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persons older than 60 years old in western countries(1). Colonic diverticula are classically
described as occurring at weak points in the colonic wall, thus creating pseudodiverticula
consisting of herniations of only the mucosal and submucosal layers. Both a lack of dietary
fiber and alteration in the connective tissue milieu have been implicated in the formation of
colonic diverticula(2). The clinical manifestations of colonic diverticular disease vary, and
many of the complications that arise can be attributed to the incomplete wall and vascular supply
of the diverticulum. Most patients with diverticular disease remain asymptomatic, though up to
and chronic abdominal symptoms such as abdominal pain, altered bowel habits, and recurrent
While the exact pathogenic factors leading to diverticulitis are uncertain, a number of
theories have been proposed. Obstruction of the diverticulum with inspissated stool and fecaliths
leading to bacterial overgrowth and tissue ischemia, and eventual inflammation, has long been
the mechanism suspected of causing acute diverticulitis. More recently, a low grade chronic
bowel disease has also been proposed(3). Research has shown that the inflammatory cascade in
diverticular disease can lead to an imbalance of cytokines and interleukins, which can also lead
have also found an increase in nitric oxide in patients with diverticulitis, which is important in
regulation of inflammation, and may be a factor in the inflammatory response seen in these
patients(6).
Mesalamine
successfully in the treatment of inflammatory bowel disease (IBD) for over 60 years.
compound exerts the beneficial anti-inflammatory effects, and is the active drug(7). 5-ASA
alone is rapidly absorbed in the jejunum, and therefore is not an effective medication for the
treatment of distal small bowel and colonic diseases. Sulfasalazine is able to deliver 5-ASA to
the colon due to the azo-bond, which requires colonic bacteria for cleavage and release of 5-ASA
and sulfapyridine in the colon. Sulfapyridine was found to be the cause of a number of the side
effects which have been attributed to sulfasalazine, which led to the development 5-ASA
products which are able to deliver the drug directly to the colon without containing sulfapyridine.
Mesalamine is one such medication, and is now widely used as a substitute to sulfasalazine due
to its superior side effect profile. A number of preparations of mesalamine are currently
available which have been formulated to be released in the colon preferentially, either via
mechanisms which allow 5-ASA delivery only at colonic pH, or through the use of inert carriers
and coatings (See Table 1). All of these medications exert a topical anti-inflammatory effect
immunosuppression, altered cytokine synthesis and necrosis factor-κB (NF- κB) pathways, free
radical scavenging, and disruption of prostaglandin synthesis via interaction with the
lipooxygenase pathways have all been proposed (8). Some studies have shown an effect of 5-
ASA products on B- and T-cell clonal proliferation, (9-11), which in turn leads to a decreased
properties via antioxidant effects (12). Mesalamine may also interrupt the synthesis of important
proinflammatory cytokines and leukotrienes through action on the lipoxygenase pathway, which
would lead to a decreased inflammatory response (13-17). 5-ASA products may also enhance
the expression of intestinal epithelial heat shock protein, which is thought to provide increased
cellular protection (18). Further studies have shown an inhibitory effect of mesalamine on
interleukin 1, interleukin 12, and tumor necrosis factor -alpha, and more recent reports have also
suggested that mesalamine may exhibit anti-inflammatory effects via the Peroxisome
mesalamine are depicted in Figure 1; note the interactions with leukotrienes, NF- κB, and PPAR-
While similar in structure, however, 5-ASA and aspirin differ significantly in pharmacology and
mode of action. While aspirin exerts effects on the cyclooxygenase (COX) enzymes, 5-ASA has
not been shown to effect the COX family of enzymes, and subsequently does not possess the
anti-thrombotic and anti-cancer effects of aspirin. It has been proposed, however, that
suppression of chronic low grade inflammation may protect against colorectal cancer (CRC), and
the use of mesalamine for prevention of CRC in patients with ulcerative colitis has been
suggested and is currently being investigated. While not mediated through COX2, in-vitro
studies have suggested the anti-cancer effect may be mediated via inhibition of β-catenin
pathway and interference with the endothelial growth factor receptor (EGFR)(21,21a). As most
of the patients affected with diverticular disease are also in the age group for colorectal cancer
risk, the use of mesalamine in these patients may in the future also prove to have a beneficial
specific, and it is occasionally difficult to distinguish between bouts of diverticulitis and IBD.
Findings of acutely inflamed mucosa affecting patients with diverticular disease have been
described and have been termed "segmental colitis associated with diverticulitis" (SCAD)
(22,23). The inflammation noted closely resembles the acute mucosal changes seen in Crohn's
disease and ulcerative colitis, but only occurs in the segments of the colon affected by
diverticulosis, with the sigmoid colon being the most common area of presentation. Patients
commonly are older, with the average age of onset of 64, present with an initial episode of
hematochezia, and have normal levels of inflammatory biomarkers(24). Whether the finding of
SCAD represents a presentation of IBD or a separate entity is still unclear, though one study
found that of 25 patients with SCAD who underwent surgical resection, 23 did not develop
Crohn's disease after a 6 year follow-up (25). A recent systematic review of 218 patients has
also shown that SCAD is a distinct entity(24), though data showing an increase in TNF-α levels
diseases such as Crohn's disease and ulcerative colitis have led researchers to consider the use of
medications widely used in the treatment of IBD in the treatment of diverticular disease and
diverticulitis. An in-depth discussion of the traditional treatments of diverticulitis are beyond the
scope of this review, but mention will be made of the use of antibiotic treatments and surgical
interventions. Most patients diagnosed clinically with uncomplicated diverticulitis are treated
with bowel rest and antibiotic treatment. There are many effective antibiotic treatments
available, with the most common prescribed drugs for diverticulitis include quinolones and
metronidazole. Recent studies have also shown the use of oral rifaxamin, and non-absorbable
complicated diverticulitis and recurrent disease are often considered for surgical resection of the
affected areas, when antibiotics are not successful or the disease is considered to be severe.
Diverticulitis
first study was performed by Tursi, et.al. in 1997 and followed 166 patients with symptomatic
large bowel diverticulitis(27). In this randomized, non-blinded study, all patients were treated
with conventional antibiotic therapy, followed by randomization into groups who received
mesalamine 400mg twice daily for 8 weeks or placebo. At four years of follow-up, there were
significantly fewer relapses and microhemorrhagic events in the group treated with mesalamine
(p<0.00005). Patients in the mesalamine group also had significantly less likelihood of having
This study was followed by a report on the use of the combination of rifaxamin and
mesalamine in the treatment of diverticulitis, which was performed with the effectiveness of
rifaxamin alone and rifaxamin plus mesalamine in the prevention of recurrent diverticulitis in
218 patients as the primary endpoint(28) . All patients enrolled had at least two documented
episodes of diverticulitis in the year prior to enrollment, and were randomized to receive either
rifaxamin alone (400mg twice daily) for 7 days, followed by a 7 day course each month for 12
months, or rifaxamin and mesalamine (800mg three times daily) together in an identical dosage
schedule. Patients were followed for one year, and assessed for recurrence of symptoms (upper
significantly higher number of patients in the combined (rifaxamin + mesalamine) group were
asymptomatic at 3,6,9 and 12 months (85% vs. 49% at 12 months, p<0.0005). In addition, those
patients receiving combined therapy had a 2.75% rate of recurrent diverticulitis at 12 months, vs.
with uncomplicated diverticular disease who received mesalamine. As many of the studies
regarding the topic of mesalamine in diverticular disease originate in Italy and are similar in
patient population and design, the definition of symptomatic uncomplicated diverticular disease
(SUDD) remains constant throughout the following studies. Symptomatic uncomplicated
mucous passage with stool, associated with diverticular disease of the colon in the absence of
acute inflammation.
One hundred and seventy patients with uncomplicated diverticular disease who received
either rifaxamin (at 200mg or 400mg twice daily) or mesalamine (at 400mg or 800mg twice
daily) for 10 days each month were followed by DiMario, et. al. for three months(29). A
score, taking into account abdominal pain, tenesmus, bloating, diarrhea, and 6 other associated
symptoms) was seen in both mesalamine groups and the 400mg rifaxamin dose, with patients
receiving the higher dose of mesalamine having the most improvement. In a follow up study
published in 2007, Comparato and colleagues compared the use of rifaxamin and mesalamine
cyclic mesalamine in SUDD(30). Two hundred and sixty eight patients who exhibited two of ten
symptoms attributed to diverticulosis for at least two months were enrolled in the study and
followed for 12 months. In a treatment schedule similar to the study by DiMario, et al in 2005,
patients received either rifaxamin (200mg or 400mg BID) or mesalamine (400mg or 800mg
BID) for ten days each month. At 6 months, both treatment groups receiving mesalamine (and
those receiving rifaxamin 400mg BID) had improvement in tenesmus, bloating, diarrhea, well-
being, and bleeding. This finding, along with the finding of an improvement in lower abdominal
The second study also compared treatment with mesalamine alone to mesalamine plus
alone (1.6 grams) for 8 weeks. At completion, 77% of patients were asymptomatic, while 2
Interestingly, 2/90 patients were forced to discontinue mesalamine due to severe diarrhea, which
prospective, randomized, non controlled study (32). This study evaluated 90 consecutive
patients with resolved uncomplicated diverticular disease for recurrence of symptoms within 12
months. All patients were treated with rifaxamin and mesalamine to achieve remission, after
which patients received either mesalamine 1.6 gram daily, probiotic (Lactobacillus casei 16
billion/day for 15 days per month) or both probiotic and mesalamine for 15 days per month.
Overall, 96% of patients treated with mesalamine and Lactobacillus for 12 months were
shown in a number of studies, the optimal dosing schedule has not been determined. In a study
evaluating daily vs. cyclic mesalamine, forty patients were enrolled after successful treatment of
recurrent symptomatic diverticular disease of the colon, which was described as recurrent
(diverticulitis)(33). At the completion of the 24 month follow up period, 70% (14/18) of the
patients receiving mesalamine at 1.6gram/day were symptom free, vs. 45% (9/16) in the group
5-ASA begins to exert its topical effects at the level of the small bowel, and as noted above is
rapidly absorbed in the jejunum. As such, it is not commonly present in therapeutic levels in the
colon. To date, we are not aware of any studies investigating the use of sulfasalazine in the
treatment of diverticular disease, though other mesalamine preparations have been considered.
molecule (4-aminobenzoil-b-alanine). Colonic bacteria cleave the bond between the two
components of the drug, leading to the delivery of the active 5-ASA directly to the colon. In
2007, Tursi et. al., studied the use of balsalazide and probiotics in the prevention of recurrent
in an unblinded fashion and followed for one year(34). One half of the patients received
balsalazide 2.25gram/daily and rifaxamin 800mg daily for 10 days, followed by balsalazide daily
and probiotic formulation VSL#3 for 15 days each month for 12 months (Group A). 15 patients
in received only the initial 10 day course of balsalazide and rifaxamin, plus 12 months of VSL#3
only for 15 days each month (group B). At the end of one year, 73% of group A patients were
asymptomatic vs. 60% in group B. One episode of recurrence occurred in group A, and two
patients recurred in group B (p<0.1, NS). Overall symptom scores at the completion of the study
were significantly better in group A, however. Although the data show a modest benefit of
balsalazide in diverticular disease, the low sample size and unblinded design are important
Future studies
A number of studies, as reviewed above, have been performed with the goal of evaluating
the effectiveness of mesalamine in the treatment of diverticular diseases, though most of these
studies have flaws which limit the validity and applicability of their findings. Recently, there
have been four large, randomized, double blinded, placebo controlled prospective studies
designed to evaluate mesalamine in the prevention of recurrent diverticulitis, all of which are
currently ongoing. Two concurrent studies on the use of MMX mesalamine in the prevention of
recurrent diverticulitis have completed enrollment, and the results are pending. In these studies,
patients were given either 1.2, 2.4, or 4.8 grams of MMX mesalamine daily for 2 years and
followed for acute diverticulitis. A third study, which has also completed clinical enrollment, has
compared the number of acute diverticulitis flares in patients with at least one episode of prior
diverticulitis who received either 1.6 grams/day of mesalamine (Asacol) for 10 days each month
The durability of mesalamine in the long term treatment of SUDD has yet to be
determined. At a recent national meeting, data was presented in abstract form regarding the five
acute diverticulitis(35,36). In sixty seven patients with SUDD who received cyclic mesalamine
for five years, 4% were found to have at least one episode of diverticulitis, vs. 11% of population
controls(35). Similar long term symptomatic improvements were also noted in a separate study
of sixty seven patients performed by the same group (36). Lastly, a study of patients with
three months is currently ongoing. It is anticipated that the results of these studies will offer
reliable data and significant insight into the clinical effectiveness of mesalamine in acute and
Mesalamine was seen to have a favorable side effect profile in all of the reported studies,
which is a finding that has been confirmed in the extensive literature available regarding the use
of mesalamine in IBD. Overall, the most common side effects of mesalamine include headache,
abdominal pain, and diarrhea. Fever and rash have also been reported (37). A number of large,
colitis (38-40) have been performed, and offer quality side effect data. In the Ascend I trial, 301
patients were assigned to 6 weeks of mesalamine, and a total of 4 (1%) were reported to have
serious side effects(38). The Ascend II trial reported an overall side effect profile of 39%, with
the most reported adverse events of headache (7.5%), abdominal pain (4.7%), diarrhea (3.7%),
and infection (3.7%)(39). Serious side effect rate was 1% (one episode each of pancreatitis,
cholecystitis, and pericarditis). A third study of 772 patients receiving mesalamine revealed an
overall side effect rate of 20%(40). The most common side effects were headache (3%), nausea
Approximately 10-15% of patients may develop diarrhea as a side effect of 5-ASA drugs.
While most commonly seen in preparations with nonabsorbable components (olsalazine and
balsalazide), patients receiving mesalamine may also experience bowel habit changes.
Acute interstitial nephritis has been described in a small number of patients receiving
mesalamine, occurring at a rate of 0.26/patient year, and routine monitoring of renal function in
patients receiving this drug is recommended(41). Pancreatitis is a rare but potentially serious
side effect of mesalamine which, if present, should preclude any further treatment with 5-ASA
compounds(42). Blood dyscrasias and hepatocellular injury have also been reported with the use
of mesalamine, though in small numbers and at a lower rate than sulfasalazine (43).
it to be contraindicated in patients with aspirin sensitivity. Most clinicians would also advise
against mesalamine therapy in this situation, though there have been reports of the successful use
hypersensitivity reaction outweigh the benefits of the use of mesalamine in diverticular disease
in this population, and until further data is available, we recommend it be avoided in these
patients.
considered safe to use in expectant women. One large study which evaluated 146 women who
received mesalamine during pregnancy did not reveal any increase in major congenital
malformations, miscarriage rate, fetal distress, or rate of live births(45). Mesalamine is widely
used throughout pregnancy in patients with IBD, and, although unlikely to be needed in this age
Conclusion
Diverticulosis is a very common finding in many patients who consume a western diet.
Despite the prevalence of the disease, however, a majority of the patients with diverticulosis
remain asymptomatic and do not require treatment. Those patients who do develop
The treatment of diverticulitis and SUDD has recently undergone a number of changes,
with the addition of non-absorbable antibiotics such as rifaxamin and probiotics to the treatment
algorithms. Mesalamine was initially considered as a treatment option for patients with
diverticular complications due to its known anti-inflammatory effects, and has shown some
between these two entities when evaluating the use of mesalamine in diverticular disease, as they
are pathogenetically somewhat different, and have different expected treatment outcomes.
and is generally described as lower abdominal pain, with or without other associated abdominal
complaints such as bloating, changes in bowel habits, or rectal mucous, in the setting of
diverticulosis coli without evidence of acute inflammation(46). SUDD may present with
symptomatology similar to irritable bowel syndrome, and some authors have suggested that the
two diagnoses should be considered manifestations of the same disease(26,47). In two studies of
patients receiving mesalamine at 400 mg and 800mg twice daily for SUDD, global symptomatic
score was improved at 3 and 12 months, with the most benefit being achieved with the higher
dose of mesalamine(29,30). This finding was also confirmed in a short study of patients
receiving mesalamine at 1.6 grams/day(31). It should be noted that none of these studies
incorporated a control group, which creates difficulty in interpreting these results, as the baseline
symptomatic improvement rate in SUDD is not yet clear. Additionally, the short follow up
period of two of the studies (eight weeks and three months, respectively) may not have been
sufficient to determine long term effectiveness of mesalamine in affecting recurrence of
symptoms, though the results were seen to be reproduced at 12 months in a later study.
The combined use of mesalamine and probiotic in SUDD has also been studied, and
beneficial effects of both have been found(32). Patients receiving both treatments for one year
had less symptoms than patients receiving only mesalamine (96% vs. 77%). One potential
confounding factor of this study, however, is the inclusion of patients with prior complaints-68%
of patients had had symptomatic diverticular disease prior to enrollment, and it is unclear if these
patients were equally represented in each group. Many authors have suggested that an alteration
in the colonic microflora may be an important pathogenetic factor in the development of SUDD
and diverticulitis, and the restoration of colonic flora achieved with the use of probiotic may
explain the additional benefit seen in patients receiving both treatments in this study.
While the studies performed to date on the use of mesalamine in SUDD are varied in
dosing, duration, and design, the number of patients who remain free of symptoms after the
administration of mesalamine 1.6 daily appears to be consistent, with rates of 70%, 77%, and
77% being reported in studies with follow up periods ranging from 8 weeks to 2 years (31-33).
Mesalamine has shown benefit in the prevention of recurrent symptoms in SUDD, but
less data are available on the use of mesalamine in acute diverticulitis. We have identified only
two studies to date in which patients with acute inflammation of a diverticulum were given
mesalamine and prospectively followed, and one in which patients received balsalazide (27,28,
34). In the initial study performed, patients received mesalamine for only the initial 8 weeks
after treatment for diverticulitis, and the beneficial effect remained at 48 months(27). In the
largest study, the addition of mesalamine to treatment with rifaxamin for one year offered a
significant decrease in rate of recurrent diverticulitis (2.75% vs. 18%)(28). The rate of recurrent
diverticulitis in control patients in this study is consistent with previous studies, which have
reported a rate of a single, recurrent episode of diverticulitis of between 13 and 19% (48-50),
recurrent disease once the acute inflammation has been treated. This finding leads to the
diverticulitis, which is contrary to the traditional belief of acute diverticular obstruction leading
to inflammation in these patients. At this time, there is not enough data to suggest that
mesalamine offers benefit in the acute treatment of these patients, however, and it should be not
To date, we are not aware of any data on the use of mesalamine in SCAD, though it is
The dose and timing of mesalamine used in these studies should also be noted, as doses
of 1.6-2.4 gram/day were used, which is on the lower end of the therapeutic dose traditionally
required in the treatment of IBD, and patients were given mesalamine in a cyclic pattern (7-15
days every month) in most of the studies. It is unclear why the dose requirements of 5-ASA may
be lower in the treatment of diverticular symptoms, though it may be related to the lower level of
chronic inflammation in these patients. This low level of inflammation, in comparison to IBD,
may also be the reason for the effectiveness of mesalamine on a cyclic dosing schedule.
Recently, a systematic review by Gatta, et al , has also investigated the issue of 5-ASA
and diverticular disease(52). Six randomized studies of 5-ASA and diverticular disease were
identified, three of which were performed on patients with diverticulitis, and three on patients
with SUDD(27,28,30,32-34). The authors concluded that 5-ASA likely has a role in the
treatment of diverticular disorders, but due to the heterogeneity of the studies available, further
chronic symptoms of SUDD. Data on the use of mesalamine in acute diverticulitis are not as
strong, but the studies that are available do suggest a decrease in the rate of recurrent
as well as the duration of treatment necessary to obtain a significant benefit, is not currently
known. Additionally, all of the studies available on the use of mesalamine in diverticular
diseases originate in Italy, which may limit the reproducibility of the findings, and this should be
considered when the data are applied to different patient populations. It is expected that further
studies, which are already ongoing, will add significant information to the discussion of
mesalamine in diverticular disease and offer answers to some of these important questions.
Given the available data and the beneficial side effect profile, we find it reasonable to consider a
trial of mesalamine in patients with suspected SUDD and resolved acute diverticulitis.
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recA total of five studies were found that investigated the use of mesalamine in the treatment of
SUDD. Importantly, data from these studies (Study, Study 3, Study 5, Study 6, Study 7) need to
be interpreted in the context of symptomatic diverticular disease, rather than acute diverticulitis.
It is unclear how these results may translate to patients with the acute diverticulitis, and the small
number of patients included in the final evaluation of one of the studies (Study 5) may limit the
reliability of the findings.
Digestive Endoscopy Unit, Lorenzo Bonomo Hospital, Via Torino, 49, 70031 Andria, BA, Italy.
antotursi@tiscali.it