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Editorial: 5‐ASA in IBD patients on biologics—'stop or continue'? Authors' reply

We appreciate the editorial on our paper by Veyrard et al.1,2 They contend that it would be premature to discontinue 5ASA in persons with IBD after initiating biologic or immunosuppressive therapy on the basis of the antineoplastic effects of 5ASA. Regardless of suggested benefit in vitro, we do not believe the evidence that 5ASA prevents dysplasia in IBD is particularly convincing. Veyrard et al point out the difficulty with 5ASA studies in terms of assessing a large enough cohort of persistent, adherent 5ASA users over time. In one metaanalysis, it was shown that in smaller referral centre cohort studies, 5ASA could be shown to be chemoprotective, but in larger administrative database studies, it could not.3 Furthermore, there is emerging evidence that dysplasia correlates with inflammation and that, by reducing inflammation, the risk of dysplasia would be reduced.46 If 5ASA adds little to nothing to reduce inflammation once a biologic has been initiated, then it may not contribute to the reduced dysplasia risk. We do not believe that there is enough evidence that 5ASA is chemopreventive in IBD to warrant its continuation postinitiation of biologic or even immunosuppressive therapy, especially if the addition of the biologic or immunosuppressive therapy has been the driver of remission of inflammation.