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I had another Prometheus test and a bit confused

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Ulcerative Colitis
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Posted 6/10/2008 5:38 PM (GMT -7)
I seen my GI today because I'm in a mild flare.  He wanted to make sure that I am metabolizing 6mp properly so he sent me to the lab.  He told me on my last Prometheus test that I was still on the low end of the theurpedic(sp?) level and if the test shows that I'm still on the low end, he may have to up my dose again.  But I'm a bit confused because most everyone on here who is on 6mp is usually at 50-75mgs range.  If I have to keep getting a higher dose, does that possibly mean that it is not working properly for me?  Right now I take 100mgs on Mon and Thurs and 50mgs for the other days.  My GI said that he wishes and hopes that he can get me down to at least a flare a year or every 2 years - yeah, wouldn't that be nice!? 
Posted 6/10/2008 9:00 PM (GMT -7)
People metabolize drugs differently. Factors such as body weight, liver function, kidney function, etc all play a role in the way one person's body handles a drug as compared to another. In regards to meds like 6MP and azathioprine [brand name: Imuran], some people do not metabolize them at anywhere near a sufficient level and they get liver problems etc. Prometheus labs developed a test to determine if a person is reaching a therapeutic level of 6MP or azathioprine on their current dosage. I have seen a wide variety of dosages on the Crohn's forum when it comes to both 6MP and azathioprine. Personally, I started out at 50 mg per day, went to 100 mg a day and then had to be brought down to 75 a day when my red cells decided to get into the act.
Posted 6/11/2008 4:00 AM (GMT -7)
Thanks Ides. When he first bumped me up to 100mgs for those 2 days, I was like isn't that a bit high?? But I guess my body seems to be handling it for the 2 days that I'm on it because all my blood tests turn out ok. It really would be nice to get into a true remission once and for all. I honestly don't think I've ever been in one!
Posted 6/11/2008 4:50 AM (GMT -7)
I was on 100mg, every day, 7 days a week.

Didn't work well enough, so they put me on Allopurinol(100mg) and 6-MP (25mg), taken together, 6 days a week.

My white cell count is usually between 3.5 and 5.
Posted 6/11/2008 5:08 AM (GMT -7)
Ive been on Azathioprine (imuran) 150mg daily for the past year without any problems.

I was under the impression they use it on a certain ratio of mg to how many kg you weigh.

Least thats what we use at the hospital i work at with kidney transplant patients.

Posted 6/11/2008 5:16 AM (GMT -7)
Imuran and 6mp dosages are at different mgs because Imuran breaks down into 6mp in the liver. So Imuran needs to be at a higher dosage then 6mp in order to get the same desired effect. Usually they base the dosage on your weight but it also depends on how your body metabolizes it too. I weigh only 130lbs (at 5'6"), so I don't think my dose is being based on my weight but rather how I metabolize it.

Severin, what is Allopurinol? And isn't your wbc a bit on the low side? I forgot what the proper numbers should be.
Posted 6/11/2008 5:28 AM (GMT -7)
Have you ever heard of a blood level or test called tpmt levels. I'm TPMT heterozygote and its got something to do with amount of azathioprine and i presume 6mp that a person can tolerate.

Prometheus test is that the same test or something different ? ive not heard of it ? is it an american name ? sorry if i sound slow !!

I do know that i was meant to start on 225mg of Azathioprine but because the TPMT level in my blood is so low i had to start on 5mg and slowly work my way up 150mg.

Maybe if you havent had this test you could ask your doc ?

Posted 6/11/2008 5:45 AM (GMT -7)

I have been on 100mgs of Imuran daily for.... jeez, over a year now! I weigh anywhere from 95-115. Usually my weight is around 110. I had a prometheus test done about 6-8 months ago, which I guess came back alright as my dose wasn't changed. My WBC count is pretty much always somewhat high, which has become my "normal" as my body is basically ALWAYS fighting some sort of inflammation! I don't really ever question my GI on dosing info- well I did push for the higher Remicade dose, but aside from that I do as he says. Not blindly, mind you- I've done a lot of research into all the drugs I take & have taken, & check up on their dosing protocols, etc. I just figure- Look, my doctor has been practicing for like 30 years, he's in the know as far as newer IBD treatments, he's willing to listen to my opinion & actually take it into consideration, he know's what he's doing! I have to believe that, & trust him enough to listen to his medical recommendations. Not to say I agree with or follow all of them- he has recommended surgery numerous times in the past, but if I find myself second guessing him, then I'm in trouble.... does that make sense? I have to feel like we're a team, & luckily, I do!


Posted 6/11/2008 9:35 AM (GMT -7)
Colitis-owns, yes that is the test I am referring to. Prometheus is the name of the lab that does the testing so I automatically just call it that. Sorry for the confusion :) I find it's easier to remember the name of the lab as opposed to remembering the test name.
Posted 6/12/2008 12:29 AM (GMT -7)
ah ok then. I was just thinking that maybe i should have had another test before i started azathioprine and my doc didnt suggest it. thats a relief then.

Apart from the side effects. How do we all rate Azathioprine/6mp vs Prednisolone ???
Posted 6/12/2008 4:49 AM (GMT -7)
I've never been on oral steroids before so I have no comparison. I can however base my comparison on everyone else's experiences that have frequented HW over the years. Aza/6mp and pred are completely different type of medications then the other. Sure pred can take care of symptoms quickly but to me, the long term effects of this med (for some) can be hazardous. I don't know the long term effects of Aza/6mp used in Uc and I doubt the doctors do either because they just started using these meds in treatment. So I think that we are among the first guinea pigs for ths line of treatment.

As for the Prometheus test. I had an initial test before I began 6mp. This test was to be sure the my blood had the certain correct amount of levels (not sure what though). This test also determined which one would probably work better for me - the Aza or 6mp. Then once I was on 6mp and still not doing well, that is when I have had repetitive tmpt metabolites test from Prometheus. That is when I found out that I have always been metabolizing this med at the low end.
Posted 6/12/2008 6:41 AM (GMT -7)
I work in a hospital and although i dont work in the Gastro department i still deal with Pred, Aza and other drugs such as methotrexate and mycophenolate. Pred is def used for short term. They actually call 6mp/aza etc steroid sparing drugs. Dermatology (where i work) has been using these drugs for a good number of years and the only long term side effects known are all well known already Basel cell and squamous cell carcinomas (skin cancers) etc. I think the doses IBD patients are on are significantly lower than the transplant patients who develop these in the long term. There are a good number of treatments to TRY and prevent these skin cancers developing which are being looked at. there is a study called "rescue study" and this is currently being undertaken in my hospital regarding the long term skin risks of the Azathioprine and mycophenolate drugs. I think some of drugs are called Aldara and imiquimod but dont hold me to that. (I only work in admin !!) The new biological drugs used such as humira, infiliximab (dont know if you have that in Amercia, im from the UK) are really really new and not a lot is known about them at all. Me personally, im happier using Azathioprine, because if you take the right precautions such as sun block and obviously the blood tests to look for lymphoma etc then i think this drug is a lot safer than pred in the long term. sorry for the ultra long post. and i hope it all made sense.    
Posted 6/12/2008 7:54 AM (GMT -7)
I had not heard about a connection between Imuran and skin cancer.  Well..thats a tad bit scary.

confused . 

Well, I have had the Promethius test a few times myself, and my dosage has always been upped.  I have not a single flare since starting this drug a few years back but I guess I must have needed my dosage upped.  I am 5'6 and weigh around 128 lbs.  I am on 150 mg (started at 75 mg) of Imuran and if you ask me, there's no going back to Prednisone if I can do ANYTHING to help it. 

Michele

Posted 6/12/2008 8:00 AM (GMT -7)
When I was on Azathioprine, I started at 75 mg then went to 100 and after my prometheus test went to like 150 or something, so it sounds like you're not taking that much to me.
James
Posted 6/12/2008 9:18 AM (GMT -7)
I state again that Imuran and 6mp dosing is different. You have a higher mg's of Imuran compared to 6mp because Imuran has to be at a higher mgs to break down to the proper 6mp level in the liver. So, I'm guessing here, but I'm thinking that 100mgs may be compared to around 25-50mgs of 6mp. If someone can find me the comparison, that would be great because I have no clue where to even start looking on the internet. It just seems that I am on a higher dose of 6mp then most the people here who are on it. I'm afraid that the higher I go, the less likely that it is going to work for me and/or cause other complications with the liver and pancreas. Of course I plan on discussing this with my GI if and when he decides to up my dose.
Posted 6/12/2008 9:26 AM (GMT -7)
http://www.aafp.org/afp/20070201/practice.html

here, here are the practice guidelines for the drugs (along with some other not needed info!). I would just ask my doctor though. If it bothered me that much I'd call his office, prior to an appt.

Posted 6/12/2008 9:35 AM (GMT -7)
Thank you Eva! So basically 6mp seems to be half the dosing of Imuran. I always wondered about that :)
Posted 6/12/2008 9:45 AM (GMT -7)
Yeah, I never knew that either- I knew they metabolize into the same drug in the liver, so I just figured they had similar dosing protocols. The things you learn.... :-)   So does your higher dose equal out to what the guidelines suggest? Oh wait, we need to find a metric convertor to figure the weight out!!! tongue
Posted 6/13/2008 12:21 AM (GMT -7)

I think this follows the same guidelines from the link posted. I found a book at work called the British National Formulary which i think is more pharmacy guided.

The doses listed are...Azathioprine 2/2.5mg per kg and Mercaptopurine  1/1.5mg per kg.

This is the information listed underneath the doses. I think it is only a section on maintenance therapy not an acute flare (i couldnt find that page in the book, sorry).

"Azathioprine or Mercaptopurine given under close supervision may be helpful, some patients will respond to lower doses of these drugs. Methotrexate is tried in Crohns disease if Azathioprine or Mercaptopurinecannot cannot be used. Infliximab is licensed for maintenance therapy in crohns disease and ulcerative colitis"

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