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Sulfasalazine

Sulfasalazine is known as a disease modifying anti-rheumatic drug (DMARD). In the gut it is broken down (by the normal gut bacteria) into 2 parts, 1 part a sulphonamide antibiotic which kills harmful bacteria and the other part acts to reduce the process driving inflammation as well as helping to control the overactive immune system.

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Name of DrugHow the drug is takenHow it worksBlood tests
Sulfasalazine (SSZ)TabletReduces over activity of the immune systemYes – initially regularly, then less frequently

The overactive immune system in JIA can cause swelling, pain, heat and redness. Sulfasalazine may help to dampen down this process. 

Sulfasalazine may be prescribed as a single DMARD or prescribed at the same time as another DMARD.

    • 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 (see Sulfasalazine explained above)
    • Following positive results from clinical trials in the late 1970s it was used more extensively in RA and subsequently used for some forms of JIA (but not extensively)
    • Sulfasalazine is also used to treat inflammatory bowel disease, ulcerative colitis and Crohn’s disease (see Sulfasalazine explained)
  • Sulfasalazine is available in liquid form or tablets. It is not used in young children or in those with systemic onset juvenile idiopathic arthritis.
  •  The daily dose of sulfasalazine is gradually increased each week, usually for 3 weeks, until the maximum prescribed daily dose has been achieved
  • Controlling the symptoms of JIA with sulfasalazine may take up to 3 months or longer

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 may include:

  • Nausea (feeling sick), vomiting, dizziness, headache, diarrhoea
  • Skin rash
  • Bruising, sore throat, mouth ulcers
  • 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 
  • 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 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 regime 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 the patient with JIA is sensitive to sulphonamides, or aspirin
  • If you are taking/giving 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.
  • 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.
  • Young men should be aware that sulfasalazine lowers the sperm count, but contraception is  still recommended to protect from an unplanned pregnancy. This is reversible when you stop sulfasalazine.

Alcohol can be consumed when taking sulfasalazine. However, caution may be required when taking other medications alongside this drug, for example methotrexate. Please see our separate articles on other JIA medications.

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 5 minutes or more in the same room) with chickenpox, without having immunity to the disease.

Most live vaccines [measles, mumps, rubella (MMR), oral polio (NOT injectable polio), BCG, oral typhoid and yellow fever] will not be given to anyone already taking methotrexate (the chickenpox vaccine is sometimes given, though advice on this may vary between rheumatology teams and dependent on individual cases). If methotrexate 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 and a nasal spray. Unlike the injection, the nasal spray is a live vaccine. There is limited research evidence around live vaccines in people with a lowered immune system (due to their medication). It is therefore important to discuss with the healthcare team which of these options would be best.

Tips regarding sulfasalazine

  • 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 do not wish to father a child even though the sperm count is likely to be lowered

Updated: 16/12/2019