Sulfasalazine rheumatoid arthritis

by Nathan Wei, MD, FACP, FACR

Nathan Wei is a nationally known board-certified rheumatologist and author of the Second Opinion Arthritis Treatment Kit. It's available exclusively at this website... not available in stores.

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Sulfasalazine (SSZ) is sold under the brand name Azulfidine. Sulfasalazine was developed in the 1930’s.

Sulfasalazine is a combination of 2 different medications: 5-amino salicylic acid and sulfapyridine. In the 1920’s and 1930’s, scientists thought that rheumatoid arthritis was an inflammatory disease due to a bowel infection. They hypothesized that they could improve rheumatoid arthritis by combining an anti-inflammatory drug (5-amino salicylic acid) with an antibacterial drug (sulfapyridine). Recent experiments suggest that it is the “sulfa” component (sulfapyridine) that acts against arthritis.

The use of sulfasalazine declined when several studies failed to show significant benefit with the drug. Over the last 20 years, more scientific studies have reconfirmed SSZs effectiveness in rheumatoid arthritis. There also is evidence that the medicine can treat ankylosing spondylitis, psoriatic arthritis and other forms of inflammatory arthritis, such as juvenile arthritis.

SSZ typically starts working in 6 to 12 weeks. The usual starting dose for adults is 500 mgs two times a day. The dose is gradually increased until a total of one gram two times a day are taken each day. It is recommended that patients take SSZ after eating. The dye in the SSZ tablets may cause an orange discoloration of the urine or skin.

About one-third of persons with rheumatoid arthritis starting SSZ have to discontinue it because of side-effects. Since SSZ has a “sulfa” drug in it, people who are allergic to sulfa drugs should not take it. Also, persons who have the medical problem called porphyria should not take SSZ. Nausea and stomach discomfort are the most common reasons for stopping SSZ. Sometimes these symptoms can be minimized by using a lower dose, taking the medication with food or by using the “coated” Azulfidine sold under the brand name “Azulfidine-ENtabs.” Headache also is a potential side-effect that may go away if the dose is lowered.

Allergic reactions to SSZ include fever and rash. The rash can look like hives or the measles. Usually the rash goes away without treatment after the medication is stopped. Rarely, more severe skin reactions require more aggressive treatment. Sun exposure may increase the risk of getting a rash from SSZ.

SSZ can reduce fertility in men by decreasing sperm counts. The reduced fertility usually reverses when the medication is stopped. It may take several months before sperm changes are normal. There is little effect on a woman’s fertility, but because of uncertain effects on the unborn child, SSZ is not recommended during pregnancy.

Rare side-effects from SSZ include: abnormal liver function and decreased blood counts. Occasional blood tests are used to look for these problems. Other rare side-effects include: shortness of breath or scarring of the lungs, mouth sores, or numbness and tingling in the arms or legs. SSZ may interfere with the absorption into the blood stream of folic acid and digitalis medications such as digoxin (Lanoxin).

Regular blood and urine tests are necessary when a person takes SSZ. Side-effects from Azulfidine most often occur during the first 6 months.

Occasionally SSZ is combined with other disease modifying anti-rheumatic drugs such as methotrexate and hydroxyxchloroquine.

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