Sulfasalazine promotes ferroptosis through AKT-ERK1/2 and P53-SLC7A11 in rheumatoid arthritis

OBJECTIVE

Ferroptosis has been reported to play a role in rheumatoid arthritis (RA). Sulfasalazine, a common clinical treatment for ankylosing spondylitis, also exerts pathological influence on the progression of rheumatoid arthritis including the induced ferroptosis of fibroblast-like synoviocytes (FLSs), which result in the perturbated downstream signaling and the development of RA. The aim of this study was to investigate the underlying mechanism so as to provide novel insight for the treatment of RA.

METHODS

CCK-8 and Western blotting were used to assess the effect of sulfasalazine on FLSs. A collagen-induced arthritis mouse model was constructed by the injection of collagen and Freund's adjuvant, and then, mice were treated with sulfasalazine from day 21 after modeling. The synovium was extracted and ferroptosis was assessed by Western blotting and immunofluorescence staining.

RESULTS

The results revealed that sulfasalazine promotes ferroptosis. Compared with the control group, the expression levels of ferroptosis-related proteins such as glutathione peroxidase 4, ferritin heavy chain 1, and solute carrier family 7, member 11 (SLC7A11) were lower in the experimental group. Furthermore, deferoxamine inhibited ferroptosis induced by sulfasalazine. Sulfasalazine-promoted ferroptosis was related to a decrease in ERK1/2 and the increase of P53.

CONCLUSIONS

Sulfasalazine promoted ferroptosis of FLSs in rheumatoid arthritis, and the PI3K-AKT-ERK1/2 pathway and P53-SLC7A11 pathway play an important role in this process.

Sulfasalazine ameliorates lipopolysaccharide-induced acute lung injury by inhibiting oxidative stress and nuclear factor-kappaB pathways

Acute lung injury/acute respiratory distress syndrome (ALI/ARDS) has a high mortality rate and incidence of complications. The pathophysiology of ALI/ARDS is still not fully understood. The lipopolysaccharide (LPS)-induced mouse model of ALI has been widely used to study human ALI/ARDS. Sulfasalazine (SASP) has antibacterial and anti-inflammatory effects and is used for treating inflammatory bowel and rheumatic diseases. However, the effect of SASP on LPS-induced ALI in mice has not yet been reported. Therefore, we aimed to investigate the effect of SASP on LPS-induced ALI in mice. Mice were intraperitoneally injected with SASP 2 h before or 4 h after LPS modeling. Pulmonary pathological damage was measured based on inflammatory factor expression (malondialdehyde and superoxide dismutase levels) in the lung tissue homogenate and alveolar lavage fluid. The production of inflammatory cytokines and occurrence of oxidative stress in the lungs induced by LPS were significantly mitigated after the prophylactic and long-term therapeutic administration of SASP, which ameliorated ALI caused by LPS. SASP reduced both the production of inflammatory cytokines and occurrence of oxidative stress in RAW264.7 cells, which respond to LPS. Moreover, its mechanism contributed to the suppression of NF-κB and nuclear translocation. In summary, SASP treatment ameliorates LPS-induced ALI by mediating anti-inflammatory and antioxidant effects, which may be attributed to the inhibition of NF-κB activation and promotion of antioxidant defenses. Thus, SASP may be a promising pharmacologic agent for ALI therapy.

Gilaburu (Viburnum opulus L.) fruit extract has potential therapeutic and prophylactic role in a rat model of acetic acid-induced oxidant colonic damage

ETHNOPHARMACOLOGICAL RELEVANCE

Ulcerative colitis (UC) which has a global impact on the health care system with its recurrent and incompletely curable characteristics, affects the patients' quality of life. Gilaburu (GB; Viburnum opulus L.) is a fruit with rich polyphenol ingredient which is used ethnobotanically in Türkiye for medicinal purposes (for example, to pass kidney stones, to treat stomach, heart, and liver diseases, hemorrhages, hypertension, ulcers, common cold, tuberculosis, rheumatic and menstrual pain, and diabetes). On the other hand, the effects of GB in the experimental UC model have not been studied.

AIM OF THE STUDY

This study aimed to explore the potential antioxidant and anti-inflammatory effects of GB fruit extract in improving acetic acid (AA)-induced UC.

MATERIALS AND METHODS

Starting immediately after (AA + GB group) or 1 week before (GB + AA + GB group) the colitis induced by intrarectal AA (5%; v/v) administration, the rats orally received GB (100 mg/kg) once per day for 3 days. The control and AA groups were administered orally saline (1 ml), while the AA + SS group were administered sulfasalazine (SS; 100 mg/kg; orally) as a positive control once per day for 3 days. Distal colonic tissue specimens were obtained for the histological and biochemical [myeloperoxidase (MPO), malondialdehyde (MDA), glutathione (GSH), chemiluminescence (CL), caspase-3, 8-hydroxy-2'-deoxyguanosine (8-OHdG), matrix metalloproteinase (MMP)-9, transforming growth factor (TGF)-β1, smad-3 and cytokine (tumor necrosis factor (TNF)-α, interleukin (IL)-1β, IL-6, IL-8, interferon (IFN)-γ), measurements] evaluations on the 3rd day.

RESULTS

Elevated macroscopic and microscopic damage scores, high tissue wet weight values, increased tissue-associated MPO, MDA, CL, caspase-3, 8-OHdG, cytokines (TNF-α, IL-1β, IL-6, IL-8), MMP-9, TGF-β1, smad-3 levels, and decreased GSH values of the AA group were all reversed by GB treatments (AA + GB and GB + AA + GB groups) (p < 0.05-0.001). However, sulfasalazine treatment (AA + SS group) did not change the IL-8, 8-OHdG, MMP-9, and TGF-β1 measurements significantly.

CONCLUSIONS

Gilaburu shows both anti-inflammatory and antioxidant effects against AA-induced colonic damage by suppressing neutrophil infiltration, regulating inflammatory mediators, inhibiting reactive species production, lipid peroxidation, and apoptosis, conserving endogenous antioxidant glutathione, and ameliorating oxidative DNA damage. Since the current ulcerative colitis drugs display limited benefits and adverse side effects, potential therapeutic and/or prophylactic role of gilaburu can be evaluated in ulcerative colitis.

Formulation and Development of Novel Sulfasalazine Bilayer Tablets for The Treatment of Arthritis Associated With IBD: In-vitro and In-vivo Investigations

Sulfasalazine needs frequent daily dosing and the administration of numerous tablets per day pose challenges to patient compliance, contributing to increased adverse effects and difficulties in disease control. These inconveniences result in less effective treatment for arthritis associated with inflammatory bowel disease i.e. ulcerative colitis etc. To improve drug bioavailability, a delayed-release mechanism that releases the drug at the colon is necessary. To develop and optimize colon-targeted controlled release bilayer tablets coated with pH-dependent polymers. The bilayer tablets containing the immediate release part and sustained release part were developed. The tablets were coated with enteric-coated with Eudragit® S-100 and l-100 to achieve release in the colon. Granule properties and tablets were evaluated. The physicochemical parameters of the tablets were evaluated including, stability study, and drug release in 0.1 N HCl (pH 1.2), pH 6.8 phosphate buffer, pH 7.4 phosphate buffer for 2, 1, and up to 24 h respectively. Radiographic imaging and in vivo pharmacokinetic studies were also done in Rabbits. The bilayer tablets containing immediate and sustained release were successfully developed for the colon targeting. The granule properties were found within the acceptable range indicating good flow properties. The physicochemical properties of the tablets were also found acceptable. The tablets did not show release in 0.1 N HCl and 6.8 phosphate buffer but drug release was found under control in the 7.4 pH buffer. Sulfasalazine coated bilayer tablets were found stable and no significant changes were observed in the stability studies. Based on the X-ray studies, the formulated tablet remained discernible in the stomach, small intestine, and colon for a duration of up to 24 h. Finally, by the 32nd hour, the tablet was no longer visible in the X-ray examination, leading to the conclusion of complete drug release. The drug concentration in plasma remained within the therapeutic range for up to 24 h in vivo. These novel formulations present substantial advantages, providing prolonged targeted drug release and reducing systemic adverse effects. The results suggest promising potential for treating arthritis in Inflammatory bowel disease (IBD) patients, offering a solution to current delivery systems.

Evaluation of Sulfasalazine as an Adjunctive Therapy in Treating Pulmonary Pre-XDR-TB: Efficacy, Safety, and Treatment Implication

Background

The rising prevalence and limited efficacy of treatments for pre-extensively drug-resistant tuberculosis (pre-XDR-TB) underscore an immediate need for innovative therapeutic options. A combination of host-directed therapy (HDT) and anti-TB treatment presents a viable alternative for pre-XDR-TB management. Sulfasalazine (SASP), by targeting the amino acid transport system xc (xCT), potentially reduces the intracellular Mycobacterium tuberculosis load and mitigates lung pathology, positioning it as a promising TB HDT agent. This study aims to assess the efficacy of SASP as a supplementary therapy for pre-XDR-TB.

Methods

A pilot study examined the safety and effectiveness of two 9-month short-course, all-oral regimens for pre-XDR-TB treatment: Bdq-regimen (consisting of Bdq, linezolid, cycloserine, clofazimine, and pyrazinamide) and SASP-regimen (comprising SASP, linezolid, cycloserine, clofazimine, and pyrazinamide). The primary endpoint was the incidence of unfavorable outcomes 12 months post-treatment.

Results

Of the 44 participants enrolled, 43 were assessable 12 months post-treatment. Culture conversion rates stood at 73.2% by Month 2 and escalated to 95.1% by Month 6. Overall, 88.4% (38/43) of the participants exhibited favorable outcomes, 85.2% (19/23) for the Bdq-regimen and 93.8% (14/15) for the SASP-regimen. The SASP-regimen group recorded no deaths or treatment failures.

Conclusion

Both 9-month short-course, all-oral regimens manifested commendable primary efficacy in treating pre-XDR-TB patients. The SASP-regimen emerged as effective, safe, well-tolerated, and cost-effective.

Regulatory network of ferroptosis and autophagy by targeting oxidative stress defense using sulfasalazine in triple-negative breast cancer

AIMS

The cellular defense system against oxidative stress is important for the survival ability and sensitization in chemotherapy; however, the regulatory mechanisms remain unknown in triple-negative breast cancer (TNBC) cells. This study aimed to investigate the relationship between ferroptosis and autophagy by targeting the defense of oxidative stress through the cystine transporter (xCT) using sulfasalazine (SASP), which is a widely employed xCT inhibitor.

MAIN METHODS

We analyzed the cell death process of SASP in human TNBC cells, and examined the effects of SASP on tumor progression by using xenograft mouse model.

KEY FINDINGS

TNBC cells demonstrated a high defense capacity against reactive oxidative species through xCT. SASP significantly attenuated oxidative stress resistance in MDA-MB-231, which is a generally used model cell as TNBC, through decreased glutathione levels, causing a marked iron-dependent ferroptotic cell death induction. Moreover, autophagy was required to trigger efficient SASP-induced ferroptosis at the early stage of cell death. Tamoxifen, which is currently in clinical use as the gold standard for endocrine therapy of estrogen receptor-positive breast cancer, was a beneficial tool as an autophagy regulator under ferroptotic cell death by SASP. Additionally, SASP suppressed tumor growth and metastasis progression through total glutathione reduction in the primary tumor, indicating high anticancer activity against TNBC without liver injury in vivo.

SIGNIFICANCE

We revealed that SASP can efficiently induce ferroptosis associated with autophagy and that an understanding of the mechanism of cell death regulation by SASP is a promising new strategy for TNBC therapy and drug repositioning.

A phase Ib/II randomized, open-label drug repurposing trial of glutamate signaling inhibitors in combination with chemoradiotherapy in patients with newly diagnosed glioblastoma: the GLUGLIO trial protocol

BACKGROUND

Glioblastoma is the most common and most aggressive malignant primary brain tumor in adults. Glioblastoma cells synthesize and secrete large quantities of the excitatory neurotransmitter glutamate, driving epilepsy, neuronal death, tumor growth and invasion. Moreover, neuronal networks interconnect with glioblastoma cell networks through glutamatergic neuroglial synapses, activation of which induces oncogenic calcium oscillations that are propagated via gap junctions between tumor cells. The primary objective of this study is to explore the efficacy of brain-penetrating anti-glutamatergic drugs to standard chemoradiotherapy in patients with glioblastoma.

METHODS/DESIGN

GLUGLIO is a 1:1 randomized phase Ib/II, parallel-group, open-label, multicenter trial of gabapentin, sulfasalazine, memantine and chemoradiotherapy (Arm A) versus chemoradiotherapy alone (Arm B) in patients with newly diagnosed glioblastoma. Planned accrual is 120 patients. The primary endpoint is progression-free survival at 6 months. Secondary endpoints include overall and seizure-free survival, quality of life of patients and caregivers, symptom burden and cognitive functioning. Glutamate levels will be assessed longitudinally by magnetic resonance spectroscopy. Other outcomes of interest include imaging response rate, neuronal hyperexcitability determined by longitudinal electroencephalography, Karnofsky performance status as a global measure of overall performance, anticonvulsant drug use and steroid use. Tumor tissue and blood will be collected for translational research. Subgroup survival analyses by baseline parameters include segregation by age, extent of resection, Karnofsky performance status, O6-methylguanine DNA methyltransferase (MGMT) promotor methylation status, steroid intake, presence or absence of seizures, tumor volume and glutamate levels determined by MR spectroscopy. The trial is currently recruiting in seven centers in Switzerland.

TRIAL REGISTRATION

NCT05664464. Registered 23 December 2022.

Theoretical and experimental studies on sulfasalazine interactions with poly (lactic acid): Impact of hydrogen bonding and charge transfer interactions on molecular structure, electronic and optical properties

The interaction between sulfasalazine (SSZ) through different functional groups and poly (lactic acid) (PLA) in the chloroform phase was investigated in this study using density functional theory (DFT) and time-dependent density functional theory (TDDFT) methods. The binding energy and thermodynamic parameters show that the hydrogen double bond interaction between SSZ and PLA in state I (-0.71 eV) is stronger than in states II (-0.64 eV) and III (-0.51 eV). The SSZ and PLA interaction results in an enhanced dipole moment, greater solubility, and more negative values for Gibbs free energy (ΔGsolv) and energy gap (Eg). Considerable changes in absorption peaks of SSZ and PLA indicate surface adsorption of the drug (SSZ) into the carrier (PLA) in UV-Vis spectra. Theoretical UV-Vis analysis demonstrates SSZ interaction with PLA happens in the ultraviolet region with a maximum absorption peak at 380 nm, which is close to experimental UV-Vis analysis. The experimental spectra showed minimal variations in the maximum absorption wavelength, with respect to theoretical calculations. The presence of SSZ was found to cause a modification in the structure of PLA, as evidenced by both experimental and theoretical Infrared (IR) spectra.

Advances in non-biological drugs for the treatment of rheumatoid arthritis

INTRODUCTION

Rheumatoid arthritis (RA) is a complex autoimmune disease that affects millions of people worldwide, with a systemic impact. This review explores the role of non-biological conventional synthetic disease-modifying antirheumatic drugs (csDMARDs) in its management.

AREAS COVERED

We discuss the effectiveness and safety of key csDMARDs such as Nonsteroidal anti-inflammatory drugs, corticosteroids, Hydroxychloroquine, Sulfasalazine, Methotrexate, and Leflunomide in relieving symptoms and slowing the progression of the disease. We also highlight the importance of combination therapy using csDMARDs, supported by clinical studies demonstrating the benefits of various csDMARD combinations. Early intervention with these drugs is emphasized to prevent joint damage, improve clinical symptoms, and enhance patient outcomes.

EXPERT OPINION

Overall, csDMARDs have proven pivotal in managing RA, providing cost-effective and versatile treatment options. We acknowledge the advantages of biologics but highlight the associated challenges, making the choice between non-biological and biological drugs a personalized decision. This comprehensive overview aims to provide a deeper understanding of RA treatment strategies, contributing to improving the quality of life for patients with this chronic condition.

An LC-MS/MS method for the simultaneous quantitation of sulfasalazine and sulfapyridine in human placenta

Sulfasalazine has been identified as a candidate molecule to be investigated as an intervention to treat preterm pre-eclampsia during pregnancy. However, placental exposure of sulfasalazine and its systemically absorbed metabolite, sulfapyridine, is unknown. A robust liquid chromatography-tandem mass spectrometry (LC-MS/MS) method was developed and validated to simultaneously quantitate these analytes in human placenta with an application to a pilot clinical trial. The placental tissue was homogenised using a water:methanol (1:1, v/v) mixture, followed by sample extraction using both protein precipitation and solid phase extraction. Sulfasalazine-d4 and sulfapyridine-d4 were used as internal standards. An Agilent Poroshell EC-C18 (3.0 ×100 mm, 2.7 µm) column was used for chromatographic separation, with gradient elution employed at a flow rate of 0.450 mL/min over a total run time of seven minutes. The mobile phases consisted of water with 0.1% formic acid (mobile phase A) and acetonitrile:methanol (90:10, v/v) with 0.1% formic acid (mobile phase B). A Shimadzu-8040 mass spectrometer was operated in multiple reaction monitoring (MRM) mode using positive electrospray ionisation (ESI). For both analytes, the assay was validated over the range 30-30,000 ng/mL, or 150-150,000 ng/g. During inter-day validations (n = 18), the average accuracies of quality controls ranged from 101.6% to 112.7% with corresponding precisions of 4.4-6.7% for sulfasalazine, and from 97.4% to 108.4%, with corresponding precisions of 3.7-10.0% for sulfapyridine. No significant matrix effects were observed, and the method proved to be sensitive and specific for both analytes. This study presents the first validated analytical method for quantifying sulfasalazine and sulfapyridine in human placenta as part of a pilot clinical trial to generate preliminary data on its pharmacokinetics and efficacy as in intervention for preterm pre-eclampsia.

Genistein and/or sulfasalazine ameliorate acetic acid-induced ulcerative colitis in rats via modulating INF-γ/JAK1/STAT1/IRF-1, TLR-4/NF-κB/IL-6, and JAK2/STAT3/COX-2 crosstalk

Ulcerative Colitis (UC) is a chronic idiopathic inflammatory bowel disease in which the colon's lining becomes inflamed. Exploring herbal remedies that can recover mucosal damage is becoming popular in UC. The study aims to investigate the probable colo-protective effect of a natural isoflavone, genistein (GEN), and/or a drug, sulfasalazine (SZ), against acetic acid (AA)-induced UC in rats, in addition to exploring the possible underlying mechanisms. UC was induced by the intrarectal installation of 1-2 ml of 5% diluted AA for 24 hours. Ulcerated rats were allocated into the disease group and three treated groups, with SZ (100 mg/kg), GEN (100 mg/kg), and their combination for 14 days, besides the control groups. The anti-colitic efficacy of GEN and/or SZ was evidenced by hindering the AA-induced weight loss, colon edema, and macroscopic scores, besides reduced disease activity index and weight/length ratio. Furthermore, treatments attenuated the colon histopathological injury scores, increased the number of goblet cells, and lessened fibrosis. Both treatments reduced the up-regulation of INF-γ/JAK1/STAT1 and INF-γ /TLR-4/ NF-κB signaling pathways and modulated the IRF-1/iNOS/NO and IL-6/JAK2/STAT3/COX-2 pathways and consequently, reduced the levels of TNF-α and IL-1β. Moreover, both treatments diminished oxidative stress, which appeared by reducing the MPO level and elevating the SOD activity, and hindered apoptosis; by decreasing the immunohistochemical expression of caspase-3. The current findings offer novel insights into the protective effects of GEN and suggest a superior benefit of combining GEN with SZ, over either drug alone, in the UC management.

[Stevens-Johnson syndrome in a patient with positive lymphocyte transformation test]

BACKGROUND

Stevens-Johnson syndrome is a severe drug reaction. Sulfonamides have been associated with drug reactions, complications, sequelae, even death.

CASE REPORT

A 40-year-old female patient with a medical history of endometriosis and recently diagnosed chronic inflammatory ulcerative colitis. She was treated at the Allergology service of the San Juan de Dios Hospital of the Costa Rican Social Security Fund, and after 20 days of treatment with sulfasalazine she had a severe drug reaction on the skin, compatible with Stevens-Johnson syndrome. The lymphocyte transformation test was positive, confirming sulfasalazine as the causative agent.

CONCLUSION

The lymphocyte transformation test is a useful method that can confirm the causative agent and prevent important complications in the future.

Central composite design-based optimization, fabrication, and pharmacodynamic assessment of sulfasalazine-loaded lipoidal nanoparticle-based hydrogel for the management of rheumatoid arthritis

Rheumatoid arthritis is a progressive, chronic, immunological, and inflammatory disorder that is distinguished by joint inflammation, joint tenderness, and synovial joint destruction. The study aimed to fabricate sulfasalazine-loaded solid lipid nanoparticle (SLN)-based gels for rheumatoid arthritis management. The SLNs were fabricated with the melt emulsification technique by employing central composite design (CCD) for SLNs optimization. The optimized formulation of SLNs (FF-1) showed particle size and drug entrapment efficiency of 117.25 nm ± 1.67 and 94.05% ± 1.05, respectively. To scrutinize the outcome of the independent variable on responses; model graphs and the polynomial equation obtained from the Design-Expert were used. The surface morphology studies of SLNs revealed a smooth surface with a slightly asymmetric shape. In vitro drug release of the optimized formulation (FF1) had shown a maximum release of up to ~ 91.89% ± 2.12 over 24 h. The optimized FF1 formulation was subsequently gelled using 1% w/v Carbopol 934 and subjected to ex vivo permeation that displayed 8.01 mg/cm² ± 0.24 and 7.49 mg/cm² ± 0.86 amount of drug permeated up to 24 h and 10 h from SLNs gel and plain gel, respectively. In vivo studies manifested a considerable reduction in the paw thickness (*p < 0.0001) and an arthritic score (*p < 0.0001) of the sulfasalazine SLN gel as compared to plain gel. Further, pro-inflammatory cytokines, viz. TNF-α, IL-1, and IL-6 levels, were significantly inhibited (p < 0.0001) by sulfasalazine SLN-based gel that exhibited substantial anti-inflammatory effects. In conclusion, sulfasalazine-loaded SLN-based gel showed sustained release of drug for up to 24 h and can be considered suitable as a topical application for rheumatoid arthritis management.

Sulfasalazine for the treatment of preeclampsia in a nitric oxide synthase antagonist mouse model

INTRODUCTION

Development of a therapeutic that targets the pathophysiological elements of preeclampsia would be a major advance for obstetrics, with potential to save the lives of countless mothers and babies. We recently identified anti-inflammatory drug sulfasalazine as a prospective candidate therapeutic for treatment of preeclampsia. In primary human cells and tissues in vitro, sulfasalazine potently decreased secretion of anti-angiogenic sFlt-1 and sENG, increased production of pro-angiogenic PlGF, mitigated endothelial dysfunction, and promoted whole vessel vasodilation.

METHODS

Using nitric oxide synthase antagonist Nω-Nitro-l-arginine methyl ester hydrochloride, a preeclampsia-like phenotype was induced in pregnant mice, including high blood pressure, fetal growth restriction, and elevated circulating sFlt-1. Mice were treated with sulfasalazine or vehicle from gestational day (D)13.5, with blood pressure measurements across gestation, fetal measurements at D17.5, and wire myograph assessment of vasoactivity.

RESULTS

Sulfasalazine had a modest effect on blood pressure, decreasing diastolic and mean blood pressure on D13.5, but not later in gestation, or systolic blood pressure. Sulfasalazine was not able to rescue fetal growth, in male or female fetuses. There was a suggestion of improved vasoactivity with sulfasalazine, but further clarification is required.

DISCUSSION

In this mouse model of preeclampsia, sulfasalazine did not sustain reductions in blood pressure nor affect fetal parameters of size and weight, both desirable attributes of a viable preeclampsia therapeutic. While these data suggest sulfasalazine might improve vasoactivity, murine toxicity considerations limited the dose range of sulfasalazine that could be tested in the current study.

Efficacy of sulfasalazine for the prevention of Pneumocystis pneumonia in patients with rheumatoid arthritis: A multicentric self-controlled case series study

INTRODUCTION

Pneumocystis pneumonia (PCP) is an opportunistic lung infection and has been reported among patients with rheumatoid arthritis (RA). An animal study revealed that sulfasalazine enhances Pneumocystis clearance from the lung by accelerating macrophage activity.

METHODS

The self-controlled case series (SCCS) method was used to investigate the association between sulfasalazine use and PCP development in patients with RA without the effect of time-invariant, interpatient confounders. PCP episodes which developed in patients with RA at five hospitals between 2003 and 2019 were identified. PCP was defined by the following criteria: 1) detection of Pneumocystis jirovecii in respiratory specimens by polymerase chain reaction; 2) clinical symptoms (pyrexia, dry cough, dyspnea or hypoxia); 3) diffuse interstitial infiltrate on chest imaging; and 4) absence of PCP prophylaxis. The PCP incidence rate ratio (IRR) was compared between periods with and without sulfasalazine use by conditional Poisson regression.

RESULTS

Fifty episodes of PCP were identified in 49 patients. Thirty patients received sulfasalazine at some point during their observation. While 49 episodes of PCP developed in 170.3 person-years without sulfasalazine use, only one episode of PCP developed in 103.7 person-years with sulfasalazine use. Sulfasalazine use was associated with a decreased PCP risk (adjusted IRR <0.01; 95% confidence interval <0.01-0.03) after adjusting for age and glucocorticoid, methotrexate, and tumor necrosis factor inhibitor administration.

CONCLUSION

Our study demonstrated a preventive effect of sulfasalazine against PCP in patients with RA.

Complications of complications: diagnosis and treatment of recurrent macrophage activation syndrome in a patient with well-controlled systemic juvenile idiopathic arthritis

Macrophage activation syndrome (MAS) is a subtype of haemophagocytic lymphohistiocytosis (HLH), and a well-described complication of systemic juvenile idiopathic arthritis (SJIA), triggered by disease onset or flare, infection, or some medications. Here, we report a 20-year-old man with previously well-controlled SJIA, who developed first time MAS after acute Epstein-Barr virus (EBV) infection, with MAS recurrence due to a drug reaction, '3-week sulfasalazine syndrome', secondary to prophylactic trimethoprim/sulfamethoxazole. Both episodes of MAS were minimally responsive to pulse corticosteroids. Initial EBV-driven MAS was treated with multiple doses of emapalumab prior to resolution, while MAS secondary to sulfasalazine-induced 3-week syndrome required the initiation of ruxolitinib. This case exhibits two rare but life-threatening causes of MAS/secondary HLH in a single patient and the difficulties in their diagnosis and management.

Electrochemical Detection of Sulfadiazine by Sensors based on Chemically Modified Carbon Electrodes: A Review

The consumption of medicines (usually pharmaceuticals and chemical health products) has increased in recent decades due to the demand for medicines for various diseases (headache, relapsing fever, dental absence, streptococcal infection, bronchitis, ear and eye infections). Instead, their overuse can lead to serious environmental damage. Sulfadiazine is one of the most often used antimicrobial medications for both human and veterinary therapy, yet its presence in the environment, even in low quantities, offers a potential concern as an emergency pollutant. It is vital to have a monitoring that's quick, selective, sensitive, stable, reversible, reproducible, and easy to use. Electrochemical techniques realizing cyclic voltammetry (CV), differential pulse voltammetry (DPV), and square wave voltammetry (SWV), using a modified electrode based on carbon as a surface modifier are an excellent option that makes control simple and quick owing to their cheap cost and convenience of use, while also safeguarding human health from drug residue buildup. This study discusses different chemically modified carbon-based electrodes such as graphene paste, screen printed electrode, glassy carbon, and boron diamond doped electrodes for SDZ (sulfadiazine) detection in various formulation feeds, pharmaceuticals, milk, and urine samples, the results obtained also show high sensitivity and selectivity with lower detection limits compared to matrix studies, which may explain its use in trace detection. Furthermore, the effectiveness of the sensors is assessed by other parameters including buffer solution, scan rate, and pH. Also, a method for real sample preparation was also discussed in addition to the different methods mentioned.

A core/shell TiO2 magnetized molecularly imprinted photocatalyst (MMIP@TiO2): synthesis and its photodegradation activity towards sulfasalazine

Although the selectivity of TiO₂ for the degradation of target molecules is not enough, it is a broadly employed photocatalyst for the degradation of many pollutants. Molecularly imprinted compounds owing to their extreme recognition specificity have become increasingly popular for preparing selective photocatalysts. In this work, based on molecularly imprinted magnetized TiO₂ (MMIP@TiO₂), a selective photocatalyst was prepared. Via the co-precipitation method, Fe₃O₄ particles were prepared and coated respectively by SiO₂, vinyl end groups, and molecularly imprinted polymers (MIP). The synthesized photocatalyst was characterized by the X-ray diffraction method (XRD), Fourier transform infrared spectroscopy (FT-IR), scanning electron microscopy (SEM), energy-dispersive x-ray spectrometry (EDX), vibrating sample magnetometry (VSM), high-performance liquid chromatography (HPLC), and photoluminescence analysis (PL). The photocatalyst was then used to degrade the sulfasalazine pharmaceutical pollutant under UV irradiation. An average crystallite size of 9 nm was obtained for the MMIP@TiO₂ sample from the Scherrer formula and 34.5 nm by the Williamson-Hall formula. The results revealed that compared to the non-imprinted counterpart, the molecularly imprinted photocatalyst had significantly higher efficiency and selectivity for the degradation of target molecules. The process was forwarded with 90% efficiency within 10 min. Optimal conditions were 10.0 min irradiation when 25 mL SSZ solution (50 mg/L), 0.07 g/L catalyst dose, and pH 6.0 were applied. The maximum removal efficiency was calculated to be 92%. The external magnetic field quickly removed the photocatalyst from the solution and regenerated it. It was revealed that after each regeneration cycle, the efficiency dropped. Nevertheless, 63% of the preliminary effectiveness remained after four regeneration steps.

Diverse but desolate landscape of gut microbial azoreductases: A rationale for idiopathic IBD drug response

Prodrugs reliant on microbial activation are widely used but exhibit a range of efficacies that remain poorly understood. The anti-inflammatory compound 5-aminosalicylic acid (5-ASA), which is packaged in a variety of azo-linked prodrugs provided to most Ulcerative Colitis (UC) patients, shows confounding inter-individual variabilities in response. Such prodrugs must be activated by azo-bond reduction to form 5-ASA, a process that has been attributed to both enzymatic and non-enzymatic catalysis. Gut microbial azoreductases (AzoRs) are the first catalysts shown to activate azo-linked drugs and to metabolize toxic azo-chemicals. Here, we chart the scope of the structural and functional diversity of AzoRs in health and in patients with the inflammatory bowel diseases (IBDs) UC and Crohn's Disease (CD). Using structural metagenomics, we define the landscape of gut microbial AzoRs in 413 healthy donor and 1059 IBD patient fecal samples. Firmicutes encode a significantly higher number of unique AzoRs compared to other phyla. However, structural and biochemical analyses of distinct AzoRs from the human microbiome reveal significant differences between prevalent orthologs in the processing of toxic azo-dyes, and their generally poor activation of IBD prodrugs. Furthermore, while individuals with IBD show higher abundances of AzoR-encoding gut microbial taxa than healthy controls, the overall abundance of AzoR-encoding microbes is markedly low in both disease and health. Together, these results establish that gut microbial AzoRs are functionally diverse but sparse in both health and disease, factors that may contribute to non-optimal processing of azo-linked prodrugs and idiopathic IBD drug responses.

[Severe cutaneous drug reactions in children]

Severe cutaneous drug reactions also occur in children and range from reactions with blister forming of skin and mucosa to extensive exanthems with altered differential blood count and involvement of internal organs. The first group includes Stevens-Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN), which are considered as one disease entity with different degrees of severity and are also referred to as "epidermal" or "epithelial necrolysis" (EN). The group of drug reactions with primarily systemic alterations is represented by a condition known as drug reaction with eosinophilia and systemic symptoms (DRESS).Although EN is generally considered as a drug reaction, a causative agent can only be identified in about 50% of all pediatric cases. Once a clear diagnosis is established, specific treatment measures should be carried out, whereby discontinuation of the causative agent plays a decisive role in drug-induced cases. In order to be able to identify and discontinue the drug responsible, a detailed medication history must be obtained. Certain antiepileptic drugs, sulfonamides and sulfasalazine are among the most frequent triggers of EN and DRESS in children. Supportive therapy including appropriate topical treatment, pain management and ophthalmological consultations are of utmost importance in EN but a short-term immunomodulating treatment with cyclosporine A has been shown to be helpful. In contrast, in DRESS middle to long-term systemic treatment with glucocorticosteroids is recommended.

High interfacial charge separation in visible-light active Z- scheme g-C3N4/MoS2 heterojunction: Mechanism and degradation of sulfasalazine

Examination of highly proficient photoactive materials for the degradation of antibiotics from the aqueous solution is the need of the hour. In the present study, a 2D/2D binary junction GCM, formed between graphitic-carbon nitride (g-C3N4) and molybdenum disulphide (MoS2), was synthesized using facile hydrothermal method and its photo-efficacy was tested for the degradation of sulfasalazine (SUL) from aqueous solution under visible-light irradiation. Morphological analysis indicated the nanosheets arrangement of MoS2 and g-C3N4. The visible-light driven experiments indicated that 97% antibiotic was degraded by GCM-30% within 90 min which was found to be quite high than pristine g-C3N4 and MoS2 at solution pH of 6, GCM-30% dose of 20 mg, and SUL concentration of 20 mgL-1. The degradation performance of GCM-30% was selectively improved due to enhanced visible-light absorption, high charge carrier separation, and high redox ability of the photogenerated charges which was induced by the effective Z-scheme 2D/2D heterojunction formed between g-C3N4 and MoS2. The reactive radicals as determined by the scavenging study were •O2-, and h+. A detailed degradation mechanism of SUL by GCM-30% was also predicted based on the detailed examination of the band gaps of g-C3N4 and MoS2.

Intracellular glutathione levels affect the outcomes of verteporfin-mediated photodynamic therapy in esophageal cancer cells

Photodynamic therapy (PDT) induces cancer cell death by generating reactive oxygen species (ROS). In this process, photosensitizers accumulate in cancer cells irradiated by laser light of a specific wavelength, leading to ROS generation. Verteporfin (VP), a second-generation photosensitizer, is used in PDT for age-related macular degeneration. However, the antitumor effects of VP-PDT remain poorly defined. This study investigated the antitumor effects of VP-PDT on esophageal cancer (EC) cell lines in vitro. Two types of EC cell lines, the KYSE30 cell line, derived from highly differentiated esophageal carcinoma, and the KYSE170 cell line, derived from moderately differentiated carcinoma, were used in this study. VP-PDT exerted effective anticancer effects in both cell lines. Our results revealed that the low-density lipoprotein receptor, albumin receptor, and heme carrier protein-1 in VP uptake were not involved in VP uptake. However, cells rich in intracellular glutathione were resistant to VP-PDT. Our study outcomes suggest that lowering intracellular glutathione via a glutathione synthesis inhibitor or sulfasalazine can increase the effectiveness of VP-PDT-mediated anticancer effects.

Systematic evaluation of the pre-eclampsia drugs, dietary supplements and biologicals pipeline using target product profiles

BACKGROUND

The Accelerating Innovation for Mothers (AIM) project established a database of candidate medicines in research and development (R&amp;D) between 2000 and 2021 for five pregnancy-related conditions, including pre-eclampsia. In parallel, we published target product profiles (TPPs) that describe optimal characteristics of medicines for use in preventing/treating pre-eclampsia. The study objective was to use systematic double screening and extraction to identify all candidate medicines being investigated for pre-eclampsia prevention/treatment and rank their potential based on the TPPs.

METHODS

Adis Insight, Pharmaprojects, WHO international clinical trials registry platform (ICTRP), PubMed and grant databases were searched (Jan-May 2021). The AIM database was screened for all candidates being investigated for pre-eclampsia. Candidates in clinical development were evaluated against nine prespecified criteria from TPPs identified as key for wide-scale implementation, and classified as high, medium or low potential based on matching to the TPPs. Preclinical candidates were categorised by product type, archetype and medicine subclass.

RESULTS

The AIM database identified 153 candidates for pre-eclampsia. Of the 87 candidates in clinical development, seven were classified as high potential (prevention: esomeprazole, L-arginine, chloroquine, vitamin D and metformin; treatment: sulfasalazine and metformin) and eight as medium potential (prevention: probiotic lactobacilli, dalteparin, selenium and omega-3 fatty acid; treatment: sulforaphane, pravastatin, rosuvastatin and vitamin B3). Sixty-six candidates were in preclinical development, the most common being amino acid/peptides, siRNA-based medicines and polyphenols.

CONCLUSIONS

This is a novel, evidence-informed approach to identifying promising candidates for pre-eclampsia prevention and treatment - a vital step in stimulating R&amp;D of new medicines for pre-eclampsia suitable for real-world implementation.

Iron ion and sulfasalazine-loaded polydopamine nanoparticles for Fenton reaction and glutathione peroxidase 4 inactivation for enhanced cancer ferrotherapy

Ferroptosis shows promising potential in tumor treatment; however, factors that compromise the efficiency of the Fenton catalyst have limited its therapeutic effectiveness. We developed a polydopamine-based nanoplatform constructed with ferric ion and sulfasalazine-loaded nanoparticles (Fe(III)PP@SAS NPs) for dual-functional ferrotherapy strategy of "sword and shield" through enhanced Fenton reaction and inactivation of glutathione peroxidase 4 (GPX4), respectively. Both the Fenton reaction-based hydroxyl radical (^·OH) production and sulfasalazine-driven GPX4 inhibition induced ferroptotic cell death, thus achieving synergistic cancer therapy. Near-infrared light irradiation and acidic tumor microenvironment enhanced the release of ferric ions and sulfasalazine from the Fe(III)PP@SAS NPs. In addition, the released iron ions underwent valence state change due to Fenton reaction and thus provided a supplementary T1-weighted signal for in situ visualization of the tumor based on magnetic resonance imaging. The Fe(III)PP@SAS NPs exhibited high pro-ferroptosis performance by utilizing ^·OH radicals as a "sword" to attack cancer cells and the GPX4 inhibitor to break down the "shield" of cancer cells, thus showing potential for cancer treatment. STATEMENT OF SIGNIFICANCE: Several strategies of cancer therapy based on ferroptosis have emerged in recent years, which have provided new insights into designing materials for therapeutic applications. The antitumor efficacy of ferroptosis is, however, still unsatisfactory, mainly because of insufficient intracellular pro-ferroptotic stimuli. In the current study, we report a multifunctional theranostic nanoplatform, namely Fe(III)PP@SAS, with three-fold synergistic effect; this nanoplatform has excellent theranostic potential with multifunctional ferrotherapy.

Sulfasalazine exacerbates Angiotensin II induced cardiac remodeling by activating Akt signal pathway

A thorough understanding of the pathological process underlying hypertension-induced cardiac remodeling may help in prevention and treatment of heart failure. Angiotensin II (Ang II) results in cardiac fibrosis and hypertrophy partly through activation of inflammation, which increases the fibroblasts and promotes extracellular matrix production. Sulfasalazine (SASP) has evident anti-inflammatory effects and pharmacological functions on autoimmune disease. The roles of SASP in the cardiac remodeling remain unknow. In this study, we established Ang II-induced cardiac remodeling mice model and then treated with SASP. Blood pressure, cardiac pump function, and pathological changes of cardiac remodeling were analyzed in these mice. To explore the mechanism, phosphorylated Akt was detected in vivo and vitro. In this study, we found that SASP aggravated cardiac dysfunction, hypertrophy and fibrosis after Ang II infusion. In addition, SASP activated Akt in Ang II-remodeled mouse hearts and cardiac cells. Our findings indicate that independent of anti-inflammatory property, SASP exacerbates Ang II-induced cardiac remodeling by activation of Akt signaling pathway.

Development and validation of HPLC-DAD and LC-(ESI)/MS methods for the determination of sulfasalazine, mesalazine and hydrocortisone 21-acetate in tablets and rectal suppositories: In vitro and ex vivo permeability studies

Controlled-release tablets and rectal suppositories of sulfasalazine (SLF) and hydrocortisone 21-acetate (HA) were prepared as recommended dosage forms for the treatment of acute episodes of ulcerative colitis, in patients who do not respond to monotherapy. A High-Performance Liquid Chromatography (HPLC) Diode-array method with a gradient elution mobile phase was developed to evaluate the production quality of both formulations (assay and dissolution profiles in gastric and intestinal fluids). Method's validation was carried out providing good linearity (r ≥ 0.9995), precision (RSD < 1.53%), recovery (96.9% - 103.7%) and limits of detection (LOD_SLF = 12 ng/mL, LOD_HA = 15 ng/mL). Experimental design and Plackett-Burman methodology was constructed to study the robustness of the analysis. In all composite substrates, a freezing lipid precipitation approach was used as purification step. The method was optimized by applying Central Composite design mode. The in-vitro/ex-vivo permeability studies of both formulations were evaluated by a Liquid Chromatography-Electron Spray Ionization Mass Spectrometry (LC-ESI/MS) +/- mode. The analysis of sulfamethazine (internal standard, SLM, m/z 279), HA (m/z 449, [M + HCOO]^-), SLF (m/z 399) and its active metabolite mesalazine (MSL, m/z 154) was performed using a C₁₈ column and gradient elution. The validation of the method met the requirements of the International Council for Harmonization (ICH) (r ≥ 0.9997, RSD ≤ 4.62%, Recovery > 95%, LOD_SLF = 1.28 ng/mL, LOD_HA = 1.07 ng/mL, LOD_MSL = 3.16 ng/mL). Based on the results, important conclusions were drawn concerning the role of excipients and SLF metabolism.

Oral Conventional Synthetic Disease-Modifying Antirheumatic Drugs with Antineoplastic Potential: a Review

There is an increasing trend of malignancy worldwide. Disease-modifying antirheumatic drugs (DMARDs) are the cornerstones for the treatment of immune-mediated inflammatory diseases (IMIDs), but risk of malignancy is a major concern for patients receiving DMARDs. In addition, many IMIDs already carry higher background risks of neoplasms. Recently, the black box warning of malignancies has been added for Janus kinase inhibitors. Also, the use of biologic DMARDs in patients with established malignancies is usually discouraged owing to exclusion of such patients in pivotal studies and, hence, lack of evidence. In contrast, some conventional synthetic DMARDs (csDMARDs) have been reported to show antineoplastic properties and can be beneficial for patients with cancer. Among the csDMARDs, chloroquine and hydroxychloroquine have been the most extensively studied, and methotrexate is an established chemotherapeutic agent. Even cyclosporine A, a well-known drug associated with cancer risk, can potentiate the effect of some chemotherapeutic agents. We review the possible mechanisms behind and clinical evidence of the antineoplastic activities of csDMARDs, including chloroquine and hydroxychloroquine, cyclosporine, leflunomide, mycophenolate mofetil, mycophenolic acid, methotrexate, sulfasalazine, and thiopurines. This knowledge may guide physicians in the choice of csDMARDs for patients with concurrent IMIDs and malignancies.

Pharmacogenetics of Drug Therapies in Rheumatoid Arthritis

Rheumatoid arthritis (RA) is a chronic systemic inflammatory disorder that can lead to severe joint damage and is often associated with a high morbidity and disability. Disease-modifying anti-rheumatic drugs (DMARDs) are the mainstay of treatment in RA. DMARDs not only relieve the clinical signs and symptoms of RA but also inhibit the radiographic progression of disease and reduce the effects of chronic systemic inflammation. Since the introduction of biologic DMARDs in the late 1990s, the therapeutic range of options for the management of RA has significantly expanded. However, patients' response to these agents is not uniform with considerable variability in both efficacy and toxicity. There are no reliable means of predicting an individual patient's response to a given DMARD prior to initiation of therapy. In this chapter, the current published literature on the pharmacogenetics of traditional DMARDS and the newer biologic DMARDs in RA is highlighted. Pharmacogenetics may help individualize drug therapy in patients with RA by providing reliable biomarkers to predict medication toxicity and efficacy.

Extracellular Concentration of L-Cystine Determines the Sensitivity to System xc - Inhibitors

Targeting the cystine/glutamate exchange transporter, system x_c^-, is a promising anticancer strategy that induces ferroptosis, which is a distinct form of cell death mediated by iron-dependent lipid peroxidation. The concentration of L-cystine in culture medium is higher than the physiological level. This study was aimed to evaluate the effects of L-cystine concentration on the efficacy of ferroptosis inducers in hepatocellular carcinoma cells. This study showed that treatment with sulfasalazine or erastin, a system x_c^- inhibitor, decreased the viability of Huh6 and Huh7 cells in a dose-dependent manner, and the degree of growth inhibition was greater in medium containing a physiological L-cystine concentration of 83 µM than in commercial medium with a concentration of 200 µM L-cystine. However, RSL3, a glutathione peroxidase 4 inhibitor, decreased cell viability to a similar extent in media containing both L-cystine concentrations. Sulfasalazine and erastin significantly increased the percentages of propidium iodide-positive cells in media with 83 µM L-cystine, but not in media with 200 µM L-cystine. Sulfasalazine- or erastin-induced accumulation of lipid peroxidation as monitored by C11-BODIPY probe was higher in media with 83 µM L-cystine than in media with 200 µM L-cystine. In contrast, the changes in the percentages of propidium iodide-positive cells and lipid peroxidation by RSL3 were similar in both media. These results showed that sulfasalazine and erastin, but not RSL3, were efficacious under conditions of physiological L-cystine concentration, suggesting that medium conditions would be crucial for the design of a bioassay for system x_c^- inhibitors.

The inhibition of NFкB signaling and inflammatory response as a strategy for blunting bile acid-induced hepatic and renal toxicity

The cholestatic liver injury could occur in response to a variety of diseases or xenobiotics. Although cholestasis primarily affects liver function, it has been well-known that other organs such as the kidney could be influenced in cholestatic patients. Severe cholestasis could lead to tissue fibrosis and organ failure. Unfortunately, there is no specific therapeutic option against cholestasis-induced organ injury. Hence, finding the mechanism of organ injury during cholestasis could lead to therapeutic options against this complication. The accumulation of potentially cytotoxic compounds such as hydrophobic bile acids is the most suspected mechanism involved in the pathogenesis of cholestasis-induced organ injury. A plethora of evidence indicates a role for the inflammatory response in the pathogenesis of several human diseases. Here, the role of nuclear factor-kB (NFkB)-mediated inflammatory response is investigated in an animal model of cholestasis. Bile duct ligated (BDL) animals were treated with sulfasalazine (SSLZ, 10 and 100 mg/kg, i.p) as a potent inhibitor of NFkB signaling. The NFkB proteins family activity in the liver and kidney, serum and tissue levels of pro-inflammatory cytokines, tissue biomarkers of oxidative stress, serum markers of organ injury, and the liver and kidney histopathological alterations and fibrotic changes. The oxidative stress-mediated inflammatory-related indices were monitored in the kidney and liver at scheduled time intervals (3, 7, and 14 days after BDL operation). Significant increase in serum and urine markers of organ injury, besides changes in biomarkers of oxidative stress and tissue histopathology, were evident in the liver and kidney of BDL animals. The activity of NFkB proteins (p65, p50, p52, c-Rel, and RelB) was significantly increased in the liver and kidney of cholestatic animals. Serum and tissue levels of pro-inflammatory cytokines (IL-1β, IL-2, IL-6, IL-7, IL-12, IL-17, IL-18, IL-23, TNF-α, and INF-γ) were also higher than sham-operated animals. Moreover, TGF- β, α-SMA, and tissue fibrosis (Trichrome stain) were evident in cholestatic animals' liver and kidneys. It was found that SSLZ (10 and 100 mg/kg/day, i.p) alleviated cholestasis-induced hepatic and renal injury. The effect of SSLZ on NFkB signaling and suppression of pro-inflammatory cytokines could play a significant role in its protective role in cholestasis. Based on these data, NFkB signaling could receive special attention to develop therapeutic options to blunt cholestasis-induced organ injury.

Comparison between leflunomide and sulfasalazine based triple therapy in methotrexate refractory rheumatoid arthritis: an open-label, non-inferiority randomized controlled trial

To compare efficacy and safety of two different combination csDMARD therapy in Methotrexate-failed Rheumatoid arthritis patients. In this 24-week open-label, parallel-group non-inferiority, single-center clinical trial, Methotrexate-failed Rheumatoid arthritis patients with disease duration < 2 years, were randomized to either of the two treatment regimens-Methotrexate + Leflunomide + Hydroxychloroquine or Methotrexate + Sulfasalazine + Hydroxychloroquine. Primary endpoint was proportion of patients achieving EULAR good response at 12 weeks. Non-inferiority of Leflunomide based therapy was confirmed if the upper limit of the 2-sided 95% confidence interval of treatment difference between the 2 groups was lower than the selected non-inferiority margin of (- 20%) in primary endpoint at 12 weeks. Secondary endpoints were improvement in DAS28, functional outcome and adverse events at 24 weeks. 136 eligible patients were randomized to either Leflunomide or Sulfasalazine group (68 in each group).63 and 59 patients in Leflunomide and 66 and 61 patients in Sulfasalazine group completed 12 and 24 weeks of trial, respectively. In Intension-to-treat analysis, EULAR good response was achieved by 58.8% and 54.4% patients (p = 0.7) at the end of 12 weeks, and 61.7% and 64.7% patients (p = 0.8) at the end of 24 weeks-in Leflunomide and Sulfasalazine group respectively. At 12 weeks, the difference in EULAR good response with 2-sided 95% confidence interval between 2 groups was 4.4% (- 12%, 20%) in intention-to-treat and 5.8% (- 11%, 23%) in perprotocol analysis.15 and 21 adverse events were recorded in Leflunomide and Sulfasalazine group respectively. Parenteral Methotrexate was required more in Sulfasalazine group due to gastrointestinal intolerance. Leflunomide based csDMARD therapy is non-inferior to Sulfasalazine based csDMARD therapy in Methotrexate-failed Rheumatoid arthritis patients with comparable safety profile. Trial registered at clinicaltrials.gov (NCT02930343) dated 10.09.2016.

In a cohort of individuals with type 2 diabetes using the drug sulfasalazine, HbA1c lowering is associated with haematological changes

OBJECTIVES

Several small studies indicate the sulphonamide component of the drug sulfasalazine lowers HbA_1c. We investigated reduction of HbA_1c following incident prescription of sulfasalazine and related aminosalicylates, lacking the sulphonamide group, in an observational cohort.

RESEARCH DESIGN AND METHODS

Individuals in the Scottish Care Information Diabetes Collaboration (SCI-Diabetes) with type 2 diabetes and incident prescription for an aminosalicylate drug (sulfasalazine, mesalazine, olsalazine or balsalazide) were identified. Baseline and 6-month HbA_1c were required for eligibility, to calculate HbA_1c response. To investigate association with haemolysis, change in components of full blood count was assessed. Paired t-tests compared difference in baseline and treatment HbA_1c measures and other clinical variables.

RESULTS

In all, 113 individuals treated with sulfasalazine and 103 with mesalazine (lacking the sulphonamide group) were eligible, with no eligible individuals treated with olsalazine or balsalazide. Baseline characteristics were similar. Mean (SD) HbA_1c reduction at 6 months was -9 ± 16 mmol/mol (-0.9 ± 1.4%) (p < 0.0001) in those taking sulfasalazine with no reduction in those taking mesalazine (2 ± 16 mmol/mol (0.2 ± 1.4%). Sulfasalazine but not mesalazine was associated with a mean (SD) increase in mean cell volume of 3.7 ± 5.6 fl (p < 0.0001) and decrease in red cell count of -0.2 ± 0.4 × 10^-12 /L (p < 0.0001).

CONCLUSIONS

In this observational, population-based study, sulfasalazine initiation was associated with a 6-month reduction in HbA_1c . This correlated with haematological changes suggesting haemolytic effects of sulfasalazine. Haemolysis is proposed to contribute to HbA_1c lowering through the sulphonamide pharmacophore. This suggests that HbA_1c is not a reliable measure of glycaemia in individuals prescribed sulfasalazine.

Preparation of Fe@Fe2O3/3D graphene composite cathode for electrochemical removal of sulfasalazine

In the present study, heterogeneous electro-Fenton (EF) process was applied to remove the sulfasalazine (SU) pharmaceutical from aqueous solutions. In the first part, 3D graphene loaded with Fe@Fe₂O₃ core-shell nanowires (Fe@Fe₂O₃/3D-GO) was used as a cathode electrode in the EF process. Graphene oxide (GO) was synthesized for the synthesis of 3D graphene nanocomposites using the improved Hummers' method and subsequently 3D graphene synthesized by the hydrothermal method using glycine. Finally, Fe@Fe₂O₃/3D-GO composite was synthesized and its properties were assessed by Scanning electron microscopy, Atomic force microscopy, Brunauer-Emmett-Teller, Fourier-transform infrared spectroscopy and X-ray diffraction methods. Then, the cathode electrode was prepared using the resulting composite and its performance was evaluated using Cyclic Voltammetry analysis. In the final part of this work, the Fe@Fe₂O₃/3D-GO electrode was used as the cathode electrode in the heterogeneous EF process to remove SU from aqueous solutions. The effect of operating parameters such as applied current (mA), initial pH of solution, initial pharmaceutical concentration (mg L^-1) and process time (min) on pharmaceutical removal efficiency under heterogeneous EF process was investigated by response surface methodology. The results showed that the optimum values for applied current, pH, initial pharmaceutical concentration and electrolysis time were respectively 300 mA, 7, 30 mg L^-1 and 100 min, resulting 99.60% of SU removal. Finally, the intermediates of SU degradation were determined by Gas chromatography-mass spectrometry analysis and the amount of mineralization was determined by total organic carbon analysis. About 5.2% drop in the SU removal efficiency was observed within 8 operational runs.

Mimicking the dynamic Colonic microbiota in vitro to gain a better understanding on the in vivo metabolism of xenobiotics: Degradation of sulfasalazine

Due to the potential effects of colonic metabolism, the interest in the composition and action of intestinal microbiota has increased significantly throughout the last 10 years. Recently focus is turning to the development and implementation of in vitro tools closely simulating in vivo colonic metabolic processes suitable for routine use. The aim of the present study is to compare the metabolization of the model drug sulfasalazine utilizing the novel dynamic bioreactor MimiCol and a standard static batch fermenter inoculated with cryopreserved faecal microbiota. Major advantages of the novel bioreactor MimiCol are the smaller media volume which is closer to in vivo conditions, the possibility to perform media changes and the closer simulation of in vivo mixing patterns. The study proved that the MimiCol is able to simulate the dynamic conditions found within the ascending colon. The dynamic conditions within the MimiCol led to an almost 2-fold increase of the metabolization rate constant in comparison to the static batch fermenter. Our study was able to prove that the novel dynamic bioreactor MimiCol is able to closely simulate physiologically relevant conditions.

Cerium oxide nanoparticles acts as a novel therapeutic agent for ulcerative colitis through anti-oxidative mechanism

BACKGROUND

Cerium (IV) oxide (CeO₂) exhibit anti-inflammatory activity via scavenge free radicals and decreasing the oxygen species (ROS) production. Here we aimed to exhibit the therapeutic effect of this nanoparticle in experimental colitis models.

METHODS

Cerium oxide nanoparticles (CeONPs) were synthesized via using UiO-66 as a precursor. We used dextran sodium sulfate (DSS) to induce colitis in experimental models to investigate the anti-inflammatory effect of CeONPs. Colitis models are divided into four groups to receive the treatment, including control, colitis, cerium oxide, and sulfasalazine. We evaluated the therapeutic effects of CeONPs for the increased colitis clinical symptoms and attenuated the histological damage to colon tissue in colitis.

RESULT

This nanoparticle was significantly able to reduce the clinical symptoms of colitis. Moreover, CeONPs can enhance the disease activity index such as body lose weight, diarrhea, rectal bleeding, colon length, and spleen weight. Moreover, CeONPs showed a significant reduction in the histological characteristics of the colitis models.

CONCLUSION

These results suggest that CeONPs can be considered as promising therapeutic agents in treating the ulcerative colitis.

Therapeutic effect of an anti-tuberculosis agent, isoniazid, and its nano-isoform in ulcerative colitis

BACKGROUND

Isoniazid (INH) is well known as a first-line anti-tuberculosis, while some studies demonstrate that it has anti-inflammatory activity via a different mechanism such as inhibitionthe production of IL-1, ROS, activation of PPARγ expression, inhibition of the transcriptional regulatory activity of NF-κB and AP-1. The aim of this study, investigate the anti-inflammatory effect of INH and INH combined with Sulfasalazine-loaded nanoparticles (NPs) in the ulcerative colitis mouse model.

METHODS

To investigate the anti-inflammatory effect of INH and NPs in the ulcerative colitis mice model, we evaluated the effect of INH clinical symptoms and colonic mucosal histology in colitis.

RESULT

The present study demonstrates that combination therapy of INH with sulfasalazine as well as NPs reduces the symptom of ulcerative colitis and improved disease activity index include body lose weight, diarrhea, rectal bleeding, colonic length, spleen weight, and colon histopathological score in DSS-induced colitis mice model.

CONCLUSION

Our results suggest that the nanoforms of INH with sulfasalazine enhances the therapeutic effect of the drugs in the treatment of ulcerative colitis.

xCT/SLC7A11 antiporter function inhibits HIV-1 infection

Human macrophages are protected by intrinsic antiviral defenses that provide moderate protection against HIV-1 infection. Macrophages that do become infected can serve as long-lived reservoirs, to disseminate HIV-1 to CD4+ T cells. Infection of macrophages with HIV-1 and HIV-2 is inhibited by constitutive mobilization of antioxidant response master transcription regulator Nrf2. The downstream mediator of this restriction was not identified. Among the tens of genes controlled directly by Nrf2 in macrophages, we found that xCT/SLC7A11, a 12-transmembrane, cystine-glutamate antiporter promotes antiretroviral activity. We show here that depletion of xCT mRNA increases HIV-1 infection. Reconstitution of xCT knock out cells with wild-type xCT but not a transport-deficient mutant restores anti-HIV-1 activity. Pharmacological inhibitors of xCT amino acid transport also increase infection. The block is independent of known restriction factors and acts against HIV-1 and HIV-2. Like the block triggered through Nrf2, xCT function impedes infection immediately before 2-LTR circle formation.

Sulfasalazine modifies metabolic profiles and enhances cisplatin chemosensitivity on cholangiocarcinoma cells in in vitro and in vivo models

Background

Sulfasalazine (SSZ) is widely known as an xCT inhibitor suppressing CD44v9-expressed cancer stem-like cells (CSCs) being related to redox regulation. Cholangiocarcinoma (CCA) has a high recurrence rate and no effective chemotherapy. A recent report revealed high levels of CD44v9-positive cells in CCA patients. Therefore, a combination of drugs could prove a suitable strategy for CCA treatment via individual metabolic profiling.

Methods

We examined the effect of xCT-targeted CD44v9-CSCs using sulfasalazine combined with cisplatin (CIS) or gemcitabine in CCA in vitro and in vivo models and did NMR-based metabolomics analysis of xenograft mice tumor tissues.

Results

Our findings suggest that combined SSZ and CIS leads to a higher inhibition of cell proliferation and induction of cell death than CIS alone in both in vitro and in vivo models. Xenograft mice showed that the CD44v9-CSC marker and CK-19-CCA proliferative marker were reduced in the combination treatment. Interestingly, different metabolic signatures and significant metabolites were observed in the drug-treated group compared with the control group that revealed the cancer suppression mechanisms.

Conclusions

SSZ could improve CCA therapy by sensitization to CIS through killing CD44v9-positive cells and modifying the metabolic pathways, in particular tryptophan degradation (i.e., kynurenine pathway, serotonin pathway) and nucleic acid metabolism.

Supplementary Information

The online version contains supplementary material available at 10.1186/s40170-021-00249-6.

Potential contributors to low dose methotrexate toxicity in a patient with rheumatoid arthritis and pernicious anemia: case report

Background

Low dose methotrexate toxicity rarely occurs, but may present with severe complications, such as pancytopenia, hepatotoxicity, mucositis, and pneumonitis. Known risk factors for methotrexate toxicity include dosing errors, metabolic syndrome, hypoalbuminemia, renal dysfunction, lack of folate supplementation, and the concomitant use of drugs that interfere with methotrexate metabolism. Vitamin B12 deficiency leads to megaloblastic anemia and may cause pancytopenia, but its role in methotrexate toxicity has not been described.

Case presentation

We present a case of a patient with rheumatoid arthritis who was admitted with febrile neutropenia, pancytopenia, and severe mucositis, likely secondary to low dose methotrexate toxicity. She had multiple factors that potentially contributed to the development of toxicity, including concurrent sulfasalazine use for rheumatoid arthritis. An evaluation of the patient’s macrocytic anemia revealed pernicious anemia. The patient’s illness resolved with cessation of methotrexate and sulfasalazine, leucovorin treatment and vitamin B12 repletion.

Conclusions

This case illustrates the multiple factors that may potentially contribute to low dose methotrexate toxicity and highlights the importance of testing for vitamin B12 deficiency in rheumatoid arthritis patients with macrocytic anemia. Addressing all the modifiable factors that potentially contribute to low dose methotrexate toxicity may improve outcomes.

BiVO4/WO3 nano-composite: characterization and designing the experiments in photodegradation of sulfasalazine

A BiVO₄-WO₃ nano-composite (NC) was hydrothermally prepared and characterized by different techniques including X-ray diffraction (XRD), scanning electron microscope equipped with an energy-dispersive X-ray (EDX) analyzer, X-ray mapping, UV-Vis reflectance spectroscopy (DRS), and photoluminescence spectroscopy (PL). The average crystallite size of 8.5 nm was estimated for the composite by the Williamson-Hall equation. The band gap energies of 2.46, 3.02, and 2.95 eV were obtained for the direct electronic transitions of BiVO₄, WO₃, and the composite, respectively. The point of zero charges (pHpzc) of the composite was also estimated at 5. The composite was then used in the photodegradation of sulfasalazine (SSZ). When the moles of WO₃ was four times greater than BiVO₄, the best photocatalytic activity and the lowest PL intensity were obtained. The simultaneous effects of the experimental variables on the boosted photocatalytic activity of the composite (to the single semiconductors) were studied by the response surface methodology (RSM). A significant quadratic model was confirmed for processing the data based on the F value of a model F value of 63.55 > F_{0.05, 14, 13} = 2.55. This was also confirmed by LOF F value of 2.56 < F_{0.05, 10, 3} = 8.79. Besides, the multiple correlation coefficients R² (R² = 0.9856), adjusted R² (adj-R² = 0.9701), and predicted R² (pred-R² = 0.9098) confirm the goodness of the model. The optimal run included C_SSZ 9 mg/L, pH 4, 40 min irradiation time, and 0.8 g/L of the composite under the visible light irradiation.

Successful combination therapy using adalimumab and 5-aminosalicylic acid for a resistant case of intestinal Behçet's disease

Behçet's disease (BD) is a recurrent, multisystemic, inflammatory blood vessel disorder that can result in mouth, genital, and skin ulcers; arthritis; and eye and intestinal inflammation. We describe a 21-year-old Korean female patient with intestinal BD refractory to conventional medical treatment and biologic drugs. The patient was initially treated with high-dose steroids and sulfasalazine. Two months later, a skin rash occurred as a side effect of sulfasalazine. Therefore, infliximab (IFX) was administered, and disease activity decreased. However, IFX also induced a skin rash; hence, the patient was switched to adalimumab. After 12 months, the patient experienced a relapse of intestinal BD. Hence, treatment was initiated using a combination of methotrexate and adalimumab; however, this treatment was ineffective. Methotrexate was discontinued and replaced with 5‑aminosalicylic acid while maintaining adalimumab, and no recurrence has been observed to date. We report this novel strategy involving the use of anti-tumor necrosis factor‑α agents for patients with resistant BD; however, further large cohort studies are required to verify its usefulness.

Combination of methotrexate and sulfasalazine is an efficacious option for axial spondyloarthritis in a resource-limited, real-world clinical setting: a prospective cohort study

OBJECTIVE

Evaluation of response to combination conventional synthetic DMARD (csDMARD) therapy with methotrexate (MTX) and sulfasalazine (SSZ) in active axial spondyloarthritis (axSpA) patients without peripheral arthritis (group 1) as compared to active axSpA with peripheral arthritis (group 2), who are economically constrained for biologicals.

METHODS

A prospective, observational, single-centre, cohort study on 150 consecutive active axSpA patients who were already initiated on the above mentioned combination csDMARD therapy and satisfying the other pre-defined eligibility criteria, was conducted between July 2016 and July 2017 using ASAS20 response as primary outcome measure at 3 and 6 months post treatment.

RESULTS

ASAS20 response at 3 months was achieved in 31/58 (53.4%) and in 24/36 (66.6%) in groups 1 and 2, respectively (p = 0.2); at 6 months, these figures were 45/76 (59.2%) and 28/44 (63.6%), respectively (p = 0.6). Similarly, there was significant reduction in mean ASAS NSAID index from 29.6 to 14 over 6 months from baseline (p = 0.001), and it was similar in both groups. Using BASDAI ≥ 4 to define active disease, a 34% reduction in requirement of biologicals was also observed.

CONCLUSION

In resource-limited population, treatment with combination of methotrexate and sulphasalazine over a period of 6 months is equally efficacious in patients with active axSpA with and without peripheral arthritis, as evidenced by improved ASAS20 response rates, reduction in NSAID use and fewer patients switching to biologicals. Key Points • Combination of MTX+SSZ was efficacious and safe in active axSpA patients who had economic hardships to use biologicals. • This benefit in axSpA patients was similar between those without any peripheral arthritis and those with. • MTX+SSZ combination therapy also demonstrated NSAID sparing action. • Combination of MTX and SSZ prevented escalation to biological therapy as per a BASDAI score driven policy.

New approach of medicinal herbs and sulfasalazine mixture on ulcerative colitis induced by dextran sodium sulfate

BACKGROUND

Sulfasalazine has been used as a standard-of-care in ulcerative colitis for decades, however, it results in severe adverse symptoms, such as hepatotoxicity, blood disorders, male infertility, and hypospermia. Accordingly, the new treatment strategy has to enhance pharmacological efficacy and stimultaneously minimize side effects.

AIM

To compare the anti-inflammatory action of sulfasalazine alone or in combination with herbal medicine for ulcerative colitis in a dextran sodium sulfate (DSS)-induced colitis mouse model.

METHODS

To induce ulcerative colitis, mice received 5% DSS in drinking water for 7 d. Animals were divided into five groups (n = 9 each) for use as normal (non-DSS), DSS controls, DSS + sulfasalazine (30 mg/kg)-treatment experimentals, DSS + sulfasalazine (60 mg/kg)-treatment experimentals, DSS + sulfasalazine (30 mg/kg) + Citrus unshiu peel and Bupleuri radix mixture (30 mg/kg) (SCPB)-treatment experimentals.

RESULTS

The SCPB treatment showed an outstanding effectiveness in counteracting the ulcerative colitis, as evidenced by reduction in body weight, improvement in crypt morphology, increase in antioxidant defenses, down-regulation of proinflammatory proteins and cytokines, and inhibition of proteins related to apoptosis.

CONCLUSION

SCPB may represent a promising alternative therapeutic against ulcerative colitis, without inducing adverse effects.

Esomeprazole and sulfasalazine in combination additively reduce sFlt-1 secretion and diminish endothelial dysfunction: potential for a combination treatment for preeclampsia

Development and repurposing of therapies that show promise in the prevention or treatment of preeclampsia would be a major advance for the obstetrics field. We recently identified esomeprazole and sulfasalazine as potential candidates for the treatment of preeclampsia. Both reduce placental and endothelial secretion of sFlt-1 and sENG and mitigate endothelial dysfunction in vitro. Here we assessed whether esomeprazole and sulfasalazine in combination would additively attenuate the elevated release of anti-angiogenic factors and markers of endothelial dysfunction, key characteristics of preeclampsia. Primary placental tissue and cells, and primary endothelial cells were treated with esomeprazole and sulfasalazine alone and in combination. We assessed secretion of sFlt-1 and sENG and performed in vitro assays of endothelial dysfunction. Combining esomeprazole and sulfasalazine in lower concentrations caused an additive reduction in sFlt-1 secretion in primary cytotrophoblasts, placental explants and endothelial cells. No additive reduction was observed in sENG secretion when esomeprazole and sulfasalazine were combined. Together, esomeprazole and sulfasalazine additively reduced TNF-α-induced VCAM and ET-1 mRNA expression, and monocyte adhesion to endothelial cells. In conclusion, combining esomeprazole and sulfasalazine additively reduced secretion of sFlt-1 and markers of endothelial dysfunction. Combined administration of esomeprazole and sulfasalazine may provide a more effective treatment or prevention for preeclampsia compared to either as single agents.

Sulfasalazine in dermatology: A lesser explored drug with broad therapeutic potential

Sulfasalazine is an aminosalicylate primarily used in the treatment of rheumatoid arthritis and ulcerative colitis. Its immunomodulatory, anti-inflammatory, and antiproliferative properties make it a potential therapeutic option for various dermatological disorders. Owing to its wide range of effects, it is often used off-label in dermatological diseases, such as alopecia areata, psoriasis and psoriatic arthritis, lichen planus, and pemphigus. However, the level of evidence supporting its efficacy and safety in dermatology is limited. More research is needed to uncover the full potential of sulfasalazine in dermatology. The present article is a detailed review of the pharmacology, modes of action, side effects, and contraindications of sulfasalazine, along with an up-to-date review of the evidence underlying its use in various dermatological conditions.

System Xc- Antiporter Inhibitors: Azo-Linked Amino-Naphthyl-Sulfonate Analogues of Sulfasalazine

The cystine/glutamate antiporter system Xc- (SXc-) mediates the exchange of intracellular L-glutamate (L-Glu) with extracellular L-cystine (L-Cys2). Both the import of L-Cys2 and the export of L-Glu take on added significance in CNS cells, especially astrocytes. When the relative activity of SXc- overwhelms the regulatory capacity of the EAATs, the efflux of L-Glu through the antiporter can be significant enough to trigger excitotoxic pathology, as is thought to occur in glioblastoma. This has prompted considerable interest in the pharmacological specificity of SXc- and the development of inhibitors. The present study explores a series of analogues that are structurally related to sulfasalazine, a widely employed inhibitor of SXc-. We identify a number of novel aryl-substituted amino-naphthylsulfonate analogues that inhibit SXc- more potently than sulfasalazine. Interestingly, the inhibitors switch from a competitive to noncompetitive mechanism with increased length and lipophilic substitutions, a structure-activity relationship that was previously observed with aryl-substituted isoxazole. These results suggest that the two classes of inhibitors may interact with some of the same domains on the antiporter protein and that the substrate and inhibitor binding sites may be in close proximity to one another. Molecular modeling is used to explore this possibility.