[Hypersensitivity to 5-aminosalicylic acid. Value of desensitization by oral route]

BACKGROUND

Treatment with sulphasalazine of patients with mild and moderate forms of Crohn's disease may result in side effects in some of them.

CASE REPORT

An 11-year-old girl with Crohn's disease was given 40 mg/kd/day of sulphasalazine after achieving remission with prednisone. She developed urticaria and eosionophilia 8 days later, then extended skin edema during a second course of sulphasalazine requiring methyl prednisolone therapy. Mesalazine administration (25 mg/kg/day), one month later, resulted to watery stools, vomiting, and fever, a side effect observed again after two further mesalazine challenges of one-month interval. Eosionophilia was present and the lymphocyte stimulation test with mesalazine was positive. Successful desensitization to sulphasalazine could be obtained 9 months later permitting further safe administration of this drug up to 18 months.

CONCLUSION

Hypersensitivity to sulphasalazine may be successfully overcame by oral desensitization, especially in those patients with low-grade activity of Crohn's disease.

Cholestasis associated with mesalazine therapy in a patient with Crohn's disease

BACKGROUND/AIMS

Mesalazine is a widely prescribed medication, developed as an alternative to sulfasalazine in the treatment of inflammatory bowel disease. In contrast to sulfasalazine, there are only a few case reports on its causing hepatic injury. We here report on a patient with cholestasis after mesalazine therapy for Crohn's disease of the ileum.

METHODS/RESULTS

The patient, a 30-year-old man, developed clinical signs of severe hepatic injury 4 months after treatment with mesalazine (4 g/day) including biopsy-proven hepatocellular cholestasis with minimal focal mononuclear inflammatory infiltration. Contrary to previous reports, no symptoms of generalized hypersensitivity were seen. The patient's illness was resolved by discontinuing the mesalazine treatment and he recovered completely in 40 days.

CONCLUSIONS

This case reinforces the possibility of a causal relationship between mesalazine treatment and toxic hepatic injury without systemic hypersensitivity.

Nephrotic syndrome from 5-ASA for ulcerative colitis? Complicated by carcinoma of the colon and sclerosing cholangitis

A patient with nephrotic syndrome had been treated with mesalazine for ulcerative colitis, and also had a carcinoma of the colon and sclerosing cholangitis. This seemingly unrelated series of complications gives us the opportunity to review the problem of nephropathy in ulcerative colitis.

Olsalazine-induced lupus syndrome

A 73 year-old woman with ulcerative colitis developed skin rashes after long-standing sulphasalazine treatment. After a switch to olsalazine, she developed a severe SLE with multiorgan involvement. When the treatment was terminated, the disease manifestations and serological findings resolved.

Mesalamine-induced hypersensitivity pneumonitis. A case report and review of the literature

A 49-year-old man with Crohn's disease treated with prednisone and mesalamine (5-ASA) developed worsening respiratory distress and fever. Symptoms improved after discontinuation of mesalamine. A rechallenge 3 months later caused similar pulmonary symptoms, confirming the association between the drug and the respiratory system. Mesalamine may cause hypersensitivity pneumonitis in patients with Crohn's disease.

5-Aminosalicylic acid-associated renal tubular acidosis with decreased renal function in Crohn's disease

The use of 5-aminosalicylic acid (5-ASA, mesalazine) in Crohn's disease is usually well tolerated. Nevertheless, the occasional occurrence of nephrotoxic side effects has been described in several case reports. We present the case of a 34-year-old female in whom chronic use of 5-ASA may have caused renal damage which manifested with tubular acidosis, severe weight loss, shortness of breath and fatigue. For 17 years the patient has suffered from Crohn's disease. She received sulfasalazine (3 g/day) for 12 years and was treated with resin-coated mesalazine (3 g/day) for the last 72 months. Onset of weight loss of 10 kg over a 6-month period, accompanied by progressive shortness of breath and fatigue, lead to a diagnosis of metabolic acidosis and renal bicarbonate loss due to damage to the tubular epithelium. Kidney biopsy demonstrated acute interstitial nephritis which may be related to 5-ASA.

Adverse events in patients treated with 5-aminosalicyclic acid: 1993-1994 pharmacovigilance report for Pentasa in France

BACKGROUND

The incidence of the side-effects of 5-aminosalicylic acid (5-ASA) in clinical practice is not known.

AIM

To present the safety reports on the use of Pentasa in France.

METHODS

Pentasa-related adverse events were recorded from 1 January 1993 to 31 December 1994. Spontaneous reports to Ferring S.A. came from physicians or pharmacovigilance regional centres.

RESULTS

In 1993 and 1994, 51 and 79 adverse events were reported; the estimated gross incidence was 6.6 and 9.0 per million days of therapy. Detailed information was obtained 64% of cases in 1993 and 53% in 1994. Adverse events with a high likelihood of causalty included five cases of diarrhoea, 14 cases of pancreatitis, seven cases of liver abnormalities, seven of blood dyscrasias, two cases of renal insufficiency (one of which was in a fetus), and eight of cardiac disorders including three myocarditis.

CONCLUSIONS

Pentasa seldom has adverse effects. The majority of the adverse events do not seem to be dose-related. Clinicians should be aware of exceptional but severe adverse events including pancreatitis, cardiac disorders, blood dyscrasias and renal insufficiency.

A comparison of mesalamine suspension enema and oral sulfasalazine for treatment of active distal ulcerative colitis in adults

OBJECTIVES

To compare the efficacy and safety of mesalamine (5-ASA) suspension enema versus oral sulfasalazine (SAS) in patients with active mild to moderate distal ulcerative colitis.

METHODS

Thirty-seven patients were randomly assigned to treatment with either rectal mesalamine, 4 g at night, (n = 19) or oral sulfasalazine, 1 g four times a day, (n = 18) in a 6-wk, double-blind, double-dummy, parallel-group, multicenter study. Patients known to be refractory to SAS or 5-ASA preparations were excluded. Efficacy was assessed by a physician-rated Disease Activity Index (DAI), which included symptom evaluations and sigmoidoscopic findings, by physician-rated Clinical Global Improvement (CGI) scores, and by Patient Global Improvement (PGI) scores. Safety was assessed by adverse event reports, clinical laboratory tests, and physical examination. Results. Mean DAI scores indicated significant improvement from baseline in both treatment groups. CGI scores indicated that 94% of the 5-ASA patients were either "Very Much Improved" or "Much Improved" at wk 6 versus 77% of the SAS patients. PGI ratings showed more improvement in the 5-ASA treatment group than in the SAS group at wk 2 (p = 0.02) and at wk 4 (p = 0.04). Adverse events, primarily headache and nausea, occurred significantly more frequently (p = 0.02) in the SAS than in the 5-ASA group (83 vs 42%). Three patients were withdrawn from SAS treatment because of adverse events.

CONCLUSIONS

Rectally administered 5-ASA is as effective as oral SAS in treatment of active distal ulcerative colitis but is associated with fewer and milder adverse events. Patients treated with 5-ASA reported improvement earlier than those treated with SAS.

Drug induced otalgia due to mesalazine and sulphasalazine

A case of left otalgia in a patient suffering from longstanding ulcerative colitis is reported. The patient was treated for an exacerbation of his disease with courses of mesalazine and sulphasalazine during which time he developed otalgia. The otalgia disappeared with cessation of the drugs. It is concluded that in the absence of any other head and neck cause that the otalgia was a complication of the drug therapy.

Mesalamine-induced lung toxicity

Lung toxicity associated with 5-aminosalicylate (5-ASA) agents is a rare entity. We report the case of a 32-yr-old woman with ulcerative colitis who developed progressive shortness of breath while taking one of the 5-ASA drugs, oral mesalamine. Bilateral pulmonary infiltrates, peripheral eosinophilia, and histological findings consistent with acute pneumonitis characterized the lung injury. Although the differential diagnosis is broad, mesalamine-induced lung damage must be considered in patients who develop unexplained respiratory symptoms while taking this agent.

Mesalazine-associated interstitial nephritis

BACKGROUND

When used for oral treatment of inflammatory bowel disease, Asacol (a coated form of mesalazine = 5-aminosalicylic acid) can cause interstitial nephritis. The spectrum of severity, frequency of occurrence and the best renal function test to detect this complication are not known. The value of immunosuppression in addition to drug withdrawal is similarly undetermined.

METHODS

Four cases of interstitial nephritis which occurred in association with oral Asacol treatment are presented and a further 12 cases who received similar treatment are reviewed. Clinical trials published previously were scrutinized to assess the frequency of impaired renal function.

RESULTS

The available evidence suggests that renal impairment of any severity may occur in up to 1 in 100 patients, but that clinically significant interstitial nephritis occurs in less than 1 in 500 patients. This is most reliably detected by an elevated serum creatinine concentration. If the diagnosis of nephrotoxicity is delayed until 18 months after commencement of medication, restoration of renal function, which is seen on withdrawal of medication alone up to 10 months, does not occur and there is no evidence to date to indicate that addition of immunosuppression confers any significant advantage at this later stage.

CONCLUSIONS

It is suggested that serum creatinine concentration should be measured each month for the first 3 months of treatment, 3-monthly for the remainder of the first year and annually thereafter. The use of concurrent immunosuppressive therapy may necessitate extension to the period of intensive monitoring. Any elevation of serum creatinine which cannot be related to a relapse of inflammatory bowel disease should prompt immediate withdrawal of Asacol and related medications and substitution of alternative therapy. Neither the lack of urinary abnormalities on routine testing nor the absence of clinical or laboratory features of drug allergy can be relied upon to rule out interstitial nephritis during oral therapy with these drugs.

Placebo-controlled clinical trial of mesalazine in the prevention of early endoscopic recurrences after resection for Crohn's disease. Groupe d'Etudes Thérapeutiques des Affections Inflammatoires Digestives (GETAID)

OBJECTIVE

Endoscopic postoperative recurrences occur early after 'curative' surgery for Crohn's disease. Pentasa has been shown to be effective in the maintenance treatment of quiescent Crohn's disease. The aim of this study was to test the efficacy of a 12-week oral intake of Claversal in the prevention of endoscopic recurrences after 'curative' resection for ileal, colonic or ileocolonic Crohn's disease. We conducted a multicentre double-blind controlled trial comparing Claversal (1g tid) with placebo, starting within 15 days after surgery. The macroscopic normality of the two anastomotic segments was assessed at surgery. Patients were clinically and biologically evaluated twice (6-week interval), and colonoscopy was performed at 12 weeks. Endoscopic relapse was defined by any anastomotic ulcerations or stenosis and staged according to a four-grade score.

RESULTS

Between May 1989 and May 1991 12 centres included 126 patients, 70 women and 56 men, aged 33 +/- 12 years (range 16-70) in the study. Disease locations were ileal, colonic and ileocolonic in 45, 6 and 49%, respectively. Claversal and placebo groups were similar at inclusion, except for ESR (37 +/- 26 vs. 27 +/- 23 mm/h in the Claversal and placebo groups, respectively; P < 0.05). Nine patients were withdrawn from the study. Adverse reactions occurred only in six patients. Five patients were excluded for protocol violation. Finally, 106 patients could be evaluated at 12 weeks (55 Claversal and 51 placebo). An endoscopic relapse was observed in 50% and 63% of the Claversal and placebo groups, respectively (P = 0.16), with a similar grade distribution. Claversal was well tolerated.

CONCLUSIONS

Our study confirms that a large proportion of endoscopic recurrences occur within 3 months of resection in Crohn's disease. There was a slight trend towards greater efficacy of Claversal; it could be worthwhile trying higher dosages and/or 5-ASA compounds with different intestinal release profiles.

An oral preparation of mesalamine as long-term maintenance therapy for ulcerative colitis. A randomized, placebo-controlled trial. The Mesalamine Study Group

OBJECTIVE

To compare the safety and efficacy of a pH-sensitive, polymer-coated oral formulation of mesalamine (Asacol, Procter & Gamble Pharmaceuticals, Cincinnati, Ohio) with those of placebo in maintaining remission in patients with ulcerative colitis.

DESIGN

Multicenter, double-blind, placebo-controlled, randomized clinical trial.

SETTING

Eight private practices, five university-based medical centers, and four hospitals or clinics.

PATIENTS

264 patients with ulcerative colitis that had been maintained in remission for at least 1 month while the patients were receiving stable doses of sulfasalazine or any oral mesalamine product.

INTERVENTION

Coated mesalamine at oral dosages of 0.8 g/d or 1.6 g/d or matching placebo for 6 months.

MEASUREMENTS

Treatment success, defined as maintenance of remission after 6 months, and treatment failure, defined as relapse during the study (as indicated by proctosigmoidoscopy at 1, 3, or 6 months of treatment) or withdrawal due to adverse events. Safety was assessed on the basis of laboratory analyses and patient- and investigator-noted adverse events.

RESULTS

189 patients were compliant with the protocol for 6 months or stopped receiving therapy because of relapse or adverse events. Of these 189 patients, 25 of the 63 patients (39.7%) in the placebo group had treatment success compared with 40 of the 68 patients (58.8% [95% CI, 46.4% to 71.3%]) in the group receiving mesalamine, 0.8 g/d (P = 0.036) and 38 of the 58 patients (65.5% [CI, 52.4% to 78.6%]) in the group receiving mesalamine, 1.6 g/d (P = 0.006). In the intention-to-treat analysis of all patients, 42 of the 87 patients (48.3%) in the placebo group had treatment success compared with 57 of the 90 patients (63.3% [CI, 52.8% to 73.8%]) in the group receiving mesalamine, 0.8 g/d (P = 0.050) and 61 of the 87 patients (70.1% [CI, 59.9% to 80.3%]) in the group receiving mesalamine, 1.6 g/d (P = 0.005). Age, sex, and race were not found to predict treatment success or failure. The mesalamine tablet was well tolerated, and no clinically significant changes were seen in hematologic, hepatic, or renal laboratory profiles.

CONCLUSION

Coated mesalamine at oral dosages of 0.8 g/d and 1.6 g/d is safe and effective in maintaining remission in patients with quiescent ulcerative colitis.

[Diffuse alopecia as side effect of mesalazine therapy in Crohn's disease]

Within the scope of the participation at the VI. European Crohn's Disease Study we observed under therapy with 4 g/day Mesalazine (Pentasa) a strong diffuse hair loss on two female patients which disappeared again after discontinuation of therapy. A repeated positive exposure in both patients confirmed the causality. One patient had thereafter a recurrence of Crohn's disease so she was given a reduced dose of Mesalazine (2 g/d). The hair loss began again but on an acceptable level for the patient. Thus, it looks like a dose-dependent side-effect as it is known in the medical literature. These are so far the first two cases of hair loss in connection with Pentasa recorded by the Swiss Drug Monitoring Center. In the medical literature there are reports about this side-effect from all producers known in Switzerland (Asacol, Pentasa, Salofalk), which suggests a Mesalazine specific side-effect. Since recently higher doses of Mesalazine (2-4 g/d) are used in Crohn's disease, a reversible and probably dose-dependent hair loss must be expected in 1-2% of these patients.