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Intest Res.  2025 Jan;23(1):37-55. 10.5217/ir.2024.00089.

Optimizing 5-aminosalicylate for moderate ulcerative colitis: expert recommendations from the Asia-Pacific, Middle East, and Africa Inflammatory Bowel Disease Coalition

Affiliations
  • 1Department of Gastroenterology, Istanbul Faculty of Medicine, Istanbul University, Istanbul, Türkiye
  • 2Department of Gastroenterology, Mater Hospital Brisbane, Brisbane, Australia
  • 3Division of Gastroenterology, King Chulalongkorn Memorial Hospital, Chulalongkorn University, Bangkok, Thailand
  • 4Department of Gastroenterology, University Medical Center, University of Medicine and Pharmacy at Ho Chi Minh City, Ho Chi Minh City, Vietnam
  • 5The Gastroenterology Group, Gleneagles Hospital, Singapore
  • 6Department of Internal Medicine, Chung-Ang University College of Medicine, Seoul, Korea
  • 7Department of Gastroenterology, Baragwanath Hospital, University of the Witwatersrand, Johannesburg, South Africa
  • 8Department of Gastroenterology, Liverpool Hospital, Sydney, Australia
  • 9South Western Clinical School, University of New South Wales, Sydney, Australia
  • 10Division of Medical Gastroenterology, P. D. Hinduja Hospital, Mumbai, India
  • 11Department of Gastroenterology, St. Vincent’s Hospital, Melbourne, Australia
  • 12Center for Advanced IBD Research and Treatment, Kitasato University Kitasato Institute Hospital, Tokyo, Japan
  • 13Global Health Program, College of Public Health, National Taiwan University, Taipei, Taiwan
  • 14Ferring Pharmaceuticals, Singapore
  • 15Department of Gastroenterology, Concord Hospital, Sydney, Australia
  • 16Pantai Hospital Kuala Lumpur, Kuala Lumpur, Malaysia
  • 17Department of Medicine, University of Hong Kong, Hong Kong, China
  • 18Deparment of Medicine, Siriraj Hospital, Mahidol University, Bangkok, Thailand
  • 19Gastrointestinal Endoscopy Center, Cipto Mangunkusumo General Hospital, Jakarta, Indonesia
  • 20Universitas Indonesia, Jakarta, Indonesia
  • 21Department of Gastroenterology, Yashoda Hospital, Hyderabad, India
  • 22Department of Gastroenterology, Zhoupu Hospital, Shanghai University of Medicine & Health Sciences, Shanghai, China
  • 23Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan
  • 24Faculty of Medicine and Surgery, University of Santo Tomas, Manila, Philippines
  • 25Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xi’an, China
  • 26Department of Gastroenterology and Inflammatory Bowel Disease Center, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
  • 27Duke-NUS Medical School, Singapore

Abstract

The lack of clear definition and classification for “moderate ulcerative colitis (UC)” creates ambiguity regarding the suitability of step-up versus top-down treatment approaches. In this paper, experts address crucial gaps in assessing and managing moderate UC. The Asia-Pacific, Middle East, and Africa Inflammatory Bowel Disease Coalition comprised 24 experts who convened to share, discuss and vote electronically on management recommendations for moderate UC. Experts emphasized that the goal of treating UC is to attain clinical, biomarker, and endoscopic remission using cost-effective strategies such as 5-aminosalicylates (5-ASAs), well-tolerated therapy that can be optimized to improve outcomes. Experts agreed that 5-ASA therapy could be optimized by maximizing dosage (4 g/day for induction of remission), combining oral and topical administration, extending treatment duration beyond 8 weeks, and enhancing patient adherence through personalized counselling and reduced pill burden. Treatment escalation should ideally be reserved for patients with predictors of aggressive disease or those who do not respond to 5-ASA optimization. Premature treatment escalation to advanced therapies (including biologics and oral small molecules) may have long-term health and financial consequences. This paper provides consensus-based expert recommendations and a treatment algorithm, based on current evidence and practices, to assist decision-making in real-world settings.

Keyword

Ulcerative colitis; 5-Aminosalicylates; Treatment optimization; Inflammatory bowel diseases

Figure

  • Fig. 1. Proposed treatment algorithm for patients with moderate ulcerative colitis (UC). aAccording to modified Truelove and Witts criteria: 4–6 bowel movements/day, temperature ≤37.8°C, pulse ≤90 beats/min, hemoglobin ≥10.5 g/dL, and C-reactive protein ≤30 mg/L. Additional assessments to measure disease activity may take into account clinical presentation, patient-reported symptoms, and objective/ laboratory criteria. In the absence of a validated definition for moderate UC, classification of moderate UC is subject to physicians’ preferences and judgement; bThe weightage for each predictor varies, and management strategies are determined at the physician’s discretion; cRectal 5-aminosalicylate (5-ASA) at a dose of ≥1 g/day at induction is recommended for patients with distal UC, specifically those with proctosigmoiditis or proctitis; dIf 5-ASA dose has been maximized to ≥4 g/day, and topical 5-ASA therapy has been added and similarly optimized (e.g., ≥1 g/day rectal 5-ASA), also optimize patient adherence, extend treatment duration, and switch 5-ASA formulation [17]; eBudesonide multimatrix (MMX) can be considered before systemic corticosteroids. In some areas, beclomethasone dipropionate is being used instead of budesonide MMX; fEarly escalation to immunomodulators such as thiopurine may be required for patients who are intolerant of 5-ASA or with specific strong predictors of aggressive disease; gFor patients with predictors of aggressive disease, consider adding 30–40 mg/day oral corticosteroids to 5-ASA. For patients with an inadequate response to 5-ASA therapy, an add-on dose of ≥40 mg/day oral corticosteroids could be considered; hInadequate response: failure to achieve ≥50% decrease in rectal bleeding and stool frequency, per an adaptation of STRIDE-II consensus recommendations [49]; iRelapse: failure to achieve rectal bleeding=0, stool frequency=0, or Mayo Endoscopic Subscore <3, per an adaptation of STRIDE-II consensus recommendations [49]; jFor maintenance therapy in moderate endoscopic activity: after tapering corticosteroids, an immunomodulator such as thiopurine should be considered in addition to 5-ASA; kFor corticosteroid-dependent patients: 5-ASA (particularly topical) can be continued for symptom control until onset of action of treatment, for chemoprotective effects, to meet reimbursement criteria, to control disease activity after de-escalation/treatment holiday, or if patient prefers. IV, intravenous; STRIDE, Selecting Therapeutic Targets in Inflammatory Bowel Disease. Adapted from Le Berre C, et al. Expert Opin Biol Ther 2020;20:363-378, with permission from Taylor & Francis [45].


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