Alternatives for Patients Experiencing Problems with Long-Term Mesalamine Therapy

First-Line Alternatives

The American Gastroenterological Association recommends balsalazide as a preferred diazo-bonded 5-ASA alternative due to its better tolerability profile while maintaining similar effectiveness to standard-dose mesalamine for induction and superior efficacy for maintenance 1, 2
Balsalazide is appropriate for treatment of extensive mild-to-moderate ulcerative colitis with similar mechanism of action but fewer side effects 1, 2
Standard dosing of balsalazide is 2.5 g/day 3

Once-daily dosing of mesalamine rather than multiple times per day has shown similar efficacy for both induction and maintenance of remission with potentially better adherence 4
Combined oral and rectal therapy may be more effective than oral therapy alone for both induction and maintenance of remission 4, 5
Combination therapy was significantly more effective for induction of remission (RR 0.68, 95%CI 0.49–0.94) 5
Superior to oral 5-ASA alone for maintenance of remission (RR 0.45, 95%CI 0.20–0.97) 5

High-dose mesalamine (>3 g/day) with rectal mesalamine may be considered for patients with suboptimal response to standard-dose therapy 4
Biologic therapies and/or immunomodulators may be considered for patients not responding to optimized 5-ASA therapy 4

Lifelong maintenance therapy is generally recommended for all patients, especially those with left-sided or extensive disease 8

Switching between different mesalamine preparations in search of more effective treatment is not recommended, as there is little evidence to suggest differences in efficacy between them 1, 2
Delaying escalation to more effective therapy in patients with worsening disease may place patients at risk for complications 4
Inadequate dosing of alternative therapies, as higher doses (≥2 g/day) are often needed for maintenance of remission 8