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TPMT Deficiency / Imuran (Azathioprine)

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Ulcerative Colitis
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Posted 6/19/2017 1:29 PM (GMT 0)
So you may remember my post from last week where I was agonizing over whether to start Imuran or Remicade. Well, I just got more of my bloodwork back and it looks like I have partial TPMT deficiency, which I guess means if I take Imuran that I can only take a reduced-dose.

Apparently 10% of people have partial TPMT deficiency so I'm hoping some people here have experience with it. Does this mean I should just go on Remicade and forget about Imuran? Should I take a low-dose of Imuran AND go on Remicade?

I'm assuming a low-dose of Imuran alone is pointless, is that the case? Will my doctor tell me to avoid it altogether?

I didn't really want to go on Imuran but not I feel like I have one less option and that makes me feel a little defeated. sad
Posted 6/19/2017 4:33 PM (GMT 0)
I wonder if the Mercaptopurine and Allopurinol combination would work for you? Essentially, it enables you to take a lower dose of 6MP (mercaptopurine) and add a second immunomodulator (allopurinol) to have as powerful an effect with less of a dose and less worry of toxicity response. I'd ask your gasteroenteroligist about it, and see if it is possible for you. Might enable you to stick to just immnomodulators if you do not feel you are ready for biologics. I believe the blood monitoring stays at bi-weekly though due to the allopurinol. Where as, IMuran only, you could do blood monitoring on a tri-monthly basis.

A low dose of Imuran alone is not likely to put you into a remission, unless your symptoms are very, very mild. I'd probably do the low dose imuran and Remicade combo (helps prevent anti-bodies to the remicade).
Posted 6/19/2017 7:46 PM (GMT 0)

iPoop said...


A low dose of Imuran alone is not likely to put you into a remission, unless your symptoms are very, very mild. I'd probably do the low dose imuran and Remicade combo (helps prevent anti-bodies to the remicade).

That's kinda what I was thinking. I guess I will wait and see what the doc recommends for going forward. I'm getting impatient!
Posted 6/22/2017 12:55 AM (GMT 0)
It's official! I'm starting Remicade in a couple weeks. Feels like a light at the end of the (long, dark) tunnel.

My doc mentioned taking me off Apriso if/when I'm in remission on Remicade, "because that's just another medication to take." I don't know if I like that, but I guess we will cross that bridge when we come to it.
Posted 6/22/2017 1:58 AM (GMT 0)
My doctold me early on that there is evidence to suggest that stopping mesalamine is not a good idea because there is evidence to suggest that its not effective after a restart if you should flare again. I don't know if that's true or not and also I wasn't on a biologic then so it might be different situation. I'm curious too because I'd just as soon lose a med I'd entyvio gets me in remission
Posted 6/22/2017 2:09 AM (GMT 0)
Yeah I will need to look into it more. The doc told me that the Apriso wouldn't hurt anything but also that she would take me off of it so I don't know what that is about. My understanding is Apriso can help ward off colon cancer so I'd like to stay on it for that since I am young and going to have UC for a long, long time.

Luckily, she said I can stay on my Canasa forever smile
Posted 6/22/2017 4:08 AM (GMT 0)
*I'm not aware of any issues of decreased efficacy when stopping mesalamines and then restarting them at a later time.

*There are concerns with stopping and restarting biologics, but that has to do with increased risk of infusion reaction, allergic reaction, and/or antibody formation.

*Meta-analysis of multiple studies on chemopreventive ability of mesalamines shows a decrease in risk of colorectal cancer for UC patients. But that decrease is actually, statistically speaking, quite small - just above the level needed to be statistically significant. Edit to add: If you look at the various individual studies, some show mesalamines decrease the risk of colorectal cancer; some show no effect; and some show a little *higher* chance of colorectal cancer when taking mesalamines. Combining the data from all the studies shows a slightly decreased risk of colorectal cancer when taking mesalamines.

*There are some who hypothesize that any medication that reduces the inflammation of UC may have chemopreventive properties as well. It's too early to know with any of the biologics, but they may reduce the risks of colorectal cancer more than mesalamines. Or they may not.

*Lots of patients stop mesalamines when they go on biologics. Lots of patients stay on them too. No right or wrong answer. Rates of improvement/remission on biologics + mesalamines is probably just slightly better than rates of improvement/remission on biologics alone (I'm not aware of data that really compares this, so that's a guess).

Post Edited (beave) : 6/21/2017 10:11:40 PM (GMT-6)

Posted 6/22/2017 9:47 AM (GMT 0)
I hope remicade is your ticket to a remission. It's the only med to do so for me.
Posted 6/23/2017 1:33 PM (GMT 0)
Thanks, iPoop. I'm very hopeful.

I have been reading up a bit and getting a little fearful that I will have an allergic reaction or build up antibodies due to not taking it with another drug like Aza or Methotrexate. But, I know that is exception rather than the rule and I probably shouldn't worry too much about that at this point.
Posted 6/23/2017 2:45 PM (GMT 0)
  • Some develop antibodies even though they are concurrently on immunomodulators (azathioprine/imuran, 6MP, Methotrexate).
  • Some never develop antibodies and don't use immunomodulators.
  • The antibody formation thing is a bit of a mystery, so I'd try not to worry about it.
For now see if you get a response to the anti-tnf class of biologics (about 65 percent of people do). You'll get a response fairly quickly within the initial loading doses (first 6 weeks). I got a response 3 weeks in, some are quicker and others are slower in getting a response.

In the event you were to develop remi-antibodies over time, then often the remi dose can be increased to successfully counteract it. In the event you were to have a lot of antibodies and a dosage increase isn't sufficient, then you could switch to Humira or Simponi and there's no guarantee that you'd ever develop antibodies to them.
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