Sulfasalazine for children and young people

JIA artwork

Picture by Emily Grant, age 10

Sulfasalazine explained

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.

This overactive immune system in JIA is the cause of swelling, pain, heat and redness in the joints and other associated symptoms such as fatigue and generally feeling unwell.

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

Background 

  • 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) 

How long does it take to work? 

  • 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

Possible side effects

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 with other medicines

  • 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. 

Sulfasalazine in Pregnancy and Breastfeeding

  • 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. 

Sulfasalazine and Alcohol 

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. 

Sulfasalazine and immunisation/vaccination

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.

Live vaccines [measles, mumps, rubella (MMR), chickenpox, oral polio (NOT injectable polio), BCG, oral typhoid and yellow fever] cannot be given to anyone already taking sulfasalazine. If sulfasalazine 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.

Vaccination of close family members can help to protect someone with a lowered immune system.

Hints and Tips

  • 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 

Table summary

Drug name How the drug is taken How it works Blood tests mandatory? 
Sulfasalazine (SSZ) Tablet  Reduces over activity of the immune system Yes – initially regularly, then less frequently 

References available on request

By retired rheumatology clinical nurse specialist Nicky Kennedy BSc RN QN HV
Original article: 26/01/2016
Reviewed: N/A
Next review due: 26/01/2019