Putting Rectal 5-Aminosalicylic Acid in Its Place: The Role in Distal Ulcerative Colitis

Abstract

Oral aminosalicylates such as sulfasalazine and mesalamine are widely prescribed for the treatment of mild or moderately active distal ulcerative colitis. However, a critical review of the literature demonstrates that rectal 5-aminosalicylic acid (5-ASA) is the optimal therapy for this disease. Meta-analyses of published trials show that rectally delivered 5-ASA is superior to placebo and to conventional rectal corticosteroids in inducing remission of distal ulcerative colitis, whereas the combination of rectal 5-ASA with a rectal corticosteroid or oral aminosalicylate is superior to rectal 5-ASA alone. For maintaining remission of distal ulcerative colitis, rectal 5-ASA is significantly better than placebo and at least as effective as oral 5-ASA. The dosage forms available for rectal delivery include suppositories, foams, and liquid enemas, and selection among these preparations should be guided by the proximal extent of disease and patient preference. The efficacy of rectal 5-ASA is complemented by its low rate of reported adverse effects, which may reflect its reduced potential for systemic absorption. This review summarizes the evidence supporting the role of rectal 5-ASA as a first-line therapy for mild or moderately active distal ulcerative colitis, and offers guidelines for its use.

Topical therapy is underused in patients with ulcerative colitis

“…33 Furthermore, a meta-analysis showed a higher efficiency of rectal 5-ASA treatments compared to topical steroids. 23,3,15 However, the combination of rectal steroids and 5-ASAs seems to be beneficial. 21 Unexpectedly, in our cohort only a minority of patients with pancolitis received rectal therapy.…”

“…22 A meta-analysis of 33 studies showed that topical 5-ASA is more effective as compared to topical conventional steroids or budesonide. 15,3,23 Remission also can be maintained by topical treatment of at least two years duration. [9][10][11]24,25 For maintenance 3 g of 5-ASA total per week is recommended.…”

Ulcerative proctitis: an update on the pharmacotherapy and management

“…Short-term remission rates may be as high as 85%. In case of suboptimal therapeutic response to topical 5-ASA, treatment can be extended with oral 5-ASA and/or topical steroids, as the combination of rectal 5-ASA with a rectal corticosteroid or oral aminosalicylate is superior to rectal 5-ASA alone [83]. Rectally administered corticosteroid therapy with suppositories or …”

Development and Optimization of Sustained Release in Situ Gel for the Treatment of Ulcerative Colitis

“…Administering of Mesalamine rectally offers the advantage of delivering the treatment directly to the site of maximal inflammation while potentially minimizing the frequency of systemic adverse effects. [7] MATERIALS AND METHODS …”