Sulfasalazine

Use with caution in CKD 4/5 (eGFR <29)

• Formulation: Salazopyrin EN
• Initiation: usually started at 500 mg bd for 1 week, thereafter 1g twice daily but if there are GI problems try 500mg once daily week 1, twice daily week 2, three times daily week 3, 1g twice daily thereafter
• Maintenance dose is usually 2g daily in 2 or 3 divided doses but higher doses may be required
• The maximum dose is 40mg/kg/day

• Pre Treatment FBC, U+E, CRP, LFT Inc albumin

then

• FBC, U+E, CRP and LFT Inc Albumin fortnightly until dose stable for 6 weeks then monthly for 3 months then 3 monthly. After 1 year no more blood monitoring is required

Patients should be asked about rash and oral ulceration at each visit.

Entering the results into a monitoring booklet will ensure that trends are not missed. Patients who do not attend for monitoring should be warned of the risk that serious adverse effects may go unnoticed. In the event of persistent failure to attend for monitoring please inform the Rheumatology department.

• WBC <3.5 – withhold and discuss with Rheumatology
• Neutrophils < 1.6
• Platelets < 140
• AST or ALT >100
• MCV >105 with normal TSH and haematinics
• Unexplained albumin <30mg/l
• Unexplained eosinophilia >0.5
• >30% rise in creatinine over 1 year
• Severe rash – withhold, seek urgent (preferably dermatology) advice
• Oral ulceration – withhold and discuss with rheumatology
• Nausea/dizziness/headache - reduce dose if severe. May need to stop or discuss
• Abnormal bruising or sore throat - withhold until FBC available

• Treatment is continued indefinitely providing it remains effective and there are no significant side effects. 
• Sulfasalazine takes about three months to become effective but may take up to six months.
• During this period there are likely to be continued symptoms or signs of disease activity. 
• It is reasonable to use IM Depo steroid (Kenalog 40mg or Depo Medrone80 mg) up to monthly, depending on the requirements of the individual patient. 
• The dose required is small (eg monthly Kenalog 40mg = 1.6mg prednisolone daily). 
• If IM steroids are still required 3 months after starting treatment, the sulfasalazine dosage should be increased to 3g daily (max dose 40mg/kg/day)

• Disease modifying drugs will not prevent all flares.
• These can be managed with IM Depo steroid as outlined above.
• If flares become more frequent, or the disease fails to settle between flares, the dosage should be increased, or an alternative discussed with the rheumatologist.

• hypersensitivity to sulfonamides, salicylates or aspirin

• Patients should be cautioned to present immediately if they develop a sore throat, fever, malaise or non-specific illness
• The drug should be stopped until blood dyscrasias has been excluded haemolysis can occur in G6 PD deficiency
• Renal impairment.
• Pregnancy and lactation.
• Transient oligospermia can occur in men

• Absorption of digoxin may be reduced

Common effects are in bold type.

Mucocutaneous

• erythematous pruritus
• exfoliative dermatitis
• Stevens-Johnson syndrome

Haematological

• neutropenia
• thrombocytopenia
• haemolytic anaemia
• aplastic anaemia

Gastrointestinal

• nausea
• diarrhoea
• vomiting
• allergic hepatitis

Other

• severe but short lived headache
• peripheral neuropathy
• reversible oligospermia
• orange discoloration of urine
• permanent staining of extended wear soft contact lenses
• standard soft and gas permeable lenses respond to normal cleaning

Secretaries 01387 241776

• Iseabail Graham
• Caron Cowen

Helpline 01387 241095 (answering machine)

Nurse Specialists:

• Petra Cannon
• Ingrid Crane
• Andrew Wilson 

Department of Rheumatology doctors via Switchboard 01387 246246

• Dr A Russell - Consultant
• Dr R Akintayo - Locum Consultant
• Dr A Drever - Associate Specialist
• Dr L Moran - Associate Specialist