The systemic load and efficient delivery of active 5-aminosalicylic acid in patients with ulcerative colitis on treatment with olsalazine or mesalazine

BACKGROUND

There have been reports of nephrotoxic reactions in patients with ulcerative colitis treated with 5-aminosalicylic acid (5-ASA) preparations.

AIM

To compare the efficacy in delivery of active 5-ASA to the colon and the systemic load as the basis for potential long-term toxicity during treatment with olsalazine or mesalazine in patients with ulcerative colitis in remission.

PATIENTS AND METHODS

Fifteen patients with ulcerative colitis were treated with olsalazine or mesalazine, each for 7 days in an open, randomized, crossover design study. 5-ASA and acetyl-5-ASA (Ac-5-ASA) in plasma and urine were measured by high performance liquid chromatography.

RESULTS

The plasma concentration of 5-ASA was 1.2 +/- 0.1 micromol/L (mean +/- S.E.M.) for olsalazine and 8.0 +/- 1.9 micromol/L for mesalazine, while the plasma concentration of Ac-5-ASA was 2.8 +/- 0.2 micromol/L for olsalazine and 10.8 +/- 1.6 micromol/L for mesalazine. The amount of 5-ASA excreted in the urine was 68 +/- 30 micromol/24 h for olsalazine and 593 +/- 164 micromol/24 h for mesalazine. The amount of Ac-5-ASA in the urine was 1260 +/- 102 micromol/24 h for olsalazine and 3223 +/- 229 micromol/24 h for mesalazine. The urinary recovery of total 5-ASA plus Ac-5-ASA (as a percentage of the given dose) was 23 +/- 2.1% for olsalazine and 39 +/- 3.6% for mesalazine. The ratio between the plasma concentrations of mesalazine and olsalazine differed significantly both for 5-ASA (5.1) and Ac-5-ASA (3.6); for 5-ASA (9. 9) and Ac-5-ASA (2.6) in urine, and for the urinary recovery of total 5-ASA plus Ac-5-ASA (1.7). Moreover, in the mesalazine group there was a large variation in the individual plasma concentrations of 5-ASA and Ac-5-ASA, with maximal values 5-6-fold higher than that in the olsalazine group.

CONCLUSION

The systemic load of active 5-ASA is significantly higher for mesalazine than for olsalazine, when based on the dosages given and when calculated on an equimolar basis. Some of the patients in the mesalazine group showed unexpected high levels of plasma and urinary 5-ASA concentrations, a finding which may have long-term safety implications.

Lupus-like syndrome caused by 5-aminosalicylic acid in patients with inflammatory bowel disease

BACKGROUND

Although 5-aminosalicylic acid (5-ASA) preparations used to treat inflammatory bowel disease are reported to have fewer side effects than sulphasalazine, increased clinical use of these compounds has resulted in increased reports of significant side effects.

OBJECTIVE

To report four patients with antinuclear antibody-positive migratory arthralgias and acute inflammation unrelated to the underlying inflammatory bowel disease, fulfilling the criteria of a drug-induced lupus-like syndrome.

SETTING

A university-affiliated teaching hospital.

INTERVENTION

Cessation of treatment with 5-ASA compounds.

RESULTS

The cases described constitute a drug-induced lupus-like syndrome. All patients improved rapidly after discontinuation of 5-ASA compounds.

CONCLUSIONS

Reversible lupus-like syndrome appears to be a rare but significant side effect of 5-ASA compounds. Patients treated with 5-ASA compounds who experience acute inflammatory symptoms or clinical deterioration not related to their gastrointestinal disease should be screened to rule out a lupus-like reaction.

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

BACKGROUND

The efficacy of sulphasalazine and mesalazine in preventing relapse in patients with ulcerative colitis is well known. It is less clear how long such maintenance should be continued, and if the duration of disease remission is a factor that affects the risk of recurrence.

AIM

To determine whether the duration of disease remission affects the relapse rate, by comparing the efficacy of a delayed-release mesalazine (Asacol, Bracco S.p.A., Milan, Italy) against placebo in patients with ulcerative colitis with short- and long-duration of disease remission.

METHODS

112 patients (66 male, 46 female, mean age 35 years), with intermittent chronic ulcerative colitis in clinical, endoscopic and histological remission with sulphasalazine or mesalazine for at least 1 year, were included in the study. Assuming that a lower duration of remission might be associated with a higher relapse rate, the patients were stratified according to the length of their disease remission, prior to randomization into Group A (Asacol 26, placebo 35) in remission from 1 to 2 years, or Group B (Asacol 28, placebo 23) in remission for over 2 years, median 4 years. Patients were treated daily with oral Asacol 1.2 g vs. placebo, for a follow-up period of 1 year.

RESULTS

We employed an intention-to-treat analysis. In Group A, whilst no difference was found between the two treatments after 6 months, mesalazine was significantly more effective than placebo in preventing relapse at 12 months [Asacol 6/26 (23%), placebo 17/35 (49%), P = 0.035, 95% Cl: 48-2.3%]. In contrast, in Group B no statistically significant difference was observed between the two treatments, either at 6 or 12 months [Asacol 5/28 (18%), placebo 6/23 (26%), P = 0.35, 95% Cl: 31-14%] of follow-up. Patients in group B were older, and had the disease and remission duration for longer, than those in Group A.

CONCLUSIONS

Mesalazine prophylaxis is necessary for the prevention of relapse by patients with ulcerative colitis in remission for less than 2 years, but this study casts doubt over whether continuous maintenance treatment is necessary in patients with prolonged clinical, endoscopic and histological remission, who are at very low risk of relapse.

A controlled trial comparing ciprofloxacin with mesalazine for the treatment of active Crohn's disease. Groupe d'Etudes Thérapeutiques des Affections Inflammatoires Digestives (GETAID)

OBJECTIVE

The aim of this randomized controlled study was to investigate the efficacy of ciprofloxacin compared with mesalazine in treating active Crohn's disease.

METHODS

Patients with a mild to moderate flare-up of Crohn's disease (mean Crohn's Disease Activity Index [CDAI]; 217; range, 160-305) were randomized to receive ciprofloxacin 1 g/day or Pentasa 4 g/day for 6 wk. Complete remission was defined at wk 6 as a CDAI < or = 150 associated with a decrease (delta) in CDAI > 75. Partial remission was defined as a CDAI < or = 150 with 50 < delta CDAI < 75 or a CDAI > 150 with delta CDAI > 50 at wk 6. Group sequential procedure with triangular continuation regions was used to monitor the trial through the difference in complete remission rates, every 20 patients included.

RESULTS

Inclusion of patients was stopped at the second step, i.e., after 40 inclusions, with the conclusion of no difference in complete remission rates between ciprofloxacin- and Pentasa-treated groups. Among the 18 patients taking ciprofloxacin, two decided to stop treatment during the trial and three were considered as treatment failures because of deterioration at wk 3. Among the 22 patients taking mesalazine, one patient was lost to follow-up and eight patients were considered as treatment failures. Complete remission was observed in 10 patients (56%) treated with ciprofloxacin and 12 patients (55%) treated with mesalazine and partial remission was observed in three and one patient, respectively.

CONCLUSIONS

This study suggests that ciprofloxacin 1 g/day is as effective as mesalazine 4 g/day in treating mild to moderate flare-up of Crohn's disease.

Pericarditis associated with longstanding mesalazine administration in a patient

An adult male patient was admitted for a pericardial effusion occurring during a longstanding mesalazine treatment for Crohn's disease. The relation between the drug's administration, symptoms and ECG changes suggests that the pericardial injury was caused by mesalazine. Also, the rapid resolution of clinical signs and ECG changes following the drug withdrawal were in agreement with this hypothesis. Eight months later, the patient remains well and symptom-free, and ECG and echocardiographic control were normal.

[Clinical effect of various 5-ASA preparations in ulcerative colitis]

Sulfasalazine (SASP), since 60 years standard in the treatment of ulcerative colitis, is a double molecule where 5-aminosalicylic acid (5-ASA) and sulfapyridine (SP) are linked together by an azobond. Bacterial splitting of SASP within the colon allows delivery of 5-ASA for its topical action (prodrug system). To target 5-ASA without the less tolerable SP down to the lower intestine new prodrugs have been developed and, in addition, mesalazine is offered which contains 5-ASA prepared as a delayed release preparation. A clinical comparison (metaanalysis) tended towards superiority of the new prodrugs and mesalazine over SASP for inducing remission, while SASP was more effective in maintaining remission. Only few studies exist comparing the efficacy of the new drugs and mesalazine. To date a slight superiority of the new prodrugs is implied. With the exception of SASP safety profiles do not significantly differ between the different drugs containing 5-ASA.

[Consequences of galenic differences and outcome of clinical trials with budesonide and 5-aminosalicylic acids for therapy of Crohn disease]

Budesonide in both galenic forms is suitable for the treatment of a flare of Crohn's disease of up to moderate activity. The same holds true for 5-amino-salicylates, although they are less effective. Topical steroids delay but do not prevent relapses. Aminosalicylates may be used in the postoperative situation for prevention of relapse but are not significantly effective after drug-induced remission.

[Clinical effects of 5-aminosalicylic acid preparations in Crohn disease]

The antiinflammatory drug 5-aminosalicylic acid is available either as mesalamine in various slightly different galenic preparations or as a prodrug with 5-ASA bound to a carrier molecule as inert as possible, which releases 5-ASA via bacterial degradation in the ileocolon. Data from therapeutic trials in patients with Crohn's disease are only available for mesalamine and sulfasalazine. In active Crohn's disease, high-dose (> 3 g per day) mesalamine only is more effective than placebo, but inferior to systemic steroids. They may be used in patients refusing treatment with classical steroids or not tolerating them if this does not make a case for budesonide. The therapeutic gain of mesalamine over placebo for the prevention recurrence in patients who have reached remission by drug treatment is marginal. Thus, its use in this clinical situation is not appealing. Results for the maintenance of a surgically induced remission appear slightly better so that the use of > 3 g of mesalamine per day may be still justified in this scenario. It is an unresolved question whether the clinical efficacy of different galenic mesalamine prepations in maintaining postoperative remission varies with the preoperative disease location. Present data are not sufficient to support differential drug treatment based on this parameter.

[Acute pancreatitis induced by drugs derived from 5-aminosalicylic acid: case report and review of the literature]

The pancreatic toxicity of oral 5-aminosalicylic acid (5ASA) derivatives used for the treatment of inflammatory bowel diseases remains controversial. A new case of mesalazine-induced acute pancreatitis (AP), with positive rechallenge, and an analysis of the previous published cases are presented. Twenty-nine patients (17 women, 12 men), aged 26.4 +/- 9.9 (12-43) years, were involved, receiving sulfasalazine (n = 11), mesalazine (n = 16), olsalazine (n = 1) or 5ASA without further informations (n = 1), for ulcerative colitis (n = 15), Crohn's disease (n = 13) or another indication (n = 1). The AP occurred in the first month of treatment in 71.4 per cent of the cases (n = 28). The clinical course was essentially benign in most of the cases. Recurrence of AP after rechallenge was observed in 17 of the 19 cases, even if the molecule, the dose or the form were modified. These results show that all 5ASA derivatives are potentially pancreatotoxic. An AP must be considered when an occurrence or increase of abdominal pain occurs during such therapy and warrants serum amylase assay and discontinuation of the drug.

Maintenance of remission of ulcerative colitis: a comparison between balsalazide 3 g daily and mesalazine 1.2 g daily over 12 months. ABACUS Investigator group

BACKGROUND

Despite widespread use of aminosalicylates as maintenance treatment for ulcerative colitis (UC), patients still report troublesome symptoms, often nocturnally.

AIM

To compare the efficacy and safety of balsalazide (Colazide) with mesalazine (Asacol) in maintaining UC remission.

METHODS

A randomized, double-blind comparison of balsalazide 3 g daily (1.04 g 5-ASA) and mesalazine 1.2 g daily for 12 months, in 99 (95 evaluable) patients in UC remission.

RESULTS

Balsalazide patients experienced more asymptomatic nights (90% vs. 77%, P=0.0011) and days (58% vs. 50%, N.S.) during the first 3 months. Balsalazide patients experienced more symptom-free nights per week (6.4+/-1.7 vs. 4.7+/-2.8; P=0.0006) and fewer nights per week with blood on their stools or on the toilet paper, mucus with their stools or with sleep disturbance resulting from symptoms or lavatory visits (each P < 0.05). Fewer balsalazide patients relapsed within 3 months (10% vs. 28%; P=0.0354). Remission at 12 months was 58%, in both groups. Similar proportions of patients reported adverse events (61% balsalazide vs. 65% mesalazine). There were five serious adverse events (two balsalazide, three mesalazine) and four withdrawals due to unacceptable adverse events (three balsalazide, one mesalazine), of which one in each group was also a serious adverse event.

CONCLUSIONS

Balsalazide 3 g/day and mesalazine 1.2 g/ day effectively maintain UC remission and are equally well tolerated over 12 months. At this dose balsalazide prevents more relapses during the first 3 months of treatment and controls nocturnal symptoms more effectively.

Mesalazine-associated severe aplastic anemia successfully treated with antithymocyte globulin, cyclosporine and granulocyte colony-stimulating factor

A 20-year-old male with ulcerative colitis complicated by mesalazine-associated severe aplastic anemia is described. The patient developed aplastic anemia four months after the start of mesalazine therapy. He was treated with antithymocyte globulin, cyclosporine, and granulocyte colony-stimulating factor (G-CSF) and responded well. Hematological complications of mesalazine are rare, but if bone marrow suppression is detected, immediate cessation of the drug and intensive immunosuppressive treatment with G-CSF should be considered.

Foetal outcome in women with inflammatory bowel disease treated during pregnancy with oral mesalazine microgranules

BACKGROUND

Little information is available about the safety of high doses of mesalazine during pregnancy.

AIM

To study the fate of pregnancy and foetal outcome in women taking 1-4 g/day of mesalazine microgranules for inflammatory bowel disease.

PATIENTS AND METHODS

Case reports were collected from the Pharmacovigilance Department of Ferring SA, France, from a survey conducted in three gastroenterology units, and from a teratology information service. The evolution of pregnancy and foetal outcome were assessed by questionnaire.

RESULTS

The study covered a total of 123 pregnancies (126 foetuses). Ninety-six women took mesalazine during the first trimester, 85 during the second and 83 during the third. The mean daily dose was 2.1+/-0.8 g; 86 women received <3 g/day (low-dose group), 37 women received > or =3 g/day (high-dose group). The following abnormalities were observed in the low-dose and high-dose groups, respectively: ectopic pregnancy (1/0), spontaneous abortions (1/1), foetal death (0/1), premature deliveries (3/5, P < 0.05), congenital malformations (3/1) and one case of lethal oxalosis. Abnormalities were not considered to be related to mesalazine.

CONCLUSIONS

The use of oral mesalazine microgranules during pregnancy is safe at doses < or =2 g/day, and probably also at a dose of 3 g/day.

A comparison of budesonide and mesalamine for active Crohn's disease. International Budesonide-Mesalamine Study Group

BACKGROUND

Crohn's disease is often treated with glucocorticoids or mesalamine. We compared the efficacy and safety of controlled-ileal-release budesonide capsules and slow-release mesalamine tablets in patients with active Crohn's disease affecting the ileum, the ascending colon, or both.

METHODS

In a double-blind, multicenter trial, we enrolled 182 patients with scores of 200 to 400 on the Crohn's Disease Activity Index (with higher scores indicating greater disease activity) and randomly assigned 93 to receive 9 mg of budesonide once daily and 89 to receive 2 g of mesalamine twice daily for 16 weeks. The primary efficacy variable was clinical remission, defined as a score of 150 or less on the Crohn's Disease Activity Index.

RESULTS

In the analysis of all patients who received at least one dose of study drug, the rates of remission after 8 weeks of treatment were 69 percent in the budesonide group and 45 percent in the mesalamine group (P=0.001); the respective rates after 16 weeks of treatment were 62 percent and 36 percent (P<0.001). Seventy-seven patients in the budesonide group completed the 16 weeks of treatment, as compared with 50 patients in the mesalamine group (P<0.001). The numbers of patients with adverse events were similar in the two groups, but those assigned to budesonide had fewer severe adverse events. Among patients who completed 16 weeks of treatment, the morning plasma cortisol value was normal in 67 percent of budesonide-treated patients and 83 percent of mesalamine-treated patients (P=0.06); 90 percent and 100 percent, respectively, had normal increases in cortisol in response to cosyntropin (P=0.02).

CONCLUSIONS

In patients with active Crohn's disease affecting the ileum, the ascending colon, or both, a controlled-ileal-release formulation of budesonide was more effective in inducing remission than a slow-release formulation of mesalamine.

Pancytopenia associated with 5-aminosalicylic acid use in a patient with Crohn's disease

We report a case of pancytopenia in a 23-year-old man with Crohn's disease who was treated with 5-aminosalicylic acid (Pentasa; Nisshin, Tokyo, Japan) 3.0 g/day. He developed fever, nausea, diarrhea, and malaise and stopped taking on the third day after commencing Pentasa. Ten days after withdrawal of Pentasa, he was admitted to hospital because of worsening symptoms. Hematologic evaluation disclosed pancytopenia: red blood cells 283 x 10(4)/mm3; white blood cells 700/mm3; and platelets 8000/mm3. Other pertinent laboratory data, including liver and renal function tests results, serology for virus infection, and serum levels of vitamin B12 and folic acids, were normal. Bone marrow examination showed a generalized hypocellular picture, suggestive of drug-induced bone marrow suppression. He received blood transfusion and recombinant human granulocyte colong-stimulating factor (filgrastim). The leucopenia and thrombocytopenia resolved on the 7th and 13th days of hospitalization, respectively. The anemia continued because of bloody stool caused by Crohn's disease. However, reticulocytes were markedly increased in number on the 13th day of hospitalization. He is well at 9 months follow-up. Excluding other causes, Pentasa-associated pancytopenia was considered. The increasing use of this agent is expected, because of the increasing number of patients with inflammatory bowel disease. Careful clinical and hematological monitoring should be performed, especially for the first 3 months, in patients beginning treatment with Pentasa. The drug should be withdrawn immediately if there is a suspicion of blood disorders.

[Chronic interstitial nephritis and mesalazine: 3 new cases?]

We report three new cases of chronic interstitial nephritis occurring in two patients with Crohn's disease and one patient with ulcerative colitis treated with mesalazine. In the three cases asymptomatic renal disease was revealed by an increase in serum creatinine which was normal before treatment. Renal biopsy showed features of severe chronic interstitial nephritis. Mesalazine withdrawal and administration of steroids in two cases led to partial improvement of renal function. Mechanism of renal toxicity of mesalazine is unknown. These observations stress the need for monitoring renal function in patients with inflammatory bowel disease treated with mesalazine.

Olsalazine versus mesalazine in the treatment of mild to moderate ulcerative colitis

AIM

To compare the efficacy and tolerability of olsalazine sodium with enteric-coated mesalazine in inducing endoscopic remission in patients with mild to moderate active ulcerative colitis.

PATIENTS AND METHODS

Patients with mild to moderate active ulcerative colitis were randomized to receive either olsalazine sodium, 3 g/day (n = 88), or mesalazine, 3 g/day (n = 80), for up to 12 weeks.

RESULTS

Of the patients treated with olsalazine sodium, 52.2% achieved endoscopic remission, compared with 48.8% of patients treated with mesalazine. This difference was not significant (P = 0.67). There was a nonsignificant trend for patients with left-sided colitis or a more severe endoscopic grade to achieve remission if they were treated with olsalazine sodium than if they were treated with mesalazine. Both treatments were comparable with respect to clinical activity index and an investigator's global assessment. Seventy patients reported one or more adverse events; adverse events were seen in 45% of olsalazine sodium-treated patients and in 36% of mesalazine-treated patients. Eleven patients treated with olsalazine sodium and nine patients treated with mesalazine withdrew from the study because of adverse events. One patient treated with olsalazine sodium compared with two treated with mesalazine stopped treatment because of diarrhoea. Serious adverse events occurred in three patients treated with olsalazine sodium and in four treated with mesalazine.

CONCLUSION

Therapeutic effectiveness and tolerance to the treatment did not differ between olsalazine sodium, 3 g/day, and mesalazine, 3 g/day, in inducing endoscopic remission in patients with mild to moderate active ulcerative colitis within 12 weeks of treatment.

[Drug prevention of Crohn disease recurrence in the neo-terminal ileum after ileocolic resection]

Crohn's recurrence is the appearance of objective signs defined radiologically, endoscopically or pathologically of Crohn's disease in the bowel of a patient who has previously had a resection of all macroscopically diseased tissue. New lesions can be visualized endoscopically within weeks to months after ileal resection and ileocolonic anastomosis in the neoterminal ileum. The evolution of these lesions mimics the natural history of ileal Crohn's disease at the onset. If we are able to prevent recurrence of early lesions we would probably interrupt the natural course of the disease. The drugs tested until today include different 5-ASA formulations, metronidazole and budesonide. 5-ASA seems to have a limited protective effect. High dose metronidazole started immediately after surgery decreases endoscopic and symptomatic recurrence rates but is associated with a lot of side effects. Budesonide 6 mg/day o.m. reduces endoscopic recurrence after one year only in patients operated upon for inflammatory activity. Studies with immunosuppression for recurrence prevention are currently underway. Thus, today 5-ASA-formulations are recommended as general pharmaco-prophylaxis.

Ketotifen treatment of active colitis in patients with 5-aminosalicylate intolerance

Mast cell stabilizers are commonly used in the treatment of asthma and allergic disorders. Although the role of mucosal mast cells in the pathogenesis of inflammatory bowel disease remains uncertain, mast cell stabilizers have been shown in animal models to attenuate the severity of experimental colitis. The authors' experience with ketotifen in three patients--one each with Crohn's disease, ulcerative colitis and collagenous colitis--who had demonstrated allergy to, or intolerance of, 5-aminosalicylic acid is reported.

Mesalazine-associated tubulo-interstitial nephritis in inflammatory bowel disease

The 5-aminosalicylic acid (5-ASA) is currently the treatment of choice for patients with inflammatory bowel disease. It can be administered as sulfasalazine (5-ASA + sulfapyridine), mesalazine (5-ASA + resins or gels) and olsalazine (two molecules of 5-ASA). The recent trend has been to use formulations without sulfapyridine since they produce less side-effects although some cases of nephrotoxicity have been described. We report the case of a young female with Crohn's disease treated with mesalazine (400 mg every 8 hours) over a period of 12 months who developed acute interstitial nephritis. The characteristic features of renal function impairment were an insidious onset with non-specific laboratory data and progression towards a chronic state which partially improved with steroid treatment. In summary, it is important to bear this possibility in mind when confronted by any renal impairment which cannot be related to a relapse of inflammatory bowel disease. Renal function should be monitored routinely in patients receiving mesalazine at least during the first year of treatment and annually thereafter.

Severe symptomatic sinus bradycardia associated with mesalamine use

A 29-yr-old white woman was hospitalized with bloody diarrhea secondary to ulcerative colitis. Within 24 h of receiving intravenous steroids, loperamide, and mesalamine, she developed symptomatic hypotension, severe sinus bradycardia, sinus pauses, and junctional escape beats. The hypotension and sinus bradycardia resolved after discontinuing mesalamine. She had a family history of conduction tissue disease but her exercise ECG and Holter studies were normal. She was rehospitalized 6 wk later with an exacerbation of ulcerative colitis and, within 8 h of receiving mesalamine, developed hypotension and severe sinus bradycardia, which resolved after stopping mesalamine. Thus mesalamine should be used with caution, especially in patients predisposed to cardiac conduction tissue disease.

Drug therapy: dose-response relationship of oral mesalazine in inflammatory bowel disease

Mesalazine is widely used in the treatment of inflammatory bowel disease. Little is known about the dose-response relationship and about possible dose related side effects. In ulcerative colitis higher dosages of mesalazine (3 g) are more effective in maintaining a remission than lower dosages (1.5 g). In mild to moderately active ulcerative colitis, studies also indicate that higher dosages might be more effective in inducing remission. Dose-comparing studies in Crohn's disease are even more sparse, but the available results indicate higher efficacy at higher dose levels. None of the known side effects of mesalazine are clearly dose-related. A pH-dependent release system, however, can cause a sudden release of high doses of mesalazine. Consequent peak levels in serum have been implicated in mesalazine induced nephrotoxicity. In conclusion, despite the current practice of using increasing dosages of mesalazine in inflammatory bowel disease, both efficacy and safety have been established tentatively.

Balsalazide is more effective and better tolerated than mesalamine in the treatment of acute ulcerative colitis. The Abacus Investigator Group

BACKGROUND & AIMS

Aminosalicylates are widely used in the treatment of ulcerative colitis (UC). Balsalazide is a novel mesalamine prodrug, activated by colonic bacteria. The aim of this study was to compare the efficacy and safety of balsalazide with that of a pH-dependent formulation of mesalamine in active UC.

METHODS

A randomized, double-blind study was performed comparing balasalazide, 6.75 g daily, with mesalamine, 2.4 g daily, administered for 4, 8, or 12 weeks to 101 (99 evaluable) patients with symptomatic, sigmoidoscopically verified UC.

RESULTS

More patients treated with balsalazide achieved symptomatic remission after 2 (64% [balsalazide] vs. 43% [mesalamine]), 4 (70% vs. 51%), 8 (78% vs. 45%), and 12 weeks (88% vs. 57%) and complete remission (none/mild symptoms, sigmoidoscopy grade 0/1, no rectal steroid use within 4 days) after 4 (38% vs. 12%), 8 (54% vs. 22%), and 12 weeks (62% vs. 37%). Patients taking balsalazide experienced more asymptomatic days (4 weeks, 24% vs. 14%) and achieved the first asymptomatic day more rapidly (median, 10 vs. 25 days). Fewer patients in the balsalazide group reported adverse events (48% vs. 71%); four serious adverse events occurred in the mesalamine group.

CONCLUSIONS

Balsalazide is more effective and better tolerated than mesalamine as treatment for acute UC.

The safety of mesalamine in human pregnancy: a prospective controlled cohort study

BACKGROUND & AIMS

Mesalamine is a first-line drug in the treatment of inflammatory bowel disease. Information regarding human pregnancy experience with mesalamine has been scarce and uncontrolled despite its frequent use in women of childbearing age. The aim of this study was to examine the fetal safety of mesalamine.

METHODS

The Motherisk Program prospectively enrolled and followed up 165 women exposed to mesalamine during pregnancy, 146 of whom had first trimester exposure. Pregnancy outcome was compared with that of a matched control group, who were counseled for nonteratogenic exposure.

RESULTS

There was no increase in major malformations (1 of 127 [0.8%] for mesalamine vs. 5 of 131 [3.8%] for nonteratogenic controls; P = 0.23). There was an increase in the rate of preterm deliveries (13.0% for mesalamine vs. 4.7% for nonteratogenic controls; P = 0.02), a decrease in the mean maternal weight gain during pregnancy (13.1 +/- 6.3 kg for mesalamine vs. 15.6 +/- 6.0 kg for nonteratogenic controls; P = 0.0002), and a decrease in the mean birth weight (3253 +/- 546 g for mesalamine vs. 3461 +/- 542 g for nonteratogenic controls; P = 0.0005). There were no significant differences in the maternal obstetric history, rates of live births, miscarriages, pregnancy terminations, ectopic pregnancies, delivery method, or fetal distress between the groups.

CONCLUSIONS

This study suggests that mesalamine does not represent a major teratogenic risk in humans when used in the recommended doses.

Comparison of oral with rectal mesalazine in the treatment of ulcerative proctitis

PURPOSE

The aim of our study was to compare the efficacy and safety of oral mesalazine with mesalazine suppositories in patients with active ulcerative proctitis.

PATIENTS AND METHODS

A four-week, randomized, single-blind trial was performed in 58 patients with active, histologically confirmed ulcerative proctitis (< or = 15 cm) to evaluate the efficacy and safety of oral 800-mg mesalazine tablets taken three times per day (n = 29) compared with 400 mg of mesalazine suppositories administered three times per day (n = 29). Patients were evaluated at study entry and after two and four weeks. Efficacy evaluations included a disease activity index, which represents a score with four variables: stools frequency, rectal bleeding, mucosal appearance, and physician's assessment of disease severity. Histologic activity was also assessed at study entry and after two and four weeks in accordance with the criteria by Truelove and Richard. Safety assessment included clinical laboratory parameters and adverse event reports.

RESULTS

There were no significant differences with regard to baseline comparisons of demographics and severity between the two treatment groups. Improvement in mean disease activity index score was significantly greater with suppositories compared with oral mesalazine, both at two-week and four-week visits (mean disease activity index scores at baseline, two, and four weeks: suppositories = 7.7, 2.59, and 1.48; tablets = 7.42, 5.72, and 3.48, respectively (P < 0.001)). The rate of histologic remission was significantly greater with suppositories compared with tablets both at two and four weeks (P < 0.01). There were no significant differences in adverse events or clinical laboratory results between treatment groups.

CONCLUSIONS

Results of this study indicate that treatment with mesalazine suppositories produces earlier and significantly better results than oral mesalazine in the treatment of active ulcerative proctitis.

Comparison of mesalazine suppositories in proctitis and distal proctosigmoiditis

BACKGROUND

Mesalazine suppositories at 500 mg b.d. are a safe and effective treatment for patients with ulcerative proctitis or distal proctosigmoiditis. Recently a mesalazine 1 g suppository (Pentasa) has been developed.

METHODS

Fifty patients with active ulcerative colitis extending not beyond 20 cm from the anus on sigmoidoscopy, participated in a randomized single-blind study comparing the efficacy, tolerance and acceptance of the new Pentasa mesalazine 1 g suppository, given once daily versus Claversal mesalazine 500 mg suppository b.d.

RESULTS

After 2 weeks, clinical remission was observed in 16 of 25 (64%) in the Pentasa group and in 7 of 25 (28%) in the Claversal 500 mg b.d. treated group; sigmoidoscopic remission occurred in 13 of 25 (52%) in the Pentasa group and in six of 25 (24%) in the Claversal group (P < 0.01). After 4 weeks, clinical and sigmoidoscopic remission were observed, respectively, in 84 and 76% of patients treated with Pentasa suppositories, and in 80 and 72% of patients treated with Claversal suppositories 500 mg b.d. (P = N.S.). The patients' evaluation for tolerability and practicality showed that the Pentasa suppository was significantly superior to the Claversal suppository.

CONCLUSIONS

Pentasa 1 g suppository once daily induces a quicker clinical and sigmoidoscopic remission, and was better tolerated, than the Claversal 500 mg suppository b.d., and it may represent an advance for the topical treatment of distal proctosigmoiditis.

Acute pancreatitis after long-term 5-aminosalicylic acid therapy

Acute pancreatitis is a known, although rare, complication of mesalamine treatment. This complication typically appears within the first days or weeks after initiation of therapy. We describe two cases of acute pancreatitis that occurred after long term mesalamine therapy for ulcerative colitis. A rechallenge, performed in both patients, confirmed the diagnosis of mesalamine-induced pancreatitis. These case reports provide evidence that 5-aminosalicylic acid may induce acute pancreatitis after long term treatment.

Factors influencing the relapse of patients with inflammatory bowel disease

The management of relapse of inflammatory bowel disease (IBD) remains a clinical challenge and a relatively neglected area of current research. Many factors contribute to relapse, and the proper identification of the cause of each case may influence optimal management. Often, relapse is related to the failure of maintenance therapy. Mesalamine sensitivity is difficult to recognize and should be considered when increased doses are associated with the worsening of symptoms. An increase in eosinophil activity could explain seasonal relapses of IBD as a result of exposure to allergens, but other eosinophil activation pathways also will influence the course of IBD. Infection, either enteric or systemic, may trigger a relapse by activating the gastrointestinal mucosal immune system. Nonsteroidal anti-inflammatory drug use is a well-recognized cause of exacerbation of disease. Smoking status is emerging as a complex factor in IBD, and a change in smoking status may influence the course of IBD.

[Therapy of chronic inflammatory bowel diseases]

The treatment of ulcerative colitis and Crohn's disease shares certain common principles. Initial treatment is primarily medical for both diseases. The most important drug classes in inflammatory bowel disease are antiinflammatory agents, corticosteroids, and 5-aminosalicylic acid formulations (5-ASA). Corticosteroids and 5-ASA preparations are effective medical treatments in up to 80% of the patients with inflammatory bowel disease. The use of immunosuppressive therapy with drugs such as azathioprine is less established and should be restricted to patients who fail on standard medical treatment.

Mesalamine in the maintenance treatment of Crohn's disease: a meta-analysis adjusted for confounding variables

BACKGROUND & AIMS

The benefit of mesalamine for maintenance of remission in Crohn's disease is controversial. The aim of this study was to assess the effectiveness of mesalamine in maintaining remission of quiescent Crohn's disease.

METHODS

Pertinent randomized clinical trials were selected using MEDLINE (1986-1997) database, reference lists from published articles or reviews. Fifteen randomized, controlled trials of mesalamine maintenance therapy involving a total of 2097 patients were selected. The crude rates of patients with symptomatic relapse in treated and control groups were extracted according to the intention-to-treat method.

RESULTS

Therapy with mesalamine significantly reduced the risk of symptomatic relapse (pooled risk difference, -6.3%; 95% confidence interval, -10.4% to -2.1%). The pooled risk difference was significant in the postsurgical setting (-13.1%; 95% confidence interval, -21.8% to -4.5%) but not in the medical setting (-4.7%; 95% confidence interval, -9.6% to 2.8%). Multivariate model predicts that the probability of symptomatic relapse significantly decreases with mesalamine treatment, by increasing proportion of patients with ileal disease, with prolonged disease duration, and with surgically induced remission.

CONCLUSIONS

Mesalamine may be recommended for maintaining remission of quiescent Crohn's disease. The benefit is mainly observed in the postsurgical setting, in patients with ileitis and with prolonged disease duration.

A double-blind comparison of oral versus rectal mesalamine versus combination therapy in the treatment of distal ulcerative colitis

OBJECTIVES

The aim of this study was to compare the efficacy of mesalamine rectal suspension enema (Rowasa) alone, oral mesalamine tablets (Asacol) alone, and the combination of mesalamine enema and mesalamine tablets in patients with active mild-to-moderate distal ulcerative colitis.

METHODS

Sixty outpatients with ulcerative colitis at least 5 cm above the anal verge and not more than 50 cm, inclusive, and a total disease activity index (DAI) score between 4 and 10, inclusive, were randomized to either mesalamine rectal enema (n = 18) once nightly, oral mesalamine 2.4 g/day (n = 22), or a combination of both treatments (n = 20). Placebo capsules and enemas were used to maintain a blind procedure. Total DAI scores and abbreviated DAI scores were evaluated at wk 3 and 6, and wk 1 and 2, respectively. Patients recorded the amount of blood in stools, urgency, straining at stools, and abdominal pain in daily diaries. Physicians and patients rated overall improvement at each visit.

RESULTS

At wk 6, combination therapy produced a greater improvement (-5.2) in total DAI scores than did either mesalamine enema (-4.4) or mesalamine tablet (-3.9) therapy alone; similar treatment differences were observed at wk 3. Compared with patients given mesalamine enemas or mesalamine tablets, combination-therapy patients reported an absence of blood in stools significantly sooner and, at all visits, the combination therapy group had the highest percentage of patients who reported no blood in their stools. Physicians' and patients' ratings of improvement indicated that combination therapy significantly improved disease status, compared with mesalamine tablet therapy alone. All treatments were well tolerated.

CONCLUSIONS

The combination of oral and rectal mesalamine therapy was well tolerated and produced earlier and more complete relief of rectal bleeding than oral or rectal therapy alone.

Mesalazine-induced lupus

We report a case of lupus induced by mesalazine therapy taken for over a year for Crohn's disease. The patient had polyarthritis, alopecia, lymphoneutropenia, antinuclear factors, anti-histone antibodies, anti-Sm and anti-RNP. Discontinuation of mesalazine was followed by rapid resolution of the joint manifestations, alopecia and lymphoneutropenia; the anti-histone antibodies fell to undetectable levels and the titers of the other auto-antibodies decreased gradually.