Rheumatology Advance Access originally published online on August 22, 2008
Rheumatology 2008 47(10):1587-1588; doi:10.1093/rheumatology/ken347
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LETTERS TO THE EDITOR |
BSR DMARD monitoring guidelines: sulfasalazine
1Department of Rheumatology, University Hospital Birmingham Foundation Trust, Selly Oak Hospital, Birmingham, UK
Correspondence to: P. Jobanputra, Department of Rheumatology, University Hospital Birmingham Foundation Trust, Selly Oak Hospital, Raddlebarn Road, Birmingham, B29 6JD, UK. E-mail: p.jobanputra{at}bham.ac.uk
SIR, Regarding the recommendations for monitoring SSZ, I and my colleagues [1] recently reported a series of patients with serious hepatotoxicity associated with SSZ including two patients with liver failure. Some, but not all, of our patients met the criteria for the DRESS (drug rash with eosinophilia and systemic symptoms) syndrome. This term, we feel, is unnecessarily restrictive and other published descriptors for early toxicity with SSZ include the terms ‘three week syndrome’ or ‘sulphone syndrome’. The purpose of this comment is to highlight that serious and potentially life-threatening toxicity with SSZ arises within 6 weeks of therapy. Whilst such toxicity is uncommon (we estimated that the frequency of hepatitis with SSZ was 0.4% in our population) it is clear that a recommendation to monitor blood every 4 weeks, according to the new BSR/BHPR guidelines [2], is likely to lead to a delay in recognizing such toxicity. Our own local guidance recommends testing of blood every 2 weeks for the first 3 months of treatment [3]. Patients are also warned, when being counselled about treatment, to discontinue the drug if they develop a rash or become generally unwell and to seek medical advice.
Disclosure statement: The author has declared no conflicts of interest.
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- Jobanputra P, Amarasena R, Maggs F, et al. Hepatotoxicity associated with sulfasalazine in inflammatory arthritis: a case series from a local surveillance of serious adverse events. BMC Musculoskel Dis (2008) 9:48.[CrossRef]
- Chakravarty K, McDonald H, Pullar T, et al. BSR/BHPR guideline for disease-modifying anti-rheumatic drug (DMARD) therapy in consultation with the British Association of Dermatologists. Rheumatology (2008) 47:924–5.
[Free Full Text] - University Hospital Birmingham NHS Foundation Trust. A–Z services: rheumatology. Guidelines for the management of rheumatology patients. http://www.uhb.nhs.uk/Services/Rheumatology/Information%20for%20Clinicians/Guidelines.aspx (24 June 2008, date last accessed).
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