Aminosalicylate

Sulfasalazine was the agent used in most of the early trials of 5-aminosalicylate (5-ASA) for maintenance of surgically induced remission in CD. Since then, trials have included other preparations in which the active agent is 5-ASA. In the past 10 years, these 5 ASA preparations have been more frequently used as they are better tolerated than sulfasalazine. The earlier data on sulfasalazine when pooled, suggested a slight improvement in 1-year relapse rates, which was statistically significant [4].

Several studies have now examined other 5-ASA-

containing preparations for medical prophylaxis against postoperative recurrence. The largest was conducted as part of the European Cooperative Crohn's Disease Study[25]. A total of 318 postoperative patients were randomized to receive mesalamine (Pentasa; 4 g/day) or placebo, and were followed for 18 months. Clinical recurrence occurred in 24.5% of treated patients and 31.4% in the placebo group. This trend was not statistically significant (P=0.10) in the group as a whole but was significant in those patients with isolated small-bowel disease.

Another randomized controlled trial of mesalamine in this setting compared 163 patients randomized to mesalamine (3 g/day) or placebo. They found a risk ratio for recurrence of 0.628 favouring the treated group and, strangely, found the greatest treatment effect in patients with isolated colonic disease [26]. More recently, a RCT evaluated mesalamine at a dose of 4 g/day compared with a dose of 2.4 g/day and found no difference in rates of clinical recurrence at 12 months [27]. Another recent randomized controlled trial, designed primarily for the evaluation of 6-mer-captopurine, evaluated mesalamine compared with 6-mercaptopurine or placebo, but did not show any significant difference between groups in terms of clinical recurrence at 2 years after surgery [28]. A meta-analy-sis of all randomized trials fully published up until 1997 suggested that mesalamine decreases the risk of postoperative recurrence by approximately 13%[29].

The main benefits appear to be for prevention of colonic disease site recurrence, whereas following ileocecal resection, the benefits appear to be minimal. Definite conclusions cannot be drawn as different studies used different preparations with varying regimens. Overall, the beneficial effect of mesalamine is likely to be small.

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