S1948 Efficacy of 5-ASA Continuation vs Discontinuation in Patients With Moderate to Severe Ulcerative Colitis Escalated to Advanced Therapy: A Systematic Review and Meta-Analysis of Adjusted Effect Estimates

Introduction: The benefit of continuing 5-aminosalicylates (5-ASA) in patients with moderate-to-severe ulcerative colitis (UC) escalated to advanced therapies remains uncertain. To address this issue, we conducted a systematic review and meta-analysis to evaluate the efficacy and safety of 5-ASA continuation vs discontinuation in this population. Methods: We systematically searched PubMed, Embase, and Cochrane databases for studies comparing continuation vs discontinuation of 5-ASA in adult patients with moderate-to-severe UC escalated to advanced therapies. We attempted to use multivariable-adjusted data to account for known confounding factors. Adjusted effect estimates were pooled using inverse-variance random-effects models for adjusted odds ratios (aORs) and hazard ratios (aHRs). Risk of bias was assessed using the ROBINS-I tool. Results: Our meta-analysis comprised 9 observational cohorts and 3 studies presenting post hoc analyses from twelve clinical trials. We included 16,461 patients, with 12,652 assigned to 5-ASA continuation and 3,809 to 5-ASA discontinuation. Compared to discontinuation, 5-ASA continuation was associated with decreased odds of achieving clinical remission (aOR 0.72; 95% CI 0.52-0.99; P = 0.046; I2 = 0%). There were no significant differences between groups for corticosteroid-free clinical remission (aOR 0.71; 95% CI 0.41-1.23; P = 0.22; I2 = 0%), clinical response (aOR 0.94; 95% CI 0.69-1.28; P = 0.70; I2 = 0%), endoscopic healing (OR 0.96; 95% CI 0.64-1.44; P = 0.85; I2 = 61%), and biochemical remission (aOR 1.13; 95% CI 0.76-1.68; P = 0.54; I2 = 31%). In time-to-event analyses, no significant differences were found between groups for UC-related hospitalization (aHR 1.08; 95% CI 0.89-1.31; P = 0.42; I2 = 51%), UC-related surgery (aHR 0.90; 95% CI 0.71-1.15; P = 0.41; I2 = 36%), new corticosteroid prescription (aHR 0.92; 95% CI 0.79-1.06; P = 0.24; I2 = 77%), composite adverse events (aHR 0.96; 95% CI 0.87-1.06; P = 0.43; I2 = 0%), and loss of response (aHR 0.90; 95% CI 0.76-1.07; P = 0.25; I2 = 77%). ROBINS-I results found one study with a serious risk of bias and eleven with a moderate risk of bias. Conclusion: In this meta-analysis of adjusted effect estimates, 5-ASA continuation was associated with a decreased odds of achieving clinical remission compared with 5-ASA discontinuation, with no significant differences observed for other efficacy and safety endpoints. These findings suggest that 5-ASA may be safely discontinued after escalation to advanced therapies in this population.