ANSWER: C
Critique
Sulfasalazine can cause reversible azoospermia and infertility. About 80% of patients taking sulfasalazine have semen abnormalities and 72% have oligospermia. Only one case of azoospermia has been reported in patients taking pure mesalamines. The sperm abnormalities are thought to be caused by the sulfapyridine moiety in the sulfasalazine molecule. Therefore, a switch from sulfasalazine to Asacol® or any other pure mesalamine is indicated.
Sulfasalazine inhibits dihydrofolate reductase and can cause folate deficiency. As a result, it should always be given along with oral folic acid supplementation. There is no clear evidence that 6-mercaptopurine affects male fertility. Holding both medications in a patient with UC would put him at increased risk of recurrence and should not be recommended. Withdrawal of an immunomodulatory agent such as 6-mercaptopurine or azathioprine in patients who are in remission can lead to rapid relapse in up to one-third of patients in 1 year and two-thirds within 5 years. Since 6-mercaptopurine is maintaining remission, there is no need for a switch to infliximab. An in vitro fertilization specialist might be required if there is no conception despite sulfasalazine withdrawal.
References
1. Nielsen O.H., Munck L.K. Drug insight: aminosalicylates for the treatment of IBD. Nat. Clin. Pract. Gastroenterol. Hepatol. 2007;4:160-70.
2. Cassinotti A., Actis G.C., Duca P., et al. Maintenance treatment with azathioprine in ulcerative colitis: outcome and predictive factors after drug withdrawal. Am. J. Gastroenterol. 2009;104:2760-7.
