Journal Mobile

MJ McDonnell, A Dhar
Journal Issue: 
Volume 39: Issue 2: 2009




Azathioprine  is  the  most  common  immunosuppressant  used  in  the management of inflammatory bowel disease (IBD). Most of the available data on the effectiveness  of  this  drug  emerge  from  large  university  teaching  hospitals,  where there  is  a  referral  bias  towards  complex  patients  combined  with  a  need  for specialist expertise and early initiation of therapy. There are limited data on the use of azathioprine in district general hospitals in the UK, particularly related to efficacy and side effect profile, with concerns about its safety potentially contributing to a reluctance  to  commence  treatment  with  the  drug  until  late  in  the  course  of  the disease.  This  audit  was  a  retrospective  case  note  review  of  patients  attending gastroenterology  clinics  in  South  Durham  over  a  decade  (1997–2007).  The population  of  the  region  is  250,000. The  Rotherham  IBD  Database  for  County Durham was used to identify patients who had ever been exposed to azathioprine. Efficacy  and  side  effect  profile  were  determined.  Remission  was  defined  as  being steroid-free at 12 months after starting azathioprine. Relapse was defined as active disease  requiring  steroids  or  surgical  intervention  after  starting  azathioprine.  Of 400 patients with IBD, 58 were treated with azathioprine over the ten-year period (13.1%),  29/318  with  ulcerative  colitis  (9.1%),  and  29/82  with  Crohn’s  disease (35.4%).  Overall,  21/58  (36.2%)  patients  were  found  to  be  steroid-free  within  a mean  period  of  five  months’  treatment.  Among  factors  favouring  response  to treatment, a disease phenotype of Crohn’s disease was the only significant one; age, sex,  disease  distribution  and  dose  were  not  significant.  27.6%  patients  relapsed despite treatment, with the relapse rate being lower in ulcerative colitis. Although 47% patients reported some side effect, myelotoxicity was recorded in only 12%. This audit reflects the efficacy and safety of azathioprine when used in the district hospital setting, comparable to larger tertiary centres. Overall, the use is lower than at specialist centres, but this is likely to change with time.