Azathioprine as monotherapy, and avoiding babies/vaccinations?

[Orpheus]

I was on 6-MP from 2008-2011 (after remission was induced by a long course of Prednisone), then I went off the drug because I was doing well. Now in 2018 I've had a painful flareup (luckily no blockage or surgeries, but I had a colonoscopy that showed moderate inflammation throughout, particularly around the terminal ileum) and my new doctor wants me to go on Azathioprine (50 mg to start, then increase the dosage as my body tolerates it). I'm doing better now but I'm not in remission, and he's suggesting this as either a monotherapy or in conjunction with Pentasa. I've veto'd Pentasa because I tried that for a while when I was first diagnosed in 2007 and it made me feel awful. Now with Azathioprine I'm worried about a few things:

1) I tolerated 6-MP with minimal side effects (minor hair thinning at first, slightly yellowed eyes when I have Gilbert's syndrome anyway, bruises/cuts lasted longer), but Azathioprine will be new. Are there benefits for going with this over 6-MP? I understand that it can be more potent, but I was on a relatively low dosage of 6-MP (50 mg/day or less) and that seemed to do the trick, so I wonder why he wouldn't suggest trying 6-MP again. I'm nervous about jumping into this, but I need to do something to try to stop the cramping and inflammation, and it seems like Aza/6-MP is the backbone of treatment for most patients that can tolerate it.

2) I've heard that Azathioprine/6-MP may not do much unless remission has already been achieved. Have any of you achieved remission (of course it's hard to know if the drug itself induced remission) and maintenance while being solely on one of these drugs? The risks of the drugs seem rather large for this uncertainty...

3) I saw this notice in the drug facts: "Avoid contact with people who have recently received live vaccines." What does this mean specifically, as in how long do you have to avoid them? A number of my close friends either recently had a baby or are about to have a baby, so I'm really curious how long I would need to stay away from the vaccinated kids if I go on Azathioprine. Do I also need to avoid the adults who have been around the kids?

Thanks for reading and for any anecdotes/advice!

 

[Scipio]

2) Azathioprine (or 6mp) alone is not very effective for induction of remission. It takes a long time (months) for the drug to really kick in. It is more commonly used as a maintenance drug - to keep the remission going once it was established, usually by a steroid such as budesonide or prednisone.

3) Staying away from adults whose kids have been recently vaccinated is probably not necessary, since they are probably already vaccinated themselves and have already achieved an immunologic equilibrium with any live vaccines. For recently vaccinated babies I really don't know, but I'd guess 2 to 4 weeks should be enough. The magic number for inducing immunity in the recipient for most vaccines seem to be about 2 weeks. After that the baby's immune system should have started to control the virus or bacterium. So maybe 4 weeks to be on the safe side.

Also, it is only the live vaccines you need to worry about, which for most babies are measles, mumps, rubella (MMR combined vaccine), rotavirus, and chickenpox, plus inhaled flu vaccines in adults. There are other such as smallpox and yellow fever vaccines, but those are seldom given. Dead virus vaccines such as hepatitis A, polio shots, and flu shots pose no risk.

In any case, you probably are not at much risk from very casual contact such as being in the same room with a baby. The bigger risk probably comes from things such close contact and especially contact with bodily fluids - such as changing a baby's diaper, since many live viral infections shed virus particles in the feces.

 

[Tuff]

I was on azathioprine alone for at least a year, then Remicade was added when I got fistulas. Altogether I think I was on aza for about four years. I had leukopenia, low white blood cells, for the whole time even on the lowest dose. I also became extremely sun sensitive and would burn badly if I didn't completely cover up. I finally refused to take it anymore because in one year, I had 9 colds, strep throat, oral thrush, yeast infections, bladder infection. It was probably due to the leukopenia. Not everyone has the same reactions, but just wanted to caution you about staying away from sick people.

 

[my little penguin]

Aza is just the sister drug of 6-mp so the same precautions you took for 6-mp apply
It isn’t even a different class of drugs
Can you get a second opinion ?
Since you were already on 6-mp for years and now your going on the same drug
Even methotrexate would be the same level of drug but at least a different drug

As other stated you need a bridge therapy to induce remission and then Aza keeps you there

Steriods or EEN (exclusive enteral nutrition-formula only no solid food for 8 weeks )

 

[my little penguin]

Vaccination of Contacts of Persons with Altered Immunocompetence
Household contacts and other close contacts of persons with altered immunocompetence should receive all age- and exposure-appropriate vaccines, with the exception of smallpox vaccine (12,13). Receipt of vaccines will prevent the vaccine-preventable disease, so there can be no potential transmission to the contact with altered immunocompetence. The live MMR, varicella, and rotavirus vaccines should be administered to susceptible household contacts and other close contacts of immunocompromised patients when indicated. Zoster vaccine can be administered when indicated. MMR vaccine viruses are not transmitted to contacts, and transmission of varicella-zoster virus vaccine strain is rare (14,15). No specific precautions are needed unless the varicella vaccine recipient has a rash after vaccination, in which case direct contact with susceptible household contacts with altered immunocompetence should be avoided until the rash resolves (14,15). All members of the household should wash their hands after changing the diaper of an infant who received rotavirus vaccine. This minimizes rotavirus transmission, as shedding may occur up to one month after the last dose (16,17). Household and other close contacts of persons with altered immunocompetence should receive annual influenza vaccination. Introduction of low levels of vaccine viruses into the environment likely is unavoidable when administering LAIV. LAIV vaccine viruses are cold-adapted, so they can replicate in the nose and generate an immune response without entering the lungs (i.e., they are temperature sensitive and replicate poorly at core body temperatures). No instances have been reported of illness caused by attenuated vaccine virus infections among health-care providers or immunocompromised patients. LAIV may be administered to healthy household and other close contacts of persons with altered immunocompetence unless the person with altered immunocompetence is in a protective environment, typically defined as a specialized patient-care area with a positive airflow relative to the corridor, high-efficiency particulate air filtration, and frequent air changes (3). No preference exists for inactivated influenza vaccine use by health-care workers or other persons who have close contact with persons with lesser degrees of immunosuppression (e.g., persons with diabetes, persons with asthma taking high-dose corticosteroids, or persons infected with HIV), and no preference exists for inactivated influenza vaccine use by health-care workers or other healthy persons aged 5-49 years in close contact with all other groups at high risk.

From
https://www.cdc.gov/vaccines/hcp/acip-recs/general-recs/immunocompetence.html

 

[Orpheus]

Thanks for all the input. I talked to a nurse who said Azathioprine is generally preferred over 6-MP because it is "slightly safer", but then she chuckled because that doesn't mean much with this class of drugs. She also said I shouldn't need to worry much about staying away from recently-(live attenuated) vaccinated babies. Just hanging in the same room with them should be ok. Last I was worried about minimal blood testing before my next appointment (in August; they want me to get the next test right before that appointment) since I've heard you need weekly tests in the beginning. She was totally unconcerned and said I should be fine... Again, goes against what I've heard, so I hope they know what they're doing. I'd like a second opinion, but my area doesn't have GI doctors with great reviews.

I'll be starting Azathioprine today and hoping it goes as smoothly as possible.