Sulfasalazine Good Alternative to Steroids in Idiopathic Urticaria

MIAMI BEACH—Sulfasalazine (Azulfidine) may be an effective treatment for chronic idiopathic urticaria that has not responded adequately to antihistamines. It may also reduce the need for systemic corticosteroids in patients with recalcitrant urticaria, according to a new study presented at the 2006 Annual Meeting of the American Academy of Allergy, Asthma & Immunology.

Chronic idiopathic urticaria often does not adequately respond to antihistamines, and recent research has focused on steroid-sparing therapies for patients with recalcitrant disease. Earlier case reports have indicated that sulfasalazine may benefit this patient population; the new data from a larger case series reinforce that suggestion.

This retrospective chart review included 19 patients with recalcitrant idiopathic urticaria who were treated with sulfasalazine between 2002 and 2005. A total of 14 patients (74%) reported significant improvements in their disease, 4 patients (21%) reported minimal improvement but were not satisfied overall, and 1 patient (5%) said that the disease had worsened with the medication.

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“If you are a primary care physician and have a patient with chronic idiopathic urticaria, and he or she is not responding to antihistamines, then this is an important medication to think about as a treatment,” coinvestigator Laura McGirt, MD, a postdoctoral fellow in the Department of Medicine and Clinical Immunology, Johns Hopkins School of Medicine, Baltimore, Md, told . “One of the findings from this study...was that 9 of the patients requiring systemic steroids to control their urticaria were all able to reduce or discontinue their steroids while taking sulfasalazine.”

Of note, 4 patients were able to stop taking all other medications for urticaria, and 1 patient tapered off of sulfasalazine and was still free of urticaria at the time these data were presented (ie, after >10 months).

Although 7 patients (37%) had side effects, such as gastrointestinal discomfort and nausea, they all continued taking sulfasalazine.

“This agent is a good alternative for patients taking systemic steroids or patients for whom you may be considering immunotherapy, such as cyclosporine, which can have deleterious side effects. Sulfasalazine is not without its own side effects, so that is why we wouldn’t try it before antihistamines, but it may be something that could be used in place of more toxic therapies,” said Dr McGirt.

The first-line therapy for this patient population are antihistamines, sedating and nonsedating. Patients who do not respond to these agents are usually treated with leukotriene antagonists, H₂ receptor antagonists, or immunomo dulatory agents, such as systemic corticosteroids and cyclosporine.