Immunosuppressant, Disease-Modifying Antirheumatic Drug – DMARD
Issues for Surgery
For rheumatology and inflammatory bowel disease (IBD) conditions – risk of perioperative flare in disease activity if omitted (see Further Information).
Risk of post-operative infection if continued (see Further Information).
Advice in the Perioperative period
Steroid exposure should be minimised prior to surgical procedures, and increases in steroid dose to prevent adrenal insufficiency are not routinely required1.
Individualised decisions should be made for procedures considered to have a high risk of infection1 and should be balanced against the risk of disease flare (see Further Information). The Surgical Team and the patient’s specialist should be involved in the planning for elective surgery.
If the decision is made to stop sulfasalazine prior to surgery, it should be stopped 2 weeks pre-operatively1.
The patient should be closely monitored for signs of infection following emergency surgery.
For high-risk surgical procedures or where there are patient factors that may increase surgical infection risk i.e. age and / or co-morbidity, consider withholding sulfasalazine in the immediate post-operative period.
If discontinued, restart once wound healing is satisfactory1.
Where sulfasalazine is continued, close monitoring of renal function is important so that inadvertent drug accumulation does not occur1.
Ensure that the correct formulation of sulfasalazine is prescribed – see Further Information.
Interaction(s) with Common Anaesthetic Agents
The manufacturers suggest that the effects of topical prilocaine / lidocaine may be additive with drugs that can cause methaemoglobinaemia – they name sulfasalazine – use with caution2.
Interaction(s) with other Common Medicines used in the Perioperative Period
Since the effects of sulfasalazine depend on release of the active metabolite, 5-aminosalicylic acid, by bacterial metabolism in the gut any drug that reduces the intestinal microflora, such as antimicrobials, may reduce the production of the active metabolite. However, a decrease in clinical effect does not seem to have been seen3.
Hepatotoxicity (see also under Paracetamol below)
Whilst single surgical prophylactic doses should not pose a problem, continued post-operative treatment may require close monitoring of LFTs and / or haematological abnormalities. Consult current product literature.
Both sulfasalazine and paracetamol increase the risk of hepatotoxicity4. Whilst single perioperative doses of paracetamol should not pose a problem, continued post-operative treatment may require close monitoring of LFTs.
Rheumatoid Arthritis (RA) Flare
RA flares develop in 10-20% of patients undergoing surgery and have a potential to impact adversely on post-operative recovery. In addition, active RA increases infection risk, further complicating decisions regarding DMARD interruption1.
Some data suggests that not all DMARDs carry the same infection risk1. There are limited data available regarding use of sulfasalazine and perioperative infection1, 5. A retrospective study found sulfasalazine was associated with a lower risk of perioperative infection compared to other DMARD5.
Crystalluria & Kidney Stone Formation
Sulfasalazine causes crystalluria and kidney stone formation, hence adequate fluid intake should be ensured during treatment6.
There are different licensed preparations of sulfasalazine and it is important to ensure that the correct product is prescribed for the correct indication. Whilst all products are licensed for use in IBD indications, only sulfasalazine enteric-coated tablets (Salazopyrin® EN-Tabs) are licensed for use in rheumatology.