How to manage gastritis caused by Salazopirin (sulfasalazine)?

Management of Salazopirin-Induced Gastritis

For patients with gastritis caused by sulfasalazine (Salazopirin), histamine-2 receptor blockers or proton pump inhibitors should be administered during steroid therapy to manage symptoms while continuing the medication if clinically necessary. 1

Initial Assessment

• Evaluate for symptoms of gastritis including nausea, vomiting, dyspepsia, epigastric discomfort, reduced appetite, epigastric pain, and heartburn 2
• Assess severity of symptoms to determine whether sulfasalazine can be continued or needs to be discontinued 2
• Rule out other causes of gastrointestinal symptoms such as Helicobacter pylori infection 3

Management Algorithm

First-Line Treatment

• For patients at higher risk of developing gastritis (those taking NSAIDs or anticoagulants) or those already experiencing gastritis symptoms:
  • Administer histamine-2 receptor blockers (H2 blockers) or proton pump inhibitors (PPIs) during sulfasalazine therapy 1, 2
  • Options include:
    • Ranitidine (H2 blocker) 1
    • Omeprazole (PPI) 1

Dose Adjustment

• If gastritis symptoms persist despite acid suppression therapy:
  • Consider reducing the dose of sulfasalazine 2
  • Split the daily dose into smaller, more frequent administrations 1
  • Take sulfasalazine with or shortly after food to reduce gastrointestinal upset 1

Severe or Persistent Symptoms

• For patients with severe or persistent symptoms despite the above measures:
  • Temporarily discontinue sulfasalazine until symptoms resolve 2
  • Consider alternative medications based on the condition being treated:
    • For inflammatory bowel disease: consider other 5-ASA formulations such as mesalamine which may cause fewer gastrointestinal side effects 1
    • For rheumatoid arthritis: consider alternative DMARDs 4

Special Considerations

• Sulfasalazine-induced gastritis is usually mild and treatment can often continue with appropriate management 2
• Monitor for signs of more serious gastrointestinal complications such as hematemesis or melena, which would require immediate discontinuation of the medication 2
• Be aware that sulfasalazine may also cause other gastrointestinal symptoms including diarrhea, mouth ulcers, and stomatitis that may require additional management 2
• Patients with a history of gastritis or peptic ulcer disease should be monitored more closely when on sulfasalazine 1

Follow-up

• Regular assessment of symptom improvement after initiating acid suppression therapy 1
• If symptoms persist despite all interventions, consider permanent discontinuation of sulfasalazine and switch to an alternative medication 2
• For patients with ulcerative colitis, standard-dose mesalamine (2-3 grams/day) or diazo-bonded 5-ASA may be better tolerated alternatives 1

Common Pitfalls to Avoid

• Failing to provide prophylactic acid suppression therapy in high-risk patients (those on NSAIDs or anticoagulants) 1
• Unnecessarily discontinuing sulfasalazine when symptoms could be managed with acid suppression and dose adjustments 2
• Not considering H. pylori infection as a potential contributing factor to gastritis symptoms 3
• Overlooking the potential benefit of sulfasalazine in reducing NSAID-induced small intestinal inflammation and blood loss in patients with rheumatoid arthritis 4