Aminosalicylates (non-steroidal anti-inflammatory drugs)
Aminosalicylates (Sulfasalazine; 5-ASA) usually are the first medicines used to treat Crohn's disease. These medicines have been used to treat Crohn's for more than 30 years. Studies show that about 45% to 55% of people treated with mesalamine go into remission (Friedman S et al, 2006)Friedman S, Lichtenstein GR (2006). Crohn's disease. In MM Wolfe et al., eds., Therapy of Digestive Disorders, 2nd ed., pp. 785-801. Philadelphia: Saunders Elsevier.. Aminosalicylates do not seem to prevent symptoms from coming back when a person is in remission due to drugs like corticosteroids.
Aminosalicylates are antibiotics which are particularly useful for colonic diseases, because they are released in the large intestine. They are an antinflammatory drug that acts by reducing the synthesis of eicosanoids and inflammatory cytokines. Sulfasalazine has no immunosuppressant action, and it does not have an additive effect or a steroid-sparing effect when used in conjunction with corticosteroids. In contrast to its action in ulcerative colitis, sulfasalazine does not seem to maintain remission in Crohn's disease.
Mesalamine (Asacol, Pentasa) releases 5-ASA in the distal small intestine secondary to pH changes, and thus it is more useful in patients with small intestinal Crohn's disease. Long-term maintenance with mesalamine may delay clinical relapse (Cezard JP et al, 2009)Cezard JP, Munck A, et al. Prevention of relapse by mesalazine (Pentasa) in pediatric Crohn's disease: a multicenter, double-blind, randomized, placebo-controlled trial. Gastroenterol Clin Biol. 2009 Jan;33(1 Pt 1):31-40.
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Side effects
Common side effects - The most common side effects of sulfasalazine are headache, nausea, fever, rash, and reversible infertility in men. Headache is one of the most common complaints, affecting up to one-third of people. Headaches are more likely with higher doses of the drug, and are less likely to occur if the dose is gradually increased. Loss of appetite, nausea, sensitivity to sunlight, and nervousness are also common at the beginning of therapy. Sperm count may be reduced in men, although this is reversible once the drug is stopped.
Uncommon side effect - Pancreatitis is seldom but possible side effect; this side effect occurs in 1 to 10 percent of people who take this drug.
Rare side effects - Rare and potentially serious side effects of sulfasalazine (affecting fewer than 1 percent of people who take this drug) include inflammation of the liver, of the lung, Stevens-Johnson syndrome, and hemolysis.
There can be a decrease in the number of infection fighting white blood cells. In some cases, the bone marrow completely stops producing a specific type of white blood cells, a condition called agranulocytosis. Agranulocytosis usually occurs within two months of starting sulfasalazine. In most people, agranulocytosis resolves within one or two weeks after stopping the medication. Monitoring of the blood count is recommended every two to four weeks initially, then every three to four months.
People who are allergic to sulfa drugs may have a cross reaction to sulfasalazine and should therefore not take it.