Azathioprine and Mercaptopurine

We use these immunomodulators in corticosteroid-refractory and corticosteroid-dependent CD, and as first line therapy in combination with corticosteroids in moderate to severe disease. We have also used these successfully in perianal CD, either initially in more severe disease or when antibiotic therapy has failed in mild to moderate disease. A pediatric study by Markowitz and colleagues (2000) showed that the use of 6-mercaptopurine (6-MP) at the onset of therapy with corticosteroids in moderate to severe luminal CD resulted in relapse rates that were markedly reduced over 12 to 18 months (4% versus 28% at 12 months; 9% versus 47% at 18 months) compared with corticosteroids alone. Starting azathioprine (AZA) or 6-MP early in the course of CD is now a strategy we employ routinely, especially in children with extensive disease, growth failure, or other complications.

To monitor for toxicity, we typically follow complete blood counts (CBCs) and liver function tests every 1 to 2 weeks until stable for 1 month, then every 1 to 3 months after that. MP metabolite levels are not routinely ordered, except in individuals who are recurrently flaring, to check compliance and to see if the dose can be adjusted upward, or in individuals who display laboratory abnormalities in whom we suspect 6-MP. Besides bone marrow suppression and hepatotoxicity, we have seen pancreatitis and a rare opportunistic infection related to the use of immunomodulators.

Constipation Prescription

Constipation Prescription

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