Sulfasalazine

Sulfasalazine is known as a disease modifying anti-rheumatic drug (DMARD).  

In the gut sulfasalazine is broken down (by the normal gut bacteria) into two parts: one part a sulphonamide antibiotic which kills harmful bacteria; and a second part which acts to reduce the process driving inflammation as well as helping to control the overactive immune system.  

This overactive immune system in RA is the cause of swelling, pain, heat and redness in the joints and other associated symptoms such as fatigue and generally feeling unwell.  

Sulfasalazine may be prescribed as a single DMARD or prescribed at the same time as another DMARD. It is frequently prescribed in combination with methotrexate 

Background  

  • Sulfasalazine was introduced in the 1950s, initially to treat inflammatory bowel disease, but also for the treatment of rheumatoid arthritis (RA) as it was believed then that bacterial infections were the cause of this form of arthritis  
  • Following positive results from clinical trials in the late 1970s it was used more extensively in RA and subsequently used for some forms of juvenile arthritis (but not extensively)  
  • Sulfasalazine is also used to treat inflammatory bowel disease, ulcerative colitis and Crohn’s disease  

How long does it take to work?  

  • Sulfasalazine is available in liquid form or tablets  
  • The daily dose of sulfasalazine is gradually increased each week, usually for three weeks, until the maximum prescribed daily dose has been achieved  
  • Controlling the symptoms of RA with sulfasalazine may take up to three months or longer  

Most commonly reported side effects  

As with any medication, sulfasalazine has a number of possible side effects although it is important to remember that these are only potential side effects and may not occur. Side effects that can occur will be experienced during the first three to six months. These include:  

  • Nausea (feeling sick), vomiting, dizziness, headache, diarrhoea, loss of appetite  
  • Skin rash, raised temperature, insomnia, itching of skin, tinnitus  
  • Bruising, sore throat, mouth ulcers, cough  
  • Effects on the blood tests, including the blood cell count, the blood chemistry and liver tests and measures of inflammation (using tests known as ESR and CRP)  
  • Yellow/orange discoloration of the urine, protein in urine (proteinuria 
  • For young men, reduced sperm count whilst on the drug, reversible on stopping  

More information on side effects can be found in the patient information leaflet for sulfasalazine 

 

Remember to report any concerns about possible side effects to the doctors or nurses.  

 
Sulfasalazine with other medicines  

  • Sulfasalazine may interfere with the absorption of folic acid (one of the B vitamins) from the diet. If methotrexate is prescribed as well as sulfasalazine the regimen for a weekly supplement of folic acid will be required  
  • Sulfasalazine may reduce the absorption of some heart drugs  
  • Sulfasalazine must not be prescribed if you are sensitive to sulphonamides or aspirin  
  • If you are taking sulfasalazine, do not buy any other medicine or remedy (eg for colds or flu) without first consulting your doctor, nurse or pharmacist  
  • Remember to take care when using any other medications or complementary therapies (even if bought ‘over the counter’ for colds or flu). Remember to check with a doctor, nurse or pharmacist that they are safe to take with sulfasalazine and any other medication taken  

Sulfasalazine during pregnancy and breastfeeding  

  • If sulfasalazine is to be prescribed during pregnancy an analysis of the risks and benefits to the mother should be undertaken, against the possible small risk to the unborn child  
  • Folic acid supplementation is required whilst trying to conceive and during pregnancy, and should be discussed with your doctor  
  • Breast-feeding is not advisable when taking sulfasalazine  
  • Young men should be aware that although sulfasalazine lowers the sperm count, contraception is still recommended to prevent an unplanned pregnancy. The lowered sperm count is reversed when you stop sulfasalazine  

Sulfasalazine and alcohol  

Alcohol can be consumed when taking sulfasalazine. However, caution may be required when taking other medications alongside this drug, for example methotrexate 

Sulfasalazine and immunisation/vaccination  

If you are taking sulfasalazine, immunisations and vaccinations can be given if required.  

Advice should be sought from your prescribing doctor regarding chickenpox vaccination before starting treatment and if the person taking sulfasalazine comes into contact (defined as five minutes or more in the same room) with chickenpox, without having immunity to the disease.  

Live vaccines (measles, mumps, rubella (MMR), chickenpox, oral polio (NOT injectable polio), BCG, oral typhoid and yellow fever) cannot be given to anyone already taking sulfasalazine. If sulfasalazine has not yet been started it is important to seek advice on how long a gap to leave after having a live vaccine.  

Flu vaccine is now available in two forms, an injection for adults and a nasal spray for children. The injection is not a live vaccine and therefore suitable for adults taking sulfasalazine and is recommended. The nasal spray is a live vaccine and not suitable for adults taking sulfasalazine. It is important to discuss having a flu vaccination with your GP.  

Vaccination of close family members can help to protect someone with a lowered immune system from infection. 

 
Hints and tips  

  • Stay safe on sulfasalazine by remembering to have regular blood test monitoring as advised by the consultant or clinical nurse specialist  
  • Remember that contraception is still required if men taking sulfasalazine do not wish to father a child even though the sperm count is likely to be lowered