Intestinal aminosalicylate and disease-modifying antirheumatic drug (DMARD)
ATC code: A07EC01 (Sulfasalazine)
Brand names
Salazopyrin, Azulfidine, Sulazine
The molecule combines sulfapyridine and 5-aminosalicylic acid (5-ASA) via an azo bond. Colonic bacterial azoreductases split the bond, releasing active 5-ASA (anti-inflammatory effect on intestinal mucosa) and sulfapyridine (systemically absorbed). In rheumatoid arthritis, action is attributed to cytokine inhibition, folate-dependent lymphocyte effects, and NF-κB inhibition. In Spain widely prescribed for IBD and RA under the brand Salazopyrina.
Second line
Second-line DMARD in rheumatoid arthritis per 2022 after methotrexate. Dose 2–3 g daily in 2–3 doses after titration from 500 mg. The 2014 Cochrane meta-analysis showed efficacy comparable to methotrexate and . Often used in combination (methotrexate + sulfasalazine + – triple therapy) when monotherapy is insufficient. Effect develops over 2–3 months.
First line
First-line for mild-to-moderate ulcerative colitis to induce and maintain remission per 2024 and the Spanish GETECCU 2023 consensus. Dose 2–4 g daily for induction; 2 g daily for maintenance. In patients intolerant to sulfonamides, pure 5-ASA agents (mesalazine, olsalazine) are preferred. Mostly used in mild colitis with distal involvement; severe disease requires systemic steroids and immunosuppressants.
The drug is promoted for these uses outside international guidelines. Each entry below is analyzed against AEMPS, FDA, EMA, Cochrane and major RCTs.
Not recommended
Sulfasalazine is a disease-modifying antirheumatic drug and an anti-inflammatory for bowel diseases. It is prescribed for rheumatoid arthritis, psoriatic arthritis, Crohn's disease, and ulcerative colitis ( 2023, 2024 guidelines). In anti-aging circles, sulfasalazine is prescribed to suppress chronic inflammation in healthy people. In healthy adults, no clinical studies of such use exist. The drug has specific risks: myelosuppression (leukopenia, agranulocytosis, aplastic anemia), severe skin reactions (Stevens-Johnson syndrome, toxic epidermal necrolysis, DRESS syndrome), hepatotoxicity, hemolytic anemia in G6PD-deficient patients, and reversible male infertility. If sulfasalazine was recommended to a healthy person to suppress inflammation, consider seeking a second opinion.
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Use in pregnancy is acceptable when indicated. Sulfasalazine reduces folate absorption – mandatory 5 mg folic acid daily supplementation in pregnant patients. T3 use needs caution due to neonatal kernicterus risk.
Compatible with breastfeeding in healthy term infants. In preterm infants or G6PD deficiency, hemolysis is possible – use caution.
Reference information, not a clinical decision. Discuss feeding pauses or changes with your physician or an IBCLC.
Sulfasalazine is evaluated for the following indications with varying evidence strength: Rheumatoid arthritis (evidence tier A), Ulcerative colitis (evidence tier A), Anti-aging and longevity (evidence tier F). See the full indication matrix with dosing and citations above on this page.
Common side effects of Sulfasalazine (≥ 1 in 100): Nausea, vomiting, appetite loss, Headache, Rash and pruritus, Yellow discoloration of urine, sweat, tears, and contact lenses, Reversible oligospermia in men, Mild anemia. See the Safety section for uncommon and serious reactions.
FDA category B. Use in pregnancy is acceptable when indicated. Sulfasalazine reduces folate absorption – mandatory 5 mg folic acid daily supplementation in pregnant patients. T3 use needs caution due to neonatal kernicterus risk.
Compatible with breastfeeding in healthy term infants. In preterm infants or G6PD deficiency, hemolysis is possible – use caution.
Sulfasalazine is contraindicated in: Hypersensitivity to sulfonamides or salicylates; G6PD deficiency (hemolytic anemia risk); Severe hepatic or renal impairment; Porphyria; Intestinal or urinary obstruction. Full list in the Safety section.