Contrary to Guidelines, 5-ASA Often Prescribed in Pediatric Crohn's Disease

DENVER -- Even though guidelines discourage the use of 5-aminosalicylate (5-ASA) in pediatric Crohn's disease, a substantial percentage of children are still being treated with the anti-inflammatory agent, which may cause problems down the road, a researcher reported here.

Of nearly 700 children diagnosed with Crohn's disease and treated at specialized centers, 28% were initially started on 5-ASA, reported Perseus Patel, MD, a clinical fellow in pediatrics at the University of California San Francisco, at a poster presentation at the Crohn's & Colitis Congress.

"We found that 5-ASAs are commonly used to treat pediatric patients with Crohn's disease," Patel told MedPage Today, adding that its "use at diagnosis is associated with a 4-month delay in starting biologic therapy."

And among the patients who first started on 5-ASA and then switched to a biologic, time to biologic failure was significantly shorter than those originally treated with a biologic agent. After 3 years, about 60% of those who were initially treated with 5-ASA remained on their biologic treatment compared with about 80% of patients who initiated on biologics (HR 2.51, 95% CI 1.17-3.63, P<0.01).

In their abstract, the researchers said the results should be a "call-to-action" to improve both guideline dissemination and to examine barriers standing in the way of evidence-based treatment for kids with Crohn's disease.

A pediatric gastroenterologist not involved with the study told MedPage Today she was surprised by the number of Crohn's patients placed on 5-ASA.

"The data suggest that it is not efficacious to use this agent in pediatric Crohn's disease," said Dawn Ebach, MD, of the University of Iowa in Iowa City.

"It could be that because these are children, their parents may be concerned about starting their children on these more intensive therapies such as biologics," she said. "The problem is that by delaying treatment with biologics it may result in the patient doing worse. Other than causing that delay, 5-ASA does not appear to be harmful, but, of course, there are potential side effects and the added cost of using 5-ASA."

Ebach said the study could be useful in helping to educate not only patients and their families but also clinicians.

"To be honest," she said, "I have prescribed 5-ASA in young patients who have relatively mild cases of Crohn's disease." She explained that since 5-ASA is an anti-inflammatory, the thought is that it might be helpful in some cases, and sometimes physicians want to "do something" for their patients even though there might not be evidence for the treatment.

For their study, the researchers used retrospective medical records from seven U.S. centers, pulled from the multicenter Biologic Discontinuation Study (BISCUIT), which was supplemented with prospectively collected data from the ImproveCareNow registry.

Included were newly diagnosed pediatric Crohn's disease patients who had been prescribed 5-ASA within 90 days of their diagnosis and compared outcomes to those never prescribed 5-ASA. Outcomes were adjusted for demographics and disease severity, Patel noted.

Overall, 498 patients were treated only with biologics, 107 were treated with 5-ASA, and 92 only received 5-ASA. Among those who were treated with biologics, the median time from diagnosis to initiation of the biologic agent was 24 days. In the patients initially treated with 5-ASA, the time to biologic therapy was 139 days (P<0.01).

At 1 year, 92.2% of patients who started on a biologic were still on the agent, compared with 79.4% of those who started on 5-ASA and then went on to a biologic.

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