Tsutomu Nishida; Takahiro Amano; Naoto Osugi; Takeo Yoshihara

doi:10.5217/ir.2025.00158

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Letter to the Editor IBD Comments on “Role of 5-aminosalicylic acid in ulcerative colitis management in 8 Asian territories: a physician survey”: Tsutomu Nishida¹, Takahiro Amano², Naoto Osugi¹, Takeo Yoshihara³; Intestinal Research 2025;23(4):565-566.
DOI: https://doi.org/10.5217/ir.2025.00158
Published online: October 28, 2025

¹Department of Gastroenterology, Toyonaka Municipal Hospital, Toyonaka, Japan

²Department of Gastroenterology, Ikeda Municipal Hospital, Ikeda, Japan

³Department of Gastroenterology and Hepatology, The University of Osaka, Suita, Japan

Correspondence to Tsutomu Nishida, Department of Gastroenterology, Toyonaka Municipal Hospital, 4-14-1 Shibahara, Toyonaka 560-8565, Japan. E-mail: tnishida@gh.med.osaka-u.ac.jp

• Received: July 25, 2025 • Accepted: September 21, 2025

This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/4.0/) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

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REFERENCES

See the reply "Response: Comments on “Role of 5-aminosalicylic acid in ulcerative colitis management in 8 Asian territories: a physician survey”" in Volume 23 on page 567.

See the article "Role of 5-aminosalicylic acid in ulcerative colitis management in 8 Asian territories: a physician survey" on page 117.

We read with great interest the article by Limsrivilai et al. [1] titled “Role of 5-aminosalicylic acid in ulcerative colitis management in 8 Asian territories: a physician survey.” This study offers a valuable comparison of regional practices, reflecting real-world clinical environments and healthcare systems across Asia. Although Japan was not included among the 8 surveyed territories (Hong Kong, Indonesia, Malaysia, the Philippines, Singapore, Taiwan, Thailand, and Vietnam), the article provided a comprehensive overview of current strategies for 5-aminosalicylic acid (5-ASA) use among inflammatory bowel disease and gastroenterology specialists. In this letter, we aim to supplement their findings by sharing the results of our cross-sectional study conducted in Japan, thereby enhancing the understanding of 5-ASA use in the broader Asian context.

Our Japanese study [2] comprised a cross-sectional internet-based survey involving 369 patients with ulcerative colitis (UC) and 153 gastroenterologists from the Osaka region. The survey investigated the real-world practice and perceptions of 5-ASA maintenance therapy from both physician and patient perspectives. A comparison of our findings with those of Limsrivilai et al. [1] revealed notable regional differences and similarities in UC management. Regarding treatment goals, Limsrivilai et al. [1] reported that symptom control and cost-effectiveness were the top priorities for physicians. In contrast, our Japanese data indicated that long-term remission and mucosal healing were emphasized more frequently, reflecting a proactive treatment approach by Japanese clinicians. This difference may be largely explained by Japan’s public healthcare support system. UC is designated as an intractable disease, allowing many patients to receive subsidies through a national program. This financial support enables physicians to make treatment decisions with fewer cost constraints. Indeed, many of our survey respondents reported deferring the choice between branded and generic 5-ASA formulations to their physicians, indicating minimal sensitivity to the medication cost. This aligns with Limsrivilai et al.’s observation that multi-matrix system (MMX) formulations are more often used in high-income countries, where economic barriers are reduced.

Patient preferences regarding the formulations showed similar trends across both studies. Limsrivilai et al. [1] noted that physicians perceived a patient preference for granule formulations (2–3 sachets per dose) rather than multiple tablets. Likewise, in our survey, granule formulations were generally well accepted by Japanese patients. Although not the primary reason, 9.8% of patients reported “difficulty taking” as one of the reasons for requesting dose reductions (as shown in Supplementary Table 1 of Amano et al. [2]), suggesting that formulation-related factors, such as the large size of MMX tablets, may influence adherence and continuation of therapy in Japan. In contrast, multiple daily dosing was more commonly reported in several lower-income countries in a study by Limsrivilai et al. [1] The authors attributed this pattern to limited access to once-daily formulations and physician concerns about patient adherence. Although economic factors such as the affordability of newer formulations were not explicitly discussed, they may also influence the availability and use of these therapies. These findings highlight how formulation preferences can be shaped by a combination of patient experiences, healthcare infrastructure, and broader socioeconomic conditions.

Once-daily dosing was positively viewed in both studies. In our patient group, the median frequency of daily 5-ASA intake was one, reflecting the widespread use of simplified regimens in Japanese clinical settings. Conversely, in several low-income countries surveyed by Limsrivilai et al. [1], preferences leaned toward twice or thrice-daily dosing. These differences may be shaped by variations in lifestyle, healthcare access, and cultural practices—even within the same region. The monitoring strategies also differed. Limsrivilai et al. reported that C-reactive protein and histological findings were rarely prioritized, whereas symptoms and endoscopic results were more influential in treatment decisions. In contrast, our data showed that Japanese clinicians frequently cited mucosal healing as a key treatment goal and employed biomarkers, such as fecal calprotectin, serum leucine-rich alpha-2 glycoprotein [3], and routine endoscopy, even during the maintenance phase. This suggests the need for a more detailed and proactive approach to disease assessment in Japan. Despite these differences, a notable consensus has emerged on the continuation of 5-ASA during remission. Limsrivilai et al. reported that 83.5% of surveyed physicians recommended continuing 5-ASA even after achieving a Mayo endoscopic subscore of 0, a view that was strongly echoed in our Japanese data.

By integrating national insights from Japan with multinational findings, we hope this letter provides further clarity on shared practices and region-specific nuances shaped by healthcare infrastructure and cultural context. We believe that our contribution will support ongoing efforts to optimize UC management across Asia and foster continued cross-national collaboration.

NOTES

Funding Source

The authors received no financial support for the research, authorship, and/or publication of this article.

Conflict of Interest

No potential conflict of interest relevant to this article was reported.

Data Availability Statement

Data sharing is not applicable as no new data were created or analyzed in this study.

Author Contributions

Conceptualization: Nishida T, Amano T. Data curation: Nishida T. Writing - original draft: Nishida T. Writing - review & editing: Amano T, Osugi N, Yoshihara T. Approval of final manuscript: all authors.

REFERENCES

1. Limsrivilai J, Lai AY, Li STH, et al. Role of 5-aminosalicylic acid in ulcerative colitis management in 8 Asian territories: a physician survey. Intest Res 2025;23:117–128.PubMed PMC
2. Amano T, Yoshihara T, Nishida T, et al. Optimizing 5-aminosalicylic acid maintenance treatment in ulcerative colitis from the patient and physician perspective: a cross-sectional multicenter study. Crohns Colitis 360 2025;7–otaf038.Article PDF
3. Amano T, Yoshihara T, Shinzaki S, et al. Selection of anti-cytokine biologics by pretreatment levels of serum leucine-rich alpha-2 glycoprotein in patients with inflammatory bowel disease. Sci Rep 2024;14:29755.Article PubMed PMC PDF

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Response: Comments on “Role of 5-aminosalicylic acid in ulcerative colitis management in 8 Asian territories: a physician survey”
Julajak Limsrivilai, Wai Keung Leung
Intestinal Research.2025; 23(4): 567. CrossRef

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Comments on “Role of 5-aminosalicylic acid in ulcerative colitis management in 8 Asian territories: a physician survey”

Intest Res. 2025;23(4):565-566. Published online October 28, 2025

DOI: https://doi.org/10.5217/ir.2025.00158

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