for Azathioprine (Adults only, non-renal patients)
Publish public / Applies to: NHS Grampian / Version 2 /
Coordinator / Authorised for issue by / Document no: NHSG/SCPa/Aza/MGPG417
Medicines Information pharmacist / Medicines Guidelines
and Policies Group / Effective date:
August 2010
Signature:
I Mweemba / Signature:
C Hind / Review Date: August 2012
Supersedes: Version 1
Please keep this document in the patients notes
UNCONTROLLED WHEN PRINTED Review Date August 2012 (sooner if recommendations change) NHSG/SCPa/Aza/MGPG417 - 1 -
SCP and Prescribing Information for GPs for AZATHIOPRINE - Version 2, August 2010
Shared Care Policy and Prescribing Information for General Practitionersfor Azathioprine (Adults only, non-renal patients)
æPATIENT NAME ö
UNIT NUMBER
CHI NUMBER
ADDRESS
DATE OF BIRTH
è Insert patient sticker here ø / HOSPITAL
TELEPHONE NO
CONSULTANT (print name)
SIGNATURE / WARD
DATE
THERAPEUTIC INDICATION FOR THIS PATIENT: (to be completed by consultant)
DOSAGE/PREPARATION/ROUTE/FREQUENCY OF ADMINISTRATION: (to be completed by consultant)
UNCONTROLLED WHEN PRINTED Review Date August 2012 (sooner if recommendations change) NHSG/SCPa/Aza/MGPG417 - 1 -
SCP and Prescribing Information for GPs for AZATHIOPRINE - Version 2, August 2010
Shared Care Policy and Prescribing Information for General Practitionersfor Azathioprine (Adults only, non-renal patients)
SAFE PRACTICE IS THAT THE CLINICIAN WHO ORDERS THE TEST MUST ACT ON THE RESULT
CARE WHICH IS THE RESPONSIBILITY OF THE HOSPITAL CONSULTANT
1. Baseline:
Full Blood Count (FBC); urea, creatinine and electrolytes (U&E); liver function tests (LTFs).
2. Copy of results to be sent to GP.
3. Initiation of therapy and recommendations for any dose increments.
4. Decision on final dose required for patient.
5. Monitoring clinical response to treatment.
6. Advise patients to immediately report any signs or symptoms of bone marrow suppression, e.g. infection, inexplicable bruising or bleeding. / CARE WHICH IS THE RESPONSIBILITY OF THE GENERAL PRACTITIONER (GP)
1. Prescribing of medication under guidance of consultant
2. Check before prescribing medication that the monitoring is up to date and that results are within the normal range.
3. The GP should be aware that the drug can cause bone marrow suppression, leucopenia, increased risk of malignancy - lymphomas and skin cancer.
Patients should be asked about the presence of sore throat, abnormal bruising or bleeding at each visit.
Check for development of lymphomas and other malignancies particularly of the skin.
When the patient has an intercurrent illness a FBC, U&E and LFTs should be done and any abnormal results including those noted above should be reported to the consultant.
4. The General Practitioner has primary responsibility for monitoring therapy according to the schedule below :
FBC and LFTs (incl. ALT and Alk Phos) weekly for six weeks and then fortnightly until dose stable for six weeks;
FBC and LFTs (incl. ALT and Alk Phos) monthly thereafter, and if dose stable after six months, three monthly;
U&Es and creatinine every six months.
When writing laboratory request forms always include details of the patient’s medication
NOTE: in addition to absolute values for haematological indices a rapid fall or a consistent downward trend in any value should prompt caution and extra vigilance.
If something unexpected occurs contact consultant.
Notify the consultant if the drug is stopped.
UNCONTROLLED WHEN PRINTED Review Date August 2012 (sooner if recommendations change) NHSG/SCPa/Aza/MGPG417 - 1 -
SCP and Prescribing Information for GPs for AZATHIOPRINE - Version 2, August 2010
Shared Care Policy and Prescribing Information for General Practitionersfor Azathioprine (Adults only, non-renal patients continued)
Abnormal Monitoring Result / Action To Be Taken
WBC <4.0 x 109/L / Withhold until discussed with consultant
*(In autoimmune hepatitis only, it is safe to continue on azathioprine with a low WBC that is due to hypersplenism due to portal hypertension. Continue treatment but still discuss with consultant)*
Neutrophils <2.0 x 109/L / Withhold until discussed with consultant
Platelets <150 x 109/L / Withhold until discussed with consultant
2-fold rise in ALT or Alk Phos
(from upper limit of reference range) / Withhold until discussed with consultant
MCV >105fl / Investigate and if B12 or folate low start appropriate supplementation
Abnormal bruising, sore throat, rash, oral ulceration / Withhold until discussed with consultant
Unexplained fever / Withhold until discussed with consultant
Malignancies / Withhold until discussed with consultant
For specific product information please consult the current summary of product characteristics (http://emc.medicines.org.uk/) and the BNF (http://www.bnf.org/bnf/)
Other information
§ Live vaccines should be avoided in patients taking azathioprine.
§ Single pneumococcal vaccination and annual influenza vaccine should be given.
§ Varicella Zoster Immunoglobulin should be given to non-immune individuals if exposed to shingles or chickenpox.
§ There are a number of drug interactions that must be considered. When a new drug is prescribed please refer to Summary of Product Characteristics, BNF or contact Medicines Information.
Some important interactions to consider include the following:
q If Allopurinol is co-prescribed the dose of Azathioprine should be reduced by 75%.
q Inhibition of the anticoagulant effect of warfarin, when administered with azathioprine has been reported. Monitor concurrent use.
q Increased risk of haematological toxicity with co-trimoxazole and trimethoprim.
§ To minimize the risk of skin cancer, exposure to sunlight and Ultra Violet light should be limited by wearing protective clothing and using sunscreen with a high protection factor.
Pregnancy
Discuss with consultant. Azathioprine should not be given to patients who are pregnant or likely to become pregnant without careful assessment of risk versus benefit. Transplant patients and those with SLE should not stop azathioprine on becoming pregnant.
Breast-feeding
Discuss with Aberdeen Maternity Hospital. Discontinue breast-feeding.
Responsibilities of GPs undertaking monitoring
A GP agreeing to monitor azathioprine should:
§ Ensure that the relevant monitoring requirements are undertaken at the correct frequency.
§ Ensure that the test results are checked for any abnormality as soon as the results are available.
§ Ensure abnormal results are acted upon.
§ Only continue to prescribe azathioprine if it is being satisfactorily monitored.
§ Contact the consultant in the event of a drug reaction or monitoring abnormality or anything you are unhappy about.
§ Be alert for any of the known adverse reactions.
** The patient should be encouraged to ensure blood tests are taken at the correct intervals**
UNCONTROLLED WHEN PRINTED Review Date August 2012 (sooner if recommendations change) NHSG/SCPa/Aza/MGPG417 - 1 -
SCP and Prescribing Information for GPs for AZATHIOPRINE - Version 2, August 2010