Maia Kayal MD, on Strategies for Managing Patients When Mesalamine Fails

Dr Kayal reviews the options available when patients with ulcerative colitis do not respond or lose response to mesalamine therapy, and the considerations of patient factors, patient preferences, and safety that should be taken into account.

Maia Kayal, MD, is an associate professor at the Icahn School of Medicine at Mount Sinai in New York, New York.

My name is Maya Kayal, I'm an associate professor at the Icahn School of Medicine at Mount Sinai in New York City. Today, during the first day of AIBD, my talk discussed strategies to manage the patient who is not responding to mesalamine-based therapy. The majority of our patients will be treated with 5-ASA-based therapy within the first year of their diagnosis of ulcerative colitis. Unfortunately, 5-ASA therapy does have limitations, and about 30 to 40% of our patients will flare within that first year. For these patients, it's important to discuss advanced therapies. We shouldn't undertreat patients who have mild to moderate disease or patients who have limited disease such as proctitis. For these patients, any of our approved advanced therapies are an option. These include anti-TNF agents, anti-interleukin agents, anti-integrin agents, and sphingosine 1-phosphate receptor modulators. There's also a potential role for CurQD, a combination of curcumin and qingdai. This has been shown in a randomized controlled trial to benefit patients who have mild to moderate ulcerative colitis and are relapsing or flaring on mesalamine therapy.

In the patient who has failed mesalamine therapy, when considering the option for advanced therapy, a number of different factors need to be taken into account. The first is patient factors. That is the patient's age, their gender, their comorbidities, their concomitant existing immune conditions, and their extraintestinal manifestations. The second is their preference. Are they willing to take an injection or an infusion, or do they favor an oral option? And of course, the third is safety considerations. For some patients, certain therapies might be contraindicated or not advised. For example, patients who have a history of lymphoma or melanoma, you might want to caution against the use of anti -TNF, or for patients who have cardiovascular risks such as heart block, you might want to caution against the use of an S1P.

So when we're making that decision about the first therapy for a patient who has not responded to mesalamine-based therapies, you want to take into account, again, patient factors, patient preferences, and safety considerations. Ultimately, your first shot is your best shot. That is the first drug that you use has the most likelihood of working. So you want to be smart about positioning for later disease activity. That is, we know that there's great data for vedolizumab as a first-line option, and there's great data that suggests infliximab doesn't lose this efficacy as a second-line option after vedolizumab. So thinking ahead, you want to future-proof your positioning plan such that you are setting the patient up for success, no matter what drug they're started on.