Crohn's and Colitis UK Drug Treatment Information

Improving life for

people affected
by inflammatory
bowel diseases

Azathioprine and Mercaptopurine

This information leaflet is designed to answer common questions you may have if you
have been given azathioprine or mercaptopurine to treat your Crohns Disease or
Ulcerative Colitis, the two main forms of Inflammatory Bowel Disease (IBD). It is not
intended to replace specific advice from your own doctor or any other health professional.
You can obtain further information from your doctor, pharmacist, the information leaflet
supplied with your medication or from the website: www.medicines.org.uk
Other names for these medicines
Azathioprine is sometimes known by the brand name Imuran. Mercaptopurine is
sometimes called 6-mercaptopurine or 6-MP, or known by the brand name Puri-nethol.
Why am I being treated with this medicine?
You may be given azathioprine or mercaptopurine if you have Ulcerative Colitis (UC) or
Crohns Disease and you keep getting relapses while being treated with 5ASA drugs
(such as mesalazine) and/or steroids. You may also be prescribed azathioprine or
mercaptopurine to help you reduce or come off steroids without getting another flare-up.
How do azathioprine and mercaptopurine work?
Azathioprine and mercaptopurine are chemically closely related: azathioprine is
converted into mercaptopurine once in the body. Both drugs act in a similar way. They
belong to a group of medicines called immunosuppressants. The immune system is
important for fighting infections, but sometimes cells in the immune system attack the
bodys own tissues and trigger chronic inflammation, like that found in IBD. Azathioprine
and mercaptopurine reduce this inflammation by dampening down the over-activity of the
immune system cells.
Although the two drugs are very similar, some people who cannot tolerate azathioprine
because of side effects may still be able to take mercaptopurine.
How long will they take to work?
Azathioprine and mercaptopurine do not work immediately. It may take up to three
months (and for some people up to six months) before you notice any benefit.
How are azathioprine and mercaptopurine taken?
Both azathioprine and mercaptopurine come in tablet form. Take the tablets as directed
by your doctor. This will usually be once or twice a day, after food. If you forget a dose,
take it as soon as you remember. If it is almost time for your next dose, do not take the
missed dose.
What is the normal dosage?
The dose will vary according to your body weight and with the severity of your condition.
You may be started on a low dose which is then increased gradually. For azathioprine,
the usual dose is between 1.5 mg and 2.5 mg per kilogram of body weight per day. The
dose for mercaptopurine is usually half that of azathioprine, ranging from 0.75 1.5 mg
per kilogram of body weight per day.

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How long will I be taking azathioprine or mercaptopurine?

If you respond well to azathioprine or mercaptopurine you should be able to keep taking it
for some years, provided the results of your monitoring blood tests are satisfactory and
you do not develop any serious adverse reactions. Research suggests that for some
people azathioprine or mercaptopurine can continue to be effective for at least five years
and possibly longer.
How effective are azathioprine and mercaptopurine?
Azathioprine has been used for IBD for over 30 years. Mercaptopurine is a newer drug
and tends to be prescribed less frequently in the UK.
A number of studies have found that these drugs can help to reduce symptoms and
maintain remission in about six out 10 people with UC and seven out of 10 people with
Crohns. There is also increasing evidence that, for some people with severe IBD, a
combination therapy of azathioprine and one of the biologic drugs, such as infliximab or
adalimumab, may be even more effective at bringing on and maintaining remission. (For
more details on these drugs, see our Infliximab and Adalimumab drug treatment
information sheets.)
However, azathioprine and mercaptopurine can also cause a range of side effects (see
below) and one or two out of every 10 people stop taking these drugs because of an
adverse reaction. The benefits of treatment with azathioprine or mercaptopurine, either
alone or in combination with other drugs, will need to be balanced against such side
effects, so discuss this with your doctor.
What checks will I need?
It is important to have regular blood tests while you are on azathioprine or
mercaptopurine At the start of treatment you will need a Full Blood Count (FBC) and a
Liver Function Test (LFT). This is because azathioprine and mercaptopurine can
suppress normal bone marrow function and may occasionally cause liver problems.
These tests may be repeated weekly at first, then monthly until you are on your
maintenance dose, and finally on a three monthly basis. Some doctors prefer to take a
Full Blood Count every 2-4 weeks for two months, and then every 4-8 weeks.
Some centres offer a blood test before treatment to measure an enzyme called TPMT
(Thiopurine Methyltransferase). This test can help to predict who is more likely to
experience side effects with azathioprine or mercaptopurine. However, it cannot identify
everyone who might be affected, so you will still need regular treatment monitoring and
blood tests.
Your treatment monitoring may be managed by your hospital team or shared between the
hospital and your GP. You may be given a booklet to record your blood test results.
Take this booklet with you every time you see your GP, hospital doctor, specialist nurse
or pharmacist, as it helps them to share information.
Will I need to take any special precautions while being treated with azathioprine or
mercaptopurine?
Try to avoid close contact with people who have infections. Azathioprine and
mercaptopurine affect the way the bodys immune system works, which can make
you more prone to infections. Also, even a mild infection such as a cold or sore
throat may develop into a more serious illness. Contact your doctor if you begin to
feel unwell and think you may have caught an infection.

 You may also be more likely to become seriously ill from the viruses that cause
chickenpox, shingles, measles and pneumococcal disease. If you are not already
immune, it could be a good idea to have a vaccination against these diseases
before starting treatment with azathioprine or mercaptopurine. Otherwise, tell your
doctor or nurse as soon as possible if you come into contact with anyone who has
any of these conditions and you may be able to have a protective injection.

Avoid driving and hazardous work until you have learned how azathioprine or
mercaptopurine affects you, as these drugs can occasionally cause dizziness.

Azathioprine and mercaptopurine increase the skins sensitivity to sunlight and the
risk of developing some forms of skin cancer. Use sunblock and wear a hat and
light clothing when out in strong sunshine. Do not use sunlamps or sun beds.
Can I take other medicines along with azathioprine or mercaptopurine?
Certain other medicines interact with azathioprine and mercaptopurine. These include
allopurinol (used to treat gout), warfarin (a blood thinning treatment), and certain
antibiotics, such as co-trimoxazole and trimethoprim.
Before you take any new medicines, check with your doctor or your IBD team whether
there could be an interaction with the azathioprine or mercaptopurine. This also applies
to any over-the-counter medicines and any herbal, complementary or alternative
medicines and treatments.
You should also always tell any other doctor or any dentist treating you that you are
taking azathioprine or mercaptopurine..
Can I have immunisations while on azathioprine or mercaptopurine?
It may be unsafe to be immunised with certain vaccinations while on azathioprine or
mercaptopurine. You should not have any of the live vaccines such as those for polio,
yellow fever, rubella (German measles), MMR (measles, mumps and rubella) and BCG
(tuberculosis). However, you may be able to have the inactivated polio vaccine. Flu
vaccines are safe because they are not live vaccines and the Department of Health
recommends an annual vaccination against flu for all people on immunosuppressants.
If anyone in your family or household needs to have a live vaccine, such as for yellow
fever, check with your IBD team whether you need to take additional precautions.
Can I drink alcohol while taking azathioprine or mercaptopurine?
Alcohol is not known to have any interaction with azathioprine or mercaptopurine, but for
general health reasons it is best to keep within the Department of Health guideline limits.

Does azathioprine or mercaptopurine affect fertility or pregnancy?

Tell your doctor if you are thinking of starting a pregnancy or find you are pregnant, and
either you or your partner are taking azathioprine or mercaptopurine.
Azathioprine and mercaptopurine are not known to affect fertility, but there is a small
amount of evidence that suggests conceiving a child with a man taking these drugs might
increase the risk of miscarriage or birth defects. Because of this some doctors have
advised men planning to father a child to switch to other medication. However, more
recent research has not confirmed these findings and most doctors now tend to advise
men to keep taking azathioprine or mercaptopurine, rather than risk a flare-up.
Most doctors also recommend women to continue with their azathioprine or
mercaptopurine while pregnant as there may be a greater risk to the baby if the woman
stops her treatment and becomes unwell. A large number of studies have looked at the
effects on azathioprine and mercaptopurine on women with IBD in pregnancy, and the
general consensus is that these drugs are safe and well tolerated. Even so, it is
important to talk to your specialist about the risks and benefits for you personally, so that
your decision can be based on your own health.
What about breastfeeding?
The drug manufacturers do not recommend breastfeeding by women taking azathioprine
or mercaptopurine. However, very little of the active drug is secreted into breast milk and
there is no evidence of harm in children of mothers who have breastfed while on these
drugs. For some women the benefits of breastfeeding may outweigh any small potential
risk. If you wish to breastfeed, discuss this with your doctor.
What are the possible side effects?
All medicines can cause unwanted side effects, although not everyone will get them.
Some side effects may improve as your body adjusts to the new medication. Side effects
from azathioprine and mercaptopurine may include the following:

Nausea (feeling sick), vomiting and loss of appetite. This reaction can be
especially strong during the first few weeks of treatment. Taking your medication
after eating or in two smaller doses each day instead of all at once may help
reduce these side effects. A temporary reduction in dosage might also help, but
talk to your doctor or nurse specialist before you make any changes to your dose
or how you take it.
In some people, a flu-like illness with fever and general aches and pains a few
days or weeks after starting treatment. Tell your doctor if you begin to feel unwell
in this way. It is not usually serious but may mean the treatment has to be
stopped.
Suppression of normal bone marrow function, which can cause anaemia and a
reduction in the number of platelets and white blood cells. This can lead to
weakness or breathlessness, a susceptibility to infections, and a tendency to
bruise or bleed easily. Regular monitoring should pick up a reduced blood count
but it is important that you contact your doctor if you develop an infection of any
kind.
More occasionally, liver inflammation. Your treatment monitoring will include
regular liver function tests (LFTs) to check your liver is working properly. Tell your

doctor if you notice a yellowing or discoloration of the skin which may be a sign of
jaundice.

Diarrhoea, which may be difficult to distinguish from flare-up symptoms.

Pancreatitis, (inflammation of the pancreas, a digestive gland in the abdomen),
which can cause acute pain in the abdomen. Contact your doctor if you
experience this type of symptom.
An increased risk of developing lymphoma (a type of cancer affecting the lymph
glands). However, research has shown that for most people the extra risk is likely
to be small and is outweighed by the potential benefits gained from treatment with
azathioprine or mercaptopurine.
An increased risk of certain types of skin cancer. This can be reduced by the
careful use of sun blocks and suitable clothing when out in strong sunshine.
Other rare side effects can include dizziness, hair loss and skin rashes.

Who should I talk to if I am worried?

If you are worried about side effect such as those described above, or have other
questions about your azathioprine or mercaptopurine treatment, discuss them with your
specialist doctor or IBD nurse. They should be able to help you with queries such as
exactly why it has been prescribed for you, what the correct dose and frequency is, what
monitoring is in place, what you should do if new symptoms occur, and also what
alternatives may be available.
Further information
You can find more information about other drugs used in the treatment of IBD from our
booklet Drugs used in IBD and from other Drug Treatment Information leaflets. All our
information sheets and booklets are available free from our office call or email the
Information Line. You can also download them from our website:
www.crohnsandcolitis.org.uk
Crohns and Colitis UK Information Line: 0845 130 2233, open Monday to Friday,
10 am to 1 pm, excluding English bank holidays. An answer phone and call back
service operates outside these hours. You can also contact the service by email
info@crohnsandcolitis.org.uk or letter (addressed to our St Albans office). Trained
Information Officers provide callers with clear and balanced information on a wide range
of issues relating to IBD.
Crohns and Colitis Support: 0845 130 3344, open Monday to Friday, 1 pm to 3.30
pm and 6.30 pm to 9 pm, excluding English bank holidays. This is a confidential,
supportive listening service, which is provided by trained volunteers and is available to
anyone affected by IBD. These volunteers are skilled in providing emotional support to
anyone who needs a safe place to talk about living with IBD.
NACC 2012
Azathioprine and Mercaptopurine Edition 3a (Amended Dec 2012)
Last review: November 2012
Next review due: 2014

Crohn's and Colitis UK publications are research based and produced in consultation with
patients, medical advisers and other health or associated professionals. They are
prepared as general information on a subject with suggestions on how to manage
particular situations, but they are not intended to replace specific advice from your own
doctor or any other professional. Crohn's and Colitis UK does not endorse or recommend
any products mentioned.
We hope that you have found the information helpful and relevant. We welcome any
comments from readers, or suggestions for improvements. References or details of the
research on which this publication is based and details of any conflicts of interest can be
obtained from Crohn's and Colitis UK at the address below. Please send your comments
to Glenys Davies at Crohn's and Colitis UK, 4 Beaumont House, Sutton Road, St Albans,
Herts AL1 5HH, or email glenys.davies@crohnsandcolitis.org.uk
Crohn's and Colitis UK is the working name for the National
Association for Colitis and Crohns Disease (NACC). NACC
is a voluntary Association, established in 1979, which has
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