([cited 2013 -]): Gardiner SJ, Gearry RB, Roberts RL, Zhang M, Barclay ML, Begg EJ "Exposure to thiopurine drugs through breast milk is low based on metabolite concentrations in mother-infant pairs." Guidelines for handling parenteral antineoplastics. He's as healthy as can be. Williamson and Karp described an infant born with preaxial polydactyly whose mother received Azathioprine 200 mg daily and prednisone 20 mg every other day during pregnancy.6 Tallent et al described an infant with a large myelomeningocele in the upper lumbar region, bilateral dislocated hips, and bilateral talipes equinovarus. The sodium salt of Azathioprine is sufficiently soluble to make a 10 mg/mL water solution which is stable for 24 hours at 59° to 77°F (15° to 25°C). Azathioprine is in a class of medications called immunosuppressants. Physicians using this drug should be very familiar with this risk as well as with the mutagenic potential to both men and women and with possible hematologic toxicities. Hepatotoxicity manifest by elevation of serum alkaline phosphatase, bilirubin, and/or serum transaminases is known to occur following Azathioprine use, primarily in allograft recipients. World Health Organization "Breastfeeding and maternal medication: recommendations for drugs in the eleventh Who model list of essential drugs. However, they might be recommended with caution during pregnancy by some physicians to combat a serious flare-up. Breast feeding Present in milk in low concentration. WARNING - MALIGNANCY Chronic immunosuppression with azathioprine, a purine antimetabolite increases risk of malignancy in humans. A lthough azathioprine in clinically used doses has no effect on human interstitial cell function or DeWitte DB, Buick MK, Cyran SE, et al. Subscribe to Drugs.com newsletters for the latest medication news, new drug approvals, alerts and updates. Whenever possible, use of Azathioprine tablets in pregnant patients should be avoided. Clinical Oncological Society of Australia. Medically reviewed by Drugs.com. Immunosuppressants: The immunosuppressive drugs azathioprine (Imuran [Pregnancy Category D]) and 6-mercaptopurine (Purinethol or 6-MP [Pregnancy Category D]) do cross the placenta and can be detected in cord blood Pregnancy Category D. Azathioprine tablets can cause fetal harm when administered to a pregnant woman. Ask about reliable forms of birth control while using this medication. It is on the World … Breastfeeding . TPMT and NUDT15 testing cannot substitute for complete blood count (CBC) monitoring in patients receiving Azathioprine. Clin Pharmacokinet 27 (1994): 486-503, Saarikoski S, Seppala M "Immunosuppression during pregnancy: transmission of azathioprine and its metabolites from the mother to the fetus." These include skin rashes, alopecia, fever, arthralgias, diarrhea, steatorrhea, negative nitrogen balance, reversible interstitial pneumonitis and hepatosplenic T-cell lymphoma (see Warnings Malignancy), and Sweet’s Syndrome (acute febrile neutrophilic dermatosis). Azathioprine is stable in solution at neutral or acid pH but hydrolysis to mercaptopurine occurs in excess sodium hydroxide (0.1N), especially on warming. Octreotide, cefotaxime, lactulose, telbivudine, prednisone, and ursodeoxycholic acid (UDCA) have been deemed pregnancy category B, as animal studies have shown no harmful effects (Tables 1 and 2 ). The cytotoxicity of Azathioprine is due, in part, to the incorporation of 6-TGN into DNA. The white blood cell count, SGOT, and bilirubin returned to normal 6 days after the overdose. There are no adequate and well-controlled studies in pregnant women. It is suggested that patients on Azathioprine have complete blood counts, including platelet counts, weekly during the first month, twice monthly for the second and third months of treatment, then monthly or more frequently if dosage alterations or other therapy changes are necessary. Genetic polymorphisms influence TPMT and NUDT15 activity. May adjust dose gradually to 2.5 mg/kg/day if needed. Additional side effects of low frequency have been reported. Saarikoski S, Seppala M. Immunosuppression during pregnancy: transmission of Azathioprine and its metabolites from the mother to the fetus. Azathioprine is considered a slow-acting drug and effects may persist after the drug has been discontinued. Azathioprine falls into category D. It has been shown that use of azathioprine in pregnant women caused some babies to be born with problems. Conversion to mercaptopurine also occurs in the presence of sulfhydryl compounds such as cysteine, glutathione, and hydrogen sulfide. Treatment should not generally be initiated during pregnancy. I had a fabulous pregnancy, and my son is in the 95th percentile in every category. UK: Use is contraindicated.AU and US: Caution is recommended.Excreted into human milk: YesDrugs and lactation database (LactMed): Breastfeeding is considered acceptable. Available from: URL: http://whqlibdoc.who.int/hq/2002/55732.pdf?ua=1" (): United States National Library of Medicine "Toxnet. These medications work by interfering with genetic material, which has raised concern for pregnancy risks, but the majority of the studied pregnancies have not had birth defects. Dose reduction to maintenance levels of 1 to 3 mg/kg daily is usually possible. Symptoms of gastrointestinal toxicity most often develop within the first several weeks of therapy with Azathioprine tablets and are reversible upon discontinuation of the drug. The increased risk of malignancy following therapy with Azathioprine tablets should be explained to the patient. It is recommended that a further dose reduction or alternative therapies be considered for patients with low or absent TPMT activity receiving Azathioprine and xanthine oxidase inhibitors because both TPMT and XO inactivation pathways are affected (see CLINICAL PHARMACOLOGY, WARNINGS, PRECAUTIONS: Laboratory Tests and ADVERSE REACTIONS sections). These patients have subnormal responses to vaccines, low numbers of T-cells, and abnormal phagocytosis by peripheral blood cells, but their mitogenic responses, serum immunoglobulins, and secondary antibody responses are usually normal. It is also used to treat severe rheumatoid arthritis (a condition in which the body attacks its own joints, causing pain, swelling, and loss of function) when other medications and treatments have not helped. In patients with severe myelosuppression, consider evaluation for TPMT and NUDT15 deficiency (see PRECAUTIONS: Laboratory Tests). Recommendations for the safe handling of parenteral antineoplastic drugs. Does it affect the baby. The risk of post-transplant lymphomas may be increased in patients who receive aggressive treatment with immunosuppressive drugs, including Azathioprine. Women with decreased activity of the enzyme that detoxifies azathioprine metabolites may pass on higher levels of drug to their infants via breast milk.If the decision is made to use azathioprine during breastfeeding, it may be advisable to monitor the complete blood count with differential, and liver function tests in exclusively breastfed infants. Whenever possible, use of IMURAN in pregnant patients should be avoided. Therapeutic response occurs after several weeks of treatment, usually 6 to 8; an adequate trial should be a minimum of 12 weeks. Procedures for proper handling and disposal of this immunosuppressive antimetabolite drug should be considered. The risks of secondary infection and malignancy are also significant (see WARNINGS). UK: Use is contraindicated. Chronic immunosuppression with Azathioprine, a purine antimetabolite increases risk of malignancy in humans. Azathioprine is an FDA Pregnancy Category D drug. Available for Android and iOS devices. Heterozygous deficiency in TPMT and/or NUDT15. Azathioprine Tablets USP, 100 mg are yellow, round, flat, radial-edged tablets with bisect on one side and other side of tablet is plain; one side of the bisect is debossed with "ZD" and other side is debossed with "09" and are supplied as follows: NDC 68382-120-01 in bottles of 100 tablets, NDC 68382-120-05 in bottles of 500 tablets. Leukopenia and/or thrombocytopenia are dose-dependent and may occur late in the course of therapy with Azathioprine tablets. The U.S. Food and Drug Administration (FDA) states that methotrexate shouldn’t be used in pregnancy, as does the service MotherToBaby.MotherToBaby is dedicated to … Whenever possible, use of AZASAN® (azathioprine) in pregnant patients should be avoided. Use during pregnancy may result in harm to the baby. A unique aspect of azathioprine is its relatively safe profile during pregnancy (US FDA category D) and lactation compared to other immunomodulatory therapeutic options and hence, makes it … The European Crohn's and Colitis Organisation consensus states that thiopurines should be considered in high-risk patients. Homozygous deficiency in either TPMT or NUDT15. Prevention of rejection in organ and tissue transplantation 1-5 mg/kg/day. The only drugs that are absolutely contraindicated for Azathioprine tablets should not be given during pregnancy without careful weighing of risk versus benefit. Very large doses of this antimetabolite may lead to marrow hypoplasia, bleeding, infection, and death. IMURAN should not be given during pregnancy without careful weighing of risk versus benefit. The use of angiotensin-converting enzyme inhibitors to control hypertension in patients on Azathioprine has been reported to induce anemia and severe leukopenia. Consider testing for TPMT and NUDT15 deficiency in patients who experience severe bone marrow toxicities. The immunosuppressive agent azathioprine is considered a pregnancy category D drug, with some evidence of increased risk of fetal abnormalities in human studies. TPMT activity correlates inversely with 6-TGN levels in erythrocytes and presumably other hematopoietic tissues, since these cells have negligible xanthine oxidase (involved in the other inactivation pathway) activities. As usual for patients with increased risk for skin cancer, exposure to sunlight and ultraviolet light should be limited by wearing protective clothing and using a sunscreen with a high protection factor. "Successful pregnancies in women treated by dialysis and kidney transplantation." Dr. Heidi Fowler answered. These symptoms may also be accompanied by diarrhea, rash, fever, malaise, myalgias, elevations in liver enzymes, and occasionally, hypotension. Despite azathioprine’s category D rating, some believe that this agent is potentially useful for treating MS in pregnancy. Therapeutic actions Azathioprine … 0. Glaxo Wellcome, Research Triangle Park, NC. Tagatz GE, Simmons RL. Pregnancy Categories. Consider genotyping or phenotyping patients for TPMT deficiency and genotyping for NUDT15 deficiency in patients with severe myelosuppression. Despite conflicting data, general expert opinion suggests that azathioprine may be considered for use during pregnancy in certain situations (where the potential benefits outweigh potential risks). Reports of malignancy include post-transplant lymphoma and hepatosplenic T-cell lymphoma (HSTCL) in patients with inflammatory bowel disease. Consider reducing the amount of immunosuppression in patients who develop PML. Both men and women should avoid methotrexate [see above]. TY - JOUR T1 - The use of azathioprine in Crohns disease during pregnancy and in the post-operative setting T2 - A worldwide survey of experts AU - Peyrin-Biroulet, L. AU - Oussalah, A. Suppression of T-cell effects, including ablation of T-cell suppression, is dependent on the temporal relationship to antigenic stimulus or engraftment. during pregnancy is not indicated or advisable . Br J Obstet Gynaecol 87 (1980): 839-45, Pirson Y, Van Lierde M, Ghysen J, Squifflet JP, Alexandre GP, van Ypersele de Strihou C "Retardation of fetal growth in patients receiving immunosuppressive therapy." The optimum duration of maintenance Azathioprine tablets has not been determined. 0. These cases have had a very aggressive disease course and have been fatal. Maintenance therapy should be at the lowest effective dose, and the dose given can be lowered decrementally with changes of 0.5 mg/kg or approximately 25 mg daily every 4 weeks while other therapy is kept constant. Pregnancy. Consider the diagnosis of PML in any patient presenting with new-onset neurological manifestations and consider consultation with a neurologist as clinically indicated. The data suggest the risk may be elevated in patients with rheumatoid arthritis, though lower than for renal transplant patients. Obstet Gynecol 58 (1981): 247-50, Ramsey-Goldman R, Mientus JM, Kutzer JE, Mulvihill JJ, Medsger TA, Jr "Pregnancy outcome in women with systemic lupus erythematosus treated with immunosuppressive drugs." A 40-year-old member asked: do you need a prescription for imuran (azathioprine)? It is insoluble in water, soluble in dilute solutions of alkali hydroxides, sparingly soluble in dilute mineral acids, very slightly soluble in alcohol and in chloroform. 8 Animals studies have demonstrated teratogenicity in mice and rats exposed to azathioprine. Clark JM. Azathioprine tablets, USP are indicated for the treatment of active rheumatoid arthritis (RA) to reduce signs and symptoms. 12 Gastroenterology 99 (1990): 443-6, Coulam CB, Moyer TP, Jiang NS, Zincke H "Breast-feeding after renal transplantation." Azathioprine and long-wave ultraviolet light have been shown to have a synergistic clastogenic effect in patients treated with azathioprine for a range of disorders. The mechanisms whereby Azathioprine affects autoimmune diseases are not known. Washington, DC: Division of Safety; Clinical Center Pharmacy Department and Cancer Nursing Services, National Institute of Health; 1992. Azathioprine may harm an unborn baby. Call your doctor for medical advice about side effects. 0. Auto-immune diseases 1-3 mg/kg/day. No information is available on the relationship of age to the effects of azathioprine injection in geriatric patients. は，経験と関係者からのフィードバックを通じて，薬剤胎児危険度分類（ pregnancy category）は混乱をもたらし，胎児へのリスクの程度の差を正確かつ一貫性をもって伝達するも のではなかったことを認識した。また，臨床医は薬剤胎児危険 Azathioprine is an immunosuppressive antimetabolite. Use with xanthine oxidase (XO) inhibitors, We comply with the HONcode standard for trustworthy health information -, ANALYSIS(68382-118, 68382-119, 68382-120), MANUFACTURE(68382-118, 68382-119, 68382-120). The dose you are given will depend on your body weight. ACTIVE LEARNING TEMPLATE: Medication STUDENT NAME_ Azathioprine MEDICATION_ REVIEW MODULE CHAPTER_ Category D- Patients on Azathioprine tablets should have complete blood counts, including platelet counts, weekly during the first month, twice monthly for the second and third months of treatment, then monthly or more frequently if dosage alterations or other therapy changes are necessary. Hepatotoxicity following transplantation most often occurs within 6 months of transplantation and is generally reversible after interruption of Azathioprine tablets. Use with Angiotensin-Converting Enzyme Inhibitors. However, in some patients, nausea and vomiting may be severe and may be accompanied by symptoms such as diarrhea, fever, malaise, and myalgias (see PRECAUTIONS). Topical fluorouracil and imiquimod are indicated for treatment of viral warts. Pregnancy Category D. See WARNINGSsection. Other drugs that are classified as Pregnancy Category C or D (infliximab, azathioprine, and 6-mercaptopurine, for example) have been safely used during pregnancy as well. If the benefits of treatment with azathioprine (for instance, to maintain remission during pregnancy) outweigh the risks, this drug may be continued during pregnancy. Azathioprine suppresses … Birth defects in child of male recipient of kidney transplant. Benefit versus risk must be weighed carefully before use of Azathioprine tablets in patients of reproductive potential. The combined use of Azathioprine tablets with disease modifying anti-rheumatic drugs (DMARDs) has not been studied for either added benefit or unexpected adverse effects. Alterations in specific immune responses or immunologic functions in transplant recipients are difficult to relate specifically to immunosuppression by Azathioprine. Notable exceptions are neomycin, azathioprine, and penicillamine, which have been designated pregnancy category D because of animal studies showing a possible risk of fetal harm (Tables 1 and 2). Dose reduction or temporary withdrawal may result in reversal of these toxicities. Azathioprine and 6-MP are knowingly given for medical reasons during pregnancy. Controlled studies in pregnant women show no evidence of fetal risk. Activation of 6-mercaptopurine occurs via hypoxanthine-guanine phosphoribosyltransferase (HGPRT) and a series of multi-enzymatic processes involving kinases to form 6-thioguanine nucleotides (6-TGNs) as major metabolites. Imuran (azathioprine): Imuran (azathioprine) is FDA pregnancy category D (Positive evidence of risk) 2 doctors agree. The initial dose should be approximately 1.0 mg/kg (50 to 100 mg) given as a single dose or on a twice-daily schedule. One is thiol methylation, which is catalyzed by the enzyme thiopurine S-methyltransferase (TPMT), to form the inactive metabolite methyl-6-MP (6-MeMP). These infections may lead to serious, including fatal outcomes. Pregnancy category: D. Lactation: Drug excreted at low levels in breast milk; use not recommended. Risk factors for PML include treatment with immunosuppressant therapies and impairment of immune function. The initial dose is usually 3 to 5 mg/kg daily, beginning at the time of transplant. 2 It works by decreasing the activity of the body's immune syst… Pregnancy and breastfeeding Azathioprine can cause birth defects. There are no controlled data in human pregnancy. The dose of Azathioprine tablets should not be increased to toxic levels because of threatened rejection. UNICEF. The use of Azathioprine tablets with these agents cannot be recommended. Imuran (azathioprine)." Usual doses produce blood levels of Azathioprine, and of mercaptopurine derived from it, which are low (<1 mcg/mL). 41,71 Data relating to 72 In a 73 The structural formula of Azathioprine is: It is an imidazolyl derivative of 6-mercaptopurine and many of its biological effects are similar to those of the parent compound. The relative incidences in clinical studies are summarized below: *Data on the rate and risk of neoplasia among persons with rheumatoid arthritis treated with Azathioprine are limited. The use of Azathioprine for inhibition of renal homograft rejection is well established, the mechanism(s) for this action are somewhat obscure. J Rheumatol 20 (1993): 1152-7. Nausea and vomiting may occur within the first few months of therapy with Azathioprine tablets, and occurred in approximately 12% of 676 rheumatoid arthritis patients. Inhibition of XO may cause increased plasma concentrations of Azathioprine or its metabolite, 6-MP, leading to toxicity. The patients were evaluated at least once in each trimester and postpartum. This preliminary study suggests that azathioprine is safe in pregnancy in inflammatory bowel disease patients and that termination of pregnancy is not mandatory for those who conceive while taking the drug. The drug suppresses hypersensitivities of the cell-mediated type and causes variable alterations in antibody production. Extra hematologic monitoring should be considered during pregnancy.A National Transplantation Pregnancy Registry (NTPR) has been established to monitor maternal-fetal outcomes of pregnant women exposed to immunosuppressant drugs, including azathioprine. Animal studies have revealed evidence of teratogenicity. 2, Azathioprine tablets can cause fetal harm when administered to a pregnant woman. Azathioprine tablets are usually given on a daily basis. Pregnancy: Azathioprine can cause fetal harm when administered to a pregnant woman. Br J Obstet Gynaecol 100 (1993): 122-5, Kirk EP "Organ transplantation and pregnancy: a case report and review." For example, the severity of adjuvant arthritis is reduced by Azathioprine. DeWitte et al reported pancytopenia and severe immune deficiency in a preterm infant whose mother received 125 mg Azathioprine and 12.5 mg prednisone daily. Jones RB, Frank R, Mass T. Safe handling of chemotherapeutic agents: a report from The Mount Sinai Medical Center. There is in vitro evidence that aminosalicylate derivatives (e.g., sulphasalazine, mesalazine, or olsalazine) inhibit the TPMT enzyme. Imuran and Pregnancy Category D The U.S. Food and Drug Administration (FDA) uses a category system to classify the possible risks to a fetus when a specific medicine is taken during pregnancy. Severe leukopenia, thrombocytopenia, anemias including macrocytic anemia, and/or pancytopenia may occur in patients being treated with Azathioprine. There are no adequate studies in women for determining infant risk when using this medication during breastfeeding. The easiest way to lookup drug information, identify pills, check interactions and set up your own personal medication records. We comply with the HONcode standard for trustworthy health information -, Ostensen M "Optimisation of antirheumatic drug treatment in pregnancy." Some of the patients were treated with Azathioprine as monotherapy and some had received concomitant treatment with a TNFα blocker at or prior to diagnosis. Use is considered contraindicated unless the benefits outweigh the risks.Rheumatoid arthritis: Contraindicated (US)AU TGA pregnancy category: DUS FDA pregnancy category: DComments: Adequate methods of contraception should be encouraged in both male and female patients of reproductive age during, and for at least 3 months after treatment cessation. A  A rare, but life-threatening hepatic veno-occlusive disease associated with chronic administration of Azathioprine has been described in transplant patients and in one patient receiving Azathioprine tablets for panuveitis.11, 12, 13Periodic measurement of serum transaminases, alkaline phosphatase, and bilirubin is indicated for early detection of hepatotoxicity. Select one or more newsletters to continue. Azathioprine (AZA), although a category D medication, can be used if the benefits outweigh the risks. Azathioprine was first made in 1957. Blood levels are of little predictive value for therapy since the magnitude and duration of clinical effects correlate with thiopurine nucleotide levels in tissues rather than with plasma drug levels. The use of Azathioprine tablets in nursing mothers is not recommended. Azathioprine tablets are usually given as a single daily dose on the day of, and in a minority of cases 1 to 3 days before, transplantation. That means two things: That means two things: Studies show a risk of adverse effects … Drugs which may affect leukocyte production, including co-trimoxazole, may lead to exaggerated leukopenia, especially in renal transplant recipients. 0 comment. Azathioprine teratogenicity: review of the literature and case report. "Product Information. The principal and potentially serious toxic effects of Azathioprine tablets are hematologic and gastrointestinal. Dose increments should be 0.5 mg/kg daily, up to a maximum dose of 2.5 mg/kg per day.    A 2003 population-based study in Denmark showed that the use of azathioprine and related mercaptopurine resulted in a seven-fold incidence of fetal abnormalities as well as a 20-fold increase in miscarriage . Relatively oliguric patients, especially those with tubular necrosis in the immediate postcadaveric transplant period, may have delayed clearance of Azathioprine tablets or its metabolites, may be particularly sensitive to this drug, and are usually given lower doses. US Dept of Health and Human Services. The p.R139C variant of NUDT15 (present on the *2 and *3 alleles) is the most commonly observed, but other less common loss-of-function NUDT15 alleles have been observed. Am J Obstet Gynecol 115 (1973): 1100-6, De Witte, DB, Buick MK, Cyran SE, Maisels MJ "Neonatal pancytopenia and severe combined immunodeficiency associated with antenatal administration of azathioprine and prednisone." If this drug is used during pregnancy or if the patient becomes pregnant while taking this drug, the patient should be apprised of the potential hazard to the fetus. Renal clearance is probably not important in predicting biological effectiveness or toxicities, although dose reduction is practiced in patients with poor renal function. If the benefits of treatment with azathioprine (for instance, to maintain remission during pregnancy) outweigh the risks, this drug may be continued during pregnancy. Always consult your healthcare provider to ensure the information displayed on this page applies to your personal circumstances. Renal transplant patients are known to have an increased risk of malignancy, predominantly skin cancer and reticulum cell or lymphomatous tumors. With a mounting body of evidence indicating its teratogenicity, the drug was recently downgraded from FDA pregnancy category C to category D, implying that its use in pregnancy should be avoided (83,84). 9, 10 In humans, including Patients who are heterozygous for both TPMT and NUDT15 deficiency may require more substantial dosage reductions (see CLINICAL PHARMACOLOGY, WARNINGS: Cytopenias, and PRECAUTIONS: Laboratory Tests). There have been reports of premature birth and low birth weight (especially in combination with corticosteroids), and spontaneous abortion after either maternal or paternal exposure; some data suggest an increased risk of intrauterine growth retardation and prematurity. The easiest way to lookup drug information, identify pills, check interactions and set up your own personal medication records. Cases of mild, asymptomatic neutropenia have been reported; however, long-term data for carcinogenesis are not available. Consider alternative therapy in patients with homozygous TPMT or NUDT15 deficiency and reduced dosages in patients with heterozygous deficiency (see DOSAGE AND ADMINISTRATION). Last updated on Feb 6, 2019. Azathioprine has been classed as FDA category D – positive evidence of risk. Data sources include IBM Watson Micromedex (updated 7 Dec 2020), Cerner Multum™ (updated 4 Dec 2020), ASHP (updated 3 Dec 2020) and others. Of neonates whose mothers took Azathioprine throughout their pregnancies is oxidation, which are low ( 1... Be significantly higher than that in azathioprine pregnancy category presence of sulfhydryl compounds such as cysteine, glutathione, and hydrogen.! Dehydrogenase ( IMDH ) is required for one of the literature and report... And cellular cytotoxicity tests being suppressed to a pregnant woman immunosuppression represents to mother! Aj, Brunner FP, Brynger H, Gokel JM, Loeshke K, et.. 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