Azathioprine and mercaptopurine in the management of patients with chronic, active microscopic colitis

Background Microscopic colitis (MC) is a common chronic diarrhoeal disease, and remission can be induced with budesonide. However, diarrhoea relapses frequently when budesonide is tapered and a few patients become budesonide intolerant. Aim To examine retrospectively the effect of azathioprine (AZA) and mercaptopurine (MP) in patients with chronic, active MC. Methods/patients Data on all MC patients who received AZA or MP in the years 19972011 at three centres representing three countries were pooled for analysis. The indications for thiopurine therapy were frequent relapses after short-term treatment (N=26), budesonide dependency on 6mg (N=15) and budesonide intolerance (N=5). The response to thiopurine treatment was defined as clinical remission, intolerance or nonresponse. Results Forty-six MC patients (32 CC and 14 LC), 32 female; median age 59years (range: 3683) with a median disease duration of 3years (range: 0.518) were included. Thirteen patients (28%) achieved long-term clinical remission on AZA therapy. AZA failed in 31 patients (67%) due to intolerance and in 2 patients (4%) because of nonresponse. Thirteen of 31 AZA-intolerant patients were switched to MP and 6 patients (46%) obtained clinical remission. Thus, the overall response rate to thiopurines was 19/46 (41%). The main side effects were nausea/vomiting and abnormally elevated liver enzymes. Conclusions In this retrospective case series, the majority of chronic, active MC patients were intolerant to AZA leading to cessation of treatment. However, further studies are needed to explore the efficacy, acceptance, tolerance and safety of MP in patients with chronic, active MC refractory to budesonide.