Mesalazine Nonadherence in Mild-to-Moderate Ulcerative Colitis: Barriers in a Moroccan Cohort

Background: Mesalazine, also known as mesalamine, remains a cornerstone first-line therapy for induction and maintenance of remission in mild-to-moderate ulcerative colitis (UC). However, real-life adherence is frequently suboptimal and may be influenced by behavioral, cultural, therapeutic, financial, and health system-related factors. Data from North African populations remain limited. This study aimed to describe the main determinants of mesalazine nonadherence in a Moroccan cohort of patients with mild-to-moderate UC. Methods: We conducted a retrospective descriptive study in the Department of Gastroenterology and Hepatology at Mohammed VI University Hospital Center, Marrakech, Morocco, over a two-year period, from September 2023 to September 2025. Consecutive adult patients with mild-to-moderate UC receiving mesalazine were included. Collected variables included demographic characteristics, disease extent, dosing frequency, pill burden, treatment behavior, use of herbal alternatives, fear of medication, forgetfulness, drug availability, financial limitations, and response to targeted counseling. Poor adherence was defined as taking less than 80% of prescribed doses. Data were analyzed using frequencies and percentages. Results: Thirty patients were included, comprising 23 females and seven males, with ages ranging from 23 to 57 years. Left-sided colitis was the most common disease extent, observed in 18 patients (60%), followed by proctitis in eight patients (26.7%) and pancolitis in four patients (13.3%). Good adherence was reported in 20 patients (66.7%), whereas 10 patients (33.3%) had poor adherence. Among poorly adherent patients, stopping treatment when asymptomatic was the most frequent behavioral factor, reported in six patients (60% of poorly adherent patients; 20% overall). Other factors included use of herbal alternatives in two patients (20%; 6.7% overall), fear of medication in one patient (10%; 3.3% overall), and forgetfulness in one patient (10%; 3.3% overall). High pill burden, defined as at least four tablets per day, was observed in 16 patients (53.3%). Once-daily mesalazine was prescribed in six patients (20%), while 24 patients (80%) received multiple daily dosing regimens. Financial constraints limiting regular drug purchase were reported by eight patients (26.7%), and drug unavailability was reported by one patient (3.3%). Targeted counseling improved adherence in seven of the 10 poorly adherent patients (70%). Conclusions: Mesalazine nonadherence in this Moroccan UC cohort was frequent and multifactorial. Behavioral factors, cultural beliefs, high pill burden, financial limitations, and health system barriers all contributed to poor adherence. Simplified dosing regimens, improved access to affordable formulations, and structured patient education may help optimize long-term adherence in real-life practice.