ABSTRACT Ulcerative colitis (UC) is traditionally managed with long‐term 5‐aminosalicylic acid (5‐ASA) administration. However, in real‐world practice, carefully selected low‐risk patients in sustained deep remission may remain stable without continuous therapy. Randomized trials have shown only modest differences in relapse between 5‐ASA and placebo treatment, and real‐world experience indicates that requests to discontinue 5‐ASA during sustained remission are not uncommon. Importantly, symptom‐based assessments can be misleading. Psychosocial factors and a disconnect between symptoms and inflammation, including irritable bowel syndrome overlap, may explain the observed differences. Noninvasive biomarkers, such as fecal calprotectin and serum leucine‐rich alpha‐2 glycoprotein, allow the early detection of subclinical inflammation, supporting the feasibility of a drug‐free active surveillance (DFAS) strategy in selected patients. Biomarker‐guided monitoring can reduce the reliance on colonoscopy and make DFAS more acceptable in practice. Consistent with treat‐to‐target and disease clearance strategies, prioritizing endoscopic and histologic remission, stable biomarkers, and favorable psychosocial conditions may help identify appropriate candidates. A patient‐centered implementation strategy that integrates patient‐reported outcomes, mental health assessments, and shared decision‐making can ensure that DFAS reflects proactive, individualized care rather than therapeutic neglect. Given the growing UC population and disease burden, increasing healthcare costs, and patient preferences to minimize long‐term medication, this review defines the clinical rationale, candidate selection criteria, and a pragmatic biomarker‐guided algorithm for selective DFAS after 5‐ASA in UC and outlines a research agenda to validate safety, feasibility, and cost‐effectiveness. We propose that DFAS be reserved for low‐risk patients under structured surveillance with predefined relapse triggers and rapid rescue pathways.
Nishida et al. (Wed,) studied this question.