Azathioprine and allopurinol

[Talaia]

So I've gotten very distracted by final exams and projects and by a mild flare (which was luckily reigned in by a couple of weeks of cortifoam). However, I am finally making some progress on what to do about maintenance meds, and was wondering if anyone has some experience with this particular combination.

To summarize what's going on: I found out a while ago that the azathioprine I was taking was not metabolizing in the most ideal way, i.e. I had high levels of 6-MMPN and lowish levels of 6-TGN. Apparently, 6-MMPN is hepatotoxic, so my azathioprine dose could not be increased because that would be dangerous. Fair enough. (Note, my current aza dose is 125 mg and I weigh about 53-54 kg.) My doctor suggested starting 100mg of allopurinol (which was apparently designed to treat gout?) and dropping my aza dose to around 50mg. This kind of approach has been shown to result in more optimal levels of 6-TGN vs. 6-MMPN.

A cursory googling reveals: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2659140/ and http://www.ncbi.nlm.nih.gov/pubmed/22386736

It seems to me like you have to be pretty careful with dosing or it shafts your whole immune system. Has anyone tried this? Did you have side effects? What about (serious) opportunistic infections? Azathioprine and I did not get along well at all at first. I constantly felt like the floor was undulating and had a kind of motion-sickness feeling and threw up a bunch of times and also felt really weak, so I'm wondering if this combination will cause something similar to happen.

 

[PsychoJane]

Hello Talaia!
I am not familiar with this approach but I've seen people taking allopurinol on the forum. I don't know if it was in a way similar to the one you are referring here. Hopefully someone will be able to share inputs regarding this co-administration. Is this the last try before getting you on biologics?

 

[Johnnysmom]

My son took 6mp and allopurinol for about a year for the same reasons. It worked very well for us and no side effects at all. His new GI (we moved) switched things up but it might be something we go back to in the future. I hope it goes as well for you as it did for us.

 

[Talaia]

Hey PsychoJane, this is pretty much the last attempt before biologics. I'd kinda like to hold off on the biologics if possible because I'm not very old and I'd rather save some approaches for later. Also my crohn's isn't severe at all, so I think my dr is hesitant. On the other hand I've had continuing mild inflammation going on for a while that isn't well controlled, which isn't great and scarring and long-term tissue damage is a concern.

Hi Johnnysmom, I'm really glad to hear this combination worked well for your son! That's awesome that it did not cause any side effects.

 

[DustyKat]

The combination, while not common, is not unusual and one which many doctors are unaware of.

Allopurinol intereferes with the metabolism and therefore the breakdown and excretion of the thiopurines resulting in higher levels of the drug's active ingredient and so toxicity. Hence the benefit of this side effect for those that have issues with the thiopurines and toxicity under normal circumstances.

Did you have a TPMT test before commencing the Azathiopurine?

The only thing I would check with the doctor is the normal recommendation when introducing Allopurinol is to reduce Azathioprine to a quarter of the original dose. So 100mg of Azathioprine becomes 25mg when coupled with Allopurinol.

Of course your doctor may have very good reasons as to why he only reduced to 50mg and perhaps that was because it is a closer approximation given the availability of Azathioprine dosages.

Good luck! I hope it does the trick and brings things back into line.

Dusty. xxx

 

[Jmrogers4]

My son was on Azathioprine and allopurinol for about 2 1/2 years with no side effects. We had trouble reaching theraputic levels on aza alone but once we added the allopurinol it seemed to make all the difference. We started at 50mg of aza and 100 of allipurinol and ended up at 75mg of aza and 100mg of allopurinol which worked well for us

 

[Talaia]

Hi Dusty. I did not have a TPMT test before starting aza. I was a little worried about the dosage as I noticed a number of cases in the two studies that I linked where those kinds of levels (relative to weight) seemed to result in some infections. It's definitely something I will ask my doctor about before starting allopurinol, which will probably be in a few weeks since I am out of the country at the moment.

Jacqui - I'm glad to hear the allopurinol/aza combination worked well for your son. Do you mind if I ask what his aza dose was before adding the allopurinol?

 

[Ams-Qld]

Hi! My son started an Imuran/Allopurinol mix yesterday. He has been on Imuran previously (weight based) and is now on the combo (25mg Imuran and 100mg Allo) as our last ditch attempt before biologics. In a few weeks we will blood test 6TGN and not just rely on weight. Before this he was on 50mg Imuran but was about to be put up to 100 for weight gain. I am hoping and praying this does the trick, he had no side effects on the Imuran for two years at 50mg. He weighs 48kg. Hope you get on top of your inflamation soon!!:smile:

 

[Jmrogers4]

He was at 150/mg a day and still not at theraputic levels, that is the same dose his dad takes and he was about 70 pounds at the time compared to his 200 pound father, when I had a mini freak out when the GI was going to raise the dose again, I thought how can he possibly have to take a higher dose then his father. No side effects even at the 150/mg a day.

 

[smiley95]

Hi Talaia,
I am currently on a combo of 6 mp and Allopurinol. I started with 100 mg, but had a reaction of a rash, so I dropped down to 50 and 50 mg of 6 mp. I just had my Prometheus test done to check my levels, so I am waiting. I get nauseous from the combo, so I take Zofran as needed. I have been on the combo since March and have felt pretty good, but over the last couple of days I have been back in a flare. I am pretty sure the dosage will have to be adjusted again. How do you feel so far?

 

[AussieChick]

Hey, I have just been instructed with this dose yesterday. Same thing has happened to me. I was on 150mg azathroprine, but now going down to 50mg and 10mg of Allopurinol. Just wondering how you're going on it??
thanks