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Sulfasalazine for rheumatoid arthritis

 

Clinical bottom line

Sulfrasalazine was better than placebo on a number of outcomes important in rheumatoid arthritis, including swollen and painful joints, morning stiffness, and pain.


SYSTEMATIC REVIEW

ME Winblatt et al. Sulfasalazine treatment for rheumatoid arthritis: a metaanalysis of 15 randomized trials. Journal of Rheumatology 1999 26: 2123-2130.

The main inclusion criteria were that trials had to be randomised and double blind, to have a placebo control and sulfasalazine treatment. Three databases were searched, and only full publications in peer reviewed journals were included.

Findings

The review provides a descriptive reporting system. Sulfasalazine was significantly better than placebo on a number of outcomes (Table 1), though not all outcomes were reported in all studies. More patients on sulfasalazine discontinued because of adverse effects (rash, abnormal liver function tests) than on placebo, but lack of efficacy discontinuations were many fewer than with placebo. Morning stiffness, pain, the number of tender and swollen joints and patient global assessment were all significantly better with sulfasalazine.

Table 1: Outcomes in studies of sulfasalazine and placebo

Outcome

Sulfasalazine

Placebo

Number randomised

552

351

Adverse event withdrawals (%)

24

7

Lack of efficacy withdrawals (%)

11

28

ESR (% reduction)

37

14

Morning stiffness duration (% reduction)

61

33

Pain VAS (% reduction)

42

15

Articular index (% reduction)

46

20

Number of swollen joints (% reduction)

51

26

Number of painful joints (% reduction)

59

33

Patient global assessment (% reduction)

26

14

Comment

The majority of the studies used 2 grams of sulfasalazine a day, and results are also given for 3 grams a day in two studies. There are also comparisons with other treatments for rheumatoid arthritis (hydroxychloroquinine, penicillamine, and gold), but in few studies with limited numbers of patients.