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Azathioprine for Crohn's Disease - The Most Effective Option?
G Radford-Smith, M Watson, P Pritchard, M Ward and T Florin.
The aim of this study was to analyse the use of azathioprine in patients with Crohn's disease (CD) attending three major centres. Patient information was entered onto the Brisbane IBD database by a dedicated database manager, including disease type, distribution, smoking history, and surgery.
Of 250 patients entered and assessed, 63 (25%) have received azathioprine between 1991-97. From data available, 41(65%) started after 1/1/96, and 18(29%) between 1991 and 1996.
Of 63 patients, 45 have CD, 15 UC, and 3 indeterminate colitis. The major distributions of disease are as follows: ileal 14(35% of all ileal CD), ileocolonic 18(54%), ileocaecal 4(31%), colonic 8(25%), and peri-anal (1).
There were significantly more smokers on azathioprine (32, 71%) compared to "never-smoked" (8, 18%) in the CD group (p<0.05), with data unavailable from 5 patients.
Of UC patients, 9 had total colitis, 3 left-sided, and 3 proctitis; 6 of these patients have undergone colectomy (all total UC). The indeterminate patients all had extensive colitis.
The mean dose of azathioprine used in CD was 2mg/kg. The indications fell into 4 groups: steroid-sparing (12), acute/severe disease (11), post-operative prophylaxis (4), and severe peri-anal disease (1).
Review of all patients started on the drug over the past 18 months (19) revealed 4 patients requiring additional steroids, with 2 of these going onto surgical resection. All 4 patients had established strictures at the time of starting azathioprine.
Mean time on drug was 10 months. Side effects occurred in 3 patients (5%): severe arthralgia/myalgia (2) and severe nausea (1).
This study confirms azathioprine to be safe and effective treatment for CD. Given the relative lack of effective therapeutic options for ileal CD and the high rate of post-operative recurrence at this site, better results may be achieved by initiating immuno-suppression at an earlier stage in the disease.
(Azathioprine is marketed in Australia under the brand name Imuran.)
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