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Crohn's Disease Forum » Parents of Kids with IBD » 6-MP Info and Instructions


 
08-29-2012, 12:20 PM   #1
Patricia56
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6-MP Info and Instructions

This is information I have posted in the past on another forum regarding 6-MP. It may be helpful for those with children on or starting 6-mp or Azathioprine (AZA) or Imuran or Purinethol - all are different formulations of the same basic drug.

Patricia

6-MP: Good Things to Know

Compiled from directions received from physicians and supplemented with information from various medical and drug websites for personal use in managing dosing/administration of 6-MP for treatment of my child’s Crohn’s illness. As always, this is not a substitute for medical advice and you should follow your doctors directions.

This med has a long list of drug interactions and you should use a drug interaction checker to double check this, especially if your child is having elevated liver enzymes. Among the listed common drug interactions are the 5-ASA meds commonly used to treat Crohn’s and UC (Mesalamine formulations like Pentasa, Asacol, Rowasa, Lialda)

For those with Lactose allergy/intolerance note that this med contains Lactose

Adminstration (ideal):
Same time each day
On empty stomach 1 hour before meal or 2 hours after meal
May be taken with food if needed to avoid nausea;
May be given at bedtime to reduce mild nausea
Do not give with milk or milk based products
(there’s an enzyme in milk products that breaks down 6-MP)

Missed dose: give within 12 hours otherwise wait for next regular dose

If the child vomits after taking it:
If it is within 15 minutes give a second dose
If it is more than 15 minutes wait for next regular dose

Call doctor and report:
Vomiting
Rashes
Unusual bruising
Chicken pox exposure

Call the doctor for fevers:
If 101.5 or higher once within 12 hours
If 100.5 twice within 12 hours

Side effects may include nausea, hair loss, rashes, low blood counts, liver damage, pancreatitis

Handling Precautions

Women of child-bearing age/pregnant should take precautions when handling this medication. At the minimum, wash your hands thoroughly following direct contact with the medication. Ideally, use gloves when handling the medication or have another person dispense it. Avoid exposure as much as possible. For example, do not crush the medication without taking precautions to prevent breathing in airborne particles.

Monitoring (labs)

Expert recommendation (Dubinsky) regarding how often to monitor for low blood counts with CBC w/diff:
every 2 weeks x 2 then
every 4 weeks x 3 then
every 8 weeks x 4 then
every 3 months

Dubinsky recommends following the same schedule for liver panel (ALT, ALP, AST, Billirubin, Albumin, Total protein and possibly GGT); others check liver function less frequently once dose titration is finished but most watch liver function closely during dose titration.

Theraputic/toxic ranges of prometheus values for 6-TGN (therapeutic metabolite) and 6-MMP (potentially toxic metabolite) are generally quoted as:

6-TGN below therapeutic range <235
optimal range of 235 to 450
toxic range >450
6-MMP below 6000 generally believed to be OK
above 6000 generally viewed as potentially toxic levels

Not all doctors agree that Prometheus metabolite testing is needed and not all insurance companies approve this testing.


Allopurinol:

Some doctors use allopurinol in combination with Imuran to boost 6-TGN levels without stressing the liver. It is one strategy used when regular dosing causes elevated liver enzymes even though therapeutic levels of 6-MP have not been reached.

Allopurinol blocks one of the pathways for inactivation of 6-TGN thus increasing the amount of circulating 6-TGN. When used in combination with Allopurinol, the Imuran dose must be reduced to 1/3 to 1/4 of usual prescribed levels.

Milk Thistle (natural herb not to be confused with milk from cows):

There is mixed research evidence showing that Milk Thistle reduces elevated liver enzymes in a variety of clinical populations. In the only pediatric research that has been reported, pediatric cancer patients receiving 6-MP as part of their chemo regimen had significantly lower levels of AST and trends toward lower ALT and Bilirubin after 56 days of treatment with Milk Thistle. There is lots of anectdotal reports of Crohn’s patients finding this successful. So you may want to talk to your doctor about using this supplement.
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Badger, 18, CD, overall great guy
Dxd age 10, 2006 after nearly 1 year of active sx
Current CD meds: Remicade, Methotrexate and Omeprazole, Vit. D, Calcium, Folic Acid, Probiotic

Nothing I say here should be construed as medical advice. I am not a doctor. These are just my opinions.

Last edited by Patricia56; 10-26-2012 at 07:24 PM.
08-29-2012, 06:18 PM   #2
Catherine
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Patricia thank you for this great information.

Our GI & GP are only doing full blood count.

If you could going get one other test added, what would you go you?
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Catherine
Mother of Sarah dx aged 16, Jan 2012
DX - CD 1/12, asthma
Small bowel to small bowel fistula

Meds: ), azathioprine 200mg, Mesalazine 1.2g x 2, seretide 250 x 2 (asthma), ventolin (as needed)

Currently no supplements.

Has previously taken Multi B, Caltrate, B12 & Iron

Prednisolone (from 30 mg 01/02/2012 to 17/06/2012, 30mg 24/10/12-28/12/12, 50mg 24/1/13-27/4/13)
08-29-2012, 06:42 PM   #3
Patricia56
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Are you sure they are not doing a metabolic panel or liver panel? I have never heard of anyone putting a kid on AZA without running those labs on a regular basis. Liver toxicity is a major concern with AZA.

As for which test, that would include the items listed in the post after "liver panel".

I could not pick "one". You really need to discuss this with your GI promptly.
08-30-2012, 02:44 AM   #4
Catherine
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She did have one metabolic panel done, will check date.

I don't believe she has ever had a liver panel done. I asked the GP on order the liver panel but was told that the GI would have order if necessary.

As Sarah was dx at 16, she is consider an adult patient. Do know whether the testing is any different for adults?
08-30-2012, 04:17 AM   #5
polly13
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She did have one metabolic panel done, will check date.

I don't believe she has ever had a liver panel done. I asked the GP on order the liver panel but was told that the GI would have order if necessary.

As Sarah was dx at 16, she is consider an adult patient. Do know whether the testing is any different for adults?
if it any help lucy gets the following bloods done
Full blood count
ESR
U/e
Ca, Mg
Creatinine
Inorg Phos
Liver function tests (Bilirubin, AST, ALT, Alk Phos, total protein Albumin)
y GT
CRP

Polly
08-30-2012, 06:57 PM   #6
Patricia56
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A comprehensive metabolic panel would include the liver enzymes tests. A basic metabolic panel would not.

It should make no difference.

the standard of care for use of these medications is to do the monitoring that I gave in the original post.

If her doctor is not following that schedule (it sounds like he is not) then I would ask very specifically why not.

The reasons for this monitoring is that two of the most serious potential side effects/complications are liver toxicity and bone marrow suppression. Both of these are "silent" side effects that often do not become apparent until they have become very serious indeed and possibly permanent and even life threatening damage has occurred.

So I would be very concerned that the GI is not running any liver function tests if I understand you correctly.

Now not all GI's feel that running labs every 3 months, once a patient is established at a set dose, is necessary and that every 6 months is good. I can see this being the trend with adult GI's more than peds since adults should be able to tell when something is wrong and call the GI. This would mostly not be true with kids.
08-30-2012, 08:18 PM   #7
Catherine
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Thank for support.

The GI confirms that liver function was done in March. Will repeat for my piece of mind.
08-31-2012, 07:08 PM   #8
NMMom
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Thank you so much for posting this! Ellie just started on AZA today and I really appreciated have your post to read!
09-01-2012, 08:16 AM   #9
AZMOM
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Patricia's advice is great!

I will say that our doc followed that blood testing schedule to the letter when Claire took 6mp. It's important to continue monitoring because like all crohns meds, they may not work forever. There's a tricky balance.

Don't be afraid to push the doc! He's getting paid to work for you.

Hugs, J.
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Julie

Mom to Claire - 11 going on 17

Dx JRA age 3, Crohn's age 6
Acute transverse myelitis at age 5

Started IVIG September 2016
Started Tacrolimus October 2016
Neurontin 100mg twice daily
Folic Acid
Calcium/D supplement
Daily Vitamin
Daily Probiotic

No more Enbrel, Stelara, Methotrexate, Allopurinal or 6MP

Last edited by AZMOM; 09-01-2012 at 08:17 AM. Reason: Typo
09-01-2012, 09:43 AM   #10
my little penguin
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Our Gi followed the same plan when DS was on 6-mp . It helped alert us to liver issues for DS early.
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09-06-2012, 06:12 AM   #11
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@Catherine - As Patricia has said, age is of no consequence when it comes to running these labs and when taking Aza they should be run as a matter of course. I personally like my kids to have bloods done at 2 monthly intervals, 3 monthly tops when on Aza. A FBC (Full Blood Count), LFT's (Liver Function Tests) and UEC's (Electrolytes, Urea and Creatinine) are the least they should be requesting.

Dusty. xxx
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09-06-2012, 06:50 AM   #12
Catherine
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I have since found out that they were done in March and were normal. Gi ordered them again at my request and they were done yesterday. Full blood and serum biochemistry after back.
09-27-2012, 02:17 PM   #13
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Patricia56, any thoughts on the risks of handling the 6mp for our kids? I took no precautions the first 6 months Alex used it a couple years ago, then had a home nurse convince me to use gloves and a mask, so I started doing that then and do it now that we have restarted it. Alex is still learning to swallow pills so I have to crush it. Even if he could, I still have to halve the pills anyway. I was mixing it with ice cream, but switched to applesauce after seeing your post. Thanks!
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currently on Humira, Feb 2012+, MTX (20mg) Aug 2017+, folic acid
past use: 6mp for Sep 2010-Apr 2011 (not effective enough), then Remicade April 2011-Dec 2011 (built antibodies); additional 6MP Aug 2012-Sep 2013; Periactin for appetite Sep 2010-Sep 2013
other: Centrum chewable multi; calcium-vitD;
Derma-Smoothe for psoriasis rashes; Alrex, Zaditor eye drops for vernal conjunctivitis; history of asthma, ear infections
09-27-2012, 03:05 PM   #14
DustyKat
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Hey Jenn,

I so hope you don't mind me butting here.

When I read your post I couldn't help but think back to one I wrote some time ago, it was a humorous mind!...

http://www.crohnsforum.com/showthread.php?t=19740

...but back to what you asked. Unless you are pregnant or you are administering 6MP in a soluble form (so liquid, cream etc) or you are breaking/crushing the tablet then you don't need to take those precautions. Since I see you are indeed crushing the tablet then yes, I would wear both gloves, so you don't absorb it through your skin and a mask so you don't inhale any of the crushed tablet dust.

Dusty. xxx
09-28-2012, 05:53 PM   #15
Jenn
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lol. uh oh, my gloves aren't purple!
09-29-2012, 08:47 AM   #16
DustyKat
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Then you can't give the tablets Jenn unless you take us up on our offer of an exclusive 12 week training program. Upon successful completion of the course each participant will receive their own pair of purple gloves with their initials embroidered on the cuff...

Dusty. xxx
09-29-2012, 10:19 PM   #17
Patricia56
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I completely agree with DustyKat in every way.

Sorry to be MIA. Spent several days in the hospital myself this month and I'm still working on recovering. Will check in as I'm able over the next few weeks.

Last edited by Patricia56; 09-30-2012 at 03:51 AM.
09-30-2012, 12:52 AM   #18
David
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Ugh, Patricia, I'm so sorry to hear you're having problems I hope you're doing better? Let us know if you need anything!

Certainly no rush, but if you want to add to the first post at some point, though it should already be done just due to IBD, unfortunately it isn't... 6-MP can lead to B12 deficiency so making sure B12 levels are tested is important.

Great post by the way, thank you!
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09-30-2012, 07:37 AM   #19
DustyKat
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I'm so sorry to hear you have been unwell Patricia.

I hope you have a speedy and uneventful recovery!

Take care,
Dusty. xxx
09-30-2012, 07:45 AM   #20
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Hugs to you.
I hope all goes well for speedy recovery!
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Ibd (microscopic)
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09-30-2012, 11:04 AM   #21
Jenn
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DustyKat, OK if the 12 week program can be in isolation on a remote tropical island, please?
09-30-2012, 04:58 PM   #22
DustyKat
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You wish! For that matter so do I!

Dusty.
10-26-2012, 07:13 PM   #23
Patricia56
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Bump
12-04-2012, 10:36 AM   #24
Patricia56
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Bump for newbies on 6-MP/Imuran/Azathioprine
12-17-2012, 01:32 AM   #25
Patricia56
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Bump for newly prescribed and new to board
01-27-2013, 04:57 PM   #26
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bump
02-13-2013, 11:57 AM   #27
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Anyone have experience with adding allopurinol? Just got results for my son's 6mp metabolite test. The 6-TGN number was only 143(too low) and the 6-MMPN was 11,495 (too high). His liver numbers are all within the normal ranges however. SED rate was 21, otherwise everything else was good. He's actually doing pretty well and I hate to mess with things or add more meds, but it doesn't seem as though the 6mp is having the desired effect. Haven't had a talk with the GI yet, just got the result yesterday. He's 13, taking 75mg/daily and weighs about 100lbs.
02-13-2013, 12:03 PM   #28
Jmrogers4
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My son took allopurinol with imuran, they drop the dose down to minimum add the allopurinol and start retesting for theraputic levels from there. Jack started at 50mg of Imuran plus 100mg of allopurinol and it wasn't quite enough so he ended up at 75mg of Imuran plus 100mg of allopurinol and he was on it for several years. Once they added it we started to see much better results and little to no symptoms
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Mom to Jack (18) dx Crohn's 2/2010
Vitamin D -2000mg
Remicade - started 1/9/14; 7.5ml/kg every 6 weeks
Centrum for Him teen multivitamin
Past meds: Imuran/Azathioprine; allopurinol; methotrexate; LDN; Prednisone; Apriso; Pentasa; EEN

Husband dx Crohn's 3/1993
currently none due to liver issues
02-13-2013, 12:24 PM   #29
NMMom
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we had to add the allopurinol to Ellie's regimen as well. She's now taking 25mg. of AZA and 50 mg. of the allopurinol. It is frustrating to have to feel like we are starting from square one with finding the therapeutic range but I'm hopeful this will finally take her to remission. You also want to make sure that the meds (AZA) that you are using to try and help the IBD doesn't do unwanted damage to another major organ (liver). Hang in there! On the good side we didn't notice any additional side effects from the allopurinol.
02-13-2013, 10:19 PM   #30
my little penguin
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Ds took allopurinol with 6-mp as well.
Unfortunately even after playing with the dose his ast and alt levels kept going up when we increased the 6-mp to therapeutic levels.
It work some for him but was never enough to get him symptom free.
Good luck .
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