Date: Aug 2000
From Current Trends in Gastroenterology - 1984-85
"Specific Drug Management" by Dr. Daniel Present
drug of choice for the management of mild to moderate Crohn's
colitis is sulfasalazine (Azulfidine). This drug is an azo-bonded
combination of sulfapyridine and 5-aminosalicylic acid. The
compound is split by bacteria in the colon (or possible small
bowel, if colonic type microflora are present). At present
the 5-aminosalicylic compound is believed to be the active
agent. The mechanism of action of sulfasalazine is uncertain.
Speculation has centered on its affinity for colonic connective
tissue and sensoral membranes, its anti-inflammatory effects,
and its inhibitory effect on prostaglandin synthesis. The
anti-inflammatory effects may be related to the blockage of
synthesis of products of the lipoxygenase pathway (responsible
for bringing inflammatory cells into areas of the bowel).
Although immunosuppressive factors have been cited, they may
be less important with recent observations that sulfasalazine
and its components do not alter T-cells, immunoglobulin-bearing
B-cells, or skin test responses.
to moderate cases of Crohn's disease, sulfasalazine therapy
should be instituted gradually, initially 1 to 2 tablets (500
mg) daily and increased by 500 mg doses to 2 to 4 g daily.
Sulfasalazine should be administered in four divided doses,
with meals and with a light snack at night. Although there
are numerous clinicians who advise dosages up to 12 g each
day, I have found that the evidence of side-effects precludes
this level of medication in most patients. Side-effects are
often dose related, reflect serum sulfapyridine levels, which
can be identified in individual patients and then used as
a guide to the dosage of sulfasalazine. Nausea and headache,
the earliest side-effects, can be alleviated by temporarily
lowering the dosage. To avoid the development of upper gastrointestinal
side- effects (heartburn, epigastric discomfort), the coated
tablet (Azulfidine-EN) can be used. Such allergic manifestations
as skin rashes and fevers are not uncommon, but do not constitute
a contradiction to further usage of sulfasalazine. My colleague,
Burton Korelitz, and I have demonstrated that approximately
90 percent of patients with Crohn's disease who have allergic
reactions to sulfasalazine can be successfully desensitized.
****We use initial dosages of one-eighth to one-fourth
tablet daily for one week, with subsequent doubling of dosages
on a weekly basis until all patients reach therapeutic dosage.
For example, we give one-fourth of a tablet daily for one
week, then one-half tablet daily for one week, then one tablet
daily for one week, and so on. Approximately three of four
patients have shown clinical improvement following desensitization.
Additional information on desensitization is provided in the
chapter on ulcerative colitis therapy.****
Deficiency is frequently encountered with sulfasalazine therapy
and requires folic acid supplementation (1 to 3 mg per day).
Other severe complications are rare and include bone marrow
depression, hepatotoxicity, "sulfasalazine lung," and pericarditis.
Hemolyticanemia is not a rare complication, but fortunately
the drug does not always have to be discontinued, and hemolysis
may improve with lowering of the dosage of sulfasalazine.
was an additional short paragraph on sulfasalaine's possible
effects on male fertility)
more about Azulfidine - on HealingCrow.com
example of someone who switched back to Sulpha:
Elaine was right!
Date: Thu, 26 Apr 2001
This is Lisa, mom to the wonderful, brave and beautiful Olivia,
who is 11 and was diagnosed with Crohn's Disease at the end
I am writing
to say that, as usual, Elaine was right. Here's the story:
we visited a new pediatric GI on Monday, and he switched Olivia
from sulfasalazine to Pentasa. He told us that Pentasa was
better because it refined (my word, but his meaning) the way
sulfasalazine worked, eliminating the sulfa (or cutting it
down) and emphasizing the salicylates that actually helped
cut down on the inflammation that is part and parcel of Crohn's.
(and others, too!) suggested I read Dr. Present's statements
about sulfasalazine, and indicated that sulfasalazine is actually
the better medication for CD. Several people expressed concern
that Olivia would actually get worse on Pentasa.
She began the Pentasa on Tuesday and by the next day, was
up from one bowel movement a day to two. This morning, for
the first time in the three plus weeks since she started on
SCD and sulfasalazine, she had to hurry to the restroom for
her second bm of the day. She also has a bit of bloating,
gas and looks paler. On the way to my office today (it is
"Take Your Child To Work Day") she felt sick to her stomach
... again, for the first time in weeks. (On Saturday last,
before we started Pentasa, we rode 40 minutes to a school
where she was to sing in a concert, and she was fine and happy
the whole way.)
already called the doctor to let him know that we are switching
back to sulfasalazine .... the reason I even let him know
is that I want sulfasalazine in pill form, because Olivia
really hates the gloppy orange flavored liquid that we have
at home. Now that I know it is available in pill form, I intend
to have him call in a prescription.
once again you were right! Thank goodness we have Elaine and
SCD and all of you. It is become clearer and clearer who *really*
knows what's what with getting these IBDs under control and
even cured, and it ain't the guys in the white coats.
good health to all, Lisa in Baltimore
Mom of Olivia, 11, CD, SCD three weeks and counting ....