Bone Marrow Suppression Risks from Salazopyrin Use

Q: Bone Marrow Suppression Risks from Salazopyrin Use

Hello, thank you for your question. <br>Here are my responses：<br>1) The package insert for Salazopyrin mentions rare side effects such as bone marrow suppression. <br>My RBC, Hb, and PLT levels seem to have started declining after taking Salazopyrin (all have dropped to the lowe

Could I be experiencing bone marrow suppression as a side effect after taking Salazopyrin?

Hello, Doctor Gao.
I would like to ask you some additional questions.
I am a patient with ankylosing spondylitis, and my main symptom is pain in my buttocks.
Since my blood test on March 2nd of last year, I have started taking 2 tablets of Salazopyrin daily and only take Voltaren when I experience pain (the pain has improved significantly).
Before March 2nd, I was only taking 1 or 2 tablets of Celebrex daily (without taking Salazopyrin).
The CBC results before and after I started taking Salazopyrin are as follows: 2021/12/21 (RBC 5.21, Hb 14.4, HCT 44.9, MCV 86.2, MCH 27.6, MCHC 32.1, PLT 316, WBC 8.5), 2022/03/02 (RBC 4.98, Hb 13.8, HCT 42.1, MCV 84.5, MCH 27.7, MCHC 32.8, PLT 259, WBC 6.7), 2022/05/25 (follow-up visit but no CBC, only CRP/ESR), 2022/08/24 (follow-up visit but no CBC or CRP/ESR), 2022/11/16 (RBC 4.74, Hb 13.6, HCT 40.9, MCV 86.3, MCH 28.7, MCHC 33.3, PLT 247, WBC 8.0), 2023/02/22 (RBC 4.45, Hb 12.6, HCT 39.2, MCV 88.1, MCH 28.3, MCHC 32.1, PLT 207, WBC 6.0).
I would like to ask the doctor:
1) The Salazopyrin leaflet mentions rare side effects of bone marrow suppression.
My RBC, Hb, and PLT seem to have started declining after taking Salazopyrin (all have dropped to the lower limit of the normal range).
If this is what is referred to as bone marrow suppression, is it considered severe? Is there a need to change medications because of this?
2) Since WBC seems to be related to immunity, I would like to specifically ask the doctor: Before taking Salazopyrin, my WBC was 8.5, and after starting Salazopyrin, it first increased to 8.0 and then decreased to 6.0.
Can it be said that Salazopyrin has suppressed the bone marrow's production of white blood cells?
3) I have been taking Salazopyrin for a year now.
The leaflet states that bone marrow suppression (if present) will resolve after discontinuing Salazopyrin.
I would like to ask the doctor if taking Salazopyrin for too long (for example, 3 years) could lead to permanent bone marrow suppression that does not resolve after stopping the medication.
4) Do I need to take some iron supplements to counteract this side effect? I feel that I have been yawning more often during the day in the last 2-3 months, even though I have been getting a full 8 hours of sleep.
5) Could the doctor provide me with some medical advice for the next steps? (In terms of pain management, Salazopyrin has been much better than Celebrex, and it seems to have improved CRP/ESR levels a bit, but my CBC was normal while taking Celebrex.) I apologize for the many questions, and thank you, doctor.

Hao, 20~29 year old female. Ask Date: 2023/03/03

Dr. Gao Jiankai reply Internal Medicine

Hello, thank you for your question.
Here are my responses:
1) The package insert for Salazopyrin mentions rare side effects such as bone marrow suppression.
My RBC, Hb, and PLT levels seem to have started declining after taking Salazopyrin (all have dropped to the lower limit of the normal range).
If this is what is referred to as bone marrow suppression, is it considered severe? Is there a need to switch medications? --> There are many reasons for the decline in RBC and Hb levels, and it is not necessarily caused by Salazopyrin.
PLT levels are normal.
If you are concerned, it is best to discuss this with your physician, who can evaluate your situation comprehensively.
Do not adjust your medication on your own.
If your condition stabilizes, there may be an opportunity to reduce the dosage of Salazopyrin.
2) Since WBC seems to be related to immune function, I would like to ask the doctor specifically: my WBC was 8.5 before taking Salazopyrin, then dropped to 6.7, and after starting Salazopyrin, it first rose to 8.0 and then fell to 6.0.
Can it be said that Salazopyrin has suppressed the bone marrow's production of white blood cells? --> The difference is minimal, and I believe it is not a concern.
3) I have been taking Salazopyrin for a year.
The insert states that bone marrow suppression (if present) will resolve after discontinuation of Salazopyrin.
I would like to ask the doctor if taking Salazopyrin for too long (for example, 3 years) could lead to permanent bone marrow suppression that does not resolve after stopping the medication.
--> No, that will not happen.
4) Do I need to take any iron supplements to counteract this side effect? I feel that I have been yawning more often during the day over the past 2-3 months, even though I have been getting a full 8 hours of sleep.
--> No, it is not necessary.
The main focus should be on investigating the cause of anemia to see if it is truly related to the medication.
5) Can the doctor provide me with some medical advice moving forward? (Taking Salazopyrin has been much better for pain control compared to when I was on Methotrexate, and it seems to have improved CRP/ESR levels as well, but my CBC was normal while on Methotrexate.) --> Your physician will have a better understanding of your condition than an online physician, who only sees partial blood test results and may not provide the most accurate advice.
If you have concerns about medication side effects, it is essential to discuss them with your physician.
If you do not receive a clear response, consider seeking a second opinion from another doctor.
The Allergy, Immunology, and Rheumatology Department at Changhua Hospital is here to support you.

Reply Date: 2023/03/03

More Info

Hello! Thank you for your detailed questions regarding the use of Salazopyrin (sulfasalazine) and its potential effects on bone marrow suppression, particularly in the context of your ankylosing spondylitis treatment. Let’s address your concerns one by one.

1. Bone Marrow Suppression and Blood Counts: Salazopyrin can indeed cause bone marrow suppression, although this side effect is relatively uncommon. The decrease in your red blood cells (RBC), hemoglobin (Hb), and platelet (PLT) counts after starting Salazopyrin could indicate some degree of bone marrow suppression. However, the severity of this condition can vary. Your current values are still within the lower limits of normal, but it’s essential to monitor these trends closely. If your counts continue to decline or if you experience symptoms such as fatigue, unusual bruising, or bleeding, it may be necessary to discuss alternative medications with your healthcare provider.

2. White Blood Cell Count (WBC): Your WBC count has shown some fluctuation, which can be concerning, especially since WBCs are crucial for your immune response. While Salazopyrin can potentially suppress WBC production, the decrease you observed from 8.0 to 6.0 is not necessarily indicative of significant suppression. It’s essential to consider other factors that could affect WBC counts, including infections or other medications. Continuous monitoring is crucial, and if your WBC count drops significantly or if you experience recurrent infections, further evaluation may be warranted.

3. Duration of Salazopyrin Use and Bone Marrow Recovery: Generally, if bone marrow suppression occurs due to Salazopyrin, it is expected to resolve after discontinuation of the medication. However, the duration of use does not typically lead to permanent bone marrow suppression. If you were to take Salazopyrin for an extended period (e.g., three years), it is unlikely that this would result in irreversible bone marrow damage. Nevertheless, individual responses can vary, and ongoing monitoring is essential.

4. Iron Supplements and Fatigue: Given your recent fatigue and the decrease in your blood counts, it may be beneficial to discuss with your doctor the possibility of taking iron supplements or other hematinic agents. However, it’s essential to confirm whether your fatigue is due to anemia or other factors. A healthcare provider can help determine the need for supplementation based on your specific blood work and overall health status.

5. Medical Recommendations: Since you have experienced better pain control and improvements in inflammatory markers (CRP/ESR) with Salazopyrin compared to your previous medication, it’s crucial to weigh the benefits against the potential side effects. Regular follow-up appointments are essential to monitor your blood counts and adjust your treatment plan as necessary. If your blood counts continue to decline or if you develop any concerning symptoms, your doctor may consider switching medications or adding supportive treatments.

In conclusion, while Salazopyrin can lead to bone marrow suppression, the effects are generally reversible upon discontinuation. Regular monitoring of your blood counts is vital, and any significant changes should be discussed with your healthcare provider. It’s also essential to maintain open communication with your doctor regarding any new symptoms or concerns you may have during your treatment. Thank you for your questions, and I wish you the best in managing your condition!

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