Credit: Tatiana Ayazo

“Are others experiencing inability to get sulfasalazine???”

When a CreakyJoints member recently raised this concern with our Facebook community, the response was swift.

Anna L. shared that it took two months to get her prescription filled and she, “still couldn’t get the enteric-coated sustained release.” Katherine N. shared that her mail-order pharmacy has been unable to get it for three months and, “several local pharmacies say they have it on back order with no delivery date.”

“My rheum said it was national shortage,” said Kelli D.

According to the drug shortage database from the U.S. Food and Drug Administration (FDA), sulfasalazine (Azulfidine) has been in shortage since April 2020. But the issue seems to be getting worse more recently.

“Our clinic first began receiving messages from patients mid-last year that their pharmacies were unable to supply their regularly supplied sulfasalazine prescription, both immediate and delayed-release formulations,” says Norman Westervelt, PharmD, a rheumatology specialty pharmacist at the University of Alabama at Birmingham. “I would not say it was common enough then to be a major concern or warrant therapy change, but it did require a few patients to seek out another local pharmacy who might have had it in stock. More recently we have had patients who are experiencing much more difficulty.”

Walgreens also told CreakyJoints that there is a large supply constraint on this medication that is affecting both versions of sulfasalazine (regular and delayed-release).

This news may be alarming and unsettling for those who take sulfasalazine to manage their inflammatory arthritis, inflammatory bowel disease, or another chronic condition.

Here is what you need to know about the shortage so you can talk to your health care team — including your doctor and pharmacist — to ensure you’re managing your chronic condition as well as possible.

What Is Sulfasalazine?

According to the American College of Rheumatology, “sulfasalazine is considered a disease-modifying anti-rheumatic drug (DMARD). It can decrease the pain and swelling of arthritis, prevent joint damage, and reduce the risk of long-term disability.”

Sulfasalazine (Azulfidine) may be prescribed for rheumatoid arthritis (RA), axial spondyloarthritis (axSpA) or ankylosing spondylitis (AS), psoriatic arthritis (PsA), inflammatory bowel disease (IBD), and some other conditions. It helps lower inflammation in the body. It may be taken alone or with other disease-modifying drugs, such as methotrexate and/or hydroxychloroquine.

The medication comes in 500 mg tablets and people can take up to 3,000 mg a day (six pills). There are two kinds of sulfasalazine:

  • Regular
  • Delayed-release/enteric-coated

The delayed-release version may be used to help reduce some of the gastrointestinal-related side effects, such as nausea and stomach upset, that some patients experience.

Sulfasalazine is considered a slower-acting DMARD; it takes time to build up in your system and start working. It can take up to two to three months to see an improvement in symptoms after starting the medication, according to ACR.

What to Know About the Sulfasalazine Shortage

According to information on the FDA drug shortage website, some versions of sulfasalazine are expected to be out of shortage by July 2021; others not until Q4 2021.

Greenstone, part of the pharmaceutical company Viatris and formerly a subsidiary of Pfizer, distributes both regular and delayed-release versions of sulfasalazine. However, both are manufactured by a third party. The company shared the following information with CreakyJoints in a statement.

“We are working very closely with the manufacturer to improve the supply of both sulfasalazine IR [immediate release] and DR [delayed release] tablets. We anticipate receiving intermittent supply from the third party through the remainder of the year. While we expect to be in an improved supply position in the fourth quarter of 2021, in the interim, we encourage patients to speak to their health care provider about alternatives if they are experiencing an inability to access the product.”

Teva Pharmaceuticals manufactures only the regular version of sulfasalazine, though it is unclear whether or to what degree the medication from this company is in shortage. We reached out to Teva but did not hear back by the time this was published.

We will update this article with new information as we receive it.

What to Do If You Have Trouble Getting Sulfasalazine

First of all, don’t panic. From what experts and patients are telling us, the sulfasalazine shortage seems to be spotty. Some patients are experiencing it; others are not. Among those who are experiencing it, the supply issues are inconsistent — sometimes the drug is unavailable and other times it can be located.

The most important thing to remember is that you want to avoid disruption to your treatment, which could cause disease flares or an increase in disease activity. Because sulfasalazine is slow-acting — meaning, it takes a while to build up in your system — this likely would not happen overnight, but you can partner with your health care team to prevent this. Here are some options.

Call around to get sulfasalazine from a different pharmacy. If you’re told that your pharmacy is out of the medication, the first thing to do is shop around. If your pharmacy is part of a chain, like Walgreens or CVS, they can try to see if the medication is at another nearby location. You can also try local pharmacies. “I was having trouble at Walmart but am able to get it at another,” shared CreakyJoints member Barbara Q on Facebook.

Switch to the regular version. Some CreakyJoints members are reporting that they can get regular sulfasalazine but not the delayed-release version. If stomach-related side effects are not a problem for you, see if your doctor or pharmacist can switch you to the regular version. “My pharmacy had to change my enteric-coated to non-coated because of supply problems,” Ambra D. shared on Facebook.

However, this may not work if the regular version also becomes in short supply. “I first had to switch off extended-release and now can’t get at all,” Leslie B. told us.

If you can access sulfasalazine, ask for a larger supply. The medication is typically prescribed in 30-day doses, but depending on your insurance plan, you could get up to a 90-day supply. If sulfasalazine is available for you now, consider getting a longer-term supply so you don’t have to worry as much about accessing it over the next few months.

Talk to your health care provider about adjusting your dose. If your disease is stable, you can talk to your doctor about lowering your dose of sulfasalazine to make your supply last longer. For example, if you currently take 2,000 mg a day (two pills twice a day), you could possibly taper down to 1,000 mg a day (two pills, once a day). Or you might be able to take the medication every other day instead of daily. “If you’ve been stable on this drug for years and your doctor recommends it, you may not notice a difference in lowering the dose,” says Dr. Westervelt.

Never make a change to your treatment plan, however, without discussing it with your doctor.  “You don’t want to stop taking something cold turkey — you never know when you could have a flare-up,” says Juan Maya, MD, a rheumatologist in West Palm Beach, Florida. “Contact your provider to see whether it makes sense to taper your dosage or try an alternative treatment.” (Dr. Maya is one of the rheumatologists who provides care at the John Whelton Arthur Virshup CreakyJoints South Florida Arthritis Clinic, which serves South Florida arthritis patients who cannot afford treatment, providing regular and free rheumatology care.)

Switch to a different medication. If difficulty accessing sulfasalazine has become a standing issue for you, consider this an opportunity to discuss trying a new therapy with your doctor.

“Sulfasalazine is a first-line treatment. These inflammatory diseases can be progressive and ‘overpower’ this medication over time,” says Dr. Westervelt. “Switching to something else could ultimately benefit the patient.”

Karen B., who was having issues on and off for months accessing sulfasalazine, said on Facebook that her “rheumy is switching me to a biologic.”

Two patients of Korey Ullrich, MD, a rheumatologist in private practice in South Florida, decided to switch to methotrexate because of difficulty accessing sulfasalazine. Dr. Ullrich also provides care at the John Whelton Arthur Virshup CreakyJoints South Florida Arthritis Clinic.

The bottom line: “The best thing to do when your drug is in short supply is to be proactive,” says Khadijah Khan, CPhT, Manager, Specialty Health Solutions for Walgreens. “Communicate with your pharmacy and your health care provider and make sure everyone is doing everything they can to make sure you stay on your therapy or find an alternative therapy.”

Track Your Medications with ArthritisPower

Join CreakyJoints’ patient-centered research registry and log your medications to track side effects and impact on disease activity. Learn more and sign up here.

Comment from Viatris, via email

Current and Resolved Drug Shortages and Discontinuations Reported to FDA. Sulfasalazine Tablets. FDA Drug Shortages. U.S. Food and Drug Administration. https://www.accessdata.fda.gov/scripts/drugshortages/dsp_ActiveIngredientDetails.cfm?AI=Sulfasalazine+Tablets&st=c&tab=tabs-4&panels=1.

Interview with Juan Maya, MD, a rheumatologist in West Palm Beach Florida

Interview with Khadijah Khan, CPhT, Manager, Specialty Health Solutions for Walgreens

Interview with Korey Ullrich, MD, a rheumatologist in South Florida

Interview with Norman Westervelt, PharmD, a rheumatology specialty pharmacist at the University of Alabama at Birmingham

Sulfasalazine (Azulfidine). American College of Rheumatology. https://www.rheumatology.org/I-Am-A/Patient-Caregiver/Treatments/Sulfasalazine-Azulfidine.

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