Sulphasalazine and Folic Acid

[Deniseelk]

My friend has just started Sulphasalazine for a diagnosed Flexor Tenosynovitis in her hands / fingers. Most likely from over use as she works with horses and has had the usual blood screenings for RA, etc with no unremarkable results. She used Prednisolone for a short period which was reducing the long inset inflammation and shortly after stopping the course the inflammation was back. She is feeling very nauseous with a very dry mouth from the starting dose of Sulphasalazine and has been given the stomach protector medication too. I wondered if she should be given Folic Acid to help with the unpleasant side effects. Has anyone got any useful guidance please?

[nomoreheels]

Hiya Denise. Folic acid is only prescribed with methotrexate, it being a folate antagonist & in order to ease the effects of the MTX diminishing our folate reserves. SSZ doesn’t do this so the (high dose, prescription only) folic acid won't be coprescribed. Nausea is a side effect of SSZ, as your friend is aware, but it usually stops the longer you take it. She could ask her GP for an antiemetic whilst she's still bothered by it?

I've never heard of SSZ being prescribed for flexor tenosynovitis. Usually NSAIDs are prescribed first, or oral steroids as your friend found, it depends on the need. Mine was pretty bad when my Rheumy first saw mine, fixed in the bent position (my GP at the time, now retired, said it wasn't FT). She injected Kenalog but did think it was advanced to the point I'd need surgery. Fortunately that wasn’t the case & whilst it does trigger from time to time it's never been as bad as before the steroid injection.

I hope your friend has success, it can be a nuisance.

[Deniseelk in reply to nomoreheels]

Thank you, that is very helpful! I found info about FA administered with Sulphasalazine but I wonder if I found a US site? They did mention to her surgery if Sulphasalazine doesn’t work ( thought it sounded a little dramatic as surely there are more options first). I think her inflammation has been set in for a little while but seeing as the Prednisolone has made a difference there should be a hope. I have suggested she asks him about a steroid injection in hands. Unfortunately, she continues to work on the horses and she knows this continually aggravates the inflammation ( I have RA in my wrists / fingers so totally know all about this)! In the meantime, she will remain on the starting dose and see if the initial side effects settle. Thank you for your help.

[nomoreheels in reply to Deniseelk]

I'm happy to be proven wrong, just never heard of it being coprescribed. An option is to start on a low dose SSZ & gradually build up, as seems to be the case. That usually helps minimise side effects, including nausea. Has she tried ginger & the other traditional nausea easing methods? Worth a try. Ultimately though, as she's aware, the very thing that ought to be done is not doing what's caused/aggravating the condition. I bet that's not an option though but what to do?! As you say as she had some response to prednisolone it would make sense to go the injection route, if that's possible. Maybe if it's extensive it's not an option? I can't say it's pleasant, it's not like having a general steroid injection into a fleshy part of the body, but it's soon over & there is lidocaine or similar in the injection.

I hope you said she could have orange wee & if she wears contact lenses it could stain them?

[Deniseelk in reply to nomoreheels]

I will suggest the ginger. She’s barely eating as feels so nauseous and her mouth is so dry she is waking frequently to wee as drinking lots of water. We know all about that ... don’t we! Yes... her wee is now orange. She doesn’t wear contacts though so not an issue there. Hoping the effects settle for her.... I tried Methotrexate for my RA and just couldn’t tolerate the side effects so can empathise with her.

[nomoreheels in reply to Deniseelk]

Biotene gel may help ease her dry mouth. I was prescribed it when I first started amitriptyline & it helped. Oh, & I did look online about SSZ & folic acid. You're right, a few US sites do mention SSZ can affect folate absorption & suggest 1mg is taken alongside but not sure what the thoughts are here, as I say I’ve never heard of it so not sure if our 5mg would be prescribed. She can only ask & see.

[nomoreheels in reply to Deniseelk]

Coincidentally my h just this morning has had a consultation via video with MSK & has been diagnosed with FT (R thumb). He was advised that normally a steroid injection would be administered but as he's in the at risk category he's being sent a splint & he's to use a topical NSAID, he can't take oral NSAIDs due to existing stomach issues. Just thought a comparison was interesting.

[Deniseelk in reply to nomoreheels]

Thank you, that is a very good point for her to ask if they have decided to use Sulphasalazine in light of Coronavirus/ risk issues and maybe would have taken a different course otherwise! They are going to send her a splint... knowing my friend she won’t use it and I have been asking her to rest her hands for many months.... I will pass on all your tips to her. Her doc rang her this morning and will get her to do a diabetes test as they are concerned why she’s so thirsty... but I thought dry mouth was one of the side effects anyway !

[nomoreheels in reply to Deniseelk]

Well, all you can do is try to help, the rest is up to her. SSZ can cause you to be more thirsty as could pred but she's not on that anymore is she? Naturally you will go to the loo more often. Maybe her GP hasn't consider this & testing for diabetes with it being a common symptom for that too. I've been drinking a lot more though due the the glorious weather, that & pulling up hundreds of bluebells in it in both the front & back garden!

[Deniseelk in reply to nomoreheels]

So true! She stopped her short course of Prednisolone around February and quickly saw the return of the inflammation so I told her to not wait for her follow up consult and get straight on it. She was tested for diabetes early on when the GP initially looked into all obvious reasons for her hand swelling ( she had just started a drug for high blood pressure so thought it was just the diuretic effect of that). They changed her blood pressure med but the swelling continued and the investigations commenced. It does seem her rheumatologist keeps in constant contact and I badger her to not suffer in so hopefully her inflammation will settle soon. I do tell her she needs to understand the cause of the inflammation ( she had a bad injury to those fingers a year ago with a mandolin slicing it) and I queried if it was an infection but her rheumatologist said an infection would not have caused that and bloods are normal. My bloods always read in range but I have severe RA and clear inflammation.... so I know how odd bloods can be!

[AgedCrone in reply to Deniseelk]

In the US they usually prescribe a much lower dose of FA to be taken with Mtx (Not with SSZ) than you can buy OTC. You cannot buy the dose we in the UK are prescribed.....

It’s never a good idea to try to add any meds to those prescribed by your doctor.....best case scenario it just stops the prescribed drugs from working, but serious unpleasant side effects are a possibility too.