Many Young People Stop UC Maintenance Tx, Risking Relapse

Nearly 70% of adolescents and young adults stop taking oral 5-aminosalicylic acid (5-ASA) maintenance therapy within 12 months of ulcerative colitis (UC) diagnosis, new research from the United Kingdom indicates.

“This is concerning as they are at risk of their condition returning and further complications. It can also lead to severe complications such as surgery to remove part of the gut,” Sonia Saxena, MBBS, director, Imperial Child Health Unit, School of Public Health, Imperial College London, United Kingdom, said in a news release.

The study “highlights the importance of counseling and education of patients at diagnosis as this is a critical window that influences long-term health behavior,” Ashwin Ananthakrishnan, MD, MPH, a gastroenterologist with Massachusetts General Hospital and Harvard Medical School, both in Boston, told Medscape Medical News.

“It has not been my experience in US-based practice that the rates of discontinuation are that high, but it would be important to examine this in different locations,” added Ananthakrishnan, who wasn’t involved with the study.

The study was published online in British Journal of General Practice.

Cases on the Rise

Globally, the incidence of UC is increasing fastest in younger populations. It’s estimated that up to 30% of individuals with UC are diagnosed in childhood or young adulthood, and these individuals are more likely to have a severe disease course and years living with disability compared with peers diagnosed later in life. This makes achieving disease control and maintaining remission “paramount” for those diagnosed in early life, Saxena and colleagues write.

International UC guidelines recommend starting therapy with 5-ASA, also known as mesalamine, soon after diagnosis and continuing it long term to maintain remission. However, some prior evidence suggests that adherence to UC medication may be less optimal in younger people — findings supported by the UK study.

Leveraging data from the UK Clinical Practice Research Datalink, Saxena and colleagues analyzed data for 607 children and young adults aged 10-24 years starting oral 5-ASA maintenance therapy for UC.

They found that 152 individuals (25%) stopped 5-ASA treatment after 1 month, and 419 (69%) discontinued it within 1 year of starting treatment. The median time to stopping the anti-inflammatory drug was 162 days.

Discontinuation rates were highest in young adults aged 18-24 years (74%). The transition to adult care and loss of support from caregivers who encourage adherence in adolescents and provide financial and practical support could be one explanation for this, the researchers write.

After accounting for other factors, young adults aged 18-24 years starting 5-ASA were 43% more likely to discontinue it in the first year than adolescents aged 10-14 years.

Individuals living in socioeconomically deprived areas were 46% more likely to stop treatment, compared with those living in more affluent areas, a finding that suggests the need to address socioeconomic disparities that could drive discontinuation, the authors say.

They also found that early corticosteroid use for an acute UC flare was associated with a 32% lower likelihood of stopping 5-ASA therapy.

Adherence Falls Short

In terms of adherence, only 72% of the cohort took the medication as prescribed. Adherence fell with older age at initiation of therapy. Adherence was 80% among those 10-14 years, 78% among those 15-17 years, and 69% among those 18-24 years. Prior research has shown that nonadherence has been associated with a 5-fold risk for disease relapse compared with adherence over 80%, the investigators note.

“If clinicians are unaware of suboptimal adherence to first-line medication, they may incorrectly assume therapy has failed, which may lead to unnecessary escalation in treatment and avoidable steroid use that remains high in UC,” the researchers write.

Psychiatric comorbidity (depression, anxiety, or antidepressant use) was not associated with discontinuation or adherence to treatment.

“As doctors, this study shows we need to be keeping a close eye on patients, particularly within that first year of starting medication,” Saxena said in the release.

“We should check if these patients are getting their medications and whether they have difficulty paying for them. We should also use the opportunity to talk through any recurring symptoms and how to access advice from providers such as a nurse specialist,” Saxena said.

Effectiveness of Therapy in Young Adults

Reached for comment, Michael Dolinger, MD, assistant professor of pediatric gastroenterology, Icahn School of Medicine and Mount Sinai Kravis Children’s Hospital, both in New York City, said he has seen 5-ASA stoppage among his younger patients.

“Generally, what we see is that the majority of patients over time are not able to be sustained on oral mesalamine treatment, and they need a more advanced therapy,” Dolinger told Medscape Medical News.

And while the UK study did not delve into the reasons for discontinuation, ineffectiveness of therapy is likely a main cause, Dolinger said.

“We especially see this in our younger adolescent and young adult patients. In these younger patients, the immune system is potentially driving inflammation a bit more than in older patients, often going beyond the inner lining of the colon to the entire bowel wall, even in ulcerative colitis, and therefore mesalamine may be ineffective over the first year,” Dolinger explained.

When choosing a more advanced therapy, Dolinger said, “it’s all about having that conversation in a shared decision-making process about what may be the most effective short- and long-term treatment options with the best safety for that patient. It’s a very individualized discussion.”

“One of the main things we preach and talk about is control of inflammation, getting into early deep remission, because the longer you have inflammation, even if it’s just smoldering, the harder it is to get into deep remission,” Dolinger added.

Br J Gen Pract. Published online September 4, 2023. Full text

The study had no commercial funding. Saxena, Ananthakrishnan, and Dolinger have disclosed no relevant financial relationships.

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