5-ASA use in paediatric CD common, deviates from recommended practices

Children with Crohn’s disease (CD) are often treated with 5-aminosalicylate (5-ASA) contrary to guidelines, and this practice is associated with a substantial delay in initiating biologic therapy, according to a study presented at this year’s Crohn's & Colitis Congress (CCC).

In a cohort of 608 paediatric patients, 142 (23.4 percent) were started on 5-ASAs (exposed group) and 466 (76.6 percent) on biologic therapy (unexposed group) within 90 days after CD diagnosis, reported Dr Perseus Patel of University of California San Francisco, San Francisco, California, US, the study’s lead author.

Of note, 5-ASA therapy was associated with a significant 84-day delay in first biologic medication (median delay, 108 days in the exposed group vs 24 days in the unexposed group; p<0.001). A biologic was initiated at least 90 days after CD diagnosis for more than twice as many patients in the exposed group (56.1 percent vs 25.2 percent; p<0.001).

Patients who were initiated on biologics were more likely to have severe symptoms (58.4 percent vs 40.9 percent; p<0.001), severe scope (56.4 percent vs 29.6 percent; p<0.001), perianal disease (17.6 percent vs 4.2 percent; p<0.001), and fistulizing disease (5.4 percent vs 0.7 percent; p=0.016).

On the other hand, those who were started on 5-ASAs were younger (age at diagnosis, 11.6 vs 13.2 years; p<0.01) and more likely to have colonic disease (Paris classification L2, 18.3 percent vs 11.4 percent; p=0.03) and have Medicaid as their primary insurance (23.2 percent vs 20.5 percent; p=0.05).

“Societal guidelines recommend against the use of 5-ASA therapy for paediatric patients with CD. Previous trials showed no benefit of 5-ASAs for inducing remission and similar 1-year relapse rates when compared with placebo,” Patel noted.

“Conversely, biologics are recommended as first-line therapy due to higher remission rates, corticosteroid-sparing effects, and potential to alter disease progression,” he added.

The findings of the present study, according to Patel, serve as a call to action not only to improve guideline dissemination but also to examine barriers such as insurance status in the evidence-based treatment of paediatric CD.

For the study, Patel and colleagues used data from the Biologic Discontinuation Study (BISCUIT), a multicentre study in which retrospective medical records from seven US centres were supplemented with prospectively collected data from the ImproveCareNow (ICN) Network Registry. They compared outcomes between children who were exposed and not exposed to 5-ASA.

Disease severity (Pediatric Crohn's Disease Activity Index score 10 vs 10; p=0.52), corticosteroid use (12.6 percent vs 21.6 percent; p=0.08), and dietary therapy (21.6 percent vs 26.6 percent; p=0.90) were similar in the 5-ASA-exposed and the 5-ASA-unexposed groups.

Patel shared that his team is already looking to study the differences in outcomes, biologic durability, and disease complication rates between children with CD who were initiated on 5-ASA and their counterparts who were treated with a biologic upfront.