Azathioprine. In general, starting dosage is from 1mg/kg body weight/day, increasing after 4-6 weeks to 2- 3mg/kg/day, depending on the clinical response (which may not be evident for weeks or months) and haematological tolerance Dosage may need to be reduced in renal or hepatic impairment. For the elderly it is recommended that the dosages used should be at the lower end of the range. Mercaptopurine- a typical dose regimen may be:- 1mg/kg/day increasing after 4-6 week to 1-1.5mg/kg/day. Dose adjustment will be made by the consultant (or IBD nurse specialist). Lower doses if there is significant renal or hepatic impairment Time to response: 6 weeks to 3 months NB - Pneumovax and annual ‘flu vaccine should be given. Passive immunisation should be carried out using Varicella Zoster Immunoglobulin (VZIG) in non-immune patients if exposed to chickenpox or shingles. Contraindications Hypersensitivity to any component of the preparation Pregnancy or breastfeeding Individuals with inherited deficiency of the enzyme thiopurine methyltransferase (TPMT) are more susceptible to bone marrow suppression and toxicity. There is an increased risk of skin malignancies - patients should be advised to wear protective clothing and use sunscreen with a high protection factor. Side effects Nausea, diarrhoea, headache, arthralgia Rash or mouth ulcers may respond to a dose reduction otherwise treatment should be discontinued. Drug Interactions1 Vaccinations with live organism vaccines are not recommended in immunocompromised individuals. When allopurinol and mercaptopurine/azathioprine are administered concomitantly it is essential that only a quarter of the usual dose of mercaptopurine/azathioprine is given since allopurinol decreases the rate of catabolism of mercaptopurine/azathioprine Possible increased risk of leucopenia when given with aminosalicylate derivatives (e.g. olsalazine, mesalazine or sulfasalazine). Increased risk of haematological toxicity when given with sulfamethoxazole and trimethoprim. Avoid concomitant use with clozapine as increased risk of agranulocytosis. Avoidance of febuxostat on manufacturers’ advice Phenytoin, sodium valproate, carbamazepine adsorption is reduced. Anticoagulants-possible reduces anticoagulant effect of coumarins Monitoring Pretreatment assessment: FBC, U&Es, creatinine, LFTs and thiopurine methyl transferase (TPMT) assay. Monitoring:- FBC and LFTs fortnightly for 8 weeks, continue every 4 weeks until dose stable for 6 weeks; then every 3 months....
Azathioprine. (Imuran®) ICB As a steroid-sparing effect in patients with Autoimmune Diseases in whom steroids cannot be reduced or are contraindicated, and for maintaining remission in vasculitis Shared Care Agreement Level 2 - Prescribe the drug and perform a more intense level of monitoring, e.g. quarterly NICE has not issued any guidance. AMB 2 Azathioprine (Generics are available) ICB Steroid-sparing effect in ulcerative colitis and Crohn's disease (Not a licensed indication). Shared Care Agreement Level 2 - Prescribe the drug and perform a more intense level of monitoring, e.g. quarterly NICE has not issued any guidance. Hospital Azelastine and Fluticasone nasal spray Dymista® ICB moderate to severe seasonal and perennial rhinitis if monotherapy with antihistamine or corticosteroid is inadequate Restricted use – Prescribing to remain with the hospital or specialist service. No prescribing in primary care NICE has not issued any guidance. BLACK Azilsartan (Edarbi®)
Azathioprine. ESCA: For the treatment of rheumatoid arthritis or psoriatic arthritis AREAS OF RESPONSIBILITY FOR THE SHARING OF CARE This shared care agreement outlines suggested ways in which the responsibilities for managing the prescribing of azathioprine for rheumatoid arthritis or psoriatic arthritis can be shared between the specialist and general practitioner (GP). You are invited to participate however, if you do not feel confident to undertake this role, then you are under no obligation to do so. In such an event, the total clinical responsibility for the patient for the diagnosed condition remains with the specialist. Sharing of care assumes communication between the specialist, GP and patient. The intention to share care will be explained to the patient by the specialist initiating treatment. It is important that patients are consulted about treatment and are in agreement with it. Patients with rheumatoid arthritis or psoriatic arthritis are usually under regular specialist follow-up, which provides an opportunity to discuss drug therapy. The doctor who prescribes the medication legally assumes clinical responsibility for the drug and the consequences of its use. RESPONSIBILITIES and ROLES Specialist responsibilities
Azathioprine. In animal models, azathioprine has been associated with skeletal abnormalities, cleft palate, hydrops fetalis and haemopoetic abnormalities of the foetus. (195, 196) In humans, lymphopenia, hypogammaglobulinaemia and thymic hypoplasia have all been reported in children born to mothers on azathioprine. However, these latter changes seem to all be reversible after birth with no long-term effects on the child. Furthermore, azathioprine has been linked to pre-term deliveries, (197) and in light of the above reports, physicians historically recommended patients with AIH to discontinue azathioprine if they were trying to conceive. Recently, experience with azathioprine in pregnancy has increased dramatically with information derived from other patient populations especially those with inflammatory bowel disease, rheumatoid arthritis and patients following solid organ transplantation. (140) In light of the above studies, it is generally recommended that azathioprine therapy should be continued during pregnancy, at the same dose used to maintain stable graft function. At present no evidence exists to suggest that discontinuing the azathioprine for the gestational period is beneficial for the mother or foetal outcomes. Azathioprine is classified as a Food and Drug administration (FDA) category as class D, which states that positive evidence of risk to the foetus exists, but it is accepted that as in many medical conditions the potential benefits of its use throughout pregnancy may outweigh the risk.
Azathioprine. ESCA: For the treatment of Auto immune haemolytic anaemia AREAS OF RESPONSIBILITY FOR THE SHARING OF CARE This shared care agreement outlines suggested ways in which the responsibilities for managing the prescribing of Azathioprine in auto immune haemolytic anaemia can be shared between the specialist and general practitioner (GP). You are invited to participate however, if you do not feel confident to undertake this role, then you are under no obligation to do so. In such an event, the total clinical responsibility for the patient for the diagnosed condition remains with the specialist. Sharing of care assumes communication between the specialist, GP and patient. The intention to share care will be explained to the patient by the specialist initiating treatment. It is important that patients are consulted about treatment and are in agreement with it. Patients with haemolytic anaemia are usually under regular specialist follow-up, which provides an opportunity to discuss drug therapy. An ESCA is not necessarily required retrospectively for patients who have already previously been prescribed a medication in primary care for a period greater than one year, or who were prescribed a medication prior to the existence of the ESCA. Any referral back to the specialist in these circumstances should be based on clinical need. GP Prescribing System Read Code SNOMED Code Description EMIS and Vision 8BM5.00 415522008 Shared care prescribing SystmOne XaB58 Shared care The doctor who prescribes the medication legally assumes clinical responsibility for the drug and the consequences of its use. RESPONSIBILITIES and ROLES Specialist responsibilities
Azathioprine. For the treatment of auto-immune haemolytic anaemia Trust Contact details Telephone No. Email address: Consultant:- Specialist Nurse Please refer to BSSE APC formulary website for complete document. BACK-UP ADVICE AND SUPPORT (To be completed by Specialist team) Patient’s name Date of birth Sex Home Address Hospital Number NHS Number Hospital Specialist/Consultant Name (please print) Signature Date To be completed by the General Practitioner: I agree to participate in this shared care agreement for the treatment of the below named patient with Azathioprine for auto-immune haemolytic anaemia. General Practitioner Name (please print) Signature Date Please keep a copy of this agreement for your own records and forward the original to the above named Consultant. In the patient's notes, using the appropriate Read Code listed below, denote that the patient is receiving treatment under a shared care agreement. GP Prescribing System Read Code SNOMED Code Description EMIS and Vision 8BM5.00 415522008 Shared care prescribing
Azathioprine. Patients should have baseline thiopurine methyltransferase (TPMT) status assessed. Hydroxychloroquine: Patients should have formal ophthalmic examination with their optician annually. This should include formal visual acuity testing for distance and reading vision, fundoscopy and 10-2 central visual field testing. If a patient is on Hydroxychloroquine for > 5years, the patient should be referred to ophthalmology for the above tests and in addition have an objective retinal assessment for using optical coherence tomography (OCT).
Azathioprine. Azathioprine is an effective disease modifying drug used in the treatment of inflammatory arthritis, inflammatory bowel disease, lupus and other inflammatory conditions. It has immunosuppressant and anti-inflammatory effects.
Azathioprine. (either alone or more usually in combination with corticosteroids and/or other drugs and procedures) ESCA: For the treatment of systemic lupus erythematosus / dermatomyositis, polymyositis and pemphigus vulgaris AREAS OF RESPONSIBILITY FOR THE SHARING OF CARE This shared care agreement outlines suggested ways in which the responsibilities for managing the prescribing of azathioprine in systemic lupus erythematosus / dermatomyositis and polymyositis can be shared between the specialist and general practitioner (GP). You are invited to participate however, if you do not feel confident to undertake this role, then you are under no obligation to do so. In such an event, the total clinical responsibility for the patient for the diagnosed condition remains with the specialist. Sharing of care assumes communication between the specialist, GP and patient. The intention to share care will be explained to the patient by the specialist initiating treatment. It is important that patients are consulted about treatment and are in agreement with it. Patients with systemic lupus erythematosus / dermatomyositis and polymyositis are usually under regular specialist follow-up, which provides an opportunity to discuss drug therapy. The doctor who prescribes the medication legally assumes clinical responsibility for the drug and the consequences of its use. RESPONSIBILITIES and ROLES Specialist responsibilities
Azathioprine. For the treatment of systemic lupus erythematosus / dermatomyositis and polymyositis / pemphigus vulgaris Please refer to BSSE APC formulary website for complete document. BACK-UP ADVICE AND SUPPORT (To be completed by Specialist team) Trust Contact details Telephone No. Email address: Consultant:- Specialist Nurse Patient’s name Date of birth Sex Home Address Hospital Number NHS Number Hospital Specialist/Consultant Name (please print) Signature Date To be completed by the General Practitioner: I agree to participate in this shared care agreement for the treatment of the below named patient with azathioprine in systemic lupus erythematosus / dermatomyositis and polymyositis / pemphigus vulgaris General Practitioner Name (please print) Signature Date Please keep a copy of this agreement for your own records and forward the original to the above named Consultant. In the patient's notes, using the appropriate Read Code listed below, denote that the patient is receiving treatment under a shared care agreement. GP Prescribing System Read Code Description GP Prescribing System Read Code Description
