Azathioprine (Imuran)

pill bottle with pills

Azathioprine (Imuran) is a drug used in certain autoimmune conditions (diseases where the body’s natural defense system attacks itself). It suppresses the immune system by interfering with the creation of DNA molecules. It is used in dermatomyositis, systemic lupus erythematosus (lupus), inflammatory bowel disease, vasculitis (inflammation of the blood vessels), rheumatoid arthritis, as well as other inflammatory conditions.

It is also used in combination with other medications to suppress the immune system after organ transplantation to prevent rejection of transplanted organs.

How to Take It

Azathioprine is usually taken orally (in doses between 50 – 150 mg), once or divided twice daily. The initial dose for rheumatoid arthritis is approximately 1 milligram/kilogram (mg/kg) of body weight. The dose can be increased every 1 - 2 months, up to a maximum dose of 2.5 mg/kg of body weight, or approximately 75 to 150 mg given twice a day.

A benefit in arthritis or other conditions may appear as early as 6 - 8 weeks. It may take up to 12 weeks to notice a full effect.

Side Effects

The most common side effects of azathioprine can involve the gastrointestinal tract (which includes the stomach, intestines, liver, and pancreas) and the blood cells. Taking the medication twice daily instead of all at once, or taking it after eating, may help avoid these problems. Less often, azathioprine may cause damage to the liver, pancreas, or an allergic reaction that may include a flu-like illness or a rash. Azathioprine also can lower the number of infection-fighting white blood cells.

Before or during treatment, your doctor may perform a blood test called TPMT activity level. TPMT helps clear the medication from your system. If you have lower amounts of TPMT, you may be at higher risk for medication toxicity. It is important to take azathioprine as directed and have regular blood tests.

Tell Your Rheumatology Provider

You should notify your rheumatology provider if you have these symptoms while taking this medication: fever, rash, easy bruising or bleeding, or signs of an infection. If vomiting occurs, you should contact your rheumatology provider, as this may be a sign of a serious reaction.

Be sure to tell your rheumatology provider about all of the medications you are taking, which may include over–the-counter drugs and natural remedies. Medications that may interfere with azathioprine and potentially cause serious problems include the gout medication allopurinol (Aloprim, Zyloprim); warfarin (Coumadin); some blood pressure medications, including some angiotensin-converting enzyme (ACE) inhibitors (Accupril or Vasotec); olsalazine (Dipentum); mesalamine (Asacol, Pentasa); and sulfasalazine (Azulfidine).

Make sure to notify your other health care providers while you are taking this drug. If you are pregnant or considering pregnancy, let your rheumatology provider know before starting this medication. Azathioprine can still be used during pregnancy, if needed. Women should still discuss birth control with their primary care providers or gynecologists. Breast-feeding can still take place while taking azathioprine, as there is a low transfer rate into breast milk.

Be sure to talk with your rheumatology provider before receiving any vaccines or undergoing any surgeries while taking this medication. You should discuss updating your vaccinations prior to starting this medication. 

Updated February 2022 by Lisa Carnago, FNP, and reviewed by the American College of Rheumatology Committee on Communications and Marketing.

This information provided for general education only. Individuals should consult a qualified health care provider for professional medical advice, diagnosis and treatment of a medical or health condition.

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