Sulphasalazine and lung toxicity

Abstract

Sulphasalazine prescribing is on the increase. Pulmonary toxicity and blood dyscrasias are rare side-effects. Numerous case reports have been published implicating sulphasalazine in pulmonary toxicity. The authors searched the literature for cases of sulphasalazine induced lung toxicity and the 50 cases identified are discussed here.All published case reports/letters referring to sulphasalazine and lung toxicity were studied. The search terms "sulphasalazine" and "sulfasalazine" were combined with the terms "lung", "pulmonary disease", "pneumonitis" and "pleuritis" using Medline and PubMed databases.Typical presentation of sulphasalazine-induced lung disease was with new onset dyspnoea and infiltrates on chest radiography. Common symptoms were cough and fever. Crepitations on auscultation and peripheral eosinophilia were noted in half of the cases. Sputum production, allergy history, rash, chest pain and weight loss were inconsistent findings. Pulmonary pathology was variable, the commonest being eosinophilic pneumonia with peripheral eosinophilia and interstitial inflammation with or without fibrosis. Fatal reports were infrequent. Most patients were managed by drug withdrawal with 40% prescribed corticosteroids.In conclusion, sulphasalazine lung disease should be distinguished from interstitial lung disease due to underlying primary disease. Despite the increase in sulphasalazine prescribing, pulmonary toxicity remains rare. The majority of patients with suspected sulphasalazine-induced lung disease improved within weeks of drug withdrawal and the need for corticosteroids is debatable. Sulphasalazine has been used worldwide since the 19409s when it was first prescribed for ulcerative colitis. Its use in the management of inflammatory bowel disease (IBD) is declining with the availability of newer nonsulphur containing aminosalicylates. Conversely, its use as a disease-modifying antirheumatoid drug (DMARD) in the treatment of rheumatoid arthritis is well known [1], its pattern of prescribing by rheumatologists is changing with the development of combination therapies and earlier prescribing of DMARD9s in the course of the disease [2,3]. Overall prescribing of sulphasalazine is on the increase. Information provided from the statistics division 1E of the Department of Health shows that in the decade 1980-1990 there were 4.3 million prescriptions for sulphasalazine with 652 million tablets prescribed. In the last decade to 1998 there were 4.6 million prescriptions with 698 million tablets prescribed.Sulphasalazine has clinically important side-effects in up to one-fifth of patients but these are mostly nausea and vomiting, skin rashes, arthralgia, fever and hepatic dysfunction. More serious side-effects include pulmonary toxicity and blood dyscrasias. Early case reports of adverse effects were published in the 19609s [4] and knowledge of adverse pulmonary effects is not new [5][6][7]. Numerous case reports have been published in the last 30 yrs implicating sulphasalazine in pulmonary toxicity. The presen...

A case of eosinophilic cholangitis: Imaging findings of contrast-enhanced ultrasonography, cholangioscopy, and intraductal ultrasonography

“…Of note, SASP had been prescribed in one of the previously reported cases [7] , and aminosalicylic acid (5-ASA) had been prescribed in another case [9] . Ten cases of eosinophilic pneumonia have been reported as a side effect of SASP by Parry et al [21] . These results suggest that there is a relationship between eosinophilic cholangitis and SASP.…”

Respiratory System Involvement in Inflammatory Bowel Diseases

“…All these medications, with the exception of glucocorticosteroids, are well known for their possible lung toxicity [62][63][64][65][66][67][68][69][70][71]. The assumed lung-toxicity manifests itself mostly as interstitial lung diseases such as eosinophilic pneumonia, organizing pneumonia, interstitial lung fibrosis, interstitial pneumonia with nonnecrotizing granulomas, not specified interstitial pneumonia, bronchiolitis [60][61][62][63][64][65][66][67][68][69].…”

“…It is always necessary to exclude infective aetiology in patients treated with immunosuppressants or biological drugs, tuberculosis and opportunistic pathogens should be also taken into consideration [75][76][77][78][79][80]. Lung complications of IBD treatment may be fatal [62,67,70,77].…”

“…The management of such complications requires the withdrawal of suspected medication. Systemic glucocorticosteroids are commonly used in addition [62,67,70]. It is always necessary to exclude infective aetiology in patients treated with immunosuppressants or biological drugs, tuberculosis and opportunistic pathogens should be also taken into consideration [75][76][77][78][79][80].…”

“…Rarely drug--induced toxicity manifests itself as pleuritis [72][73][74]. There are no differences between symptoms and radiological features of the respiratory tract diseases appearing as a consequence of drug toxicity and in other circumstances [62][63][64][65][66][67][68][69][70][71].…”