Azulfidine (Sulfasalazine) and Alcohol

Sulfasalazine (brand name Azulfidine) is an anti-inflammatory medication used to treat rheumatoid arthritis and other types of arthritic conditions. It is also used for inflammatory bowel disease and some autoimmune disorders.

Using alcohol while taking sulfasalazine can potentially lead to liver injury in people who have hypersensitivity or a drug allergy to the medication. Allergic reactions tend to occur soon after starting the medication, and acute liver failure is possible. Sulfasalazine has, in rare cases, been shown to cause liver disease.

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Mixing Alcohol and Medications

Using alcohol while taking certain medications regularly can be dangerous. Interactions can occur within the body that could lead to undesired side effects including headache, dizziness, nausea, and vomiting. In more serious cases, alcohol mixed with medications can lead to heart problems, internal bleeding, or induced medication toxicity.

Medications that can have negative effects on the body when mixed with alcohol can be both prescribed and over-the-counter. Alcohol also has the ability to counteract the effects of a medication, making it less effective and thus putting your health at risk. Reactions can occur with one or all of the ingredients in the medicine. This makes the risk of negative side effects that much higher.

Azulfidine and Alcohol

There is no mention of avoiding alcohol on the FDA label, and it's not known what level of drinking is safe when on sulfasalazine. Heavy alcohol use, however, can have adverse effects on the body while taking the medication. In one case study, a 57-year-old man who had a history of alcoholism and had just started taking sulfasalazine was hospitalized with signs of liver injury. When the medication was stopped, his liver function significantly improved, which suggested that the liver injury was drug-induced and not from his prior alcohol misuse.

How Much Can You Drink While on Sulfasalazine

One or two alcoholic drinks a week are unlikely to cause a problem, but more than four drinks on one occasion, even if infrequently, is discouraged for people who are taking sulfasalazine.

Liver toxicity from heavy alcohol use while on sulfasalazine can include:

The risk of liver toxicity in mixing alcohol and sulfasalazine is the result of the way the medication is broken down within the body into two metabolites, sulfapyridine and 5-aminosalicylic acid. Sulfapyridine is absorbed in the gut and eliminated after a chemical reaction, the speed of which can vary depending on the patient's genotype Patients who have genotypes for a slow chemical reaction are found to be more predisposed to sulfasalazine-induced liver toxicity.

Liver Toxicity

When the body is exposed to certain substances, a negative reaction in the liver can occur, referred to as liver toxicity or toxic hepatitis. It can be caused by alcohol, chemicals, medications, or nutritional supplements. It can take hours or days to develop after exposure to a substance. In the case of sulfasalazine, liver toxicity can occur shortly after treatment with the medication begins if alcohol is consumed.

The liver is responsible for metabolizing medications, detoxifying chemicals, and filtering the blood from the digestive tract. When it becomes overwhelmed by the presence of both alcohol and sulfasalazine, it can't properly do its job of both metabolizing the sulfasalazine and detoxifying the blood of alcohol. This extra strain can lead to liver injury in rare cases.

Reports of whether drinking alcohol while taking sulfasalazine is safe are mixed. Some suggest that no alcohol should be consumed, while others suggest that consuming moderate amounts of alcohol is safe. As a general rule of thumb, it's better to err on the side of caution when it comes to alcohol consumption if you are on a medication.

Guideline for Alcohol Consumption

According to the Centers for Disease Control and Prevention, to reduce the risk of alcohol-related harms, the 2015-2020 U.S. Dietary Guidelines for Americans recommends that if alcohol is consumed, it should be consumed in moderation—up to one drink per day for women and two drinks per day for men.

A Word From Verywell

While the use of alcohol is generally safe if consumed in moderation, it's important to remember that alcohol use can still have negative effects on your health. In general, drinking alcohol while on medications could limit or even negate the efficacy of your medication, and should be generally avoided if possible.

Research has shown that moderate consumption of alcohol is generally safe for people on sulfasalazine. There is, however, no definitive proof that this behavior is completely risk-free when it comes to liver toxicity. The best way to decide if you can consume alcohol while taking sulfasalazine is to consult your doctor. If your doctor gives you the go-ahead, they may ask you to do routine liver checks to ensure that your liver is functioning normally.

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Article Sources
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  1. LiverTox: Clinical and Research Information on Drug-Induced Liver Injury [Internet]. Bethesda (MD): National Institute of Diabetes and Digestive and Kidney Diseases; 2012-. Sulfasalazine. Updated September 25, 2017.

  2. Masood U, Sharma A, Nijjar S, Krenzer B. Unusual Case of an Alcoholic with Liver Injury from Sulfasalazine Use. J Basic Clin Pharm. 2016 Dec;8(1):38-39. doi: 10.4103/0976-0105.195126

  3. Australian Rheumatology Association. Patient Information on Sulfasalazine. Updated April 2016.

  4. Centers for Disease Control and Prevention. Dietary Guidelines for Alcohol. Updated December 30, 2019.