Sulfasalazine (SSZ)

SSZ is a DMARD used to treat inflammatory types of arthritis, such as rheumatoid arthritis (RA) and psoriatic arthritis (PsA).

SSZ is taken orally in pill form.

The most common dose is 1,000 mg (two tablets) twice daily. Each tablet contains 500 mg of SSZ. Your prescriber may increase the dose to 1,500 mg (three tablets) twice daily.

SSZ may upset the stomach, so it is important to start the medication at lower doses (one tablet daily) and gradually increase to the recommended dosage. SSZ is often used in conjunction with other drugs, such as methotrexate (MTX) and hydroxychloroquine (HCQ), in combination therapy.

While the exact mechanism of how sulfasalazine works is not completely understood, it is believed that the sulfa portion of the drug has anti-inflammatory properties that can suppress the immune system and help to reduce pain, swelling and joint stiffness.

Similar to other DMARDs, you will not feel the effects of SSZ right away. Most people start noticing the effects about six to eight weeks after they start to take the medication, but its full benefits may not occur for up to three months. It is important to be patient and continue taking your medication.

You may not be able to take SSZ if you have severe kidney or liver disorders.

Anyone who has had a previous allergic reaction to SSZ or medications containing sulfa should avoid the medication. SSZ should also be avoided if you have had an allergy to acetylsalicylic acid (ASA, Aspirin®).

Generally, SSZ should be avoided during pregnancy. Occasionally this medication may need to be continued during pregnancy and/or breastfeeding/chestfeeding, but only after discussion between you and your prescriber. People who experience low sperm counts while taking SSZ should discontinue the medication three months prior to attempting conception.

Like all medications, taking SSZ carries some risk of side effects, which must be balanced with its potential benefits. In general, the risk of joint damage and permanent disability (resulting from arthritis) is much greater than the risks of side effects from SSZ. When monitored properly the vast majority of side effects are rare, generally improve over time and are reversible.

The most common side effects of SSZ are nausea and feeling unwell. This usually gets better over time, as you get used to taking the medication. Some people may also experience diarrhea and abdominal pain.

SSZ may cause a rash; stop the medicine and let your doctor know if this occurs.

In rare cases, people experience headaches and increased sensitivity to the sun. In some patients SSZ may also cause the urine and skin to turn an orange-yellow colour or may stain contact lenses yellow. This side effect does not require medical attention. Please speak with your healthcare provider if you have concerns.

SSZ may affect your liver and kidney function as well as blood count. This should be closely monitored with routine blood work.

Also in rare occurrences, some people treated with SSZ experience low sperm counts. This complication is reversible when the drug is stopped.

Most side effects are dose-dependent, and the symptoms can be alleviated by reducing the dosage. Take SSZ as prescribed and contact your healthcare provider if you have any concerns while taking the medication.

To reduce the stomach upset associated with SSZ, your prescriber might suggest you start with a lower dose (one tablet once or twice daily) and increase slowly (adding one tablet per day every week). Using delayed-release formulations or taking SSZ with food can also help.

You may experience sun sensitivity while taking SSZ, so it is advisable to use sunscreen regularly while taking this medication.

You will need regular blood tests to monitor your liver and kidney function and blood counts for side effects. When you begin taking SSZ your prescriber may request blood work more frequently (every two to four weeks) for a period of time. If you have no issues with the medication during this time, blood tests will be required less frequently (every four to 12 weeks).

Your healthcare provider may meet with you regularly to ensure that SSZ is adequately controlling your inflammatory arthritis and not causing adverse effects.

Store this medication at room temperature (15 to 30 degrees Celsius) and keep it out of reach of children.