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Giovanni C. Actis, Alfredo Marzano, Rinaldo Pellicano, Mario Rizzetto, How important is mesalamine in the maintenance of steroid-refractory colitis?, Inflammatory Bowel Diseases, Volume 14, Issue 7, 1 July 2008, Page 1026, https://doi.org/10.1002/ibd.20422
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Mesalamine is thought to play only a corollary role in the maintenance of ulcerative colitis (UC) if steroids or any rescue therapy are required to achieve remission.1 We recently observed a patient in remission from such a severe presentation in whom mesalamine withdrawal was followed by relapse progressing to colectomy.
In March 2007 we admitted a 38-year-old man with a 1-month history of 10 daily passages of bloody stools and colonoscopic findings of pancolitis; based on histology confirming UC, he was begun on parenteral steroids elsewhere, but failure to respond prompted referral to our unit. Despite intensive conventional treatment his condition worsened, and with a hemoglobin (HB) down to 7 g/dL he became transfusion-dependent. He was begun on 5 mg/kg/day NEORAL on March 7. In 2 weeks the stool passages fell from 8 to 1, the HB rose to 10 g/dL, albumin went up to 4.2 from 2.3 mg/dL at baseline, and C-reactive protein fell from 88 to 5 mg/L (reference 0-5). He was discharged March 19 on NEORAL and tapering steroid doses and began azathioprine (AZA) at 2 mg/kg/day on April 17. At the end of April he relapsed while on 10 mg steroids; despite increasing the dose to 25 mg and adding 4.8 g mesalamine he worsened and was readmitted. He responded to maximum dose parenteral steroids and was discharged on May 21. By the 20th of June he had stopped NEORAL, was in clinical remission on 30 mg steroids to be tapered further, and unchanged doses of AZA and mesalamine. By mid-July he began to complain of rest and exercise dyspnea. By August steroid weaning was accomplished and remission maintained on AZA and mesalamine. With the colitis in remission, dyspnea prevented work in early September. Hemogas analysis revealed PO2 65 (expected 85) and SO2 92 (expected 96); on pulmonary function tests a diffusing capacity of 57% denoted obstructive lung dysfunction. Based on a previous experience of our group and on the literature, 2,3 mesalamine-related lung injury was diagnosed and mesalamine discontinued. Dyspnea gradually improved. The colitis relapsed at the end of October and did not respond to prednisone. By mid-November mesalamine was reinstituted but again discontinued for dyspnea in 2 weeks. The colitis worsened and severe universal disease was seen by colonoscopy. Colectomy was performed December 13.
