Aminosalicylate use Increases Corticosteroid Exposure and Decreases Biologic Durability in Pediatric Crohn's Disease

Despite lack of evidence for efficacy, 5-aminosalicylates (5-ASA) continue to be prescribed for pediatric Crohn's Disease (pCD). There are limited data examining current practice patterns in pCD, and the impact of 5-ASA use on clinical outcomes. We aimed to determine the prevalence 5-ASA use in pCD and evaluate its association with biologic durability, corticosteroid exposure, and disease-related complications.

We conducted a prospective, multicenter inception cohort study using data from the Biologic dISContinuation sTudy (BISCUIT). Early therapy (< 90 days from diagnosis) groups included biologics, immunomodulators, 5-ASA, and none of the above. The primary outcome was biologic durability. Secondary outcomes included corticosteroid use, therapy failure, and disease complications. Stabilized inverse probability of treatment weighting and Cox regressions were employed to equate for baseline differences among groups.

Of 679 patients, 18% received early 5-ASA monotherapy. Early 5-ASA was associated with greater systemic corticosteroid use (p=0.036) and delayed time-to-biologic (median ∼11 months), with 58.0% of patients escalating therapy. Among those who escalated, early 5-ASA increased risk of biologic discontinuation (hazard ratio 4.47 [1.28-15.65]; p=0.029). Furthermore, early 5-ASA and immunomodulator use did not prevent disease complications, whereas early anti-TNF therapy protected against perianal disease (odds ratio 0.24 [0.06-0.93]; p=0.039).

Early 5-ASA use in pCD is common, represents undertreatment, and is associated with inferior outcomes, including greater steroid exposure, delayed initiation of effective biologic therapy, and decreased biologic durability, without protection against disease complications. These findings support avoidance of 5-ASA in pCD and prioritizing early anti-TNF therapy to improve long-term outcomes and reduce perianal disease risk.