Background Recent studies have demonstrated that nonsteroidal anti-inflammatory drugs (NSAIDs) often cause damage to the small intestine, and NSAID-induced enteropathy is mediated by different inflammatory cytokines. Sulfasalazine is being widely used in patients with rheumatoid arthritis (RA), and this drug have the potential to induce mucosal healing in patients with intestinal diseases such as inflammatory bowel diseases.
Objectives To evaluate the preventive effect of sulfasalazine against small intestinal damage due to chronic NSAID use in RA patients.
Methods Between March 2012 and December 2013, capsule endoscopy was performed in 51 consecutive RA patients who received NSAIDs for more than 3 months with or without sulfasalazine therapy over a period of 3 months. The findings were scored as follows according to the method described by Graham et al. (Clin Gastroenterol Hepatol. 2005): 0, normal; 1, red spots; 2, 1 to 4 erosions; 3, >4 erosions; and 4, large erosions/ulcers. Scores of 3 and 4 indicated severe damage. The relationship between the use of sulfasalazine therapy and risk of severe damage (score 3 or 4) or severest damage (score 4) were assessed using multiple logistic regression.
Results Comparative data were analyzed for 47 patients, and 4 patients were excluded because the entire small bowel could not be visualized in these patients. Of the 25 patients who did not receive sulfasalazine therapy, 12 (48%) had severe damage (score of 3 [n=8] or 4 [n=4]). On the other hand, of the 26 patients receiving sulfasalazine therapy, 5 (19.2%) had severe damage (score of 3 [n=3] or 4 [n=2]). On stratifying the patients by sulfasalazine therapy, we obtained a crude odds ratio (OR) of 0.26 for severe damage with a 95% confidence interval (CI) of 0.10 to 0.66, and of 0.38 for severest damage with a 95% CI of 0.17 to 0.88. This effect of sulfasalazine therapy on NSAID-induced enteropathy remained robust to adjustment for age, gender, history of peptic ulcers, disease activity score-28 (a disease activity index for RA), use of selective cyclooxygenase-2 inhibitors or steroids, blood hemoglobin concentration, and all these variables, with the adjusted ORs for severe damage ranging from 0.19 to 0.25 and those for severest damage ranging from 0.30 to 0.40.
Conclusions Sulfasalazine therapy may protect against NSAID-induced small intestinal damage in RA patients and may be effective in the treatment of NSAID-induced enteropathy.
Park SCl, Chun HJ, Kang CD, Sul D. Prevention and management of non-steroidal antiinflammatory drugs-induced small intestinal injury. World J Gastroenterol 2011 November 14; 17 (42): 4647-4653.
Disclosure of Interest None declared