be as effective as conventional steroids but with significantly lower inhibition of plasma cortisol levels. Patients with unresponsive disease or those with more severe presentation will require oral corticosteroids and sometimes intravenous therapy. Approximately 10% of patients with unresponsive UC have severe attacks requiring hospitalization. Patients with severe disease should be managed jointly by a medical and surgical team, and intensive intravenous treatment should be started with high-dose steroids. Early recognition of failure of therapy will allow the introduction of immunosuppressive therapy with intravenous cyclosporine. Patients who respond are shifted to oral cyclosporine associated with azathioprine/6-mercaptopurine, whereas those who fail will require proctocolectomy. Oral aminosalicylates are the first-line therapy in maintenance of remission. Topical 5-ASA may play a role in distal disease. Patients who are steroid dependent can be started on azathioprine or 6-mercaptopurine although it may take up to 3 months for the treatment to become effective. They may have reversible immediate side effects, such as pancreatitis or bone marrow suppression, which disappear upon discontinuation of therapy. Close monitoring of these hematologic and biochemical parameters will improve safety. The use of biologic therapy with infliximab in more severe disease has not been established.

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Is maintenance therapy always necessary for patients with ulcerative colitis in remission?

Cited by 77 publications

References 22 publications

Decision Tree Construction and Cost-Effectiveness Analysis of Treatment of Ulcerative Colitis With Pentasa®mesalazine 2 G Sachet

Decision Tree Construction and Cost-Effectiveness Analysis of Treatment of Ulcerative Colitis With Pentasa®mesalazine 2 G Sachet

Medical Therapy of Inflammatory Bowel Disease

Standard Treatment of Ulcerative Colitis

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