Editing Azathioprine (section)

==Medical uses==
Azathioprine is used alone or in combination with other immunosuppressive therapy to prevent rejection following organ transplantation, and to treat an array of [[autoimmune disease]]s, including [[rheumatoid arthritis]], [[pemphigus]], systemic lupus erythematosus, [[Behçet's disease]], and other forms of [[vasculitis]], [[autoimmune hepatitis]], [[atopic dermatitis]], [[myasthenia gravis]], [[neuromyelitis optica]] (Devic's disease), [[restrictive lung disease]], and others.<ref name="derma">{{cite journal | vauthors = Patel AA, Swerlick RA, McCall CO | title = Azathioprine in dermatology: the past, the present, and the future | journal = Journal of the American Academy of Dermatology | volume = 55 | issue = 3 | pages = 369–389 | date = September 2006 | pmid = 16908341 | doi = 10.1016/j.jaad.2005.07.059 }}</ref> It is also an important therapy and steroid-sparing agent for [[inflammatory bowel disease]] (such as Crohn's disease and ulcerative colitis) and for [[multiple sclerosis]].<ref name="pmid12891528">{{cite journal | vauthors = Evans WE | title = Pharmacogenetics of thiopurine S-methyltransferase and thiopurine therapy | journal = Therapeutic Drug Monitoring | volume = 26 | issue = 2 | pages = 186–191 | date = April 2004 | pmid = 15228163 | doi = 10.1097/00007691-200404000-00018 | s2cid = 34015182 }}</ref>

In the United States, it is approved by the [[Food and Drug Administration]] for use in [[kidney transplantation]] from human donors, and for rheumatoid arthritis.<ref name="ahf" >{{cite book | title = AHFS Drug Information 2012 |date=January 2012 | publisher = American Society of Health-System Pharmacists | isbn = 978-1-58528-267-8 | chapter =Azathioprine, Azathioprine Sodium | author =American Society of Health-System Pharmacists | author-link =American Society of Health-System Pharmacists }}</ref>

===Transplantation===
Azathioprine is used to prevent rejections of kidney or liver [[allograft]]s, usually in conjunction with other therapies, including [[corticosteroids]], other immunosuppressants, and local [[radiation therapy]].<ref>{{cite journal | vauthors = Nuyttens JJ, Harper J, Jenrette JM, Turrisi AT | title = Outcome of radiation therapy for renal transplant rejection refractory to chemical immunosuppression | journal = Radiotherapy and Oncology | volume = 74 | issue = 1 | pages = 17–19 | date = January 2005 | pmid = 15683663 | doi = 10.1016/j.radonc.2004.08.011 }}</ref><ref name="myco" /> The administration protocol starts either at the time of transplantation or within the following two days.<ref name="ahf" />

===Rheumatoid arthritis===
Being a [[disease-modifying antirheumatic drug]] (DMARD), azathioprine has been used for the management of the signs and symptoms of adult rheumatoid arthritis.<ref>{{cite journal | vauthors = Suarez-Almazor ME, Spooner C, Belseck E | title = Azathioprine for treating rheumatoid arthritis | journal = The Cochrane Database of Systematic Reviews | volume = 2010 | issue = 4 | pages = CD001461 | year = 2000 | pmid = 11034720 | pmc = 8406472 | doi = 10.1002/14651858.CD001461 | veditors = Suarez-Almazor ME }}</ref> [[Nonsteroidal anti-inflammatory drugs]] and corticosteroids may be combined or continued (if they were already in use) with azathioprine, but the combination with other DMARDs is not recommended.<ref name="ahf" />

===Inflammatory bowel disease===
Azathioprine has been used in the management of moderate to severe chronically active Crohn's disease,<ref name="art">{{cite journal | vauthors = Sandborn WJ | title = Azathioprine: state of the art in inflammatory bowel disease | journal = Scandinavian Journal of Gastroenterology. Supplement | volume = 225 | issue = 234 | pages = 92–99 | year = 1998 | pmid = 9515759 | doi = 10.1080/003655298750027290 }}</ref> to maintain [[clinical remission]] (absence of disease activity) in corticosteroid-dependent patients,<ref>{{cite journal | vauthors = Biancone L, Tosti C, Fina D, Fantini M, De Nigris F, Geremia A, Pallone F | title = Review article: maintenance treatment of Crohn's disease | journal = Alimentary Pharmacology & Therapeutics | volume = 17 | issue = Suppl 2 | pages = 31–37 | date = June 2003 | pmid = 12786610 | doi = 10.1046/j.1365-2036.17.s2.20.x | s2cid = 23554085 }}</ref> and to provide benefit in people with [[Fistula|fistulizing]] Crohn's disease.<ref>{{cite journal | vauthors = Rutgeerts P | title = Review article: treatment of perianal fistulizing Crohn's disease | journal = Alimentary Pharmacology & Therapeutics | volume = 20 | issue = Suppl 4 | pages = 106–110 | date = October 2004 | pmid = 15352905 | doi = 10.1111/j.1365-2036.2004.02060.x | s2cid = 71968695 | doi-access = free }}</ref> The onset of action is slow, and several months may be required to achieve a clinical response.<ref name="art" />

Azathioprine treatment is associated with an increased risk of [[lymphoma]], but whether this is due to the drug or a predisposition related to Crohn's disease is unclear.<ref name=Kan2005>{{cite journal | vauthors = Kandiel A, Fraser AG, Korelitz BI, Brensinger C, Lewis JD | title = Increased risk of lymphoma among inflammatory bowel disease patients treated with azathioprine and 6-mercaptopurine | journal = Gut | volume = 54 | issue = 8 | pages = 1121–1125 | date = August 2005 | pmid = 16009685 | pmc = 1774897 | doi = 10.1136/gut.2004.049460 }}</ref> Lower doses of azathioprine are used as a therapy in children with refractory or corticosteroid-dependent Crohn's disease, without causing many side effects.<ref>{{cite journal | vauthors = Kirschner BS | title = Safety of azathioprine and 6-mercaptopurine in pediatric patients with inflammatory bowel disease | journal = Gastroenterology | volume = 115 | issue = 4 | pages = 813–821 | date = October 1998 | pmid = 9753482 | doi = 10.1016/S0016-5085(98)70251-3 | doi-access = free }}</ref> It may also be used to prevent flares in those with [[ulcerative colitis]].<ref>{{cite journal | vauthors = Timmer A, Patton PH, Chande N, McDonald JW, MacDonald JK | title = Azathioprine and 6-mercaptopurine for maintenance of remission in ulcerative colitis | journal = The Cochrane Database of Systematic Reviews | volume = 2016 | issue = 5 | pages = CD000478 | date = May 2016 | pmid = 27192092 | pmc = 7034525 | doi = 10.1002/14651858.CD000478.pub4 }}</ref>

===Others===
Azathioprine is sometimes used in systemic lupus erythematosus, requiring a maintenance dose of 15&nbsp;mg or higher of [[prednisone]] in those who experience recurrent flares.<ref name=Abu2001>{{cite journal | vauthors = Abu-Shakra M, Shoenfeld Y | title = Azathioprine therapy for patients with systemic lupus erythematosus | journal = Lupus | volume = 10 | issue = 3 | pages = 152–153 | year = 2001 | pmid = 11315344 | doi = 10.1191/096120301676669495 | s2cid = 71558242 }}</ref>

It is used as an add-on therapy when steroid therapy is given by mouth for pemphigus and myasthenia gravis, as a "steroid-sparing" agent.<ref name="derma" /><ref>{{cite journal | vauthors = Olszewska M, Kolacinska-Strasz Z, Sulej J, Labecka H, Cwikla J, Natorska U, Blaszczyk M | title = Efficacy and safety of cyclophosphamide, azathioprine, and cyclosporine (ciclosporin) as adjuvant drugs in pemphigus vulgaris | journal = American Journal of Clinical Dermatology | volume = 8 | issue = 2 | pages = 85–92 | year = 2007 | pmid = 17428113 | doi = 10.2165/00128071-200708020-00004 | s2cid = 10699017 }}</ref><ref>{{cite journal | vauthors = Richman DP, Agius MA | title = Treatment of autoimmune myasthenia gravis | journal = Neurology | volume = 61 | issue = 12 | pages = 1652–1661 | date = December 2003 | pmid = 14694025 | doi = 10.1212/01.wnl.0000098887.24618.a0 | s2cid = 24755812 }}</ref> Azathioprine is also used to maintain remission in people who have granulomatosis with polyangiitis.<ref name=Sing2017/>

It can be very effective in eczema and atopic dermatitis, though it is not commonly used.<ref name="derma" /> The British National Eczema Society lists it as a [[Drug of last resort|third-line treatment]] for severe to moderate cases of these skin diseases.<ref>{{cite journal | vauthors = Meggitt SJ, Gray JC, Reynolds NJ | title = Azathioprine dosed by thiopurine methyltransferase activity for moderate-to-severe atopic eczema: a double-blind, randomised controlled trial | journal = Lancet | volume = 367 | issue = 9513 | pages = 839–846 | date = March 2006 | pmid = 16530578 | doi = 10.1016/S0140-6736(06)68340-2 | s2cid = 1616660 }}</ref>

It was widely used to treat multiple sclerosis until the first half of the 1990s. Concerns about increased risk of [[malignancy]] have led to a decreased use, yet it is still used in maintenance treatment for people who frequently [[relapse]].<ref>{{cite journal | vauthors = Casetta I, Iuliano G, Filippini G | title = Azathioprine for multiple sclerosis | journal = Journal of Neurology, Neurosurgery, and Psychiatry | volume = 80 | issue = 2 | pages = 131–2; discussion 132 | date = February 2009 | pmid = 19151017 | doi = 10.1136/jnnp.2008.144972 | s2cid = 207001537 }}</ref> A 2007 Cochrane review found that azathioprine reduced the number of relapses in the first year of treatment and disease progression in the first two to three years and did not find an increase in cancer, and noted the need for direct comparison of azathioprine and [[Interferon-beta|interferon beta]], conflicting conclusions regarding cancer, and the potential for long-term risks.<ref>{{cite journal | vauthors = Casetta I, Iuliano G, Filippini G | title = Azathioprine for multiple sclerosis | journal = The Cochrane Database of Systematic Reviews | volume = 2007 | issue = 4 | pages = CD003982 | date = October 2007 | pmid = 17943809 | pmc = 6823213 | doi = 10.1002/14651858.CD003982.pub2 }}</ref>

A widely used therapy for [[idiopathic pulmonary fibrosis]] was azathioprine in combination with prednisone and ''N''-[[acetylcysteine]]. A 2012 study showed that this combination produced worse outcomes than a placebo.<ref>{{cite journal | vauthors = Raghu G, Anstrom KJ, King TE, Lasky JA, Martinez FJ | title = Prednisone, azathioprine, and N-acetylcysteine for pulmonary fibrosis | journal = The New England Journal of Medicine | volume = 366 | issue = 21 | pages = 1968–1977 | date = May 2012 | pmid = 22607134 | pmc = 3422642 | doi = 10.1056/NEJMoa1113354 }}</ref>