Sulfasalazine

About Sulfasalazine

In the gut, bacteria split sulfasalazine into sulfapyridine and 5-aminosalicylic acid (mesalamine), whose anti-inflammatory and immune-modifying properties may explain its effect. Both tablets treat mild to moderate ulcerative colitis, help in severe ulcerative colitis alongside other treatment, and lengthen remission between attacks; adults usually start with 3 to 4 g a day in evenly divided doses no more than eight hours apart and continue on 2 g a day, and children 6 and older take a weight-based dose. Only the delayed-release tablet is labeled for rheumatoid arthritis and for polyarticular-course juvenile rheumatoid arthritis in children 6 and older, when salicylates or other NSAIDs have not worked well enough, and it is particularly indicated in ulcerative colitis for people whose stomachs cannot tolerate the plain tablet. For rheumatoid arthritis it is usually 2 g a day in two divided doses, started lower; a response can appear by 4 weeks but may take 12, and painkillers or NSAIDs continue until it does.

There is no boxed warning, but deaths have been reported from hypersensitivity reactions, blood disorders such as agranulocytosis and aplastic anemia, and kidney or liver damage, among other causes, and serious infections, including fatal sepsis and pneumonia, have occurred. Blood counts and liver tests are done before starting, every second week for the first three months, monthly for the next three and every three months after that. Sore throat, fever, pallor, purple spots on the skin or yellowing can signal a serious blood or liver problem, and the drug is held until blood results are back; it is stopped at the first sign of a severe skin reaction, most of which occur in the first month. It must not be taken by anyone allergic to sulfasalazine, sulfa drugs or salicylates, or with porphyria or a blocked bowel or urinary tract. Loss of appetite, headache, nausea, vomiting, stomach upset and a low sperm count are the most common side effects.

Men can develop a low sperm count and infertility, which appear to reverse when the drug is stopped. Sulfasalazine reduces the absorption of folic acid, which matters before and during pregnancy because folic acid lowers the risk of neural tube defects; sulfapyridine passes into breast milk, and breastfed infants are watched for diarrhea or bloody stools. Drinking enough fluid helps prevent crystals and stones in the urine, people with G6PD deficiency are watched for hemolytic anemia, and MedlinePlus warns of sensitivity to sunlight. It is not recommended for systemic-course juvenile arthritis, where it frequently caused a serum sickness-like reaction, often a severe one. If whole delayed-release tablets appear in the stool, the label says to stop them.

Taking Sulfasalazine

How to take it

In evenly divided doses, preferably after meals; MedlinePlus advises a full glass of water with each dose and plenty of fluids through the day, and for ulcerative colitis no more than 8 hours between doses. Swallow delayed-release tablets whole, without crushing or chewing. Keep taking it even if you feel well, and protect your skin from the sun with clothing, sunglasses and sunscreen.

If you miss a dose

Take it as soon as you remember, unless it is almost time for the next dose; then skip the missed dose and continue the regular schedule. Do not take a double dose.

Storage

At room temperature in the container it came in, tightly closed, away from heat and moisture (not in the bathroom), out of reach of children. Do not flush it; use a medicine take-back program.

Interactions to know about

It reduces the absorption of folic acid and digoxin. With methotrexate, stomach side effects, especially nausea, were more common than with either drug alone. Tell the prescriber about any reaction to aspirin or other salicylates, or to mesalamine, balsalazide or olsalazine.

This summarizes the official prescribing information. Your prescriber’s and pharmacist’s instructions, and the leaflet that comes with your medicine, take priority.

Why the cash price for Sulfasalazine differs from pharmacy to pharmacy

Plain sulfasalazine tablets are an old generic from several makers and cost pharmacies little, but adult doses of 2 to 4 g a day mean four to eight tablets a day, at least 120 a month, so the tablet count, not just the dispensing fee, shapes the quote. Whether it is on a flat-price generic list varies.

Delayed-release tablets have fewer generic sources, and a prescription for them cannot be filled with plain tablets, a different product. A prescription that names a brand and blocks substitution is filled with the brand and priced as one.

Ways to pay less for Sulfasalazine without insurance

• Ask for generic substitution, and make sure the prescription does not block it.
• Ask whether sulfasalazine is on the pharmacy’s flat-price generic list, and compare more than one pharmacy.
• Once your dose is settled, ask for a ninety-day supply.
• If you take delayed-release tablets for ulcerative colitis, ask the prescriber whether the plain tablets would suit you; for arthritis, the delayed-release tablet is the labeled form.
• Upload the prescription to Script Unlock so licensed pharmacies can quote their cash price. You pay the pharmacy directly.

Questions to ask your pharmacist about Sulfasalazine

1. 1.When are my blood counts and liver tests due?
2. 2.Is my prescription for plain or delayed-release tablets, and can it be filled with a generic?
3. 3.Should I take folic acid while I am on it, especially if I could become pregnant?
4. 4.Is it safe with my digoxin or methotrexate?

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