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Therapeutic level

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Ulcerative Colitis
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Posted 12/6/2014 7:11 AM (GMT 0)
I've been on the azathioprine and allopurinol combo for 8 weeks now and I am now at a very good therapeutic level with the drug I.e.there is enough of the aza in my blood to work effectively with my uc. My GI doc wanted me at a level of over 400 for my weight and I'm now at 440.

My question is when should I see the effects on my uc of being in therapeutic range? I'm on a pred taper and I'm finding it difficult to go below 20mg. I've been on 15mg a couple of days and already my stool is getting looser and gooey. And the pain in my colon is not stopping.

But my GI doc says that if aza works for me it's the best drug for me to be on. And now I'm in range I doubt he will take me off it. Do I need to just give it more time! Only be in range for about a week.

I just want some relief now :( so sad and down. I feel I am close but yet so far.
Posted 12/6/2014 9:29 AM (GMT 0)
In my experience GIs rather overstate how many people are helped by AZA/6MP. I seem to remember in trials that a third improved anyway with placebo and no more than another third got better with AZA. So you might be in the 1-in-3 for whom it doesn't help for whatever reason.

Give it time, but if it isn't working after 4-5 months then push hard for another drug.
Posted 12/6/2014 12:34 PM (GMT 0)
Yeah I will give it some time as I've only just entered in to the therapeutic range and never was before. So I will see.
Posted 12/6/2014 1:21 PM (GMT 0)
Can anyone explain what number gives the Dr. information on and if the therapeutic range is reached? I have been on 6MP about 3 weeks now. I get weekly blood counts& comprehensive metabolic panels taken. I know they monitor these values for the liver, white count, RBC etc. What number/value gives info about therapeutic level attainment?? Also at what values do I have to be concerned regarding Amylase & Lipase? My amylase is 155 ( normal range 31-124) and my lipase is 96 ( normal range 1-59 ). Are these on the way up leading to pancreatitis??? It is the weekend & I wont be speaking to my Dr. until Monday. Am I worrying for nothing???
Really appreciate any input.
Posted 12/6/2014 11:51 PM (GMT 0)
I don't really understand all the numbers but I was told by my GI that he wanted my levels to be over 400 and that he would deem the treatment a success if it reached that level and it has. I think my colon needs to heal and may take a while as the food poisoning bug I contracted really sent my colitis crazy and I've never had such a high CRP in my life than I did a few weeks ago. It's now at 1 so it's gone now but don't know if that's with steroids or with this drug combo.
Posted 12/7/2014 4:13 AM (GMT 0)
I think 6 weeks at the therapeutic level. It is generally stated 6mp takes a while to kick in.

@twingirl: your bloodwork is screening for toxicity. I am not sure if your elevation is a problem or not. generally if there is a really bad level, you got a phone call. Also, when liver enzymes spike, it is an early warning sign, so no immediate worry. The test for therapeutic levels is a specific text for metabolites of 6mp. Ask if you have had this test.

"Historically, weight-based dosing of immunomodulators has been employed with target doses being 2.0 to 2.5 mg/kg for azathioprine and 1.0 to 1.5 mg/kg for 6-MP. More recently, advances in pharmacogenomics and an increased understanding of thiopurine metabolism has led to the practice of measuring TPMT enzyme activity prior to commencing therapy, and then using measurements of the thiopurine metabolites 6-TGN and 6-MMP to help optimize dosage and efficacy." (www.healio.com/gastroenterology/curbside-consultation/%7B67faf0e0-974c-4f86-a430-d735ef89a8d7%7D/how-do-you-monitor-patie)
Posted 12/7/2014 6:39 AM (GMT 0)
It's great that the levels have gotten to where your doctor says they're therapeutic but how you feel is much more important than lab results. Especially when the symptom is pain.

Pain is typically one of the first symptoms to improve on Pred or any medication that's working.

Are you using any rectal meds?

To answer your specific question, you won't know if it's working until you give it more time. Regardless, if I were you I'd go back up on the Pred to 17.5 or 20, and stay there until your pain improves. Tapering Pred while still having significant issues can set you back. Being on steroids sucks but you have to heal.
Posted 12/7/2014 9:10 AM (GMT 0)
Yeah I'm using Salofalk enema every other day.

I think you are right with the pred as I did not get any pain on 25mg and above. It started when I started 20mg but I am just so eager to get off them. Plus so is my GI nurse.

I think I will have to go back on 25mg to treat the pain and stay on until no more pain and I have healed.
Posted 12/7/2014 1:18 PM (GMT 0)
Thanks DB. I am an intermediate metabolizer of 6MP so I know they have to watch me carefully. From what I understand 90% of population are normal metabolizers, then there are patients like me,
and then there is a small group who cant break down 6MP at all & these patients can not take 6MP at all.
Posted 12/7/2014 3:13 PM (GMT 0)
Stupid question:

Is it possible that you can be at the "therapeutic" level and not have the med do much for you? If so, then I guess it really wouldn't be very "therapeutic" then, would it?
Posted 12/7/2014 5:00 PM (GMT 0)
lol well I was thinking the exact same thing Gary. Because I'm not feeling very therapeutic at the moment!
Posted 12/7/2014 6:12 PM (GMT 0)
Therapeutic levels of 6mp did not help my daughter get off the Pred or feel a reduction of symptoms. If you cannot get off the Pred in a month or so, it's time to switch it up. She went on Remicaide, stayed on the 6mp, and achieved remission( after a few dose adjustments of both). The testing level for 6mp is a Prometheus test, right? Long time ago... CRP and other inflammatory markers were reliable markers for her early in the disease, and then showed little abnormality and the symptoms were wild. Go figure...
Posted 12/7/2014 6:51 PM (GMT 0)
Well that's worrying. I feel so sad that for all these months I've been waiting to get in to therapeutic level and now I am at a high level I feel nothing. But like I said I need to give it more time maybe. All I know is my stools are still ok bit getting softer but still formed and solid. But my colon is aching so bad.
Posted 12/8/2014 12:55 AM (GMT 0)
Have you considered hydrocortisone enemas? Maybe alternate with the Salofalk?

Hydrocortisone enemas are a steroid but have fewer systemic effects than the pills. Using them might help you taper. They were a huge part of my recovery during my last flare.

You could also try the Salofalk enemas every day. Some people use both that type of enema (or suppository) AND a steroid enema in the same day.

Hope you're feeling g better.
Posted 12/8/2014 6:27 AM (GMT 0)
I did have the pred foam enema before but it didn't help as my colitis is right at the top of my descending colon so the foam didn't reach the high up. But I have a few packets at home and I suppose I could try it. I've just started the VSL3 probiotic too. Trying anything!!
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