Structure formula of azathioprine
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Azathioprine

Azathioprine is a chemotherapy drug, now rarely used for chemotherapy but more for immunosuppression in organ transplantation and autoimmune disease such as rheumatoid arthritis or inflammatory bowel disease or Crohn's disease. It is a pro-drug, converted in the body to the active metabolite 6-mercaptopurine. more...

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Azathioprine was first introduced into clinical practice by Sir Roy Calne, the British pioneer in transplantation. Following the work done by Sir Peter Medawar in discovering the immunological basis of rejection of transplanted tissues and organs, Calne introduced 6-mercaptopurine as an experimental immunosuppressant for kidney transplants. When azathioprine was discovered, he then introduced it as a less toxic replacement for 6-mercaptopurine. For many years, dual therapy with azathioprine and steroids was the standard anti-rejection regime, until cyclosporine was introduced into clinical practice (also by Calne) in 1978.

Azathioprine acts to inhibit purine synthesis necessary for the proliferation of cells, especially leukocytes and lymphocytes. It is a safe and effective drug used alone in certain autoimmune diseases, or in combination with other immunosuppressants in organ transplantation. Its most severe side effect is bone marrow suppression, and it should not be given in conjunction with purine analogues such as allopurinol. The enzyme thiopurine S-methyltransferase (TPMT) deactivates 6-mercaptopurine. Genetic polymorphisms of TPMT can lead to excessive drug toxicity, thus assay of serum TPMT may be useful to prevent this complication.

Mycophenolate mofetil is increasingly being used in place of azathioprine in organ transplantation, but azathioprine certainly still has a major role.

Mycophenolate mofetil (MMF): seven RCTs compared MMF to azathioprine (AZA). MMF reduced the incidence of acute rejection. There was no significant difference in patient survival or graft loss at 1-year or 3-year follow-up. There appeared to be differences in the side-effect profiles of MMF and AZA. No RCTs comparing MMF with azathioprine were identified. Woodroffe R, Yao GL, Meads C, Bayliss S, Ready A, Raftery J, et al. Clinical and cost-effectiveness of newer immunosuppressive regimens in renal transplantation: a systematic review and modelling study. Health Technol Assess 2005;9(21).

Reference

  • Konstantopoulou M, Belgi A, Griffiths KD, Seale JR, Macfarlane AW. Azathioprine-induced pancytopenia in a patient with pompholyx and deficiency of erythrocyte thiopurine methyltransferase. BMJ 2005;330:350-1. PMID 15705694.

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Treatment of idiopathic pulmonary fibrosis solely with anti-acid gastro-esophageal reflux therapy: a case series of four patients with long-term follow-up
From CHEST, 10/1/05 by Ganesh Raghu

PURPOSE: Idiopathic pulmonary fibrosis (IPF) is a relentless, progressive and fatal disease with no known effective treatment. Increased acid gastro-esophageal reflux (GER) has been associated with IPF. We speculate that acid gastroesophageal reflux (GER) is an important factor for the development and/or progression of IPF.

METHODS: Patients with new onset IPF and presenting with symptoms and documented gastro-esophageal reflux disease (GERD) or abnormal acid GER by 24-hour esophageal pH probe testing, who refused conventional therapy (prednisone and azathioprine) or other concurrent medical treatments implicated for IPF and chose to be treated solely with anti-acid GER therapy.

RESULTS: Adequate suppression of acid GER was ascertained by 24-hour esophageal pH monitoring. Patients were followed regularly with pulmonary function tests (PFT) over 2-6 years. The PFTs (Forced vital capacity [FVC] and diffusion capacity for carbon monoxide [DLCO]) in all 4 patients stabilised or improved while being maintained on adequate daily treatment for acid GER, and were alive at last follow-up. None of the patients manifested acute exacerbation of IPF nor needed additional treatment for respiratory problems or antibiotics during this period. After maintaining 4 years of improved status in PFTs and exercise testing while adhering to treatment for acid GER, one patient's deterioration correlated with poor compliance to daily treatment during the 5th year, although the PFTs at last follow-up 6 years since diagnosis showed stabilisation compared to baseline. Another patient stabilised upon adhering to anti-acid GER treatment after an initial period of deterioration that was associated with non-adherence.

CONCLUSION: This case series suggests that add GER might be an important risk factor for IPF progression and that adequate treatment for abnormal acid GER may in part improve the outcome of patients with IPF. We also hypothesize that pulmonary fibrosis occurs in individuals who are genetically susceptible to develop fibrosis from recurrent chronic add GER.

CLINICAL IMPLICATIONS: Future clinical studies are indicated to determine the efficacy of treatment for acid GER in IPF either in combination with other agents or as a sole agent.

DISCLOSURE: Steve Yang, None

Ganesh Raghu MD Steve T. Yang MBBS * Carolyn Spada RN Jennifer Hayes RN Carlos Pelligrini MD Singapore General Hospital, Singapore, Singapore

COPYRIGHT 2005 American College of Chest Physicians
COPYRIGHT 2005 Gale Group

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