Editorial: To Stop or Not to Stop, Is It Still a Question? Authors' Reply

Abstract

We sincerely thank Vavricka et al. for their thoughtful insights on our study [1, 2]. Their editorial offers a timely and relevant discussion of topics such as mucosal healing, the top-down strategy and treatment de-escalation, all of which represent important shifts in the management of inflammatory bowel disease (IBD) [3-5]. Due to space constraints, we were unable to cover these aspects in sufficient detail in our study's discussion, and we thank their in-depth consideration of these evolving treatment paradigms.

We are particularly grateful for Vavricka et al.'s recognition of our study in contributing to the ongoing discussion on treatment de-escalation in IBD, specifically regarding the safety of discontinuing 5-aminosalicylates (5-ASA) after starting anti-tumour necrosis factor (TNF) therapy. The insights they provided regarding the economic implications of 5-ASA withdrawal, particularly its potential to significantly reduce healthcare costs, are highly valuable. According to the database of the Korean National Health Insurance Service Claims, which covers over 97% of South Korean population, between 2006 and 2015, the total annual healthcare costs for patients with IBD significantly increased from $9,536,195 to $59,709,133 (a sixfold rise) [6]. Considering the limited healthcare budget, precise allocation of resources and efforts to reduce the financial burden on the national health insurance system are becoming increasingly critical.

Within the Korean healthcare system, the average annual cost of most commonly used oral 5-ASA medications—Mezavant, Asacol and Pentasa—at their approved maintenance doses is approximately $500 per patient per year ($1 = KRW 1351). In our study, the 5-ASA continuation group included 6405 patients with a median follow-up of 4.3 years. If a controlled discontinuation of 5-ASA had been implemented for these patients, an estimated $13.65 million could have been saved.

Vavricka et al. have also raised valid concerns about the potential chemopreventive role of 5-ASA against colorectal cancer (CRC). In our study, the low number of CRC cases in both the continuation (25 cases, incidence rate 0.084/100 person-years) and discontinuation groups (2 cases, incidence rate 0.041/100 person-years) limited meaningful statistical analysis. Although the chemopreventive role of 5-ASA remains unclear, as previously highlighted, mucosal inflammation is thought to be the primary driver of CRC development in patients with IBD [7, 8]. Achieving mucosal healing through biologics or small molecules may, therefore, reduce the need for additional 5-ASA use for CRC prevention. We not only concur with this viewpoint but also emphasise the need for large-scaled, prospective studies to further clarify this issue.

Beyond the ongoing discussions on chemopreventive role of 5-ASA, and the economic advantages highlighted in the editorial, we believe that discontinuing 5-ASA can also enhance patient adherence by simplifying treatment regimens. The concept of treatment de-escalation could reduce the burden of polypharmacy, making long-term management of IBD more feasible [9]. As IBD treatment shifts towards more targeted and efficient approaches, we hope our study adds valuable insights into this evolving paradigm. Further research is crucial to confirming these findings and optimising treatment strategies for patients with IBD.

Jeongkuk Seo: writing – original draft. Byong Duk Ye: conceptualization, funding acquisition, writing – review and editing, project administration, supervision.

This article is linked to Seo et al papers. To view these articles, visit https://doi.org/10.1111/apt.18102 and https://doi.org/10.1111/apt.18298.