Azathioprine is a drug prescribed to dampen the immune system in the body. The immune system safeguards the body from infection, but it can also make you unwell and have some undesirable effects.
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Azathioprine is an immunosuppressant used to tackle conditions created by a defective immune system, such as rheumatoid arthritis, autoimmune hepatitis and systemic lupus erythematosus. It is also used to treat the immune system’s refusal of a new organ, following a transplant. The medicine stops the immune system from reacting in such a way, and thereby allows the organs to function properly. It works in partnership with other drugs such as corticosteroids to improve organ transplants’ survival.
Rheumatoid arthritis produces painful, swollen and stiff joints, typically affecting the hands, wrists and feet. The immune system attacks these regions in error, which causes discomfort and swelling. What gives rise to this dysfunction of the immune system remains uncertain, but the risks are greater for women, and if the condition already runs in your family, or if you are a smoker.
Autoimmune Hepatitis is a condition that results in inflammation of the liver. It is estimated that only around 10,000 people in the UK have it, but it is a chronic condition and treatment with Azathioprine is usually lifelong. It is 3 to 4 times more common in women than men, it can affect all ethnicities and it may develop at any point in your life, but it is most prevalent amongst women around 45 years old.
Systemic lupus erythematosus, like Rheumatoid arthritis, causes joint inflammation, but also inflammation of the skin and other organs. It’s an autoimmune condition, which is when the immune system attacks healthy tissue. Although it isn’t entirely clear what causes lupus, viral infections, strong medications, sunlight, puberty, childbirth and the menopause are all triggers. There is no cure as such but lupus in most cases responds well to treatment.
In terms of organ transplants and their survival in the body, the process is made difficult when the immune system judges the new organ to be foreign, ultimately leading to the complete destruction of the organ. Immunosuppressive drugs, like Azathioprine, can help to stop and address the rejection of organs by reducing the immune system’s reaction. However, these medicines can leave people more vulnerable to disease as a result of being non-specific, and there are a series of unpleasant side effects.
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When using this medication, you should always follow the instructions provided by your prescriber, and read the patient information leaflet prior to use.
- In cases where there is a risk of organ rejection, it is advised that the starting dose should be up to 5mg per kg of body weight per day. Your doctor will review your reaction to the drug and select the most appropriate dose for you. This could take weeks or months.
- Following this first review, your dose will typically range from 1 to 4mg per kg of your body weight each day.
- Swallow tablets whole with water. Do not break or chew them.
- Usually, Azathioprine is taken in the mornings with or immediately after food to reduce stomach pain. It can however also be taken before bed if nausea is an issue.
- Speak to your nearest A&E department or doctor if you take too many tablets. You should take the container and any tablets remaining with you.
- Should you forget to take the medication, take the dose as soon as you can. However, if the window between your missed dose and your next dose is small, take your dose as normal and consult your pharmacy prescriber.
- It may be between 6 and 12 weeks before you start to observe any positive impact.
- Continue to take the drug even if your condition begins to improve.
- Blood tests at regular points during treatment are essential as the medicine can increase your likelihood of getting infections and impact on the blood or the liver. You must have your blood count checked at least once per week for the first two months of treatment, and then on a monthly basis.
In the event that you have any queries about treatment, your doctor or pharmacist can advise you.
Side effects and warnings
You should consult your doctor or your pharmacy prescriber if you experience any allergic reactions, or any other serious side effects. This includes any allergic response to azathioprine, mercaptopurine (a medicine used to treat leukaemia, a cancer of the white blood cells) or any of the other ingredients of this medicine.
Very common (can affect more than 1 in 10 people):
Any signs of a viral, fungal or bacterial infection or fever (infections are very common if you are taking Azathioprine after an organ transplant, and with another immunosuppressant or corticosteroid). Low levels of white blood cells that make you more susceptible to infections.
Common (1 in 10 people or less):
Reduction in blood platelets which increase the risk of bleeding or bruising
Rare (1 in 1000 people or less):
Various types of cancers including blood, lymph and skin cancers, stomach pain and swelling, yellowing of the skin or whites of the eyes (Azathioprine can cause a rare but severe form of liver disease which can be fatal), disturbances of the bowel such as inflammation which causes abdominal pain, fever, discomfort, vomiting or diarrhoea (severe diarrhoea may happen, especially if you are being treated for inflammatory bowel disease), severe reduction of all types of blood cells which can cause weakness, bruising or make infections more likely, severe blistering of the skin, mouth, throat, nose, genitals and conjunctivitis (red and swollen eyes).
Very rare (may affect up to 1 in 1000 people):
Inflammation of the lungs which can cause weakness, breathlessness, cough and fever.
Stop taking Azathioprine and tell your doctor immediately if you come into contact with anyone who is suffering from chickenpox or shingles.
Other side effects may include:
Rare side effects (may affect up to 1 in 1,000 people): hair loss, especially if you are also taking another immunosuppressant, increased sensitivity of the skin to sunlight.
Not known (frequency cannot be estimated from the available data):
Nausea (feeling sick) particularly when first taking Azathioprine. This can be relieved if you take your tablets following meals.
Conditions to look out for
Inform your prescriber about any conditions you currently have or have had.
You should not use Azathioprine if you’re allergic to any of its ingredients.
Chicken pox or shingles can be very serious for people using immunosuppressive medication. You should avoid contact with anyone who has these conditions.
Discuss with your doctor or pharmacy prescriber before taking this medicine if you: have a metabolic abnormality called Lesch-Nyhan syndrome, have a shortage of a liver enzyme called thiopurine methyltransferase (TPMT) or have liver or kidney disease.
If you have an inherited mutation in the NUDT15-gene (a gene involved in the break-down of Azathioprine in the body), you have an increased risk of infections and hair loss.
If you are receiving immunosuppressive therapy, Azathioprine may make you more susceptible to tumours, including skin cancer. In light of this, when taking Azathioprine, avoid excessive exposure to sunlight, wear protective clothing and make sure you use high factor sunscreen.
You may also be at increased risk of: lymphoproliferative disorders, lymphoproliferative disorder (can lead to death), Epstein-Barr virus (EBV) - associated lymphoproliferative disorders, Macrophage Activation Syndrome (excessive activation of white blood cells associated with inflammation).
Taking it with other medications
You should tell your pharmacy prescriber about any other medications you are taking.
These medicines may impact on Azathioprine. Tell your doctor if you are using them (this includes medicines obtained without a prescription) or the following: other immunosuppressants e.g. ciclosporin, methotrexate, tacrolimus, medicines to treat cancer e.g. doxorubicin, allopurinol, oxipurinol or thiopurinol (for gout or kidney stones), cimetidine (for gut or stomach ulcers), furosemide (‘water tablets’), penicillamine (for rheumatoid arthritis), warfarin (to ‘thin’ the blood),captopril (for blood pressure or heart failure), indomethacin (an anti-inflammatory), co-trimoxazole (an antibiotic), mesalazine, olsalazine, sulfasalazine or balsalazide (mainly used to treat ulcerative colitis).
If you are going to have an operation, you should tell your doctor or the hospital staff as Azathioprine can impact on medicines called muscle relaxants (e.g. succinylcholine or tubocurarine), which you may be given during your operation. If you are going to have a vaccination, consult your doctor as certain vaccines should not be provided or may be less effective, when used in conjunction with Azathioprine.
Pregnancy and breastfeeding
You should not consume Azathioprine if you are pregnant, become pregnant, are attempting to become pregnant, or are breastfeeding, as this medicine may harm your baby. Consult your doctor as soon as you can.
Driving and using machines
If you experience dizziness with Azathioprine, you should avoid driving or using machinery.
Food, drink and alcohol
Alcohol may be consumed in moderation with this medication but it should be noted that it can make nausea more severe.
Taking Azathioprine after food is advisable to prevent stomach pain.
Azathioprine does not appear to have any impact on fertility.
Can I still drink alcohol?
Yes, but it should be consumed in moderation. It may also make any nausea worse.
Will I still be able to drive?
If the medication causes any dizziness, you should refrain from driving and speak to your doctor.
Can I take the medicine while pregnant?
No. Azathioprine should not be taken whilst pregnant or breastfeeding.
How should I store it?
Keep this medicine out of sight and reach of children.
Do not use this medicine beyond its expiry date.
You should not dispose of any medicines using wastewater or household waste. Consult your pharmacy prescriber as to how to throw away medicines you no longer use.
Am I allergic to anything in the medicine?
This medicine contains: azathioprine, maize starch, microcrystalline cellulose, mannitol, povidone K25, croscarmellose sodium, hypromellose and macrogol.
Is it available over-the-counter?
No. It is available by prescription only.
Is it possible to buy Azathioprine online?
Azathioprine should only be issued having spoken with a doctor or pharmacy prescriber first.
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