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Using this page · Individualise medicines monitoring

This medicines monitoring page has been written using publications and expert opinion. It is designed to save clinician time, but not replace professional responsibility. When using this page you should: ensure an individualised monitoring plan is developed in partnership with the patient and take account of any locally agreed advice and guidance.

Before starting

Required

  • Baseline
    • ALT or AST
    • Blood pressure
    • Calculated glomerular filtration rate or Serum creatinine (for creatinine clearance)
    • Cervical screeningcheck this is up to date
    • Full blood count
    • Height
    • Liver function tests
    • TPMT assay
    • Weight
    • Vaccination status
    • Varicella Zoster Virus Immunityif no history of chicken pox, shingles or varicella vaccination

Interpreting TPMT assay

Patients with absent TPMT activity should not receive thiopurine drugs.

Patients with reduced TPMT activity may be treated under specialist supervision.

Patients with intermediate (heterozygous) activity should receive a lower maintenance dose.

The British Society of Gastroenterology advises the following dosing schedule based on TPMT:

  • Normal TPMT = 2mg/kg
  • Low TPMT = 1mg/kg
  • Very low TPMT = avoid

Vaccination status

Consider vaccination against pneumococcus and influenza prior to starting treatment.

Consider in patients at risk of infection

  • Baseline
    • Hepatitis B
    • Hepatitis C
    • HIV

After started or dose changed

Dermatology patients

  • More frequently than every 3 months
    • Full blood count
    • Liver function tests

Gastroenterology patients

  • 14 days after starting; then at 4, 8, and 12 weeks; then 3 monthly
    • Full blood count
    • Urea and electrolyes
    • Serum creatinine (for creatinine clearance) or Calculated glomerular filtration rate
    • Liver function tests

Rheumatology patients

  • Every 2 weeks until on stable dose for 6 weeks, then monthly
    • Full blood count
    • Serum creatinine (for creatinine clearance) or Calculated glomerular filtration rate
    • Albumin
    • ALT or AST

Patients at higher risk of toxicity

More frequent monitoring is appropriate in patients at higher risk of toxicity

Consider

  • At week 4 and 16
    • Methylmercaptopurine to Thioguanine ratio

Ongoing once stable

Required

  • Every 3 months
    • Albumin
    • ALT or AST
    • Full blood count
    • Serum creatinine (for creatinine clearance) or Calculated glomerular filtration rate
    • Liver function tests
    • Urea and electrolyes

Consider

  • Annually
    • Methylmercaptopurine to Thioguanine ratio
  • Periodically
    • Skin examination

Abnormal results

Be aware of trends in results (e.g. gradual decreases in white blood cells or albumin, or increasing liver enzymes). A downward trend of FBC and neutrophil count or an upward trend in liver transaminases could be a sign of toxicity, even if the absolute levels are normal.

Respond to absolute levels

Consider stopping treatment and contacting a specialist any of the following develop:

Full blood count

  • WCC less than 3.5 x 109/L,
  • Neutrophils less than 1.6 x 109/L
  • Unexplained eosinophilia less than 0.5x 109/L
  • Platelets less than 140 x 109/L
  • Unexplained fall in serum albumin less than 30g/L
  • MCV greater than 105f/L (check B12, folate, thyroid-stimulating hormone levels – if abnormal treat, if normal discuss with specialist team)

Liver function

  • AST and/or ALT greater than 100units/mL

Renal function

  • Creatinine increase greater than 30% above baseline over 12 months
  • Calculated GFR less than 60ml/min/1.73m2 (repeat in 1 week, if still more than 30% from baseline, withhold and discuss with specialist team)

Notes

Vaccine use

Live vaccinations should not normally be given until at least three months after stopping immunosuppressive therapy.

However, long-term low-dose non-biological DMARDs (e.g. azathioprine in doses of or less than 3mg/kg/day) may not be immunosuppressive and so patients may receive live vaccines. Only consider vaccination with live vaccines for those on low-level immunosuppression after careful consideration of risks and benefits.

Advice to patients

Advise patients to seek urgent medical attention if they develop symptoms suggestive of:

  • bone marrow suppression
  • liver impairment
  • specifically high fever or severe flu-like illness
  • unexplained bleeding or bruising
  • new onset jaundice

Advise patients to use sunscreens, wear protective clothing, and reduce sunlight exposure.

During serious infections

During a serious infection, azathioprine should be temporarily discontinued until the patient has recovered from the infection.

Bibliography

Enquiries about this page

Contact us if you have any enquiries about the drug monitoring information on this page.