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Sulfasalazine
Aka: Sulfasalazine, Azulfidine, Olsalazine, Dipentum
- Mechanism
- 5-Aminosalicylic Acid Derivative which is metabolized into sulfapyridine and Mesalamine
- Indications
- Inflammatory Bowel Disease (e.g. Ulcerative Colitis)
- Early Rheumatoid Arthritis (especially seronegative)
- Psoriatic Arthritis
- Arthritis in Reiter's Syndrome
- Contraindications: Sulfa Allergy
- Consider Mesalamine (Asacol, Pentasa) as alternative
- Consider slowly tapering to dose if unclear allergy
- Start: 250 grams per day
- Increase: 250 grams per week
- Dosing: Sulfasalazine
- Ulcerative Colitis dosing target
- Active disease: Sulfasalazine 4-6 grams/day divided four times daily
- Maintenanance: Sulfasalazine 2-4 grams/day divided four times daily
- General
- Increase slowly to lowest effective dose
- Co-administer Folic Acid 1 mg/day
- Increase Protocol
- Start: 500 mg per day
- Increase: 500 mg per week up to 2 grams per day
- Increase: 3 grams per day after 3 months
- Maximum: 4 grams per day (2 grams twice daily) after 6 months
- Maintenance Doses
- Adult: 500-1000 mg PO qid with food
- Pediatric: 20-60 mg/kg/day divided qid with food
- Dosing: Olsalazine (Dipentum)
- Olsalazine (Dipentum) 500 mg orally twice daily (as of 2022, >$1500/month)
- Adverse effects
- General
- Prevent adverse effects with Folic Acid 1-2 mg/day
- Nausea and other Gastrointestinal Intolerance (30%)
- Consider enteric coated Azulfidine EN-tablets
- Neurologic adverse effects
- Headache (20%)
- Dizziness or lightheaded (<20%)
- Hematologic adverse effects
- Folate-inhibition Anemia
- Hemolytic Anemia
- Granulocytopenia
- Skin rash associated with Sulfa Allergy
- Requires discontinuing medication immediately
- Renal adverse effects: Micro-crystalluria
- Risk of Interstitial Nephritis
- Avoid Dehydration
- Avoid high doses
- Monitoring
- Complete Blood Count (CBC) every 4-6 months
- Aspartate Aminotransferase (AST, SGOT) at 2 months
- References
- Adams (2013) Am Fam Physician 87(10): 699-705 [PubMed]
- Adams (2022) Am Fam Physician 105(4): 406-11 [PubMed]
- Kornbluth (2010) Am J Gastroenterol 105(3): 501-23 [PubMed]
- Matteson (2000) Mayo Clin Proc 75:669-74 [PubMed]
- Pincus (1999) Clin Rheumatol 17(6 Suppl 18):S2-S124 [PubMed]