Compare Asacol (Mesalamine) with Alternatives: What Works Best for Ulcerative Colitis

When you’re managing ulcerative colitis, finding the right medication isn’t just about taking a pill-it’s about finding one that fits your life. Asacol (mesalamine) has been a go-to for decades, but it’s not the only option. Many people switch because of cost, side effects, or simply because it stops working as well over time. So what else is out there? And more importantly, which one might work better for mesalamine users who need a change?

What Asacol Actually Does

Asacol is a brand-name version of mesalamine, an anti-inflammatory drug that targets the lining of the colon. It doesn’t suppress your whole immune system like steroids or biologics. Instead, it works locally where the inflammation is-right in the colon. That’s why it’s used for mild to moderate ulcerative colitis, especially when symptoms are limited to the lower part of the colon.

Asacol uses a special coating that lets the pill pass through the stomach without breaking down. It only releases mesalamine once it hits the ileum and colon. This targeted delivery is why you take it multiple times a day-it needs to keep releasing medicine as it moves through your gut.

But here’s the catch: you have to take it exactly right. Miss a dose? The medication doesn’t build up in your system. You need consistent levels to keep inflammation under control. That’s a big reason why some people switch to alternatives with simpler dosing.

Generic Mesalamine: The Cheaper Same Drug

Let’s cut to the chase: generic mesalamine is chemically identical to Asacol. The active ingredient is the same. But the coating? That’s different. And that changes how it works.

Some generic versions, like those from Teva or Mylan, use a delayed-release coating that breaks down in the small intestine instead of the colon. That means less drug reaches the exact spot where it’s needed. In a 2023 study of 312 patients switching from Asacol to generic mesalamine, 28% reported a return of symptoms within three months. Not everyone. But enough to make doctors cautious.

There are also extended-release versions of generic mesalamine that only need to be taken once or twice a day. These can be easier to stick with. But if your condition is in the lower colon, you might not get the same coverage as Asacol.

Pentasa: A Different Kind of Release

Pentasa is another mesalamine-based drug, but it uses a totally different delivery system. Instead of a coating that dissolves at a certain pH, Pentasa uses microgranules that slowly release mesalamine all the way through the GI tract. That makes it useful for people with inflammation in both the small intestine and colon-something Asacol doesn’t cover well.

It’s often prescribed for Crohn’s disease too, but it’s also used for ulcerative colitis, especially when the disease spreads beyond the rectum. Dosing is four times a day, which is more than Asacol, but the release pattern gives broader coverage. For someone whose colitis extends into the ileum, Pentasa might be more effective than Asacol alone.

Side effects are similar: headache, nausea, abdominal pain. But because it’s released continuously, some people report fewer spikes in discomfort.

Apriso: Once-Daily Convenience

If you hate taking pills multiple times a day, Apriso might be your best bet. It’s a mesalamine formulation designed to release medication slowly over 24 hours. One capsule a day. That’s it.

Apriso uses a special enteric-coated capsule that dissolves gradually as it moves through the colon. It’s approved for maintaining remission in ulcerative colitis. In clinical trials, 73% of patients stayed in remission after 6 months on Apriso-comparable to Asacol’s 70%.

But here’s the trade-off: Apriso doesn’t work as well for active flare-ups. It’s meant for maintenance. So if you’re in the middle of a bad flare, you’ll still need something stronger. And it’s more expensive than generics. But if you’re stable and just trying to stay that way, Apriso’s simplicity can be a game-changer.

Delzicol: For the Upper Colon

Delzicol is another once-daily mesalamine option. It’s designed to release its contents in the terminal ileum and colon, similar to Asacol. But its capsule dissolves faster, so it’s better at targeting the upper part of the colon.

It’s often recommended for people whose inflammation is more widespread-not just in the rectum, but up through the descending colon. A 2024 study comparing Delzicol and Asacol in 200 patients found Delzicol led to slightly higher rates of mucosal healing (61% vs. 54%) after 8 weeks.

Side effects are nearly identical: gas, diarrhea, headache. But because it’s taken once a day, compliance improves. That alone can make a difference in long-term outcomes.

Balsalazide and Olsalazine: Less Common, But Still Options

Balsalazide (Colazal) and olsalazine (Dipentum) are other mesalamine prodrugs. They break down in the colon to release mesalamine, just like Asacol. But they’re not first-line anymore.

Balsalazide is taken three times a day and has a slightly better side effect profile-fewer people report headaches or nausea. But it’s not widely used in the U.S. because it’s less available and more expensive than generics.

Olsalazine is taken twice daily and can cause watery diarrhea in up to 20% of users. That’s why it’s usually a backup option. But for someone who can’t tolerate other mesalamines, it’s still a valid alternative.

When Mesalamine Just Isn’t Enough

Not everyone responds to mesalamine. About 30% of people with ulcerative colitis don’t get full relief from these drugs. That’s when you look beyond mesalamine entirely.

For moderate to severe cases, doctors often turn to:

• Biologics like Humira, Remicade, or Entyvio-these block specific immune signals that cause inflammation.
• Small molecules like Xeljanz (tofacitinib), which work inside immune cells to reduce inflammation.
• Steroids like prednisone-fast-acting but not for long-term use due to serious side effects.

These aren’t alternatives to mesalamine-they’re next steps. But if you’ve tried multiple mesalamine options and still flare up, it’s time to talk about stepping up your treatment.

Cost and Insurance: The Hidden Factor

Asacol can cost over $600 a month without insurance. Generic mesalamine? Around $50. Apriso and Delzicol sit in the middle-$300-$500. That’s a huge difference if you’re paying out of pocket.

Insurance often requires you to try generics first. Many patients don’t realize this until they get denied coverage. If your doctor prescribes Asacol, make sure they write "dispense as written" on the prescription. Otherwise, the pharmacy will automatically switch you to the cheapest generic.

Some manufacturers offer patient assistance programs. Asacol’s maker, Allergan, has a savings card that can bring the cost down to $10 a month for eligible people. Always ask.

Which One Should You Choose?

There’s no single best option. It depends on:

• Where your inflammation is-lower colon? Asacol or Delzicol. Whole colon? Pentasa or Apriso.
• How often you can take pills-once a day? Apriso or Delzicol. Four times a day? Pentasa.
• What you can afford-generics win on price, but may not work as well for everyone.
• How your body reacts-some people get headaches with one, nausea with another. Trial and error is part of the process.

Most people start with a generic mesalamine. If it doesn’t work, try a branded version with a different release pattern. If that fails, it’s time to consider biologics or other advanced therapies.

The key is not to give up after one try. Finding the right mesalamine can take time. But it’s worth it-better control means fewer hospital visits, fewer flares, and a life that’s not ruled by your colon.