5-ASA Therapy Research Articles

Cost Effectiveness of Treatments for Inflammatory Bowel Disease

Traditionally, half of the direct costs associated with chronic inflammatory bowel diseases (IBD) [Crohn's disease (CD) and ulcerative colitis (UC)] have related to hospital inpatient treatment for a sub-group of more severely affected, often therapy-resistant individuals. The advent of effective but relatively expensive biological agents has increased the contribution of drugs to overall medical care costs. This has focussed interest on the relative cost effectiveness of rival therapies for IBD and, in particular, on the affordability of long-term biological therapy. The purpose of this article is to review the available literature on this topic and to identify areas for future research. Head-to-head trials of competing treatment options are uncommon and clinical trials have seldom addressed cost effectiveness. In UC, models have explored the cost utility of 'high-' versus 'standard-' dose 5-aminosalicylic acid (5-ASA) therapy and the theoretical impact of improved adherence with once-daily formulations. In CD, cost-utility models for anti-tumour necrosis factor (TNF) drugs versus standard care have suggested consistently that incremental benefits are achieved at increased overall cost. However, studies of varying design have produced a wide spectrum of incremental cost-effectiveness ratio estimates, which highlights the challenges and limitations of existing modelling techniques.

A Distinct Mechanism for Reflux in Patients With Cystic Fibrosis: A Study Using High Resolution Manometry-Impedance

neoplasia. Cox proportional hazard regression analysis was used to calculate the risk of advanced neoplasia in patients with and without thiopurine or 5-ASA use. Results: A total of 2605 patients with a confirmed IBD diagnosis were included in this study. Of these, 981 patients (38%) used 5-ASA, 315 patients (12%) used thiopurines, 459 patients (18%) used both 5-ASA and thiopurines and 850 patients (33%) used none of these drugs. No statistically significant differences were found for type of IBD, gender, age, duration of IBD and extent of IBD between these groups. Thirty-one patients (1%) developed advanced neoplasia during 16,568 person years of follow-up. Of these, 12 patients (39%) had used 5-ASA, 2 (7%) thiopurines and 1 (3%) both drugs. Increasing age and disease involvement of more than 50% of the colon were associated with an increased risk of developing advanced neoplasia (adjusted hazard ratio (HR) 1.07, 95% confidence interval (CI) 1.04-1.11 and adjusted HR 5.88, 95% CI 2.00-17.3, respectively). Thiopurine use was associated with a significantly decreased risk of developing advanced neoplasia (adjusted HR 0.10, 95% CI 0.01-0.73). 5ASA therapy had also a protective effect on developing advanced neoplasia, but this was not statistically significant (adjusted HR 0.51, 95% CI 0.20-1.26). Conclusion: Thiopurine use protects colitis patients against the development of advanced neoplasia. The effect of 5ASA appeared to be less pronounced.

Impact of a tailored patient preference intervention in adherence to 5-aminosalicylic acid medication in ulcerative colitis: Results from an exploratory randomized controlled trial

Up to 40% of patients with ulcerative colitis (UC) fail to comply with 5-aminosalicylic acid (5-ASA) therapy. This study aimed to evaluate multifaceted adherence-enhancing interventions for oral 5-ASA therapy in UC and consider changes in health beliefs and satisfaction with information. Adults attending a UK gastroenterology outpatient clinic were recruited to an exploratory randomized controlled trial. The tailored intervention included educational and motivational components, plus options including simplified dosing regimes and practical reminders such as pill dispensers. Adherence was assessed objectively at baseline and after 1 year based on levels of urinary 5-ASA and N-acetly-5-ASA concentration. Changes in relevant beliefs and satisfaction with information were measured using validated questionnaires. Seventy-one people completed the study. Adherence levels in the study population were relatively high at baseline (76%) but a decline in adherence levels over the study period was noted. However, at follow-up adherence in the intervention group was 44% greater than in the control group. Intervention group status had a significant positive impact on maintaining adherence levels after adjusting for potential confounders including baseline adherence (P = 0.001). This finding was supported by the results of a sensitivity analysis including patients who withdrew from the study. Changes in questionnaire scores suggested a positive effect of the intervention on satisfaction with information (P < 0.001). The multifaceted approach studied has potential for implementation in routine care for enhancing persistence with 5-ASA and thus improving patient outcomes.

Oral 5‐aminosalicylic acid therapy for mild‐to‐moderate ulcerative colitis

5-aminosalicylic acid (5-ASA) is the recommended first-line treatment for patients with ulcerative colitis (UC). These patients frequently fail to receive the full benefit from this treatment, often as a result of nonadherence to complex dosing regimens. The purpose of this review is to update nurse practitioners (NPs) on the available 5-ASA formulations for patients with UC and to explore the role of NPs in the effective use of these drugs in disease management. Pubmed and recent conference abstracts were searched for studies that examined either 5-ASA therapy in UC or the role of NPs in their treatment. Patients frequently fail to adhere to their 5-ASA treatment regimens, perhaps owing to a lack of understanding about their disease, or a lack of awareness of their medical management options. The unique relationship between patients and NPs allow barriers to treatment success to be identified and overcome. For patients with UC, NPs are often a primary point of contact, and are therefore ideally placed to take steps to positively influence and change patient behavior.

The Use of Appropriate Medical Therapy in an Underserved Population with Inflammatory Bowel Disease (IBD)

Purpose: Immunomodulators and biologics are effective in both ulcerative colitis (UC) and Crohn's disease (CD) for induction and maintenance of remission in patients with moderate-to-severe disease activity. However, several barriers may prevent patients from getting these medications. Our aim was to examine the appropriate utilization of medical therapy in an underserved patient population in Miami, Florida. Methods: A retrospective chart review of all patients with ICD9-CM diagnoses of UC or CD was conducted in the outpatient gastroenterology clinic of Miami-Dade County's public hospital (Jackson Memorial Hospital) from January 1, 2004 to December 31, 2009. Information concerning demographics, medication history, and criteria for immunomodulator and/or biologic therapy were obtained. Patients were included if any of the following criteria were met: 1) ≥2 courses of steroids; 2) steroid-dependency; 3) steroid-refractoriness; 4) IBD-related surgery; 5) perianal disease; 6) active disease on 5-ASA therapy. Patients meeting these criteria and on either an immunomodulator or biologic were considered on appropriate therapy. The percentage of patients on appropriate medical therapy was then calculated and cohorts on appropriate and suboptimal therapy were compared. Results: 152 charts were reviewed, of which 97 (51 male, 46 female) met inclusion criteria. The mean age was 43 years, consisting of 54% Hispanics, 31% African Americans, and 15% Caucasians. Of those who met inclusion criteria, 63 (65%) were on appropriate therapy. Patients meeting only one criteria were significantly less likely to be on appropriate therapy compared to those with greater than one indication (38% vs. 62%; p=0.026). Patients first seen before 2008 were less likely to be on appropriate therapy compared to those first seen after 2008 (76% vs. 52%; p=0.02). No difference between those on appropriate and suboptimal therapy was observed with respect to age, gender, ethnicity, IBD subtype, smoking history, or insurance status. Conclusion: In the underserved IBD population of Miami-Dade County (85% non-Caucasian), approximately two-thirds of patients met criteria for immunomodulator or biologic therapy; only 65% of these subjects were given appropriate therapy. This underutilization of therapy was observed in subjects meeting only one inclusion criterion and those initially seen prior to 2008. Studies examining reasons for underutilization of these resources in our patient population are currently underway.

Compliance and Adherence with 5-ASA Therapy for Ulcerative Colitis in Canada: A Retrospective Analysis of a Large Claims Database

Compliance and Adherence with 5-ASA Therapy for Ulcerative Colitis in Canada: A Retrospective Analysis of a Large Claims Database

Recent advances in the management of distal ulcerative colitis

The most frequent localization of ulcerative colitis (UC) is the distal colon. In treating patients with active distal UC, efficacy and targeting of the drug to the distal colon are key priorities. Oral and rectal 5-aminosalicylic acid (5-ASA) preparations represent the first line therapy of mild-to-moderate distal UC for both induction and maintenance treatment. It has been reported that many UC patients are not adherent to therapy and that non-compliant patients had a 5-fold risk of experiencing a relapse. These findings led to the introduction of once-daily oral regimens of 5-ASA as better therapeutic options in clinical practice due to improved adherence. New formulations of mesalazine, including the multi-matrix delivery system, and mesalazine granules, which allow once-daily administration, have been developed. They have been demonstrated to be efficacious in inducing and maintaining remission in mild-to-moderate distal UC in large clinical trials. However, existing data for distal UC are rather insufficient to make a comparison between new and classical 5-ASA formulations. It seems that the new formulations are at least as effective as classical oral 5-ASA formulations. Other treatment options, in the case that 5-ASA therapy is not effective, include systemic corticosteroids, thiopurines (azathioprine or 6-mercaptopurine), cyclosporine, infliximab and surgery. The combination of a prompt diagnostic work-up, a correct therapeutic approach and an appropriate follow-up schedule is important in the management of patients with distal UC. This approach can shorten the duration of symptoms, induce a prolonged remission, improve patient's quality of life, and optimize the use of health resources.

An investigation of medication adherence to 5‐aminosalicylic acid therapy in patients with ulcerative colitis, using self‐report and urinary drug excretion measurements

Non-adherence to 5-aminosalicylic acid (5-ASA) medication can limit the established benefits of this therapy in ulcerative colitis (UC). To determine rates and predictors of non-adherence to 5-ASA therapy in UC patients. Medication adherence was assessed using self-report data and urinary drug excretion measurements. Participants completed a study-specific questionnaire and two validated questionnaires: Beliefs about Medicine Questionnaire (BMQ)-Specific and Satisfaction with Information about Medicines Scale. A total of 169 participants provided self-report adherence data; 151 also provided urine samples. Adherence rates were 111/151 (68%) according to self-report and 90/151 (60%) according to urine analysis, but the two measures were not correlated (chi(2) = 0.12, P = 0.725). Logistic regression identified a significant association between self-reported non-adherence and younger age [odds ratio (OR) for increased age 0.954, 95% confidence interval (CI) 0.932-0.976] and also doubts about personal need for medication (OR for BMQ - Specific Necessity scores 0.578, 95% CI 0.366-0.913). For non-adherence based on urine analysis, only South Asian ethnicity was independently associated with non-adherence (OR 2.940, 95% CI 1.303-6.638). Our observations confirm the difficulty of accurately assessing medication adherence. Nonmodifiable (younger age, South Asian ethnicity) and potentially modifiable (medication beliefs) predictors of non-adherence were identified.

Nitazoxanide to Treat Exacerbations of Pediatric Inflammatory Bowel Disease (IBD)

Purpose: Nitazoxanide (NTZ) is a thiazolide antibiotic indicated for the treatment of Cryptosporidium parvum and Giardia lamblia in adults and children as young as one year of age. NTZ also has excellent in vitro activity against anaerobic bacteria. Unlike many antibiotics used in IBD, NTZ has a unique pharmacokinetic profile in which 2/3 of the drug concentrates in the bowel and 1/3 is absorbed, allowing for drug on both sides of the gastrointestinal lumen. Furthermore, NTZ is well tolerated, not associated with peripheral neuropathies, and does not induce Clostridium difficile disease. This paper documents our clinical experience utilizing NTZ in pediatric patients with exacerbations of IBD. Methods: An IRB approved review of children with IBD experiencing disease exacerbation and treated with NTZ. To qualify for evaluation, patients needed to be on at least maintenance 5-ASA therapy and present with one of the following symptoms: 1) GI bleeding, 2) diarrhea, or 3) abdominal pain. Efficacy was measured as resolution of presenting symptoms, and patient/parent reported overall wellness at follow-up evaluation. Patients with a known infectious origin of disease like Clostridium difficile were excluded from the study. Results: Twenty patients mean age 12 years (range 3-18) met the inclusion criteria. Of these, 9 had Crohn's disease, 6 ulcerative colitis, and 5 indeterminate colitis. NTZ was dosed 100-500 mg (age adjusted) BID for 5-14 days (mean 10 days), 8 patients also received a prednisone course. Symptom presentation was as follows: 70% (14/20) GI bleeding, 60% (12/20) diarrhea, and 85% (17/20) abdominal pain; 25% (5/20), 35% (7/20), and 40% (8/20) presented with 1, 2, and 3 symptoms respectively. Efficacy measures are detailed in Table 1. No significant adverse reactions to therapy were identified.Table 1: Patient outcomesConclusion: Nitazoxanide with or without adjunctive steroids is well tolerated and appears to improve symptoms associated with IBD exacerbations in pediatric patients. Further studies are warranted to confirm this observation. Disclosure: Dr Al-Tawil- Unrestricted educational grant, Romark Laboratories. Dr Eidelwein, Dr Cuevas, Wendy Taylor, and Molly Hansen have nothing to disclose.

Predictors of persistence with 5‐aminosalicylic acid therapy for ulcerative colitis

Individuals with ulcerative colitis (UC) are at risk for poor persistence with therapy. To identify factors predicting persistence with 5-aminosalicylic acid (5-ASA) therapy after 3 and 12 months in subjects with UC. In this retrospective cohort study, persistence with 5-ASA therapy was determined from prescription refill data from a commercial health insurance claims database. The analysis included subjects with UC who filled a prescription for any oral 5-ASA between October 2002 and September 2004. Persistence was defined as prescription refill at 3 and/or 12 months. Multivariate logistic regression modelling identified variables independently associated with persistence at 3 and 12 months. In all, 3574 subjects were identified. Fifty-seven per cent (2044) were persistent at 3 months. Glucocorticoid use before the index prescription predicted improved persistence at 3 months. Psychiatric diagnosis, mail order of the index prescription, female gender and co-pay predicted decreased persistence. At 12 months, 1124 (55%) remained persistent. Rectal 5-ASA use, older age and switching to a different 5-ASA predicted improved persistence at 12 months. Hospitalization for a gastrointestinal condition, mail order of the 3-month prescription and number of co-morbid illnesses predicted lower persistence. Persistence with 5-ASA treatment in UC is complex and multifactorial, and differs by time period.

Systematic review: does concurrent therapy with 5‐ASA and immunomodulators in inflammatory bowel disease improve outcomes?

With greater use of immunomodulators in inflammatory bowel disease (IBD), it is uncertain whether concurrent therapy with both 5-aminosalicylic acid [5-ASA, mesalazine (mesalamine)] and an immunomodulator is necessary. To determine whether concurrent therapy with both 5-ASA and immunomodulator(s) improves outcomes in IBD. Systematic review with search terms 'azathioprine, 6-mercaptopurine, thiopurine(s), 5 aminosalicylic acid, mesalazine, inflammatory bowel disease, ulcerative colitis, Crohn's disease, immunosuppressant(s), immunomodulator and methotrexate' in November 2007 to identify clinical trials on concurrent 5-ASA and immunomodulator therapy. Two small controlled studies were found. Neither showed a benefit on disease control beyond immunomodulator monotherapy. Potential pharmacological interactions exist between 5-ASA and thiopurines. Whilst circumstantial, epidemiological and laboratory evidence suggests that 5-ASA may assist colorectal cancer (CRC) chemoprevention, it may simply be via anti-inflammatory effects. With changes in practice, ethical issues and the long lead-time needed to demonstrate or disprove an effect, no clinical studies can/will directly answer this. The costs of avoiding one CRC in IBD may be as low as 153 times the annual cost of 5-ASA therapy. It is unclear whether concurrent 5-ASA and immunomodulator therapy improves outcomes of disease control, drug toxicity or compliance. Concurrent therapy of 5-ASA and immunomodulators may decrease CRC risk at 'acceptable' cost.

P008 - Adalimumab sustains quality-of-life improvements in patients with Crohn's disease: 3-year data from CHARM

A C). Four of them (57%) had fistula associated CRC. They suffered from CD for a median of 13 years (range 12 33). Seven patients with CRC were matched 1:3 to randomly selected Crohn’s patients based on age (9 male, 12 female). The medical records of these patients were evaluated with respect to duration and pattern of intestinal involvement of CD, fistula history, intestinal surgery, perianal surgery, prior immunosuppressive and 5-ASA derivative intake. Three patients of the matched group had involvement of the terminal ileum, 13 of ileocolon, 1 of upper GI and 4 of ileocolon and upper GI tract, with a disease duration of a median of 26 years (range 5 62). From these 21 patients 11 suffered from perianal fistula (52%). Results: Colorectal cancer was significantly (p = 0.048) associated with longstanding anorectal fistula (median = 11 years, range 0 28) in the CRC group compared to the matched Crohn’s patients [median = 1 year (range 0 6)]. The formation of cancer in a fistula showed a significant (p = 0.08) correlation with duration of the perianal disease. Earlier colonic surgery seemed to protect from later malignancy (p = 0.036; 16 matched controls had colonic surgery versus 2 patients in the CRCgroup). No significant symptoms preceded rectal carcinoma, except for new blood drainage from fistula in 2 patients. Two patients underwent ileocolonoscopy within 1 year before the diagnosis of malignancy without hint of dysplasia or carcinoma and 2 patients underwent MRI of the pelvic region within 4 months before surgery without recognizing malignant changes. There were no significant differences in 5-ASA, azathioprine intake or infliximab therapy, perianal surgery, extension and duration of the Crohn’s disease in both groups. The one year survival rate was 84% in patients with CRC. Conclusion: Colorectal carcinoma is generally rare in patients with Crohn’s disease, but is frequently associated with the presence of longstanding (>10 years of duration) anorectal fistula. It occurred with minimal change of symptoms and was not visible in previous MRI.

Effect of 5-aminosalicylates on renal function in patients with inflammatory bowel disease: 4-year follow-up study

ObjectiveNephrotoxicity has been described in some patients with inflammatory bowel disease (IBD) treated with 5-aminosalicylates (5-ASA). Our aim was to conduct a retrospective study of IBD patients, both with and without 5-ASA treatment, who underwent regular evaluation of renal function over a 4-year period. MethodsSerum creatinine was measured before the start of 5-ASA therapy, and thereafter yearly up to 4 years. Creatinine clearance (ClCr) was estimated from serum creatinine (Cockroft & Gault formula). The influence of 5-ASA treatment on renal function was assessed by univariate and multivariate analysis. ResultsA total of 150 IBD patients (ulcerative colitis in 45%, Crohn's disease in 55%) were included. Sixty-two patients were receiving 5-ASAs (95% coated mesalazine, mean dose 1.9±0.8g/day). Both serum creatinine levels and ClCr were similar in patients with and without 5-ASA treatment, and remained stable throughout the 4-year follow-up in patients taking 5-ASAs. In the multivariate analysis, 5-ASA treatment (or its dose) was not correlated with serum creatinine levels or ClCr. No interstitial nephritis was reported during follow-up. Conclusion5-ASA-related renal disease was not found in our series, suggesting that the occurrence of renal impairment in IBD patients receiving these drugs is exceptional. Our results do not support the recommendation of serum creatinine monitoring in patients receiving 5-ASA treatment.

Cost-Effectiveness of 5-Aminosalicylic Acid Therapy for Maintenance of Remission in Ulcerative Colitis

Oral 5-aminosalicylic acid (5-ASA, mesalamine) is effective in inducing and maintaining remission in ulcerative colitis (UC). The relative benefits and costs of maintenance 5-ASA therapy are uncertain. Our aims were to evaluate this strategy's potential cost-effectiveness. We constructed a Markov model to compare two strategies over 2 yr: (a) no maintenance 5-ASA, with 5-ASA 4.8 g/day given for flares, (b) maintenance 5-ASA 2.4 g/day, escalated and maintained at 4.8 g/day after the first flare. In both arms, the failure to induce remission led to other treatments, as needed: prednisone, parenteral corticosteroids, cyclosporine, 6-mercaptopurine, infliximab, and colectomy. Without maintenance 5-ASA, the mean flares per person were 1.92, and the mean cost per person was $3,402. With maintenance 5-ASA providing a relative risk of flare of 0.7 at 5-ASA cost of $198/month, flares per person decreased to 1.38 at a cost of $8,810/flare prevented. Maintenance 5-ASA increased discounted quality-adjusted life-years per person (QALYs per person) from 1.75 to 1.77 at a discounted cost of $224,000/QALY gained. The results were most sensitive to the flare risk reduction and cost of 5-ASA, the utilities of being in remission without or with 5-ASA, and the colectomy rates. At $15/month (the cost of sulfasalazine), maintenance 5-ASA cost $640/flare prevented and $16,300/QALY gained. Maintenance 5-ASA therapy decreases UC flares, but its cost may be substantial, depending on society's willingness to pay. If sulfasalazine can be tolerated and yields comparable benefits, sulfasalazine maintenance therapy is likely to be cost-effective. The cost per QALY gained by 5-ASA maintenance is highly dependent on the quality of life while taking versus not taking maintenance 5-ASA, highlighting the importance of patients' preferences.

W1229 5-ASA Therapy and a Lower Inflammatory Score in Chronic Ulcerative Colitis Are Associated with a Decreased Risk of Dysplasia and Colorectal Cancer

W1229 5-ASA Therapy and a Lower Inflammatory Score in Chronic Ulcerative Colitis Are Associated with a Decreased Risk of Dysplasia and Colorectal Cancer

T1053 Gastroenterologist Visits and Endoscopy Are Associated with Improved Persistence to 5-ASA Therapy

T1053 Gastroenterologist Visits and Endoscopy Are Associated with Improved Persistence to 5-ASA Therapy

Oral 5-ASA Therapy in Ulcerative Colitis

5-aminosalicylic acid (5-ASA) is the standard first-line treatment for mild-to-moderate ulcerative colitis. A variety of 5-ASA delivery systems are available and in development, including both oral and rectal formulations; all of which aim to deliver the active drug to the colon while minimizing systemic absorption. Because the efficacy of most oral 5-ASA therapies is broadly similar, the appropriate selection of a given formulation often relies on other factors. This article explores the differences between oral 5-ASA formulations in terms of their delivery system, reviews the available data on oral 5-ASA treatment efficacy and tolerability, and examines the rationale for changing from one 5-ASA formulation to another if a patient does not respond to, or worsens on, their existing agent.

MMX mesalazine for the induction of remission of mild‐to‐moderately active ulcerative colitis: efficacy and tolerability in specific patient subpopulations

Two phase III studies have evaluated mesalazine (mesalamine) with MMX (Multi Matrix System) technology in patients with active mild-to-moderate ulcerative colitis. To determine the efficacy of MMX mesalazine for the induction of clinical and endoscopic remission in specific subgroups of patients with active, mild-to-moderate ulcerative colitis. Data from two double-blind, placebo-controlled trials were analysed (517 out-patients). Patients were randomized to receive MMX mesalazine [2.4 g/day (once daily or 1.2 g twice daily) or 4.8 g/day (once daily)] or placebo for 8 weeks. The percentages of patients treated with MMX mesalazine, 2.4 or 4.8 g/day, in clinical and endoscopic remission at week 8 were similar and significantly (P < 0.05) greater than placebo in subgroups stratified by disease extent, disease severity and gender and among patients not previously receiving low-dose 5-aminosalicylic acid. Among patients transferring directly from prior low-dose oral 5-aminosalicylic acid, MMX mesalazine 4.8 g/day was significantly (P = 0.018) more effective than placebo in inducing clinical and endoscopic remission. Efficacy over placebo did not reach significance in patients transferring directly to MMX mesalazine 2.4 g/day. MMX mesalazine is effective in active UC regardless of disease extent, disease severity, gender and previous, low-dose, 5-ASA therapy.

Patient and Physician Perceptions on Living with Ulcerative Colitis: Results from Two Internet Surveys

Table: Incidence of Renal Insufficiency and Leukopenia with 5-ASA MedicationsPurpose: To understand how the perception of the impact of ulcerative colitis (UC) on patients’ lives differs between patients and gastroenterologists. Methods: Two national internet surveys were conducted: one in patients with UC and one in gastroenterologists. Here we present selected results from these surveys. Patients with a history of colectomy were excluded. Results: 451 patients with UC (20% mild, 63% moderate, 13% severe [as informed by their physician]) and 300 gastroenterologists (unassociated with the patients) were included in the surveys. In total, 36% of patients reported having ≥6 flares per year (subjective self-definition). This number exceeded gastroenterologists’ expectations for a patient population with this distribution of disease severities. When patients were asked what being in remission meant to them, 44% believed it meant living with UC symptoms, but managing life without interruption. Although ∼55% of patients reported being prescribed 5-aminosalicylic acid (5-ASA) therapy, the gastroenterologists reported prescribing 5-ASA therapy to 87% of their patients. Both patients and gastroenterologists reported that managing UC medication is a struggle for patients (49 and 41%) and that it is difficult for patients to take medication as prescribed every day (42 and 90%). Indeed, 46% of patients admitted to not taking all of their medication in the past week, while gastroenterologists believed that 41% of their patients were not adherent. Conclusion: These surveys show important disparities between how patients and gastroenterologists perceive the impact of living with UC. Results suggest that many patients have adapted to live with their symptoms rather than acting to optimize therapy and compliance. Improvements in management strategies, education, and communication among patients and gastroenterologists are necessary.

Poor compliance with 5-ASA therapy in patients with gastrointestinal disorders increases the burden on healthcare services

Poor compliance with 5-ASA therapy in patients with gastrointestinal disorders increases the burden on healthcare services