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

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.