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What is Sulfasalazine
Sulfasalazine (salicylazosulfapyridine) is a prodrug that is metabolized by intestinal bacteria to sulfapyridine and 5-aminosalicylate (5-ASA) (mesalamine). Sulfasalazine is used in the treatment of ulcerative colitis (UC), rheumatoid arthritis (RA), and juvenille idiopathic arthritis (JIA).
Guidelines include the use of sulfasalazine as a conventional DMARD in selected adult patients with RA and pediatric patients with JIA.
The local actions of 5-ASA in the colon from sulfasalazine are believed to be responsible for the effectiveness of sulfasalazine in the treatment of inflammatory bowel disease, particularly ulcerative colitis (UC).
Guidelines for UC support the use of standard-dose mesalamine (2 to 3 grams/day) or diazo-bonded 5-ASAs (balsalazide or olsalazine) for induction and maintenance of remission rather than sulfasalazine in patients with extensive mild to moderate UC.
Indications
- Crohn’s disease
- juvenile rheumatoid arthritis (JRA)/juvenile idiopathic arthritis (JIA)
- rheumatoid arthritis
- ulcerative colitis
Side Effects
- abdominal pain
- acute generalized exanthematous pustulosis (AGEP)
- agranulocytosis
- alopecia
- anaphylactoid reactions
- angioedema
- anorexia
- anuria
- aplastic anemia
- arthralgia
- ataxia
- cholestasis
- colitis
- crystalluria
- cyanosis
- cystitis
- depression
- diarrhea
- diuresis
- dizziness
- drowsiness
- Drug Reaction with Eosinophilia and Systemic Symptoms (DRESS)
- dyspepsia
- elevated hepatic enzymes
- enterocolitis
- eosinophilia
- erythema multiforme
- exfoliative dermatitis
- fever
- folate deficiency
- goiter
- Guillain-Barre syndrome
- hallucinations
- headache
- hearing loss
- hematuria
- hemolytic anemia
- hemolytic-uremic syndrome
- hepatic failure
- hepatic necrosis
- hepatitis
- hypoglycemia
- hypoprothrombinemia
- infection
- infertility
- insomnia
- interstitial nephritis
- jaundice
- leukopenia
- lupus-like symptoms
- megaloblastic anemia
- meningitis
- methemoglobinemia
- myelitis
- myocarditis
- nausea
- nephrolithiasis
- nephrotic syndrome
- neutropenia
- oligospermia
- oliguria
- pancreatitis
- pericarditis
- peripheral neuropathy
- photosensitivity
- pneumonitis
- proteinuria
- pruritus
- purpura
- rash
- rhabdomyolysis
- seizures
- serum sickness
- skin discoloration
- Stevens-Johnson syndrome
- stomatitis
- thrombocytopenia
- tinnitus
- toxic epidermal necrolysis
- urine discoloration
- urticaria
- vertigo
- vomiting
Monitoring Parameters
- CBC with differential
- glucose-6-phosphate dehydrogenase (G6PD) activity
- LFTs
- serum creatinine/BUN
- urinalysis
Contraindications
- 5-aminosalicylates hypersensitivity
- agranulocytosis
- aplastic anemia
- asthma
- bone marrow suppression
- breast-feeding
- children
- dehydration
- folate deficiency
- G6PD deficiency
- GI obstruction
- hematological disease
- hepatic disease
- hepatotoxicity
- hypovolemia
- infants
- infection
- infertility
- jaundice
- laboratory test interference
- nephrolithiasis
- neutropenia
- porphyria
- pregnancy
- premature neonates
- renal failure
- renal impairment
- salicylate hypersensitivity
- serious rash
- slow acetylation
- sulfonamide hypersensitivity
- sunlight (UV) exposure
- urinary tract obstruction
Interactions
- Abacavir; Lamivudine, 3TC; Zidovudine, ZDV
- Acalabrutinib
- Acarbose
- Acetaminophen; Aspirin, ASA; Caffeine
- Acetaminophen; Caffeine; Magnesium Salicylate; Phenyltoloxamine
- Acetaminophen; Caffeine; Phenyltoloxamine; Salicylamide
- Acetohexamide
- Albiglutide
- Alogliptin; Metformin
- Alpelisib
- Alpha-glucosidase Inhibitors
- Aminosalicylate sodium, Aminosalicylic acid
- Amlodipine; Celecoxib
- Amoxicillin
- Amoxicillin; Clarithromycin; Lansoprazole
- Amoxicillin; Clarithromycin; Omeprazole
- Amoxicillin; Clavulanic Acid
- Ampicillin
- Ampicillin; Sulbactam
- Articaine; Epinephrine
- Aspirin, ASA
- Aspirin, ASA; Butalbital; Caffeine
- Aspirin, ASA; Butalbital; Caffeine; Codeine
- Aspirin, ASA; Caffeine; Dihydrocodeine
- Aspirin, ASA; Caffeine; Orphenadrine
- Aspirin, ASA; Carisoprodol
- Aspirin, ASA; Carisoprodol; Codeine
- Aspirin, ASA; Citric Acid; Sodium Bicarbonate
- Aspirin, ASA; Dipyridamole
- Aspirin, ASA; Omeprazole
- Aspirin, ASA; Oxycodone
- Aspirin, ASA; Pravastatin
- Atropine; Benzoic Acid; Hyoscyamine; Methenamine; Methylene Blue; Phenyl Salicylate
- Azathioprine
- Benzocaine
- Benzocaine; Butamben; Tetracaine
- Benzoic Acid; Hyoscyamine; Methenamine; Methylene Blue; Phenyl Salicylate
- Bismuth Subsalicylate
- Bismuth Subsalicylate; Metronidazole; Tetracycline
- Bortezomib
- Bromocriptine
- Bupivacaine
- Bupivacaine Liposomal
- Bupivacaine; Lidocaine
- Canagliflozin
- Canagliflozin; Metformin
- Capmatinib
- Cardiac glycosides
- Celecoxib
- Chloroprocaine
- Chlorpropamide
- Choline Salicylate; Magnesium Salicylate
- Colchicine; Probenecid
- Cyclosporine
- Daclatasvir
- Dapagliflozin
- Dapagliflozin; Metformin
- Dapagliflozin; Saxagliptin
- Dapsone
- Darolutamide
- Dicloxacillin
- Dienogest; Estradiol valerate
- Digitoxin
- Digoxin
- Dipeptidyl Peptidase-4 Inhibitors
- Diphenhydramine; Naproxen
- Drospirenone; Ethinyl Estradiol; Levomefolate
- Dulaglutide
- Elbasvir; Grazoprevir
- Eltrombopag
- Empagliflozin
- Empagliflozin; Linagliptin
- Empagliflozin; Linagliptin; Metformin
- Empagliflozin; Metformin
- Ertugliflozin
- Ertugliflozin; Metformin
- Ertugliflozin; Sitagliptin
- Esomeprazole; Naproxen
- Estradiol
- Estradiol Cypionate; Medroxyprogesterone
- Etanercept
- Ethinyl Estradiol; Levonorgestrel; Folic Acid; Levomefolate
- Exenatide
- Fenoprofen
- Fluvastatin
- Folic Acid, Vitamin B9
- Fostamatinib
- Glecaprevir; Pibrentasvir
- Glimepiride
- Glimepiride; Pioglitazone
- Glimepiride; Rosiglitazone
- Glipizide
- Glipizide; Metformin
- Glyburide
- Glyburide; Metformin
- Hydrochlorothiazide, HCTZ; Losartan
- Hyoscyamine; Methenamine; Methylene Blue; Phenyl Salicylate; Sodium Biphosphate
- Incretin Mimetics
- Insulin Degludec; Liraglutide
- Insulin Glargine; Lixisenatide
- Insulins
- Isoniazid, INH; Pyrazinamide, PZA; Rifampin
- Isoniazid, INH; Rifampin
- Itraconazole
- Lamivudine, 3TC; Zidovudine, ZDV
- Lansoprazole; Naproxen
- Leflunomide
- Levomefolate
- Lidocaine
- Linagliptin; Metformin
- Liraglutide
- Lixisenatide
- Losartan
- Magnesium Salicylate
- Meglitinides
- Mepivacaine
- Mepivacaine; Levonordefrin
- Mercaptopurine, 6-MP
- Metformin
- Metformin; Pioglitazone
- Metformin; Repaglinide
- Metformin; Rosiglitazone
- Metformin; Saxagliptin
- Metformin; Sitagliptin
- Methenamine
- Methenamine; Sodium Acid Phosphate
- Methenamine; Sodium Acid Phosphate; Methylene Blue; Hyoscyamine
- Methotrexate
- Methoxsalen
- Miglitol
- Naproxen
- Naproxen; Pseudoephedrine
- Naproxen; Sumatriptan
- Omeprazole; Amoxicillin; Rifabutin
- Oral Contraceptives
- Osimertinib
- Oxacillin
- Ozanimod
- Penicillin G
- Penicillin G Benzathine
- Penicillin G Benzathine; Penicillin G Procaine
- Penicillin G Procaine
- Penicillin V
- Pexidartinib
- Photosensitizing agents (topical)
- Piperacillin
- Piperacillin; Tazobactam
- Ponatinib
- Porfimer
- Pramlintide
- Prilocaine
- Prilocaine; Epinephrine
- Probenecid
- Pyrimethamine
- Pyrimethamine; Sulfadoxine
- Regorafenib
- Rifampin
- Riluzole
- Rimegepant
- Rituximab
- Rituximab; Hyaluronidase
- Rolapitant
- Ropivacaine
- Safinamide
- Salicylates
- Salsalate
- Semaglutide
- SGLT2 Inhibitors
- Simeprevir
- Sodium Iodide
- Sodium picosulfate; Magnesium oxide; Anhydrous citric acid
- Sofosbuvir; Velpatasvir; Voxilaprevir
- Sulfonylureas
- Tafamidis
- Talazoparib
- Tedizolid
- Tetracaine
- Thiazolidinediones
- Thioguanine, 6-TG
- Tolazamide
- Tolbutamide
- Topotecan
- Typhoid Vaccine
- Ubrogepant
- Verteporfin
- Voriconazole
- Warfarin
- Zidovudine, ZDV