Psoriatic Arthritis treatments: Disease-modifying antirheumatic drugs (DMARDs)

Anakinra is a Disease modifying antirheumatic drug that belongs to the group of medicines which are known as Interleukin-1 antagonists.

How does it work?

Normally, your body produces a protein that blocks the harmful effects of interleukin-1. In rheumatoid arthritis your body does not produce enough of this blocking protein. The active anakinra is produced by DNA technology using the micro-organism E coli and works in the same way as your natural blocking protein. By blocking IL-1, Kineret inhibits the inflammatory response in RA including pain.

How is it used?

Kineret is given by injection at the same time every day. This is usually done by the patient in the same way that a diabetic patient treats themselves.

The most suitable places to inject yourself are:
• the top of thighs; and
• the abdomen, except for the area around the navel.
Change the place that you inject each time so you don't become sore in one area. If someone else is injecting for you, they can also use the back of your arms.

What are the side effects?

Very common side effects are:
Injection site reactions
The most common and consistently reported treatment-related adverse event associated with Kineret were ISRs. The majority (95%) of ISRs were reported as mild to moderate. These were typically characterised by 1 or more of the following: erythema, ecchymoses, inflammation, and pain. At a dose of 100 mg/day, 71% of patients developed an ISR compared to 28% of the placebo treated patients, which was typically reported within the first 4 weeks of therapy. The median duration of the above mentioned typical symptoms was 14 to 28 days. The development of ISRs in patients who had not previously experienced ISRs was uncommon after the first month of therapy.
Serious infections
The incidence of serious infections in the studies conducted at the recommended dose (100 mg/day) was 1.8% in Kineret-treated patients and 0.7% in placebo-treated patients. These infections consisted primarily of bacterial events such as cellulitis, pneumonia, and bone and joint infections, rather than unusual, opportunistic, fungal, or viral infections. Most patients continued on study drug after the infection resolved. There were no on-study deaths due to serious infectious episodes.
In clinical studies and post-marketing experience, rare cases of opportunistic infections have been observed and included fungal, mycobacterial, bacterial, and viral pathogens. Infections have been noted in all organ systems and have been reported in patients receiving Kineret alone or in combination with immunosuppressive agents.
Neutropenia
In placebo-controlled studies with Kineret, treatment was associated with small reductions in the mean values for total white blood count and absolute neutrophil count (ANC). Neutropenia (ANC < 1.5 x 109/l) was reported in 2.4% patients receiving Kineret compared with 0.4% of placebo patients.
Kineret treatment should not be initiated in patients with neutropenia (ANC < 1.5 x 109/l). It is recommended that neutrophil counts be assessed prior to initiating Kineret treatment, and while receiving Kineret, monthly during the first 6 months of treatment and quarterly hereafter. In patients who become neutropenic (ANC < 1.5 x 109/l) the ANC should be monitored closely and Kineret treatment should be discontinued
Malignancies
Rheumatoid arthritis (RA) patients may be at a higher risk (on average 2-3 fold) for the development of lymphoma. In clinical trials, whilst patients treated with Kineret had a higher incidence of lymphoma than the expected rate in the general population, this rate is consistent with rates reported in general for RA patients.
In clinical trials, the crude incidence rate of malignancy was the same in the Kineret-treated patients and the placebo-treated patients and did not differ from that in the general population. Furthermore, the overall incidence of malignancies was not increased during 3 years of patient exposure to Kineret.
Immunogenicity
In clinical trials, up to 3% of patients tested seropositive at least once during the study for antibodies capable of neutralising the biologic effects of anakinra. The occurrence of antibodies was typically transient and not associated with clinical adverse reactions or diminished efficacy.

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Anakinra is known commercially as Kineret and is marketed in the UK by Swedish Orphan Biovitrum Ltd

Azathioprine is a type of medicine called an immunosuppressant which belongs to the group of drugs known as disease modifying antirheumatic drugs. It is used to treat severe rheumatoid arthritis

How does it work?

The immune system normally recognises and protects the body from foreign substances such as bacteria and viruses. It also recognises and attacks transplanted tissue and cells that have become cancerous. Sometimes however, the immune system can react excessively, or mount an attack against normal healthy tissues. This can result in various disorders known as autoimmune diseases. For example, in rheumatoid arthritis the immune system attacks the joints, causing pain and inflammation. In systemic lupus erythematosus the immune system attacks the skin and internal organs. The activity of the immune system can also be a problem following organ transplants, because it recognises the transplanted tissue as foreign and attacks it, causing the organ to be rejected. In situations such as these it is useful to suppress the activity of the immune system.

The immune system relies on different types of white blood cells that are produced in the bone marrow and lymph glands. Azathioprine works by decreasing the production of these white blood cells. It does this by interfering with the production of the cells genetic material, DNA, which stops the cells from dividing and multiplying. The decrease in the numbers of white blood cells reduces the ability of the immune system to reject organ transplants. In autoimmune diseases it reduces the immune system attack on normal tissues and so reduces the severity of the symptoms, and in many cases halts the progress of the disease. However, it can take weeks to months of treatment for the full effect of the medicine to become apparent.
Unfortunately white blood cells are needed to fight invading micro-organisms, so during treatment the body becomes more susceptible to infections. Azathioprine also interferes with the growth and division of other types of blood cells in the bone marrow. Reduced production of red blood cells can cause anaemia and reduced production of platelets can cause problems with blood clotting. For this reason, your doctor will monitor the levels of all your blood cells.
Azathioprine is often used in combination with other immunosuppressants such as corticosteroids. When combined with corticosteroids it can often allow a reduced dose of corticosteroid to be used.

Who can get it?

This medicine is available on prescription for adults and children

How is it used?

The dosage is very variable and it may be changed from time to time by your doctor. The usual daily dosage of Imuran is from 1 - 3 mg per kilogram body weight for adults and children. The usual dosage for elderly patients and those with liver or kidney disease should be at the lower end of the dosage range for adults. Imuran Injection may only be given intravenously (into a vein) as an injection or an infusion. Your doctor will discuss the best method of treatment for you. While you are on Imuran, your doctor will want you to have a blood test from time to time to check the blood cell count and to adjust the dosage if necessary.

What are the side effects?

See your doctor immediately if any of the following occur:

• if you feel sick, dizzy, lose your appetite, vomit or develop bad diarrhoea or jaundice (yellowing of the skin or eyes)
• if you start feeling more tired than usual, or if you notice any signs of a fever (chills), rash, muscle or joint pain, or an infection
• if you have any unexpected bruising or bleeding
• if you start feeling more ill while taking Imuran
• if you develop lumps on the body or patches on the skin.

You may notice some hair loss while taking Imuran. This is a rare side effect of Imuran that could happen in less than 1 in 1,000 patients. Often hair does grow again, even if you carry on taking Imuran. If you are worried ask your doctor.
Imuran can cause kidney problems (symptoms may include changes in the amount of urine passed and changes in the colour of the urine) or a drop in blood pressure.
Very rarely, liver or lung problems may occur.

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Azathioprine is known commercially as Imuran and is marketed in the UK by Aspen.

Chloroquine belongs to the group of drugs known as disease modifying antirheumatic drugs and it is used in the treatment of rheumatoid arthritis.

How does it work?

Chloroquine has anti-inflammatory activity and is sometimes used in high doses to treat the autoimmune diseases rheumatoid arthritis, juvenile rheumatoid arthritis, systemic lupus erythematosus, and discoid lupus erythematosus.

In these diseases, the body's immune system is overactive and causes inflammation that results in the disease symptoms. Chloroquine suppresses the inflammation and the disease process.

It doesn't have an immediate effect, but requires four to six months of treatment for a full response.

If there is no real benefit on the disease after taking this medicine for six months, your doctor will usually ask you to stop taking it and try a different DMARD.

Who can get it?

This medicine is available on prescription for adults and children.

How is it used?

15 ml should be taken daily.

What are the side effects?

• Headache,
• GI upset,
• hair loss,
• skin eruptions,
• depigmentation,
• blurred vision,
• corneal opacities,
• retinal damage.
• Blood disorders.
• Allergy,
• anaphylaxis

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Chloroquine is known commercially as Nivaquine Syrup and is marketed in the UK by Sanofi Aventis.

Ciclosporin belongs to the group of drugs known as disease modifying antirheumatic drugs and it is a type of medicine called a cytotoxic antimetabolite. Methotrexate is used to treat three different conditions: rheumatoid arthritis, psoriasis and cancer of various types.

How does it work?

Ciclosporin suppresses the immune system by preventing white blood cells called T lymphocytes from producing substances called lymphokines. Lymphokines normally stimulate the growth of T and B lymphocytes, which are white blood cells responsible for regulating and triggering immune responses. They provide defence against infection and foreign cells.

By preventing the production of lymphokines, ciclosporin suppresses the action of T and B lymphocytes. This prevents certain immune responses from occurring – the immune system is suppressed.

The skin conditions psoriasis and dermatitis are also affected by the immune system. It is thought that T cells over-react to a stimulus in these conditions, causing the scaling and inflammation of the skin. Ciclosporin can be used in severely disabling and resistant forms of these conditions to suppress the action of the T cells and therefore improve the scaling of the skin.

Rheumatoid arthritis, and a syndrome involving the kidneys called nephrotic syndrome, are also treated with ciclosporin in certain cases. These conditions are thought to be caused by inappropriate activity of the immune system towards the body’s own cells. T cells are involved in producing inflammation as part of their immune function, thus suppressing their action can help to reduce the inflammation in the joints seen in arthritis, and the inflammation in the kidneys seen in the nephrotic syndrome

Who can get it?

This medicine is available on prescription for adults over the age of 18.

How is it used?

For the treatment of severe rheumatoid arthritis, the total daily dose is usually within the range of 2.5 mg/kg body weight per day and 4 mg/kg body weight per day.

What are the side effects?

Many side effects associated with ciclosporin therapy are dose-dependent and responsive to dose reduction. In the various indications the overall spectrum of side effects is essentially the same; there are, however, differences in incidence and severity. As a consequence of the higher initial doses and longer maintenance therapy required after transplantation, side effects are more frequent and usually more severe in transplant patients than in patients treated for other indications.
Frequency estimate: very common 10%, common 1% to <10%,
Uncommon 0.1% to <1%, rare 0.01% to <0.1%, very rare <0.01%.

Blood and the lymphatic system disorders:
Uncommon: anaemia, thrombocytopenia
Rare: micro-angiopathic haemolytic anaemia, haemolytic uraemic syndrome

Endocrine disorders:
Rare: menstrual disturbances, gynaecomastia

Metabolism and nutrition disorders:
Very common : hyperlipidaemia
Common: hyperuricaemia, hyperkalaemia, hypomagnesaemia
Rare: hyperglycaemia

Nervous system disorders:
Very common: tremor, headache
Common: paraesthesia
Uncommon: signs of encephalopathy or demyelination, especially in liver transplant patients, such as convulsions, confusion, disorientation, decreased responsiveness, agitation, insomnia, visual disturbances, cortical blindness, coma, paresis, cerebellar ataxia.
Rare: motor polyneuropathy
Very rare: optic disc oedema including papilloedema with possible visual impairment secondary to Benign Intracranial Hypertension.

Cardiovascular disorders:
Very common: hypertension

Gastrointestinal disorders:
Common: anorexia, nausea, vomiting, abdominal pain, diarrhoea,
gingival hyperplasia,

Hepato-biliary disorders:
Common: hepatic dysfunction
Rare: pancreatitis.

Skin and subcutaneous tissue disorders:
Common: hypertrichosis
Uncommon: allergic rashes

Musculoskeletal, connective tissue and bone disorders:
Common: muscle cramps, myalgia
Rare: muscle weakness, myopathy

Renal and urinary disorders:
Very common: renal dysfunction (see 4.4 'Special Warnings and special precautions for use')

General disorders and administration site conditions:

Common: fatigue
Uncommon: oedema, weight increase
The increased risk of developing malignancies and lymphoproliferative disorders appears to be related to the degree and duration of immunosuppression rather than to the use of specific agents.

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Ciclosporin is known commercially as Neoral oral solution and is marketed in the UK by Novartis Pharmaceuticals ltd.

Hydroxychloroquine belongs to the group of medicines known as disease modifying antirheumatic drugs and is for the treatment of rheumatoid arthritis, juvenile rheumatoid arthritis, and lupus erythematosus.

How does it work?

Hydroxychloroquine is thought to act by interfering with the production and release of blood cells that are involved in the body's immune defence system. Hence the autoimmune response of the antibodies against its own body is reduced and as result the amount of damage to the cells is minimized and prevented. As it has the potential to prevent progression of the disease, by limiting the damage caused, it is often referred to as a disease-modifying antirheumatic drug (DMARDS) and is commonly used very early in the treatment of rheumatoid arthritis.

Hydroxychloroquine is also used in treating skin conditions that are caused or aggravated by sunlight

Who can get it?

Available on prescription

How is it used?

Initially 2 daily in divided doses with meals,
Discontinue after six months if no improvement.

What are the side effects?

Medicines and their possible side effects can affect individual people in different ways. The following are some of the side effects that are known to be associated with this medicine. Because a side effect is stated here, it does not mean that all people using this medicine will experience that or any side effect.

• Retinal changes,
• corneal opacity,
• impaired visual accommodation (discontinue if occur).
• Skin reactions,
• bleaching of hair,
• alopecia,
• GI upset

Hydroxychloroquine may increase the blood levels of digoxin, resulting in an increased risk of side-effects or toxicity. Therefore close monitoring is required.

The absorption of hydroxychloroquine may be reduced by antacids (indigestion remedies). It is advisable to leave a 4-hour interval between the two doses.

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Hydroxychloroquine is marketed in the UK by Sanofi Aventis and is known commercially as Plaquenil

Leflunomide is a disease modifying antirheumatic drug used in the treatment of moderate to severe active rheumatoid arthritis and active psoriatic arthritis

How does it work?

Leflunomide is an immunosuppressive medicine. It helps to suppress overactivity of the immune system in rheumatoid arthritis and psoriatic arthritis. It can help to reduce pain and swelling by limiting inflammation.
Due to the effects on the immune system, people who take Leflunomide are prone to getting infections. This includes serious infections such as tuberculosis and sepsis. It is for this reason that people who have Leflunomide are monitored for infections.
Leflunomide stays in the body for several months so the effects of this medicine will persist for some time after you take your last dose.
The effects of Leflunomide are not usually seen or felt until it has been taken for several weeks

Who can get it?

Suitable for adults only.

How is it used?

• swallow whole with a glass of water
• this medicine can be taken with or without food

What are the side effects?

Clinical studies have shown the following side effects when taking Leflunomide

• Increased Blood Pressure
• GI upset
• oral mucosal disorders
• abdominal pain
• altered liver function
• leucopoenia
• tenosynovitis
• headache
• dizziness
• asthenia
• paraesthesia
• weight loss
• allergy
• hair loss
• dry skin.

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Leflunomide is known commercially as Arava and is marketed in the UK by Sanofi-Aventis Ltd.

Methotrexate  belongs to the group of drugs known as disease modifying anti-rheumatic drugs and it is a type of medicine called a cytotoxic antimetabolite. Methotrexate is used to treat three different conditions: rheumatoid arthritis, psoriasis and cancer of various types.

How does it work?

In rheumatoid arthritis methotrexate is thought to work by suppressing the excessive activity of the immune system that causes the inflammation in this condition, though the exact mechanism of action is not fully understood. It is used when the arthritis does not improve sufficiently with conventional treatment, or for people who cannot tolerate conventional treatments. In arthritis methotrexate is sometimes referred to as a disease-modifying antirheumatic drug (DMARD), because it suppresses the disease process.

In low doses methotrexate can also affect the division of normal, healthy cells, and it has the potential to produce serious side effects. For this reason, treatment with methotrexate is usually only initiated by hospital specialists, and regular blood tests are needed to monitor for potential side effects.

Who can get it?

This medicine is available on prescription for adults over the age of 18.

How is it used?

Dosage

Jylamvo oral solution

For the treatment of severe psoriasis  take 2.5-5mg test dose one week prior to therapy.  Then 7.5mg once weekly, increasing gradually as necessary; maximum 25mg weekly.  After desired response reduce gradually to lowest effective dose.

Maxtrex
7.5mg to be taken once weekly or 2.5mg at 12 hour intervals for 3 doses as a course once weekly.  Adjust dose according to response: use lowest effective dose.  Max 20mg weekly.

Methofill

7.5mg by subcutaneous injection, increasing gradually depending on individual tolerance and disease activity up to a maximum weekly dose of 25mg  After desired response reduce gradually to lowest effective dose.

Methotrexate

7.5mg to be taken once weekly or 2.5mg at 12 hour intervals for 3 doses as a course once weekly.  Adjust dose according to response: use lowest effective dose.  Max 20mg weekly.

Methotrexate oral solution
7.5mg to be taken once weekly or 2.5mg at 12 hour intervals for 3 doses as a course once weekly.  Adjust dose according to response: use lowest effective dose.  Max 20mg weekly.

Metoject
7.5mg by subcutaneous injection once weekly, increasing gradually depending on individual tolerance and disease activity.  Max weekly dose 25mg.  After desired response gradually reduce to lowest effective dose.

Nordimet

7.5mg by subcutaneous injection, increasing gradually depending on individual tolerance and disease activity up to a maximum weekly dose of 25mg  After desired response reduce gradually to lowest effective dose.

Ziatal
7.5mg by subcutaneous or intramuscular injection once weekly, then adjust according to indvidiaul tolerance and disease activity.  Maximum weekly dose of 25mg.  After desired response gradually reduce to lowest effective dose.

What are the side effects?

The most common unwanted effects are nausea, stomach pains and soreness of the mouth and lips,

Methotrexate can make you more likely to catch infections. If you think you have an infection, a sore throat, fever, chills, or achiness during treatment you should tell your doctor immediately. Methotrexate can cause inflammation of the lung with breathlessness. If you develop a persistent cough, experience pain or difficulty breathing, or become breathless, you should seek medical attention.

Less common unwanted effects include vomiting, diarrhoea, loss of appetite, tiredness, drowsiness, feeling weak, dizziness, eye irritation, mood changes, loss of interest in, or inability to have sex, fever, chills, pain in joints or muscles, acne, boils, rash itchiness, vaginal ulcers.

In a small number of patients methotrexate may cause serious unwanted effects, and on rare occasions, death. You should contact your doctor immediately if you notice any of the following:

• Unusual bleeding (including vomiting blood) or bruising
• Blood in urine or stools
• A discoloration or yellowing of the skin
• A serious skin rash with reddening of the skin
• A painless lump in your neck, groin or armpits with associated backache fever or night sweats
• Pain or difficulty in passing urine
• The need to drink much more than usual
• A dry cough
• A numb or tingling feeling
• Fits (convulsions)
• Unusual body movements or a lack of balance
• Hair loss
• Loss of consciousness
• Black or tarry stools
• Tiny red spots on the skin
• Pain in the shoulders or back
• The need to pass urine more often than usual
• Constipation
• Pain or difficulty in breathing or shortness of breath
• Confusion
• An inability to move
• Difficulty with speech
• An allergic reaction which may cause a skin rash or swelling of your lips or tongue
• Thickening of the skin
• Photosensitivity (reaction to UV and sun light).

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Methotrexate is known commercially as Jylamvo which is marketed in the UK by Intrapharm, Maxtrex which is marketed in the UK by Pfizer Ltd, Methofill which is marketed in the UK by Accord,  Methotrexate oral solution which is marketed in the UK by Rosemont Pharmaceuticals Limited,  Metoject which is marketed in the UK by Medac, Nordimet which is marketed in the UK by Nordic and Ziatal which is marketed in the UK by Nordic.

Penicillamine is one of a group of drugs called disease-modifying antirheumatic drugs (DMARDS) used to treat serious, active rheumatoid arthritis.

How does it work?

Penicillamine is a chelating agent. This means that it binds to certain metals, including lead and copper, to help remove them from your body if necessary. Distamine also helps to relieve the pain and stiffness of rheumatoid arthritis if other medicines and rest have not worked.

Who can get it?

Available for adults and children over 8 years of age.

How is it used?

Rheumatoid arthritis: take 125mg to 250mg a day for the first month. (1) Your doctor will then tell you how to increase the dose gradually over several months until you are feeling better. He or she may then change your dose to keep you well. This new dose is usually 500mg to 750mg a day, but it can be as high as 1500mg. It may be several months before you feel better. If there is no improvement you should stop taking the tablets after a year. If you stay well for six months your doctor may reduce your dose. If you are elderly, you may be given a smaller dose. Do not take more than 1000mg a day.

What are the side effects?

When you start taking the tablets you may feel sick or even be sick. You may lose your appetite or notice that food tastes different. These side effects usually wear off, but tell your doctor if they trouble you.
You will have regular blood and urine tests, especially when you start taking the tablets and when you increase the dose. These are to check for changes in your blood cell counts and to look for protein or blood in your urine.

Other known side effects include the following:

Very common side effects (more than 1 in 10 patients) of Distamine include:

• protein in your urine (this is detected by a urine test).

Rare side effects (more than 1 in 10,000 patients) of Distamine include:

• sore mouth
• swollen breast tissue
• lung problems (e.g. wheezing, coughing or difficulty breathing)
• hair loss
• wrinkly skin.

Other side effects of Distamine include:

• loss of taste
• feeling or being sick (especially at the start of treatment)
• loss of appetite (especially at the start of treatment)
• severe stomach and back pain
• jaundice which is the yellowing of the skin or eyes as a result of liver or blood problems (this may include changes in lood tests which show how your liver is working)
• redness, a rash or itching
• fever or frequent infections
• blistering, swollen skin
• muscle weakness
• worsening of the pain and swelling in your joints

How do I get Penicillamine?

Penicillamine is available on prescription.

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Penicillamine is known commercially as Distamine and is marketed in the UK by Alliance Pharmaceuticals Ltd.

Sodium aurothiomalate belongs to a group of medicines known as disease modifying antirheumatic drug and is used for the treatment of Rheumatoid arthritis and juvenile chronic arthritis.

How does it work?

Sodium aurothiomalate in the treatment of rheumatoid arthritis limits inflammation which helps to reduce signs and symptoms of the disease such as pain and swelling. It has to be taken for a few months before you feel or notice an improvement in your symptoms.
Myocrisin is an injection that is usually given by a healthcare professional. The person responsible for giving you your medicine will make sure that you get the appropriate dose. A small dose of medicine may be given initially as a test dose the first time that you have Myocrisin. You will be under medical observation for about half an hour after Myocrisin has been given to you. If you feel that the medicine is making you feel unwell or you think it is not working, you should talk to someone who is involved in your care.

Who can get it?

Not recommended for the elderly or for those with a history of urticaria, eczema or colitis.
Blood, skin and urine should be checked before each injection.

How is it used?

This medicine will be given to you as an injection. If you have any concerns about this medicine or how this will be given to you, talk to someone who is involved in your medical care.

What are the side effects?

Albuminuria, rash, eosinophilia. These may lead to a temporary suspension of treatment for 1 or 2 weeks.

Pruritus, metallic taste, oropharyngeal disorders, bruising, unexpected bleeding, menorrhagia, or diarrhoea can be experienced and should be reported to someone who is involved in the patient’s medical care

How do I get Sodium aurothiomalate?

Sodium aurothiomalate is available on prescription.

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It is known commercially as Myocrisin and is marketed in the UK by Sanofi Aventis.

Sulfasalazine is disease modifying antirheumatic drug used in cases of Rheumatoid arthritis that are not responding to NSAIDs

How does it work?

Sulfasalazine is an immunosuppressive medicine. It helps to suppress over-activity of the immune system in rheumatoid arthritis. It can help to reduce pain and swelling by limiting inflammation.
Sulfasalazine needs to be taken for at least six weeks before any improvement is noticed.
Other information about Sulfasalazine:
people starting treatment with this form of medicine will normally be prescribed a low dose. The dose will then be gradually increased as necessary. This is to reduce the chances of getting side-effects

Who can get it?

Not recommended for children

How is it used?

Initially 1 daily for one week after meals, increasing by 1 each week to max. 6 daily in divided doses.

What are the side effects?

This medicine may cause side-effects in some people. The most common side effects are nausea, headache, rash, loss of appetite and raised temperature. These usually settle down during treatment as the body adjusts to the medicine.
Salazopyrin may cause temporary infertility in men. Fertility returns when treatment is stopped. Normal contraception should still be used.
Occasionally the drug causes a reduction in the number of cells in the blood. In about 1 in 700 patients there is a serious fall in the number of white cells, the majority of such patients suffering from rheumatoid arthritis. This is why blood tests are made during the first three months of treatment. If you do not have these tests there is the possibility of a very serious reaction being missed. A fall in your white cell count may be noticed as tiredness, sore throat or difficulty in getting over an infection. If you have these or feel generally unwell or if you find that you are bruising easily, tell your doctor straight away.
Very infrequently a serious skin condition may occur, with rash (sometimes confined to the cheeks and bridge of the nose) peeling skin or blistering. It may be triggered or aggravated by sunlight. Should this occur, stop taking the tablets, avoid strong sunlight and contact your doctor promptly. Hair loss or thinning may occur.
Other rare side-effects which have been noted are:
allergic reactions {rash, itching}, nervous reactions {vertigo (dizziness), tinnitus (ringing in the ears), tingling in hands and feet, loss of control over movements, fitting, depression, hallucinations, difficulty in sleeping}, breathlessness, mouth ulcers, stomach pain, swollen face or neck, kidney pain, blood in urine, anaemia, bloodshot eyes, cough, joint pain, heart muscle inflammation, sore or swollen glands, hepatitis or jaundice
If you notice any of these or anything else you are concerned about, please tell your doctor or pharmacist.

How do I get Sulfasalazine?

Sulfasalazine is available on prescription.

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It is known commercially as Salazopyrin EN-Tabs and is marketed in the UK by Pfizer Ltd