This shared care guideline sets out details for the sharing of care of patients with rheumatoid arthritis prescribed sulfasala

Sulfasalazine Monitoring Information
Dr H L Averns

This shared care guideline sets out details for the sharing of care of patients with
rheumatoid arthritis prescribed sulfasalazine. These guidelines provide
additional limited information necessary to aid in the treatment of rheumatology
patients. As with all shared care guidelines these highlight significant prescribing
issues but should be used in conjunction with the summary of product
characteristics (Data sheet) and do not replace the drug company information .
INDICATIONS FOR THE PURPOSES OF THIS GUIDELINE
Management of adults with inflammatory joint disease.
Sulfasalazine usually takes 3-4 months to show an effect. Week 3 – 500mg in the morning and 1gram evening The dose may be increased to 3 grams if no response (after 3 months). Tablets should not be crushed or broken. It is recommended that the tablets should be taken with water. CONTRAINDICATIONS
 Children under 2 years of age (N.B. Use in children over 2 years of age is  Patients with significant hypersensitivity to sulphonamides or salicylates  Patients with a history of acute intermittent porphyria PRECAUTIONS
 Hepatic disease  Glucose-6-Phosphate dehydrogenase deficiency  Diabetes, there is the possibility of interference with blood glucose  Previous significant hepatic drug reactions may mean increase of side effects due to sulfapyridine metabolite.  Pregnancy - Sulfasalazine has been given safely during pregnancy. However, all drugs can potentially affect the unborn child. Men and women of childbearing potential are advised therefore to use a reliable method of contraception during and for three months after treatment. When planning a pregnancy it is important that both men and women on this drug discuss medication with the Rheumatology Team. This should be at least six months before conception.  Breastfeeding is acceptable with the small amounts of sulfasalazine that MONITORING
PRIOR TO STARTING THERAPY:
Measure baseline FBC, LFTs and renal function ONGOING MONITORING:
 FBC and LFT’s fortnightly for the first three months then 3 monthly  In order to monitor disease activity 3 monthly CRP would be helpful. STOP AND REFER TO THE RHEUMATOLOGY TEAM IF:
 Rash.  Liver enzymes especially transaminase increased x 3 upper limit of  WCC falls on 3 successive occasions and/or WCC falls below 3.5 x 109  Platelet count falls on 3 successive occasions  Platelet count falls below 150 x 109 SIDE EFFECTS
75% of all side effects are seen within 3 months of starting sulfasalazine and 90% are identified within 6 months. Patients must report mouth ulcers, sore throat, fever, epistaxis, purpura,
unexpected bruising or bleeding, and any unexplained illness/infection and
should be seen urgently for full blood count and liver function tests.
 Discolouration of urine and other secretions  Certain types of extended wear contacts lenses may be permanently  Nausea, vomiting, rash, headache, raised temperature and loss of appetite in approximately 15% (try reducing dose).  Diarrhoea, abdominal pain, exacerbation of symptoms of colitis, headache, hypersensitivity reactions (including rash and urticaria)  Bone marrow suppression and hepatitis are rare but monitoring mandatory  Oligospermia (reversible).  Rarely:  Acute pancreatitis  Lung disorders  Vertigo, tinnitus, peripheral neuropathy, aseptic meningitis, ataxia, convulsions, insomnia, mental depression and hallucinations  Renal dysfunction  Skin reactions (including lupus erythematosus-like syndrome, Stevens- Johnson syndrome), photosensitization, and alopecia. COMMON/SIGNIFICANT DRUG INTERACTIONS
 Absorption of digoxin and folate may be reduced  Ampicillin and Rifamipicin may alter sulfasalazine levels  Toxicity increased when Azathioprine or Mercaptopurine are co-  Warfarin levels may be affected on starting Sulfasalazine  Antacids may decrease the absorption of sulfasalazine REFERENCES
BNF 50 Stockley’s Drug Interactions 7th Ed

Source: http://rheumors.com/wp-content/uploads/2013/09/Sulfasalazine_monitoring.pdf