What You Should Know About Azulfidine (Sulfasalazine) Interactions

Azulfidine (sulfasalazine) is a disease-modifying antirheumatic drug used to treat conditions like ulcerative colitis and rheumatoid arthritis (RA). The most common side effects of this drug include headache, nausea, vomiting, gastric distress, anorexia, and oligospermia. Sulfasalazine interacts with a number of medications, and taking these drugs at the same time can result in adverse reactions. Here's an overview of potential drug interactions, from severe to mild.

Reviewing sulfasalazine interactions

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Severe Drug Interactions

Taking the following drugs while on sulfasalazine can lead to very serious health issues. Always consult with your practitioner or healthcare provider about concerns over specific interactions and whether you should start or stop a specific course of treatment.

Hepatitis B Medications

  • Hepsera or Preveon (adefovir) may cause kidney problems. If you have any signs of kidney damage like nausea, vomiting, changes in urination, fluid retention, or weight changes, consult your healthcare provider.
  • Viread (tenofovir) can lead to kidney problems, along with fluid retention, weight loss and gain, decreased urination, and nausea.
  • Vemlidy (tenofovir alafenamide) can result in kidney damage, with symptoms that include nausea, bone pain, muscle cramps, and changes in urination.

Arthritis Medications

  • Miradon (anisindione) may increase risk of bleeding, especially for people who are elderly, have liver impairment, or problems with kidney function. Seek medical attention if you have signs like unusual bleeding, swelling, and blood in your urine or stools.
  • Arava (leflunomide) can increase the risk of side effects that impact bone marrow function. This can lead to a low numbers of blood cells, resulting in a higher risk of anemia, bleeding problems, and infection.

Botulism Toxin Type A and B Medications

BabyBIG (botulism immune globulin) may result in kidney problems and lead to nausea, loss of appetite, swelling, muscle cramps, fluid retention, and vomiting.

Antiviral Medications

Vistide (cidofovir) may cause kidney problems and lead to nausea, vomiting, change in appetite, shortness of breath, bone pain, muscle cramps, and tiredness.

Immunosuppressive Medications

  • Neoral, Sandimmune, Gengraf (cyclosporine) can increase the risk of organ rejection tied to low cyclosporine levels and the risk of kidney problems.
  • Rapamune (sirolimus) can result in kidney damage along with shortness of breath, vomiting, weight changes, and fatigue.

CMV Medications

Cytogam (cytomegalovirus immune globulin) is prescribed to protect against CMV (cytomegalovirus), and when combined with sulfasalazine, can result in nausea, dizziness, confusion, and irregular heart rhythm.

Iron Chelation Medications

Exjade and Jadenu (deferasirox) can cause sudden weight gain, nausea, bone pain, muscle cramps, and vomiting.

Imaging Procedure Medications

Gastrografin (diatrizoate) might be administered through an injection for imaging procedures. Before administering this medication, healthcare providers might take special precautions for people on sulfasalazine who have diabetes or preexisting kidney issues, are older, or have congestive heart failure or kidney problems. If the risk is too great, a practitioner might consider a different imaging procedure.

Kidney damage is similarly a risk when the following are injected for imaging procedures:

  • Amipaque (metrizamide)
  • Iodamide
  • Iodipamide
  • Iodixanol
  • Iohexol
  • Iopamidol
  • Iopromide
  • Iothalamate
  • Ioversol
  • Ioxaglate
  • Ioxilan

Blood Thinners

  • Coumadin and Jantoven (warfarin) may increase bleeding risk, especially for the elderly and those with kidney or liver impairment.
  • Dicumarol may increase the risk of bleeding, particularly for people who have liver problems and the elderly.

Immunodeficiency Medications

  • Carimune (immune globulin intravenous) can cause sudden weight gain or loss, fluid retention, nausea, swelling, and irregular heart rhythm.
  • Gammagard Liquid and Gammaked (immune globulin intravenous and subcutaneous) can result in kidney damage or irregularities, and cause weight fluctuations, nausea, vomiting, and changes in urination.

Nerve Damage Medications

Tegsedi (inotersen) may cause kidney issues like glomerulonephritis, an inflammatory condition. Glomerulonephritis can lead to kidney failure, and combining this drug with sulfasalazine can exacerbate kidney issues.

Cholesterol Medications

  • Juxtapid (lomitapide) can impact the liver and anyone using this drug and sulfasalazine at the same time should avoid or limit alcohol use to no more than one drink a day.
  • Kynamro (mipomersen) can affect the liver, and as with Juxtapid, anyone using this medication and sulfasalazine simultaneously should limit or avoid alcohol use. Contact your healthcare provider if you have chills, fever, skin rash, swelling, fatigue, or other unusual symptoms.

Bladder and Kidney Infection Treatments

Hiprex (methenamine) combined with sulfasalazine is not recommended at all because it can cause crystals to form in your urine.

Multiple Sclerosis Medications

  • Aubagio (teriflunomide) may increase side effects that impact bone marrow function. You may be more likely to develop bleeding problems, infection, or anemia.
  • Zeposia (ozanimod) interactions may come in the form of an increase in blood levels. Your healthcare provider may adjust your dosage or ask for more frequent monitoring.

CSF1R Inhibitors

Turalio (pexidartinib) may cause liver injury when used with sulfasalazine, and you should avoid or limit alcohol use while on these medications.

Anesthetics

With Citanest (prilocaine), a serious interaction with sulfasalazine can be increased risk of methemoglobinemia, a condition that reduces the blood's capacity to carry oxygen, leading to oxygen deprivation in vital organs and tissues.

Respiratory Medications

Respigam (respiratory syncytial virus immune globulin) is used to treat respiratory syncytial virus (RSV), and interactions with sulfasalazine can cause kidney problems.

Pregnancy Medications

MICRhoGam, WinRho-D, and BayRho-D can cause kidney damage, with symptoms of nausea, vomiting, loss of appetite, increased or decreased urination, and sudden weight change.

When to See a Healthcare Provider

Going on sulfasalazine can make you more prone to infections, and its use comes with common side effects like diarrhea, stomach pain, headaches, and rashes. If any of these symptoms get significantly worse without letting up, especially if you are also taking any of these other medications that are known to lead to severe interactions, contact your medical provider right away.

Moderate Drug Interactions

While not as risky as the drugs that can cause severe interactions, it is recommended that combinations of these drugs and Azulfidine be avoided.

Arthritis Medications

  • Celebrex (celecoxib) can cause kidney problems, potentially resulting in nausea, vomiting, dizziness, fluid retention, and loss of appetite.
  • Clinoril (sulindac) can cause some kidney problems and lead to symptoms such as nausea, vomiting, loss of appetite, and changes in urination.
  • Daypro (oxaprozin) can lead to kidney issues and result in symptoms like nausea, changes in urination, and loss of appetite.
  • Disalcid (salsalate) can cause kidney problems.
  • Dolobid (diflunisal) can result in kidney problems, and lead to nausea, vomiting, swelling, weakness, and fatigue.
  • Nalfon (fenoprofen) can cause kidney problems and symptoms including nausea, vomiting, and weight changes.
  • Naprosyn (naproxen) may cause kidney problems, and result in nausea, vomiting, swelling, and sudden weight changes.
  • Ocufen (flurbiprofen) can cause kidney problems such as nausea, vomiting, and swelling.
  • Ponstel (mefenamic acid) can cause kidney problems such as nausea, vomiting, swelling, and changes in appetite.
  • Relafen (nabumetone)  can cause kidney problems like nausea, vomiting, and sudden weight changes.
  • Tolectin (tolmetin) can cause kidney problems such as nausea, vomiting, dizziness, and weakness.

Diabetes Medications

  • Byetta (exenatide) can cause kidney problems and symptoms like nausea, loss of appetite, fluid retention, and swelling.
  • Dymelor (acetohexamide) can increase risk of low blood sugar, with symptoms including headache, dizziness, drowsiness, nausea, and rapid heartbeat.
  • Glucotrol, GlucotrolXL (glipizide) might increase risk of low blood sugar.
  • Insulin in different forms and products may increase the risk of hypoglycemia.

Antiviral Medications

  • Valtrex (valacyclovir) can result in kidney problems, and can cause symptoms that include nausea, swelling, and shortness of breath.
  • Veklury (remdesivir) may cause liver problems.
  • Zovirax (acyclovir) can cause kidney problems, and can result in nausea, vomiting, sudden weight changes, and loss of appetite.

Cancer Medications

  • Adcetris (brentuximab vedotin) can lead to liver problems.
  • Alimta (pemetrexed) can impact kidney function and increase blood levels.
  • Alunbrig (brigatinib) may increase blood levels.
  • Asparlas (calaspargase pegol) may increase chance of liver damage.
  • Braftovi (encorafenib) may increase blood levels.
  • Clolar (clofarabine) can lead to kidney damage, elevated blood levels, nausea, vomiting, weight changes, anemia, and bleeding.
  • Erleada (apalutamide) may reduce blood levels.
  • Elspar (asparaginase Escherichia coli) can increase risk of liver damage.
  • Erwinaze (asparaginase Erwinia chrysanthemi) can increase the risk of liver damage.
  • Kisqali (ribociclib) may increase blood levels.
  • Nubeqa (darolutamide) may increase blood levels.
  • Piqray (alpelisib)  can result in blood level increases if combined with sulfasalazine.
  • Platinol (cisplatin) can cause kidney problems, resulting in weight changes, nausea, vomiting, weakness, and fatigue.
  • Rozlytrek (entrectinib) may increase blood levels.
  • Rydapt (midostaurin) may increase blood levels.
  • Tabrecta (capmatinib) may increase blood levels.
  • Zykadia (ceritinib) may increase blood levels.

Bacterial Infections Medications

  • Arikayce (amikacin liposome) can cause kidney issues like diarrhea, weight changes, vomiting, fluid retention, and swelling.
  • Amikin (amikacin) can lead to kidney problems and result in diarrhea, vomiting, changes in appetite, and dizziness.

Photosensitizing Agents

Levulan Kerastick (aminolevulinic acid topical) can make your skin more sensitive to light, and increase the risk and severity of redness, swelling, stinging, and scaling.

Fungal Infections Medications

Abelcet and Ambisome (amphotericin B, amphotericin b cholesteryl sulfate, amphotericin b lipid complex, amphotericin b liposomal) can cause kidney problems like vomiting, sudden weight gains or losses, fluid retention, and swelling.

Immunosuppressant Medications

Imuran (azathioprine) can cause nausea, vomiting, stomach pain, bleeding, and diarrhea.

Antibiotics

  • Bacitracin can cause kidney problems and lead to nausea, vomiting, fluid retention, and changes in weight.
  • Coly-Mycin M (colistimethate) can affect the kidneys and lead to nausea, vomiting, sudden changes in weight, muscle cramps, and fatigue.
  • Gentak (gentamicin) can cause kidney problems, resulting in nausea, fluid retention, dizziness, fatigue, and sudden weight changes.
  • Tobi (tobramycin) may cause kidney problems.
  • Vancocin (vancomycin) can cause kidney problems, and result in nausea, vomiting, muscle cramps, tiredness, and weakness.
  • Vibativ (telavancin) can cause kidney problems with symptoms that include changes in weight, loss of appetite. muscle cramps, and fatigue.

Tuberculosis Medications

  • Capastat (capreomycin) can cause kidney problems, and lead to sudden weight changes, vomiting, and changes in urination.
  • Sirturo (bedaquiline) can impact the liver.

Menopause Medications

Black cohosh (Cimicifuga racemosa) is often used in herbal medicine. Reactions from products containing this plant can result in liver damage.

Anti-Inflammatory Medications

  • Advil (ibuprofen) can lead to kidney problems with symptoms that include, nausea, shifts in weight, and dizziness.
  • Frotek (ketoprofen) can cause kidney problems and symptoms including nausea, changes in urination, confusion, and irregular heart rhythm.
  • Voltaren (diclofenac) can cause kidney problems, and result in nausea, fluid retention, swelling, and shortness of breath.
  • Xibrom (bromfenac) can result in kidney problems, and lead to nausea, dizziness, fluid retention, and weight changes.

Seizure Medications

Epidiolex (cannabidiol) may cause liver damage.

Anesthetics

  • Altacaine (tetracaine) may decrease the effects of sulfasalazine.
  • Nesacaine (chloroprocaine) may decrease the effects of sulfasalazine.

Antidiabetes Medications

Diabinese (chlorpropamide) could increase the risk of hypoglycemia.

Multiple Sclerosis Medications

Zinbryta (daclizumab) can affect your liver.

Heart Health Medications

Digitek, Digox, Lanoxin, Lanoxicaps, and Cardoxin (digoxin) with sulfasalazine can actually lessen the effects of digoxin.

HIV Medications

Sustiva (efavirenz) can cause liver problems.

Bone Marrow Medications

Promacta (eltrombopag) may increase blood levels.

Hepatitis B Medications

Baraclude (entecavir) may increase blood levels.

Epilepsy Medications

Peganone (ethotoin) might cause twitching eye movements, slurred speech, loss of balance, tremor, and muscle stiffness.

Mood Stabilizer Medications

Lithobid and Eskalith (lithium) can cause kidney problems and can lead to changes in appetite, fluid retention, dizziness, and nausea.

Antimalarial Medications

Daraprim (pyrimethamine) can increase risk of anemias.

Parkinson's Disease Medications

Xadago (safinamide) may increase blood levels.

Minor Drug Interactions

While the below drugs interactions fall under the category of being considered minimally clinically significant, they still interact with sulfasalazine and can produce adverse effects.

Folic Acid Supplements

  • FA-8 (folic acid), your ability of intestinal absorption of folic acid in its physiologically useful form may be impaired if taken with sulfasalazine.
  • Deplin (L-methylfolate), intestinal absorption or metabolism of folic acid in its physiologically useful form may be impaired when this is taken with sulfasalazine.

Chemotherapy Protective Medications

The intestinal absorption or metabolism of leucovorin in its physiologically useful form may be impaired when this is taken with sulfasalazine.

Prenatal Multivitamins

Taking sulfasalazine with prenatal multivitamins may impair proper intestinal absorption or metabolism of folic acid in its physiologically useful form.

Seizure Medications

Solfoton and Luminal (phenobarbital) might increase biliary excretion of sulfasalazine, but there are no official precautions that are recommended when taking these two drugs concurrently.

Alcohol Interactions

Alcohol use while on sulfasalazine can lead to potential liver injury in people who have a drug allergy to the medication, potentially resulting in acute liver failure. One 2016 study showed that a 57-year-old man with a past history of alcoholism was hospitalized with evidence of liver injury after starting sulfasalazine. After he finished using the drug, his liver function improved.

A Word From Verywell

All medications can come with potential interactions, from mild to very serious. While Azulfidine can be incredibly effective at treating inflammation and chronic pain from arthritis, it's important that you review with your practitioner or healthcare provider both your medical history and list of other medications you're currently taking. While thorough, this is not an exhaustive list of all possible interactions that could occur with sulfasalazine. If you encounter any unusual side effects while taking sulfasalazine or your overall health worsens in any way, make sure to contact your provider immediately.

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