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azathioprine (ex. Imuran), cyclosporine (Sandimmune), mycophenolate mofetil (ex. CellCept)

Immunosuppressants are sometimes used when the more common treatments for ITP fail to raise the platelet count. These drugs were designed for use in organ transplant patients to decrease the body's tendency to reject the new transplants. Because they deactivate the immune system, they have been used to treat a number of autoimmune diseases.

IMPORTANT: These drugs should not be used during pregnancy or by women who may become pregnant. They can put patients at increased risk of opportune infections or activate latent viral infections. They may also can increase the risk of developing certain types of cancer. 3 4 9

Before taking these drugs, be sure to tell your doctor if you have ever had cancer or are taking other medications that suppress the immune system. 4

azathioprine (ex. Imuran, Azamun) suppresses the division of white blood cells.1 It is slow to raise the platelet count in responders and should be continued for about 4 months before determining whether it has been effective. It is sometimes given along with prednisone. 2 Side effects include excessive tiredness, pale skin, headache, confusion, dizziness, fast heartbeat, difficulty sleeping, weakness, shortness of breath, sore throat, fever, chills, and other signs of infection. 3

IMPORTANT:  Imuran can cause irreversible bone marrow failure for those with a particular polymorphism of the TPMT gene.  GlaxoSmithKline has a predictive DNA test for this type of problem.

cyclosporine (ex. Sandimmune) blocks the action of T-cells, a type of white blood cell responsible for fighting infections.4 For patients with ITP, the response rate in one study was 55%, but the relapse rate was high 7 Cyclosporine may damage the kidneys, raise blood pressure, and increase your risk of developing cancer. Side effects include flu-like symptoms, coughing, difficult or painful urination, changes in the skin, fatigue, and swollen glands. 4

Grapefruit juice ,and perhaps Sun Drop or Fresca (citrus sodas), can increase the level of circulating cyclosporine.5 St. John's wort reduces the concentration of cyclosporine, making it less effective.6

mycophenolate mofetil (ex. CellCept), a newer medication than those listed above, inhibits the proliferation of B and T lymphocytes, types of white blood cells. In a small study in ITP patients, 7 of 18 responded, but 3 of the 7 responders had some bouts with lower platelets while taking the medication.8 The side effects include: bowel changes, insomnia, headache, dizziness, swelling, pain, difficulty breathing, rapid heartbeat, blood in stools or vomit 9. Extremely rare, but very serious side effects, include Pure Red Cell Aplasia, a type of anemia 9 and progressive multifocal leukoencephalopathy , a rare, incurable neurological condition. 10

1. Wikipedia: Azathioprine http://en.wikipedia.org/wiki/Azathioprine
2. Quiquandon I et al. “Re-evaluation of the role of azathioprine in the treatment of adult chronic idiopathic thrombocytopenic purpura: a report on 53 cases.” Br J Haematol. 1990 Feb;74(2):223-8. http://www.ncbi.nlm.nih.gov/pubmed/2317458
3. Medline Plus: Azathioprine http://www.nlm.nih.gov/medlineplus/druginfo/meds/a682167.html
4. Medline Plus: Cyclosporine http://www.nlm.nih.gov/medlineplus/druginfo/meds/a601207.html
5. Schwarz UI et al. “Impact of citrus soft drinks relative to grapefruit juice on ciclosporin disposition.” Br J Clin Pharmacol. 2006 Oct;62(4):485-91. http://www.ncbi.nlm.nih.gov/pubmed/16995870
6. Dasgupta A. “Herbal supplements and therapeutic drug monitoring: focus on digoxin immunoassays and interactions with St. John's wort.” Ther Drug Monit. 2008 Apr;30(2):212-7. http://www.ncbi.nlm.nih.gov/pubmed/18367983
7. Kappers-Klunne MC, van't Veer MB. “Cyclosporin A for the treatment of patients with chronic idiopathic thrombocytopenic purpura refractory to corticosteroids or splenectomy.” Br J Haematol. 2001 Jul;114(1):121-5. http://www.ncbi.nlm.nih.gov/pubmed/11472356
8. Provan D et al. “Efficacy of mycophenolate mofetil as single-agent therapy for refractory immune thrombocytopenic purpura.” Am J Hematol. 2006 Jan;81(1):19-25. http://www.ncbi.nlm.nih.gov/pubmed/16369979
9. Medline Plus: Mycophenolate http://www.nlm.nih.gov/medlineplus/druginfo/meds/a601081.html
10. Wikipedia: Mycophenolic acid http://en.wikipedia.org/wiki/Mycophenolic_acid