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Sulfasalazine

A Review of its Pharmacological Properties and Therapeutic Efficacy in the Treatment of Rheumatoid Arthritis

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An Erratum to this article was published on 01 October 1995

Summary

Synopsis

Sulfasalazine was first used for rheumatic polyarthritis in the 1940s and in the past 2 decades has become firmly established as a disease-modifying antirheumatic drug (DMARD). The drug is split by the action of bacterial azoreductases in the large intestine into sulfapyridine and mesalazine (mesalamine, 5-aminosalicylic acid), although whether the parent molecule or the sulfapyridine moiety, or both, is the active principle remains uncertain.

Sulfasalazine is an effective treatment for rheumatoid arthritis (RA), producing improvements in disease parameters similar to those seen with penicillamine, hydroxychloroquine or oral or parenteral gold in comparative clinical trials. However, there are no direct comparisons of the drug with methotrexate. Most adverse events associated with sulfasalazine are minor and tend to occur within 3 months of starting therapy. A meta-analysis of studies investigating DMARD therapy, which, included almost 5000 evaluable patients, concluded that sulfasalazine was close to methotrexate in terms of efficacy but was slightly less well tolerated. However, unlike sulfasalazine, many DMARDs may be unsuitable for women who are, or may become, pregnant because of their potential to cause teratogenic effects.

Sulfasalazine may also offer a more rapid onset of action than other DMARDs and may slow down the radiological progression of RA. Combination therapy with other DMARDs, particularly methotrexate, appears more effective than single DMARD therapy. If the safety of these regimens is shown in large numbers of patients they are likely to become more widely used in the future.

Sulfasalazine is a therapy of first choice in patients with RA and may be the DMARD of choice in women who are, or may become, pregnant.

Overview of Pharmacology

Sulfasalazine is split into sulfapyridine and mesalazine (mesalamine, 5-aminosalicylic acid) by bacterial azoreductases in the large intestine. However, the exact mode of action and the major active principle remain uncertain. Sulfasalazine and sulfapyridine have a number of cellular effects which appear to affect the rheumatoid process in a beneficial way. Intact sulfasalazine is thought to exert its effects primarily on mucosa-associated lymphoid tissue in the gut and sulfapyridine appears to act mainly in the synovium.

Sulfasalazine itself is not absorbed to any great extent after oral administration. Sulfapyridine is almost entirely absorbed from the large intestine, while mesalazine is only poorly absorbed and undergoes presystemic acetylation.

The main determinant of sulfapyridine pharmacokinetics is acetylator pheno-type. The general population shows a bimodal distribution of fast and slow acetylators. Slow acetylators show increased peak and steady-state plasma sulfapyridine concentrations in relation to fast acetylators. Area under the plasma concentration-time curve and plasma elimination half-life are also increased whereas renal and total clearance are decreased in slow compared with fast acetylators. Despite these differences, determination of acetylator status is unnecessary in the majority of patients with rheumatoid arthritis (RA).

Therapeutic Efficacy

The efficacy of sulfasalazine in RA noted in many noncomparative studies has been confirmed in placebo-controlled trials and comparisons with other disease-modifying antirheumatic drugs (DMARDs). Sulfasalazine therapy produces significant improvements in many clinical and laboratory parameters associated with the disease, including erythrocyte sedimentation rate (ESR), Ritchie articular index (RAI) or number of swollen joints, grip strength and duration of early morning stiffness (EMS).

In comparative clinical studies of up to 12 months duration, sulfasalazine 1.0 to 3.0g daily was at least as effective as oral or parenteral gold, hydroxychloroquine, lobenzarit or penicillamine for the treatment of adult patients with RA as assessed by ESR, RAI, duration of EMS and grip strength. The relatively rapid onset of clinical benefit (within approximately 4 to 8 weeks) and the possible slowing of the radiological progression of RA may constitute an advantage for sulfasalazine over other DMARDs. A meta-analysis of studies investigating DMARD therapy, which included almost 5000 evaluable patients, concluded that sulfasalazine was close to methotrexate in terms of efficacy but, overall, was slightly less well tolerated.

Recent studies have investigated the use of DMARD combinations early in the rheumatoid process. Sulfasalazine plus methotrexate appears significantly more effective than, and as well tolerated as, either agent used alone, although patient numbers remain small at the present time. Sulfasalazine has also been combined successfully with penicillamine, parenteral gold and azathioprine.

Tolerability

Adverse events most frequently encountered with sulfasalazine are those associated with the gastrointestinal and central nervous systems. These account for up to two-thirds of drug-related withdrawals from therapy. Other events which can lead to treatment discontinuation are mucocutaneous events (15% of all withdrawals), haematological disturbances (5%), hepatotoxicity (5%), pulmonary complications and immune disorders. Up to 20% of patients will discontinue the drug because of adverse events, which tend to occur in the first 3 months of therapy and are rarely serious. This incidence compares favourably with that seen for penicillamine or azathioprine (20%), is lower than that for parenteral gold (30%) but is higher than for methotrexate or antimalarials (15%).

Many years of clinical use of sulfasalazine have failed to demonstrate any teratogenic or icteric effects of the drug. Indeed, sulfasalazine is distinguished among DMARDs by its lack of teratogenic potential. Sulfasalazine, however, has been frequently associated with male infertility. This is because of drug-induced seminal abnormalities and is reversible on withdrawal of the drug.

Dosage and Administration

Maintenance dosage is reached by starting patients on sulfasalazine 0.5g daily and increasing the dose in weekly increments of 0.5g until an appropriate maintenance dose is achieved. A usual adult maintenance dosage is 2.0 to 3.0g daily in 2 divided doses and an enteric coated tablet formulation is generally used. In some countries, an alternative schedule has been introduced which reaches maintenance dosage more rapidly. Patients receive 0.5g twice daily on days 1 to 4, 0.5g in the morning and 1.0g in the evening on days 5 to 8, and 1.0g twice daily from day 9 onwards. Dosages can be increased up to 3.0g daily if no response is seen after 2 months’ therapy.

Complete blood counts and liver function tests should be performed at baseline, every second week during the first 3 months of therapy, and at 3 to 6 monthly intervals thereafter. In addition, patients developing sore throat, malaise, nonspecific illness or other possible indicators of haematological disturbance at any time during therapy should be advised to report these symptoms immediately. Sulfasalazine is contraindicated in patients hypersensitive to the salicylates or sulfonamides and should be used with caution in patients with renal or hepatic failure. Providing renal function is adequate, dosage reduction is not required for elderly patients. Sulfasalazine is not involved in any clinically important drug interactions.

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  1. Adis International, 41 Centorian Drive, Private Bag 65901, Mairangi Bay, Auckland 10, New Zealand

    Christopher P. Rains, Stuart Noble & Diana Faulds

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  1. Christopher P. Rains
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  2. Stuart Noble
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Various sections of the manuscript reviewed by: P. Brooks, St Vincent’s Hospital, Darlinghurst, New South Wales, Australia; H. Capell, Centre for Rheumatic Diseases, Royal Infirmary, Glasgow, Scotland; E.D. Harris, Department of Medicine, Stanford University School of Medicine, Stanford, California, USA; F.D. Hart, Harmont House, Harley St, London, England; D.M.F.M. van de Heijde, Department of Rheumatology, University Hospital Maastricht, Maastricht, The Netherlands; B. McConkey, Postgraduate Centre, City Hospital NHS Trust, Birmingham, England; V. Wright, Rheumatology and Rehabilitation Research Unit, School of Medicine, University of Leeds, Leeds, England.

An erratum to this article is available at http://dx.doi.org/10.1007/BF03259121.

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Rains, C.P., Noble, S. & Faulds, D. Sulfasalazine. Drugs 50, 137–156 (1995). https://doi.org/10.2165/00003495-199550010-00009

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