SCD FAQ Section


  Azulfidine (sulfasalazine)

SCD discussion often centers around the benefits and effects of prescribed drugs. The following post centers around Dr. Present's article on Azulfidine, and includes Elaine Gottschall's highlighted notes (bold) regarding desensitization.

In short, Elaine prefers Azulfidine over Asacol.



From: Deanna
Date: Aug 2000

From Current Trends in Gastroenterology - 1984-85
"Specific Drug Management" by Dr. Daniel Present

The official 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.

In mild 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.****

Folate 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.

(There was an additional short paragraph on sulfasalaine's possible effects on male fertility)

-- Deanna G

|> more about Azulfidine - on

Another example of someone who switched back to Sulpha:

Subject: Elaine was right!
Date: Thu, 26 Apr 2001

Hi, everyone! This is Lisa, mom to the wonderful, brave and beautiful Olivia, who is 11 and was diagnosed with Crohn's Disease at the end of March.

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.

Elaine (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.

Bingo! 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.)

I have 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.

So, folks, 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.

Love and good health to all, Lisa in Baltimore
Mom of Olivia, 11, CD, SCD three weeks and counting ....




Updated: Wednesday, 31-Dec-69 16:25:11 PST