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Clinical data
Trade names Azulfidine, Salazopyrin, Sulazine, others
AHFS/ Monograph
MedlinePlus a682204
Routes of
by mouth
ATC code
Pharmacokinetic data
Bioavailability <15%
Biological half-life 5-10 hours
CAS Number
PubChem CID
ECHA InfoCard 100.009.069
Chemical and physical data
Formula C18H14N4O5S
Molar mass 398.394 g/mol
3D model (Jmol)
 NYesY (what is this?)  (verify)

Sulfasalazine (SSZ), sold under the trade name Azulfidine among others, is a medication used to treat rheumatoid arthritis, ulcerative colitis, and Crohn's disease.[1] It is often considered as a first line treatment in rheumatoid arthritis.[2] It is taken by mouth.[1]

Significant side effects occur in about 25% of people.[2] Commonly these include loss of appetite, nausea, headache, and rash.[1] Severe side effects include bone marrow suppression, liver problems, and kidney problems.[2][3] It should not be used in people allergic to aspirin or sulfonamide.[2] Use during pregnancy appears to be safe for the baby. Sulfasalazine is in the disease-modifying antirheumatic drugs (DMARDs) family of medications. It is unclear exactly how it works but is broken down into sulfapyridine and 5-aminosalicylic acid.[1]

Sulfasalazine was approved for medical use in the United States in 1950.[1] It is on the World Health Organization's List of Essential Medicines, the most effective and safe medicines needed in a health system.[4] Sulfasalazine is available as a generic medication.[1] The wholesale cost in the developing world is about 9.24 to 32.64 USD a month.[5] In the United States it costs 25 to 50 USD per month.[3]

Medical uses[edit]

Sulfasalazine is used in the treatment of inflammatory bowel disease, including ulcerative colitis and Crohn's disease. It is also indicated for use in rheumatoid arthritis and used in other types of inflammatory arthritis (e.g. psoriatic arthritis) where it has a beneficial effect. It is often well tolerated compared to other DMARDs.

In clinical trials for the treatment of chronic alcoholics, sulfasalazine has been found to reverse the scarring associated with liver cirrhosis. A study at Newcastle University found that the drug may act to aid the healing of cirrhosis of the liver.[6][7] Cells called myofibroblasts, which contribute to scar tissue in a diseased liver, also appear to secrete proteins that prevent the breakdown of the scar tissue. Sulfasalazine appears to retard this secretion.

It is usually not given to children under 2 years of age.

The use of sulfasalazine in inflammatory bowel disease has declined due mainly to the fact that it yields the metabolite sulfapyridine (SP) which gives rise to side-effects such as agranulocytosis and hypospermia. However, the other metabolite of sulfasalazine, 5-aminosalicylic acid (5-ASA) is credited with causing the drug's therapeutic effect. Therefore, 5-ASA and other derivatives of 5-ASA, are now usually preferred and given alone (as mesalazine), despite their increased cost, due to their more favourable side-effect profile.

Sulfasalazine has also been used successfully to treat cases of idiopathic urticaria that do not respond to antihistamines.[8]

Side effects[edit]

Sulfasalazine metabolizes to sulfapyridine. Serum levels should be monitored every three months, and more frequently at the outset. Serum levels above 50 μg/l are associated with side effects. In rare cases, Sulfasalazine can cause severe depression in young males. It can also cause temporary infertility. Immune thrombocytopenia has been reported.[9]

Sulfasalazine inhibits dihydropteroate synthase, and can cause folate deficiency and megaloblastic anemia.[10][11][12] and various other undesirable effects.[13]

Sulfasalazine can cause hemolytic anemia in people with G6PD deficiency.[14]

Sulfasalazine may cause stomach upset, nausea, vomiting, loss of appetite, headache, dizziness, or unusual tiredness. Skin and urine can become orange, with occasional allergic reactions.[15]

Mechanism of action[edit]

Sulfasalazine, and its metabolite 5-ASA, are poorly absorbed from the small intestine. Its main mode of action is therefore believed to be inside the intestine. Approximately one third of a dose of sulfasalazine is absorbed from the small intestine. The remaining two thirds passes into the colon where it is split by bacteria into 5-ASA and SP. SP is well absorbed from the colon (estimated bioavailability 60%); 5-ASA is less well absorbed (estimated bioavailability 10% to 30%).[citation needed]

It also inhibits the cystine-glutamate antiporter.[16]

Bowel disease[edit]

In Crohn's disease and ulcerative colitis, it is thought to be an antinflammatory drug that provides topical relief inside the intestine. It does this via a number of mechanisms such as reducing the synthesis of inflammatory mediators known as eicosanoids and inflammatory cytokines. However, compared to glucocorticoids (another class of drug used in the treatment in inflammatory bowel disease), sulfasalazine is only a mild immunosuppressant.


When treatment for arthritis is successful, pain, joint swelling and stiffness will be reduced and this may slow down or stop the development of joint damage.[tone] The precise reasons why sulfasalazine are effective in various forms of arthritis is not clearly understood.[tone] However, sulfasalazine is thought to work by inhibiting NF-κB.[17][18]

Because sulfasalazine and its metabolite mesalazine (or 5-aminosalicylic acid (5-ASA)) are poorly absorbed into the bloodstream, it is surprising that the drug is effective against symptoms outside of the intestine. One possible explanation is that, given that ulcerative colitis produces arthritic symptoms, the arthritic symptoms resolved by sulfasalazine are actually[tone] a product of unrecognized[clarify] ulcerative colitis,[citation needed] which is effectively treated with sulfasalazine.

The other metabolite, sulfapyridine, is absorbed into the blood, and is believed to be the source of the side-effects discussed above. It is possible that the sulfapyridine is responsible for some of the anti-arthritic effects of sulfasalazine.


  1. ^ a b c d e f g "Sulfasalazine". The American Society of Health-System Pharmacists. Retrieved 8 December 2016. 
  2. ^ a b c d WHO Model Formulary 2008 (PDF). World Health Organization. 2009. p. 41,45. ISBN 9789241547659. Retrieved 8 December 2016. 
  3. ^ a b Hamilton, Richart (2015). Tarascon Pocket Pharmacopoeia 2015 Deluxe Lab-Coat Edition. Jones & Bartlett Learning. p. 464. ISBN 9781284057560. 
  4. ^ "WHO Model List of Essential Medicines (19th List)" (PDF). World Health Organization. April 2015. Retrieved 8 December 2016. 
  5. ^ "Sulfasalazine". International Drug Price Indicator Guide. Retrieved 8 December 2016. 
  6. ^ "Drug 'may reverse liver disease'". BBC News. 2006-09-26. Retrieved 2010-05-24. 
  7. ^ Fiona Oakley; Muriel Meso; John P. Iredale; Karen Green; Carylyn J. Marek; Xiaoying Zhou; Michael J. May; Harry Millward-Sadler; Matthew C. Wright; Derek A. Mann (Jan 2005). "Inhibition of inhibitor of κB kinases stimulates hepatic stellate cell apoptosis and accelerated recovery from rat liver fibrosis". Gastroenterology. 128 (1): 108–120. doi:10.1053/j.gastro.2004.10.003. 
  8. ^ McGirt LY, Vasagar K, Gober LM, Saini SS, Beck LA (Oct 2006). "Successful treatment of recalcitrant chronic idiopathic urticaria with sulfasalazine". Arch Dermatol. 142 (10): 1337–1342. doi:10.1001/archderm.142.10.1337. PMID 17043190. 
  9. ^ Cantarini L, Tinazzi I, Biasi D, Fioravanti A, Galeazzi M (June 2007). "Sulfasalazine-induced immune thrombocytopenia". Postgraduate Medical Journal. 83 (980): e1. doi:10.1136/pgmj.2006.055194. PMC 2600053Freely accessible. PMID 17551063. 
  10. ^ Inflammatory Bowel Disease~workup at eMedicine
  11. ^ Women With Autoimmune Diseases: Medications During Pregnancy and Lactation: Sulfasalazine;
  12. ^ Hernández-Díaz, Sonia; Werler, Martha M.; Walker, Alexander M.; Mitchell, Allen A. (2000). "Folic Acid Antagonists during Pregnancy and the Risk of Birth Defects". New England Journal of Medicine. 343 (22): 1608–14. doi:10.1056/NEJM200011303432204. PMID 11096168. 
  13. ^ Dixon, Scott J; Patel, Darpan N; Welsch, Matthew; Skouta, Rachid; Lee, Eric D; Hayano, Miki; Thomas, Ajit G; Gleason, Caroline E; Tatonetti, Nicholas P (2014-05-20). "Pharmacological inhibition of cystine–glutamate exchange induces endoplasmic reticulum stress and ferroptosis". eLife. 3. doi:10.7554/eLife.02523. ISSN 2050-084X. PMC 4054777Freely accessible. PMID 24844246. 
  14. ^ "SulfaSALAzine: Drug Information Provided by Lexi-Comp". Merck & Co., Inc. Jan 2012. Retrieved 2012-07-28. 
  15. ^ "DRUGS & MEDICATIONS Sulfasalazine". WebMD. WebMD. 
  16. ^ Bridges, Richard J; Natale, Nicholas R; Patel, Sarjubhai A (2012-01-01). "System xc- cystine/glutamate antiporter: an update on molecular pharmacology and roles within the CNS". British Journal of Pharmacology. 165 (1): 20–34. doi:10.1111/j.1476-5381.2011.01480.x. ISSN 0007-1188. PMC 3252963Freely accessible. PMID 21564084. 
  17. ^ Wahl C, Liptay S, Adler G, Schmid RM. Sulfasalazine: a potent and specific inhibitor of nuclear factor kappa B. Journal of Clinical Investigation. 1998;101(5):1163-1174.
  18. ^ Weber CK, Liptay S, Wirth T, Adler G, Schmid RM. Suppression of NF-kappaB activity by sulfasalazine is mediated by direct inhibition of IkappaB kinases alpha and beta. Gastroenterology. 2000 Nov;119(5):1209-18.

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