Outcome of 5-Aminosalicylate (5-ASA) Continuation Versus Discontinuation in Patients With Inflammatory Bowel Disease Started on Biologic Therapy: A Systematic Review and Meta-analysis

Background:
Patients with inflammatory bowel disease (IBD), including ulcerative colitis (UC) and Crohn’s disease (CD), started on biological therapy are usually continued on 5-aminosalicylates (5-ASA). Studies have yielded conflicting results regarding the efficacy of continuing 5-ASA in patients who escalate to biologic therapies. The present meta-analysis aimed to compare the outcome of 5-ASA continuation vs discontinuation in patients with IBD started on biologic therapy.
Methods:
A comprehensive literature search of 3 electronic databases was conducted from inception to July 2024 for studies comparing the outcome of 5-ASA continuation vs discontinuation in patients with IBD started on biologic therapy. The outcomes assessed included the risk of hospitalization, corticosteroid use, surgery, and composite outcome of all events. The adjusted hazard ratios (aHR) were pooled using a random effects model.
Results:
A total of 4 studies were included in the present analysis, of which 3 reported on patients with UC and 4 on CD. One study by Ungaro et al. reported data from 2 separate cohorts – US and Danish. The pooled analysis for studies on UC showed that the discontinuation of 5-ASA was not associated with increased risk of composite outcome (aHR 1.01, 95% CI: 0.91-1.11; I2 = 0.0%), hospitalization (aHR 0.99, 95% CI: 0.84-1.15; I2 = 0.0%), corticosteroid use (aHR 1.00, 95% CI: 0.89-1.11; I2 = 0.0%), and surgery (aHR 0.90, 95% CI: 0.62-1.30; I2 = 25.1%). The pooled analysis for studies on CD showed that the discontinuation of 5-ASA was not associated with increased risk of composite outcome (aHR 0.95, 95% CI: 0.88-1.03; I2 = 0.0%), hospitalization (aHR 1.01, 95% CI: 0.93-1.11; I2 = 56.9%), corticosteroid use (aHR 0.99, 95% CI: 0.92-1.07; I2 = 73.9%), and surgery (aHR 1.02, 95% CI: 0.86-1.22; I2 = 0.0%). Leave-one-out analysis did not show any significant difference in the effect size.
Conclusions:
The present analysis showed that discontinuing 5-ASA after starting biological therapy was not associated with an increased risk of adverse outcomes in patients with IBD. Hence, 5-ASA can be safely stopped in patients with IBD once biological therapy is initiated.