Sulfasalazine, a disease-modifying antirheumatic drug (DMARD), has a well established role in the treatment of patients with rheumatoid arthritis, spondyloarthritis, and inflammatory bowel disease—diseases in which therapeutic benefit may primarily derive from the drug's inhibitory effect on tumour necrosis factor (TNF) and prostaglandin synthesis. In view of this mechanism, it is of note that several independent studies identified baseline treatment with sulfasalazine or mesalamine as a major risk factor (second only to rituximab and other B cell-depleting therapies) for severe COVID-19 in patients with autoimmune and rheumatic diseases. In the physician-reported case registry of the COVID-19 Global Rheumatology Alliance, use of sulfasalazine was associated with a significantly higher risk of death in patients with COVID-19 (odds ratio [OR] 3·6), which contrasted with that of TNF inhibitors (OR 0·85).1Strangfeld A Schafer M Gianfrancesco MA et al.Factors associated with COVID-19- related death in people with rheumatic diseases: results from the COVID-19 Global Rheumatology Alliance physician-reported registry.Ann Rheum Dis. 2021; 80: 930-942Crossref PubMed Scopus (304) Google Scholar Similarly, data from the SECURE-IBD registry showed an increased risk of severe COVID-19 among patients treated with sulfasalazine (adjusted OR 3·1), but not with TNF inhibitors (OR 0·9).2Brenner EJ Ungaro RC Gearry RB et al.Corticosteroids, but not TNF antagonists, are associated with adverse COVID-19 outcomes in patients with inflammatory bowel diseases: results from an international registry.Gastroenterology. 2020; 159 (91.e3): 481Summary Full Text Full Text PDF PubMed Scopus (436) Google Scholar In a post-hoc analysis of data from Swedish patients with rheumatoid arthritis, spondyloarthropathies, psoriatic arthritis, or juvenile idiopathic arthritis (n=110 567), increased point estimates for COVID-19-related hospitalisation and intensive care unit admission were seen for patients on sulfasalazine monotherapy (n=4675) compared with patients on any other conventional synthetic DMARD therapy (n=28 621).3Bower H Frisell T Di Giuseppe D et al.Impact of the COVID-19 pandemic on morbidity and mortality in patients with inflammatory joint diseases and in the general population: a nationwide Swedish cohort study.Ann Rheum Dis. 2021; 80: 1086-1093Crossref PubMed Scopus (42) Google Scholar These findings could not be explained by the known mechanisms of action of sulfasalazine; however, recent findings suggest that the association of clinical use of sulfasalazine with poor COVID-19 outcomes could be related to a previously unappreciated ability of the drug to inhibit type I interferon (IFN) production by plasmacytoid dendritic cells.4Grzes KM Sanin DE Kabat AM et al.Plasmacytoid dendritic cell activation is dependent on coordinated expression of distinct amino acid transporters.Immunity. 2021; 54 (30.e7): 2514Summary Full Text Full Text PDF PubMed Scopus (6) Google Scholar Plasmacytoid dendritic cells sense DNA and single-stranded RNA via toll-like receptors and produce type I IFNs in response. These cells play an important role in immunity to viruses, including SARS-CoV-2, where they have been implicated in protective type I IFN-mediated immune responses in individuals who are infected but remain asymptomatic.5Onodi F Bonnet-Madin L Meertens L et al.SARS-CoV-2 induces human plasmacytoid predendritic cell diversification via UNC93B and IRAK4.J Exp Med. 2021; 218e20201387Crossref PubMed Google Scholar However, plasmacytoid dendritic cells are also implicated in autoimmune diseases, such as systemic lupus erythematosus (SLE) and dermatomyositis—diseases in which type I IFN production plays a role in immunopathogenesis. Recent work revealed a pivotal role for interleukin (IL)-3-driven JAK2-STAT5 signalling for subsequent toll-like receptor-induced plasmacytoid dendritic cell activation and showed that activated plasmacytoid dendritic cells express SLC7A11 (cystine/glutamate transporter), a subunit of the xc− amino acid transporter that imports cystine for the production of the crucial anti-oxidant glutathione.4Grzes KM Sanin DE Kabat AM et al.Plasmacytoid dendritic cell activation is dependent on coordinated expression of distinct amino acid transporters.Immunity. 2021; 54 (30.e7): 2514Summary Full Text Full Text PDF PubMed Scopus (6) Google Scholar SLC7A11 is important in part because it is a negative regulator of iron-dependent programmed cell death (ferroptosis).6Figuera-Losada M Thomas AG Stathis M Stockwell BR Rojas C Slusher BS Development of a primary microglia screening assay and its use to characterize inhibition of system xc(-) by erastin and its analogs.Biochem Biophys Rep. 2017; 9: 266-272PubMed Google Scholar To address the unmet need for diseases such as SLE, we explored new treatment possibilities that target plasmacytoid dendritic cells and tested combinations of inhibitors with known selectivity for targets within the plasmacytoid dendritic cell activation pathway, including JAK2 (eg, baricitinib) and xc− (eg, sulfasalazine6Figuera-Losada M Thomas AG Stathis M Stockwell BR Rojas C Slusher BS Development of a primary microglia screening assay and its use to characterize inhibition of system xc(-) by erastin and its analogs.Biochem Biophys Rep. 2017; 9: 266-272PubMed Google Scholar). Sulfasalazine strongly inhibited the production of type I IFN at clinically relevant concentrations, and the combination of sulfasalazine and a JAK2 inhibitor had a synergistic effect.4Grzes KM Sanin DE Kabat AM et al.Plasmacytoid dendritic cell activation is dependent on coordinated expression of distinct amino acid transporters.Immunity. 2021; 54 (30.e7): 2514Summary Full Text Full Text PDF PubMed Scopus (6) Google Scholar Although sulfasalazine affects additional pathways, we believe that it is the ability to inhibit xc− that confers its inhibitory effect on plasmacytoid dendritic cells (figure). This observation supports the possible repurposing of sulfasalazine, a relatively cheap oral drug, for the treatment of type I IFN-driven autoimmune and autoinflammatory diseases. At the same time, it might provide a mechanistic explanation for the as-yet unexplained epidemiological association between sulfasalazine and COVID-19 severity, since sulfasalazine-mediated impairment of type I IFN production by plasmacytoid dendritic cells would be expected to inhibit effective early immune responses during SARS-CoV-2 infection. Indeed, the reported increase in risk of herpes zoster in patients with rheumatoid arthritis taking sulfasalazine might indicate a broader effect of this drug on immunity to viral infections than previously appreciated. The realisation, over the space of a few months, that sulfasalazine is an inhibitor of type I IFN production by plasmacytoid dendritic cells and also a risk factor for death due to SARS-CoV-2 infection;1Strangfeld A Schafer M Gianfrancesco MA et al.Factors associated with COVID-19- related death in people with rheumatic diseases: results from the COVID-19 Global Rheumatology Alliance physician-reported registry.Ann Rheum Dis. 2021; 80: 930-942Crossref PubMed Scopus (304) Google Scholar that autoantibodies against type I IFNs are observed in about 20% of critical COVID-19 cases and deaths;8Bastard P Gervais A Le Voyer T et al.Autoantibodies neutralizing type I IFNs are present in ∼4% of uninfected individuals over 70 years old and account for ∼20% of COVID-19 deaths.Sci Immunol. 2021; 6eabl4340Crossref Scopus (158) Google Scholar and that SLE risk alleles associated with high type I IFN production are associated with asymptomatic SARS-CoV-2 infection (ie, potentially less severe disease),9Nln I Fernandez-Ruiz R Wampler Muskardin TL et al.Interferon pathway lupus risk alleles modulate risk of death from acute COVID-19.Transl Res. 2022; (published online Jan 31)https://doi.org/10.1016/j.trsl.2022.01.007Summary Full Text Full Text PDF PubMed Scopus (1) Google Scholar have helped crystalise understanding of autoimmunity as it relates to anti-viral immunity. The data strongly support a role for type I IFN in resistance to SARS-CoV-2 and highlight the possibility that autoimmune diseases related to increased type I IFN production might be a consequence of evolutionary pressure to maintain genetic alleles that ensure resistance to viral pathogens. This view has consequences for the treatment of patients with autoimmune diseases during viral pandemics, including the therapeutic use of antibodies that inhibit the type I interferon receptor, as used in the treatment of patients with SLE. Further, the findings on sulfasalazine are surprising. Previously, little attention has been paid to the use of this drug for the treatment of autoimmune and rheumatic diseases in which type I IFNs are strongly implicated. To our knowledge, sulfasalazine has never been systematically explored for the treatment of SLE, possibly due to concerns about potential drug-induced autoimmunity and intolerance to sulfa drugs. However, three studies reported high rates of complete responses (including some lasting for years) in patients with refractory cutaneous lupus treated with sulfasalazine.10Artuz F Lenk N Deniz N Alli N Efficacy of sulfasalazine in discoid lupus erythematosus.Int J Dermatol. 1996; 35: 746-768Crossref PubMed Scopus (17) Google Scholar With a more detailed understanding of the mechanism of action of sulfasalazine, related to its ability to inhibit type I IFN production by modulating plasmacytoid dendritic cell function,4Grzes KM Sanin DE Kabat AM et al.Plasmacytoid dendritic cell activation is dependent on coordinated expression of distinct amino acid transporters.Immunity. 2021; 54 (30.e7): 2514Summary Full Text Full Text PDF PubMed Scopus (6) Google Scholar the possibility of repurposing this drug for diseases such as SLE, dermatomyositis, Sjögren's syndrome, and monogenic interferonopathies—for which there is an unmet need for affordable, effective therapeutics—should be considered. MFK was supported by Jerome L Greene Foundation Scholar and Discovery Awards and the Peter and Carmen Lucia Buck Foundation Myositis Discovery Fund. EJP is a founder and advisor of Rheos Medicines. KMG and EJP have filed, in Germany, a provisional application for an international patent titled “Combined inhibition of amino acid transporters for inhibiting human plasmacytoid dendritic cell activity during autoimmunity” (PCT/EP2021/084428). All other authors declare no competing interests.