Assessing Bone Marrow Suppression Risks from Salazopyrin Use

Have I already experienced bone marrow suppression as a side effect from taking Salazopyrin?

Hello Dr.
Tseng, I would like to ask you another question.
I am a patient with ankylosing spondylitis, and my main symptom is pain in the buttocks.
Since my blood test on March 2 of last year, I have been taking 2 capsules of Salazopyrin daily and only taking Voltaren when I experience pain (the buttock pain has improved significantly).
Before March 2, I was only taking Celebrex, 1 or 2 capsules daily (without taking Salazopyrin).
The CBC results before and after starting 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 but no CBC, only CRP/ESR), 2022/08/24 (follow-up 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 normal).
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: my WBC was 8.5 before taking Salazopyrin, then it dropped to 6.7 after starting Salazopyrin, then it rose to 8.0, and finally dropped 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 if Salazopyrin is discontinued, any bone marrow suppression (if present) will resolve.
I would like to ask the doctor: if I take Salazopyrin for too long (for example, 3 years), will the bone marrow suppression not resolve after stopping the medication and become permanent?
4) Do I need to take some iron supplements to counteract this side effect? I feel that in the last 2-3 months, I have been yawning more often during the day, even though I have been getting a full 8 hours of sleep.
I apologize for having so many questions, thank you, doctor.

Zheng, 20~29 year old female. Ask Date: 2023/03/06

Dr. Zeng Guosen reply Internal Medicine

The user's PLT and WBC are within normal ranges, but Hb is slightly low.
Drug-induced bone marrow suppression typically affects WBC and PLT, so it is okay to continue the medication.
Follow up with the attending physician for further discussion.
There is no need to take iron supplements; instead, monitor the reason for the low Hb and address it accordingly.

Reply Date: 2023/03/06

More Info

Salazopyrin, or sulfasalazine, is a medication commonly used to treat inflammatory conditions such as ankylosing spondylitis. While it is effective in managing symptoms, it is important to be aware of its potential side effects, including the risk of bone marrow suppression.
1. Bone Marrow Suppression and Blood Counts: Bone marrow suppression refers to a decrease in the production of blood cells due to the impairment of bone marrow function. This can lead to lower levels of red blood cells (RBC), hemoglobin (Hb), and platelets (PLT), which you have observed in your blood tests. The decline in these values after starting Salazopyrin could indeed suggest bone marrow suppression, although it is essential to consider other factors that might contribute to these changes. The severity of bone marrow suppression can vary; if your blood counts are still within the lower limits of normal, it may not be considered severe. However, it is crucial to discuss these findings with your healthcare provider, who may recommend monitoring your blood counts more closely or considering alternative treatments if the trend continues downward.

2. White Blood Cell Count (WBC): Your WBC count is an important indicator of immune function. The fluctuation you noted—from 8.5 before starting Salazopyrin to 6.0 after—could suggest that the medication is affecting your bone marrow's ability to produce white blood cells. While Salazopyrin can lead to leukopenia (low white blood cell count), it is essential to evaluate this in the context of your overall health and any symptoms you may be experiencing. If your WBC continues to decline or if you develop signs of infection, your doctor may need to reassess your treatment plan.

3. Duration of Treatment and Bone Marrow Recovery: The concern about long-term use of Salazopyrin leading to permanent bone marrow suppression is valid. Generally, if bone marrow suppression occurs, it is expected to resolve upon discontinuation of the medication. However, the duration of treatment and individual patient factors can influence recovery. If you have been on Salazopyrin for an extended period (e.g., three years), it is crucial to have regular blood tests to monitor your blood counts. If significant suppression is noted, your healthcare provider may consider switching medications or implementing a treatment holiday to allow your bone marrow to recover.

4. Nutritional Support and Supplements: If you are experiencing symptoms such as fatigue or increased daytime sleepiness, it may be beneficial to discuss dietary changes or supplements with your healthcare provider. While iron supplements or other blood-building nutrients may help, it is essential to ensure that any supplementation is appropriate for your specific situation. Additionally, maintaining a balanced diet rich in vitamins and minerals that support blood health (such as folate, vitamin B12, and iron) can be beneficial.

In summary, while Salazopyrin is an effective treatment for ankylosing spondylitis, monitoring for side effects such as bone marrow suppression is crucial. Regular communication with your healthcare provider about your blood counts and any symptoms you experience will help ensure that your treatment remains safe and effective. If you have concerns about your current treatment plan, do not hesitate to bring them up during your next appointment. Your health and well-being are the top priority, and your doctor can provide guidance tailored to your specific needs.

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