What is the safety and efficacy of off-label treatment with azathioprine in patients with dermatological diseases?


When comparing the tables about off-label use with the known undesirable effects distilled from the summary of product characteristic and the Dutch “Farmacotherapeutisch kompas” and “SPC”, it becomes clear that although the profile of undesirable effects versus adverse events is the same, the number of adverse events reported in the off -label studies is generally larger. An explanation could be the limited number of patients in the off-label studies, which widens the confidence interval and standard deviation. The same can be said about the occurrence of serious adverse effects. Remarkable is the number of deaths due to neoplasms, CVA, pulmonary and heart disease. However, these causes of death are also the most common in general society. Therefore it is questionable whether those deaths are related to the treatment with AZA, especially when taking into account the time window between the occurrence and the treatment.


Considering that the strength of evidence regarding safety is low (see ‘Conclusion’) there remains uncertainty about the exact safety risk when using azathioprine as an off-label prescribed drug. The working group took this uncertainty into consideration when formulating recommendations for the separate dermatological diseases.


Azathioprine is an imidazole derivative of 6-mercaptopurine (6-MP) and is available since 1963. It is rapidly broken down in vivo into 6-MP and a methylnitroimidazole moiety. The 6-MP readily crosses cell membranes and is converted intracellularly into a number of purine thioanalogues, which include the main active nucleotide, thioinosinic acid. The rate of conversion varies from one person to another. Nucleotides do not traverse cell membranes and therefore do not circulate in body fluids. Irrespective of whether it is given directly or is derived in vivo from azathioprine, 6-MP is eliminated mainly as the inactive oxidised metabolite thiouric acid. This oxidation is brought about by xanthine oxidase, an enzyme that is inhibited by allopurinol. The activity of the methylnitroimidazole moiety has not been defined clearly. Determination of plasma concentrations of azathioprine or 6-MP have no prognostic values as regards effectiveness or toxicity of these compounds.


While the precise modes of action remain to be elucidated, some suggested mechanisms include:

  1. the release of 6-MP which acts as a purine antimetabolite.
  2. the possible blockade of -SH groups by alkylation.
  3. the inhibition of many pathways in nucleic acid biosynthesis, hence preventing proliferation of cells involved in determination and amplification of the immune response.
  4. damage to deoxyribonucleic acid (DNA) through incorporation of purine thio-analogues.

Because of these mechanisms, the therapeutic effect of azathioprine may be evident only after several weeks or months of treatment.


Azathioprine is used as an immunosuppressant either alone or, more commonly, in combination with other agents (usually corticosteroids) and procedures which influence the immune response. Therapeutic effect can include a steroid-sparing effect, thereby reducing the toxicity associated with high dosage and prolonged usage of corticosteroids. Azathioprine, in combination with corticosteroids and/or other immunosuppressive agents and procedures, is used to enhance the survival of organ transplants and to reduce the corticosteroid requirements of renal transplant recipients. Azathioprine, either alone or more usually in combination with corticosteroids and/or other drugs and procedures, has been licensed for treatment of the following diseases:

  • severe rheumatoid arthritis
  • systemic lupus erythematosus
  • dermatomyositis and polymyositis
  • auto-immune chronic active hepatitis pemphigus vulgaris
  • ulcerative colitis and Crohn’s disease polyarteritis nodosa
  • auto-immune haemolytic anaemia
  • chronic refractory idiopathic thrombocytopenic purpura 



There is important inconsistency in the way that safety issues are addressed and (serious) adverse events are reported. There is also a considerable amount of indirectness and probability of reporting bias. The remaining body of evidence, consisting of other fundamental study designs(case series and cohort studies) do not deliver the strong evidence needed to increase the grade.

Zoeken en selecteren

Figure 1 summarizes the selection process. An initial search retrieved 3867 articles. After screening title and abstract for eligibility, 148 articles were selected. Then, after screening the full texts of the articles, 43 articles were considered relevant. Reasons for exclusion were lack of relevance in 13 articles, review articles without additional new evidence in 13 articles and case report with less than 5 subjects in 52 articles. Outcome data on safety and efficacy were not available in 17 articles and for 3 articles only an abstract was available. Four other articles were comments and 2 were double publications. All those articles were therefore excluded. Included were 11 RCT’s, 2 cohorts and 30 case series concerning 12 dermatological diseases.


A random sample of 20 articles was taken from the publications that were excluded because the case report had less then 5 subjects. The random sample was screened on missed relevant data regarding adverse effects. This was not the case.


Figure 1. Flowchart summarizing the selection process for studies concerning off-label treatment with azathioprine indermatological diseases.


  1. 1 - Buckley DA, Baldwin P, Rogers S. The use of azathioprine in severe adult atopic eczema. J Eur Acad Dermatol Venereol 1998; 11: 137-40.
  2. 2 - Kuanprasert N, Herbert O, Barnetson RS. Clinical improvement and significant reduction of total serum IgE in patients suffering from severe atopic dermatitis treated with oral azathioprine. Australas J Dermatol 2002; 43: 125-7.
  3. 3 - Malthieu F, Guillet G, Larregue M. [Azatropin in severe atopic dermatitis: 24 cases]. Ann Dermatol Venereol 2005; 132: 168-70.
  4. 4 - Beissert S, Frieling U, Luger TA. Results of a multicenter, randomized clinical study to compare azathioprine versus mycophenolate mofetil for the treatment of aquired bullous autoimmune diseases. 11th Congress of the European Academy of Dermatology and Venereology 2002; W1-W2.
  5. 5 - Guillaume JC, Vaillant L, Bernard P et al. Controlled trial of azathioprine and plasma exchange in addition to prednisolone in the treatment of bullous pemphigoid. Arch Dermatol 1993; 129: 49-53.
  6. 6 - Burton JL, Harman RR, Peachey RD et al. Azathioprine plus prednisone in treatment of pemphigoid. Br Med J 1978; 2: 1190-1.
  7. 7 - Burton JL, Greaves MW, Burton JL et al. Azathioprine for pemphigus and pemphigoid--a 4 year follow-up. Br J Dermatol 1974; 91: 103-9.
  8. 8 - Hewitt J, Escande JP, Leibowitch M et al. [Trial therapy of psoriasis with azathioprine]. [French]. Bull Soc Fr Dermatol Syphiligr 1970; 77: 392-6.
  9. 9 - Le Quintrec JL, Menkes CJ, Amor B. Severe psoriatic rheumatism. Treatment with azathioprine. report of 11 cases. Rev Rhum Mal Osteoartic 1990; 57: 815-9.
  10. 10 - Leigh IMH. Treatment of chronic actinic dermatitis with azathioprine. Br J Dermatol 1984; 110: 1984.
  11. 11 - Heurkens AH, Westedt ML, Breeveld FC. Prednisone plus azathioprine treatment in patients with rheumatoid arthritis complicated by vasculitis. Arch Intern Med 1991; 151: 2249-54.
  12. 12 - Callen JP, Spencer LV, Burruss JB et al. Azathioprine. An effective, corticosteroid-sparing therapy for patients with recalcitrant cutaneous lupus erythematosus or with recalcitrant cutaneous leukocytoclastic vasculitis. Arch Dermatol 1991; 127: 515-22


General treatment considerations

Nota bene!

The text in this section is based on the summary of product characteristics (SPC) text (last update 27-5-2009). The text was modified by the working group to reflect the best practice in the Netherlands at the time the guideline was made. Modifications are depicted in a grey box. It is advisable to consider the recommendations when prescribing azathioprine, however the text is not intended as a substitute for the complete SPC text. The complete and up to date Dutch SPC text is available on www.cbg-meb.nl.


Dosage in other conditions then organ transplant patients - adults and children

  • In general, starting dosage is from 1 to 3 mg/kg body weight/day, and should be adjusted, within these limits, depending on the clinical response (which may not be evident for weeks or months) and haematological tolerance.
  • When therapeutic response is evident, consideration should be given to reducing the maintenance dosage to the lowest level compatible with the maintenance of that response. If no improvement occurs within 3 months, consideration should be given to withdrawing azathioprine.


Therapeutic response is evident after approximately 6-12 weeks


  • The maintenance dosage required may range from less than 1 mg/kg body weight/day to 3 mg/kg body weight/day, depending on the clinical condition being treated and the individual patient response, including haematological tolerance.
  • In patients with renal and/or hepatic insufficiency, dosages should be given at the lower end of the normal range (see Special Warnings and Precautions for Use for further details).


Use in the elderly (see also renal and/or hepatic insufficiency)

There is limited experience of azathioprine in elderly patients. Although the available data do not provide evidence that the incidence of side effects among elderly patients is higher than that among other patients treated with azathioprine, it is recommended that the dosages used should be at the lower end of the range.

Particular care should be taken to monitor haematological response and to reduce the maintenance dosage to the minimum required for clinical response.


Use in elderly

All the studies concerning bullous pemphigoid were conducted with elderly patients only (see Table 5) (Beissert et al. 2007, Guillaume et al. 1993, Burton et al. 1978, Ahmed et al. 1977, Burton et al. 1974, Van Dijk et al. 1973, Greaves et al. 1971). The mean age range of the subjects in the studies ranged from 68.2 to 81.4. It is not possible to compare effectiveness and dosage of elderly for bullous pemphigoid with non-elderly because there are no studies available with non-elderly patients. Death was an important parameter with a total of 15 deaths among a total of 128 studied patients. However, the reported causes of death are comparable with the general population. As a result, the recommendations mentioned above (to be extra careful with the off-label use of in elderly patients) remain valid.


Use in children (also see www.kinderformularium.nl)

The only study concerning the off-label use of azathioprine in children is a case series in which 48 patients were treated for atopic dermatitis (Murphy et al. 2002). Mean age was 6.9 years (SD 6-16). The dosage was an individual determined dose of 2.5-3.5 mg/kg. Reported effectiveness was similar compared to other studies (Table 2). Reported adverse effects were transient mild lymphopenia (15), transient thrombocytopenia (1), transient abnormalities in liver enzymes (5), mild microcytosis (3), eczema herpeticum (1), nausea, vomiting, diarrhoea (1) and a hypersensitivity reaction (1). It is recommended that the dosages used should be at the lower end of the range and individually determined according to the weight of the patient.



Azathioprine is contra-indicated in patients known to be hypersensitive to azathioprine. Hypersensitivity to 6-mercaptopurine (6-MP) should alert the prescriber to probable hypersensitivity to azathioprine. Azathioprine therapy should not be initiated in patients who may be pregnant, or who are likely to become pregnant without careful assessment of risk versus benefit (see Special Warnings and Precautions for Use and Pregnancy and Lactation).


In addition (according to the dutch ‘Farmacotherapeutisch Kompas’ (online available on www.fk.cvz.nl)

  • severe infections

  • serious disrupted liver-, kidney- or bone marrow function.

  • pancreatitis

  • Lesh-Nyhan syndrome

  • ‘living’ vaccin (especially BCG, smallpox, yellow fever)


Special warnings and precautions for use



There are potential hazards in the use of azathioprine. It should be prescribed only if the patient can be adequately monitored for toxic effects throughout the duration of therapy. It is suggested that during the first 8 weeks of therapy, complete blood counts, including platelets, should be performed weekly and more frequently if high dosage is used or if severe renal and/or hepatic disorder is present. The blood count frequency may be reduced later in therapy, but it is suggested that complete blood counts are repeated monthly or at least at intervals of not longer than 3 months.


Complete blood counts should be repeated at least at intervals not longer than 3 months.


Patients receiving azathioprine should be instructed to immediately consult their doctor in case of evidence of fever, chills , unexpected bruising or bleeding or other manifestations of bone marrow depression (e.g. chest pain, dizziness, fatigue, petechiae).


There are individuals with an inherited deficiency of the enzyme thiopurine methyltransferase (TPMT) who may be unusually sensitive to the myelosuppressive effect of azathioprine and prone to developing rapid bone marrow depression following the initiation of treatment with azathioprine. This problem can be exacerbated by co-administration with drugs that inhibit TPMT, such as sulfasalazine.


Bone marrow depression/myelotoxicity could also be exacerbated by co-administration of drugs such as sulfasalazine.


It has been reported that decreased TPMT activity increases the risk of secondary leukaemias and myelodysplasia in individuals receiving 6-mercaptopurine (the active metabolite of azathioprine) in combination with other cytotoxic drugs (see section Undesirable effects).


The working group advises to determine the TPMT activity prior to the initiation of AZA. If this test is not available, starting AZA on a low dose (1.0 mg/kg) and frequent laboratory evaluations (see above) are an alternative.


Renal and/or hepatic insufficiency

It has been suggested that the toxicity of azathioprine may be enhanced in the presence of renal insufficiency, but it has not been supported by controlled studies. Nevertheless, it is recommended that the dosages used should be at the lower end of the normal range and that haematological response should be carefully monitored. Dosage should be further reduced if haematological toxicity occurs. During the administration of azathioprine to patients with hepatic dysfunction, regular (two times a week in the first 8 weeks) complete blood counts and liver function tests should be undertaken. In such patients the metabolism of azathioprine may be impaired, and the dosage of azathioprine should therefore be reduced if hepatic or haematological toxicity occurs.

Limited evidence suggests that azathioprine is not beneficial to patients with hypoxanthine-guanine-phosphoribosyltransferase deficiency (Lesch-Nyhan syndrome). Therefore, it is not recommended to give these patients azathioprine.


Carcinogenicity (see also section Undesirable Effects)

  • Patients receiving immunosuppressive therapy are at an increased risk of developing non-Hodgkin's lymphomas and other malignancies, notably skin cancers (melanoma and non-melanoma), sarcomas (Kaposi's and non-Kaposi's) and uterine cervical cancer in situ. The risk appears to be related to the intensity and duration of immunosuppression rather than to the use of any specific agent. It has been reported that reduction or discontinuation of immunosuppression may be associated with partial or complete regression of non-Hodgkin's lymphomas and Kaposi's sarcomas.
  • Patients receiving multiple immunosuppressive agents may be at risk of over-immunosuppression, therefore such therapy should be maintained at the lowest effective level.
  • Exposure to sunlight and UV light should be limited and patients should wear protective clothing and use a sunscreen with a high protection factor to minimize the risk of skin cancer and photosensitivity (see also section Undesirable Effects).
  • Infection with varicella zoster virus (VZV; chickenpox and herpes zoster) may have a severe clinical outcome during the administration of immunosuppressants. Caution should be exercised especially with respect to the following: Before starting the administration of immunosuppressants, the prescriber should check if the patient has a history of VZV. Serologic testing may be useful in determining previous exposure. Patients who have no history of exposure should avoid contact with individuals with chickenpox or herpes zoster. If the patient is exposed to VZV, special care must be taken to avoid patients developing chickenpox or herpes zoster and passive immunisation with varicella zoster immunoglobulin (VZIG) may be considered. If the patient becomes infected with VZV, appropriate measures should be taken, which may include antiviral therapy and supportive care.


Interaction with other medicinal products and other forms of interaction


  • Allopurinol

Xanthine oxidase activity is inhibited by allopurinol which results in reduced conversion of biologically active 6 thioinosinic acid to biologically inactive 6-thiouric acid. When allopurinol is given concomitantly with azathioprine, the dose of azathioprine should be reduced to one-quarter of the original dose.


  • Neuromuscular blocking agents

Azathioprine can potentiate the neuromuscular blockade produced by depolarising agents such as suxamethonium and can reduce the blockade produced by non-depolarising agents such as tubocurarine. There is considerable variation in the potency of this interaction.


Coumarin derivatives

Inhibition of the anticoagulant effect of coumarins, when administered together with azathioprine, has been reported.


  • Cytostatic/myelosuppressive agents

Where possible, concomitant administration of cytostatic drugs, or drugs which may have a myelosuppressive effect, such as penicillamine, should be avoided. There are conflicting clinical reports of interactions, resulting in serious haematological abnormalities, between azathioprine and co-trimoxazole. There has been a case report suggesting that haematological abnormalities may develop due to the concomitant administration of azathioprine and ACE inhibitors. It has been suggested that cimetidine and indometacin may have myelosuppressive effects, which may be enhanced by concomitant administration of azathioprine.


  • Other interactions

As there is in vitro evidence that aminosalicylate derivatives (eg. sulfasalazine) inhibit the TPMT enzyme, they should be administered with caution to patients receiving concurrent azathioprine therapy (see Special Warnings and Special Precautions for Use). Furosemide has been shown to impair the metabolism of azathioprine by human hepatic tissue in vitro. The clinical significance is unknown.


  • Vaccines

The immunosuppressive activity of azathioprine could result in an atypical and potentially deleterious response to live vaccines and the administration of live vaccines to patients receiving Azathioprine therapy is contra-indicated on theoretical grounds. A diminished response to killed vaccines is likely and such a response to hepatitis B vaccine has been observed among patients treated with a combination of azathioprine and corticosteroids.

A small clinical study has indicated that standard therapeutic doses of azathioprine do not deleteriously affect the response to polyvalent pneumococcal vaccine, as assessed by mean anti-capsular specific antibody concentration.


Use in Pregnancy and Lactation

Azathioprine should not be given to patients who are pregnant or likely to become pregnant without careful assessment of risk versus benefit. There have been reports of premature birth and low birth weight following maternal exposure to azathioprine, particularly in combination with corticosteroids. There have also been reports of spontaneous abortion following either maternal or paternal exposure. Azathioprine and/or its metabolites have been found in low concentrations in foetal blood and amniotic fluid after maternal administration of azathioprine. Leucopenia and/or thrombocytopenia have been reported in a proportion of neonates whose mothers took azathioprine throughout their pregnancies. Extra care in haematological monitoring is advised during pregnancy. 6-Mercaptopurine has been found in the colostrum and breast-milk of women receiving azathioprine treatment. Treatment with azathioprine is therefore not recommended during lactation.

The need for anti-conception in men during treatment is unclear and is currently subject of debate.


Undesirable effects

There is no modern clinical documentation that can be used for determining the frequency of undesirable effects. Undesirable effects may vary in their incidence depending on the indication. The following convention has been utilised for the classification of frequency: Very common,  1/10; common,  1/100 and < 1/10; uncommon,  1/1000 and < 1/100; rare,  1/10000 and < 1/1000; very rare, < 1/10000.


Azathioprine may be associated with a dose-related, generally reversible, depression of bone marrow function, most frequently as leucopenia, but also sometimes as anaemia and thrombocytopenia, and rarely as agranulocytosis, pancytopenia and aplastic anaemia. These occur particularly in patients predisposed to myelotoxicity, such as those with TPMT deficiency and renal or hepatic insufficiency and in patients failing to reduce the dose of azathioprine when receiving concurrent allopurinol therapy.

Reversible, dose-related increases in mean corpuscular volume and red cell haemoglobin content have occurred in association with azathioprine therapy. Megaloblastic bone marrow changes have also been observed but severe megaloblastic anaemia and erythroid hypoplasia is rare.


A minority of patients experience nausea when first given azathioprine. This appears to be relieved by administering the tablets after meals. Pancreatitis has been reported in a small percentage of patients on azathioprine therapy, particularly in renal transplant patients and patients with inflammatory bowel disease. There are difficulties relating pancreatitis to the administration of one particular drug, although re-challenge has confirmed an association with azathioprine .


Cholestasis and deterioration of liver function have occasionally been reported in association with azathioprine therapy and are usually reversible on withdrawal. This may be associated with symptoms of a hypersensitivity reaction (see hypersensitivity reactions).

Rare, but life-threatening hepatic damage associated with chronic administration of azathioprine has been described primarily in transplant patients. In some cases withdrawal of azathioprine has resulted in either a temporary or permanent improvement in symptoms and histological changes.


Several different clinical syndromes, which appear to be idiosyncratic manifestations of hypersensitivity, have been described occasionally following administration of azathioprine. Clinical features include general malaise, dizziness, nausea, vomiting, diarrhoea, fever, rigors, exanthema, rash, vasculitis, myalgia, arthralgia, hypotension, renal dysfunction, hepatic dysfunction and cholestasis (see hepato-biliary disorders). In many cases, re-challenge has confirmed an association with azathioprine. Immediate withdrawal of azathioprine and institution of circulatory support where appropriate have led to recovery in the majority of cases. Other marked underlying pathology has contributed to the very rare deaths reported. Following a hypersensitivity reaction to azathioprine, the necessity for continued administration of azathioprine should be carefully considered on an individual basis.


Summary of registered adverse events

Occurrence Events

Undesirable effect

Infections (indications other than transplant patients)



Viral, fungal and bacterial infections. Patients receivingazathioprine alone, or in combination with otherimmunosupressants, particularly corticosteroids, have shown increased susceptibility to viral, fungal and bacterial infections, including severe or atypical infection with varicella, herpes zoster and other infectious agents (see also section Special Warnings and Precautions for use).

Neoplasms benign and malignant (including cysts and polyps)


Neoplasms including non-Hodgkin's lymphomas, skin (cancers melanoma and non-melanoma), sarcomas (Kaposi's and non-Kaposi's) and uterine cervical cancer in situ, acute myeloid leukaemia and myelodysplasia (see also section Special Warnings and Special Precautions for Use)

Blood and lymphatic disorders


Very common:







Agranulocytosis, pancytopenia, aplastic anaemia,

megaloblastic anaemia, erythroid hypoplasia.

Respiratory, thoracic and mediastinal disorders


Very rare:

Reversible pneumonitis.

Gastrointestinal disorders



Nausea and vomiting




Colitis, diverticulitis and bowel perforation reported in transplant patients, severe diarrhoea in inflammatory bowel disease.

Hepato-biliary disorders



Cholestasis and elevation of liver enzymes.


Life-threatening hepatic damage (primarily in transplant patients).

Skin and subcutaneous tissue disorders



Alopecia, photosensitivity. Hair loss has been described in patients receiving azathioprine and other immunosuppressive agents. In many instances the condition resolved spontaneously despite continuing therapy. The relationship between alopecia and azathioprine treatment is uncertain.

Immune system disorders



Hypersensitivity reactions

Very rare:

Stevens-Johnson syndrome and toxic epidermal





  • Symptoms and signs

Unexplained infection, ulceration of the throat, bruising and bleeding are the main signs of overdosage with azathioprine and result from bone marrow depression which may be maximal after 9 to 14 days after overdosage. These signs are more likely following chronic overdosage, than after a single acute overdose.


  • Treatment

There is no specific antidote. Gastric lavage has been used for acute overdose. Subsequent monitoring, including haematological monitoring, is necessary to allow prompt treatment of any adverse effects which may develop. The value of dialysis in patients who have taken an overdose of azathioprine is not known, though azathioprine is partially dialysable.


Safety data off-label azathioprine


The safety data described here are derived from all the identified studies reporting about safety (see section ’Methodology’ for more information. The total number of patients treated with azathioprine in studies that mentioned adverse events was 877. The individual studies and tables can be found in section IV: Tables.


Adverse events

Occurance event

Adverse events without SAE (total number of patients= 877)

Infections (indications other than transplant patients)


Viral, fungal and bacterial infections. (36)

Neoplasms benign and malignant (including cysts and polyps)


Neoplasms including non-Hodgkin's lymphomas, skin cancers (melanoma and non-melanoma), sarcomas (Kaposi's and non-Kaposi's) and uterine cervical cancer in situ, acute myeloid leukaemia and myelodysplasia (1)

Blood and lymphatic disorders


Very common:

Leucopenia. (127)


Thrombocytopenia. (9)

Anaemia (9)


Pancytopenia (2), megaloblastic anaemia (1)

Respiratory, thoracic and mediastinal disorders


Asthma (1)

Gastrointestinal disorders

Very common:

Nausea, vomiting, diarrhea; gastro-intestinal complaints (120)

Hepato-biliary disorders

Very common:

Cholestasis and elevation of liver enzymes . (131)


Reverse mild portal fibrosis (8)

Mild hepatitis (2)

Skin and subcutaneous tissue disorders



Immune system disorders


Hypersensitivity reactions (12)


Fever (3)



Joint and muscle pain (15)


Paresthesia of hands (1)

Weight loss 2-3 kg (2)

Abnormalities of taste (2)

Otitis media (1)

Fatigue (8)

Migraine (2)

Depression (1)

Hay fever (1)

Headache (6)

Sore tongue (1)

Yawning (1)

The following classification has been utilised for the classification of frequency: Very common,  1/10; common, 1/100 and < 1/10; uncommon,  1/1000 and < 1/100; rare,  1/10000 and < 1/1000; very rare, < 1/10000.


Serious adverse events

  • Atopic dermatitis

Four serious adverse events (SAE) were described, 2 of which occurred during treatment with AZA, leading to discontinuation of AZA.1-3 One subject experienced a severe pancytopenia, which required blood transfusion. The time between initiating AZA and the occurrence of the severe pancytopenia was not reported. It is noteworthy that in this study the TPMT activity was not measured prior to initiation of AZA. Another subject developed pancreatitis after 15 days of treatment, which resolved after discontinuation. Two SAE occurred in the follow up period. A non Hodgkin Lymphoma emerged 8 months after treatment with AZA (duration of treatment 12 months). A fatal event due to a ruptured cerebral aneurysm occurred 7 years after AZA treatment.


  • Bullous pemphigoid

Due to the mean age of the subjects and the severity of the disease, serious adverse events were not uncommon. Beissert et al. reported 2 deaths, 2 cases of severely raised liver enzymes and 1 severe infection.4Guillaume et al. reported 15serious adverse events, 6 of which deaths, 4 cases of severe cytopenia and 3 hepatitis.5 The remaining 2 adverse events were not further specified. The causes of death were unspecified. Burton et al. described 3 deaths, 2 due to cerebrovascular accidents (CVA) and one due to heart failure.6Another study by Burton et al. reported 4 serious adverse events , all occurring during treatment with AZA and leading to death .7 The causes of death were adenocarcinoma, a pre-exisisting mammacarcinoma, myocardal infarction and CVA.


  • Psoriasis

Three serious adverse events were described which occurred during treatment with AZA, leading to discontinuation of the treatment.8,9 One patient died due to respiratory insufficiency 6 years after AZA treatment was stopped. In that same study (Le Quintrec et al.) another subject died due to a pulmonary embolus. The time between initiating AZA and the pulmonary embolus was not reported. In the publication of Hewitt et al., one subject experienced a severe anemia, which required blood transfusions. The time between initiating AZA and the occurrence of the severe anemia was not reported. Another subject had a myocard infarction in the third week of the third treatment course of AZA.


  • Chronic actinic dermatitis

Three subjects died: CVA (1), airway disease (1) and heart disease (1) after 15, 15 and 12 months of AZA treatment respectively.10


  • Cutaneous vasculitis

Two serious adverse events occurred, both of infectious origin; a septic arthritis and an epidural abcess.11 One subject with severe and rapid onset of vasculitis died during treatment with AZA due to renal failure, which could be attributed to the natural course of the underlying disease.


  • Cutaneous lupus erythematosus

One serious adverse event occurred; pancreatitis.12


Serious adverse events

Occurrence Event?

Serious adverse events (total number of patients = 877)

Infection and infestations (indications other than transplant patients)


Severe infection (3)

Neoplasms benign and malignant (including cysts and polyps)


Death due to neoplasm (adenocarcinoma, pre-existing

mammacarcinoma) (2)

Non-Hodgkin's lymphoma (1)

Blood and lymphatic system disorders


Severe anaemia (1)

Pancytopenia (5)

Respiratory, thorasic and mediastinal disorders


Myocardial infarction (1)

Death due to heath failure (1)

Death due to heath disease (2)

Death due to airway disease (2)

Death due to pulmonary embolus (1)

Gastrointestinal disorders


Pancreatitis (2)

Hepato-biliary disorders


Severely increased liver enzymes (2)

Hepatitis (3)



Death due to CVA (4)

Death unspecified (8)

Ruptured cerebral aneurysm (1)

Unspecified serious adverse event (2)


Evidence on safety derived from included RCT’s

There is a limited number of eligible RCT’s comparing one treatment with another. However, the relative risk of specific adverse events from a particular RCT could be of value in formulating a recommendation for a therapy.

In the study of Beissert et al. the subjects randomized to the AZA group had significant higher elevated liver enzymes than the mycofenolaat group; the number of subjects having elevated liver enzymes was comparable (Table 7).

Adverse events that occurred during AZA treatment compared to betamethasone treatment are shown in Table 30. There were statistically significant (Fisher exact < 0.05) more AE’s related to corticosteroid use (acne, striae, Cushingoid features, weight gain, rise in blood pressure) in the group B. However, there was no difference in the other AE’s. Adverse events that occurred during AZA treatment compared to CYC are shown in Table 38.

Autorisatiedatum en geldigheid

Laatst beoordeeld : 22-06-2010

Laatst geautoriseerd : 22-06-2010

A guideline can only be leading, if it is maintained on a continuous base, with systematic monitoring of medical scientific literature as well as regular contributions from clinical practice. In case of important developments, it can be decided that the complete working group shall meet to propose amendments, which will be distributed among the various professional groups. A revision will be planned at least every five years.

Initiatief en autorisatie

Initiatief : Nederlandse Vereniging voor Dermatologie en Venerologie

Geautoriseerd door:
  • Nederlandse Vereniging van Ziekenhuisapothekers

Doel en doelgroep


A guideline is a document with recommendations to support patient care in daily practice. The guideline is based on results of scientific research and subsequent formation of opinion, aimed at deciding on the appropriate medical intervention. A guideline and the documents derived from it, give recommendations for the treatment of patients, including psychosocial care and patient information.


Intended users

The guideline is intended for members of the medical and paramedical professional group, including: dermatologists, general practitioners, pharmacists and dermatology nurses, nurse practitioners and physician assistants. A text derived from the guideline is available for patients.

Samenstelling werkgroep

A working group was appointed for the development of the guideline. This group consisted of dermatologists, pharmacists and a general practitioner from Lareb (the Dutch pharmacovigilance centre). During the formation of the group, the geographical distribution of its members was taken into account as well as a balanced representation of academic and non-academic employment . The members of the working group have acted independently and not a single member received any favour aimed at influencing the guidelines.


J.G. (Jan Gerrit) van der Schroeff, MD, PhD

Dermatologist, Chairman working group

J.J.E. (Jannes) van Everdingen, MD, PhD

Director NVDV

M. E. (Mandy) Schram, MD

PhD candidate and resident Dermatology

P. (Pieter) van der Valk, MD,PhD


W.R. (William) Faber MD. PhD, FRCP


A.Y. (Amber) Goedkoop, MD, PhD


R.J. (Rinke) Borgonjen, MD

PhD candidate

A. (Annemieke) Horikx, PharmD

Pharmacist KNMP

E.P. (Eugène) van Puijenbroek, MD

General practitioner Lareb

R.I.F. (Rutger) van der Waal, MD, PhD


A. (Annemieke) Floor, PharmD


W. (Wouter) Goldtschmidt, MD, PhD


E.L. (Noortje) Swart PhD

Clinical pharmacist

Ph. I. (Phyllis) Spuls, MD, PhD



List of conflicts of interest

None reported

Methode ontwikkeling

Evidence based


During the various phases of developing the draft guideline, the implementation of the guideline and the actual workability of the recommendations are taken into account as much as is possible. The guideline is distributed to all relevant professional groups and hospitals through the internet and in various medical journals attention will be given to the guideline.


During a period of year ( meetings) the working group worked on a draft guideline. An expert group made a bottleneck analysis during the preparatory phase. The expert group compiled a list of drugs which are frequently subscribed for off-label use in dermatology. The listed drugs were prioritized according to frequency of use and occurrence of potential serious adverse events. The members of the working group had the opportunity to propose alterations in the list of selected drugs The members of the working group agreed on composing a guideline about the off-label use of the following six selected drugs:

  • Azathioprine
  • Cyclosporine
  • Methotrexate
  • sulfasalazine dapsone
  • Hydroxychloroquine


The working group agreed that the outcomes efficacy/effectiveness and safety are crucial for decision making. . The working group started by making a draft guideline for azathioprine and decided that the applied methods would serve as a blueprint for the other five drugs. Useful literature was found by systematic searches and by checking of references (see “Methodology of literature search”). The members of the working group assessed the relevant literature with regard to content and quality. Subsequently, conclusions were drawn and recommendations were made for off-label use of the selected drugs by the members of the working group. The final version of the guideline was approved by all scientific societies involved on.


Methodology of literature search

Research question

For each selected drug a research question according to PICO was made.

PICO stands for:

  • Participants/population: population of patients with a dermatological disease who are treated with a drug that is not registered for the use in this particular disease.
  • Intervention: the selected drug.
  • Comparison: any other treatment (e.g. other systemic therapy, placebo, quality of life intervention), in case of lack of a control group; no other treatment.
  • Outcome: safety and/or efficacy.


Search strategy

For each selected drug a standardized search was performed in the Medline (by PubMed) (1950-2009), EMBASE (1980-2009) and CENTRAL databases. This search strategy was designed by a literature specialist of the department ‘Professionele Kwaliteit van de Orde van Medisch Specialisten’. Also references of included articles were screened for eligibility.


Pre-selection with keywords 

After the searches were uploaded in Reference Manager, articles labeled with possible keywords for exclusion were selected. A sample was taken of these selected articles to check if there were any relevant articles in that selection. The sample size was either 20 or 50 articles, depending on the number of articles labeled with a specific keyword. If the sample didn’t contain any relevant articles, all the articles labeled with a specific keyword were excluded.


In the searches of cyclosporine, methotrexate, dapsone, hydroxychloroquine and sulfasalazine articles with the keywords ‘case report’ were excluded after a sample of 50 articles didn’t reveal any relevant articles for inclusion.


In addition, articles with the following keywords were excluded after a sample of 20 articles didn’t show any relevant articles:









Transplantation immunology


Mycobarterium leprae


Transplantation immunology [Physiology]


Pneumocystis carinii


Acute graft rejection [Complication]




Acute graft rejection [Diagnosis]




Acute graft rejection [Drug therapie]


-    Acute graft versus host disease




Bone Marrow Transplantation


Reumathoid arthritis


Breast cancer




Graft Survival




Graft Recipient




Kidney Graft




Kidney Transplantation


Breast Cancer


Liver Transplantation






Multiple sclerosis










Heart transplantation

-    Cancer + skin + cutaneous







Rheumatoid arthritis





Rheumatic disease




Systemic lupus erythematodes


Ulcerative colitis


Discoid lupus erythematodes




Lupus erythematosus



In the methotrexate search articles with the note ‘review’ were excluded after a sample of 20 articles didn’tcontain any relevant articles.


An overall validation of this method was provided by the double search strategy on azathioprine. An initial/broad search (thus without using keywords) was compared with the search that used specific keywords for exclusion. Articles with the keywords ‘case report’, ‘polymyositis’ and ‘idiopatic thrombocytopenic purpera’ were excluded after a sample showed no relevant articles.

We found that all studies that were included in initial/broad search were present in the search using keywords for exclusion. This validates the method of excluding articles by using keywords.


Selection of articles 

All articles with title and abstract referring to off-label treatment with the predefined drug in patients with dermatological diseases were selected. To determine eligibility, the full text of the selected articles was screened according to the predefined in-and exclusion criteria. Data on methodological quality, study characteristics, efficacy and safety were extracted by using a data extraction form. All stages of literature selection and data extraction were performed by two independent reviewers. Disagreements about study selection and data extraction were solved by discussion.


In- and exclusion criteria

Selection of the articles was performed by using the following pre-defined in- and exclusion criteria. Inclusion criteria:

-       The article concerns the selected drug and

-       The selected drug is used in the treatment of a dermatological disease for which that particular drug is not registered.


Exclusion criteria:

-      Case reports with less than 5 subjects*

-      Lack of data on safety and efficacy

-      Articles concerning treatment other than systemic treatment with the selected drug

-      Animal studies

-      In vitro studies

-      Double publications

-      Articles concerning diseases that are primarily treated by other specialists

-      Language other than English, French, German and Dutch

No restrictions were imposed regarding age, gender, skin type and number of subjects in a study and date of publication.

A random sample of the excluded articles was taken to check if any relevant adverse effects were missed.



Of all the included articles, data were extracted by two independent reviewers. This was done by using a standardized data extraction form. Disagreements on data extraction were solved by discussion.

Data- extraction was performed on:

-      Methodological quality

-      Demographics

-      Efficacy

-      Safety


Methodological quality

Randomized controlled trials (RCT’s) were assessed following the criterion grading system described in the Cochrane Handbook for systematic reviews of interventions 5.0.0 (updated February 2008). To assess the risk of bias withinincluded RCT’s, the following parameters for methodological quality were used; sequence generation, concealment of allocation, blinding (of participants, researchers and outcome assessment), reporting of incomplete data, presence of selective outcome reporting and other potential threats to validity.


The methodological quality of cohort studies was assessed by using the checklists for cohort studies described by the Dutch Cochrane Centre.



Data of demographics were extracted concerning:

-      Study design: randomized? controlled? prospective, retrospective?

-      Treatment arms

-      Disease of the subjects: severity, stage, subtype, duration

-      Previous medications

-      Diagnostics: what was the method of diagnosis? Clinical, histopathological, other diagnostic criteria?

-      Subjects: number, male/female, age, subgroups

-      Duration of treatment

-      Duration of follow up

-      Concomitant medication

-      Dosing schedule of the selected drug



-      Used outcome parameters: clinical assessment, global assessment, quality of life measurement, laboratory markers, onset of effect, duration of remission, relapse rate, etc)

-      Severity outcomes: the result of the used outcome parameters. Differences between baseline and end of the study and between treatment groups.



Safety is an important issue in off-label use of medication. The working group scored all adverse events, including a special focus on serious adverse effects. Within the included studies, every study that reported (serious) adverse events was taken into account. Adverse events reported in RCT’s or cohorts will be compared with the adverse events that occurred in the control group. If possible a relative risk will be calculated.


Extracted safety data:

-      Adverse events: which? how many? at what time during treatment or after treatment? 

-      Serious adverse events: which? how many? at what time during treatment or after treatment?

-      Withdrawals due to adverse events?


An Adverse Event (AE) was defined as an unfavorable and unintended sign, including an abnormal laboratory finding, symptom or disease associated with the use of a medical treatment or procedure, regardless whether it is considered related to the medical treatment or procedure, that occurs during the course of the study.


A Serious Adverse Events (SAE) was defined as any untoward medical occurrence that results in death, is life threatening, requires inpatient hospitalization or prolongation of existing hospitalization, results in persistent or significant disability/incapacity, is a congenital anomaly/birth defect or is reported in the study as such.


Handling of the data

Extracted data will be presented in tables and with accompanying text per disease following standardized means.


Level of evidence 

The description and assessment of the articles according to the data extraction (see above) are listed in separate sections under the headers “Safety data off -label azathioprine” or “Efficacy/effectiveness data off-label azathioprine” and in tables (see section Tables).

Not all data extracted from articles are equally valuable. Therefore every set of articles is summarised in a conclusion, in which the level of the evidence is indicated according to the GRADE system (see boxes below). Consequently the recommendations in this guideline are based on evidence generated by scientific research, with emphasis on the outcomes safety and effectiveness/efficacy. The search results that were used are up to date until at least 01-10-2009, unless stated otherwise.


GRADE system

Type of evidence

Randomized trial = high

Observational study = low

Any other evidence = very low

Decrease* grade if

Important inconsistency

• Some or major uncertainty about directness

• Imprecise or sparse data

• High probability of reporting bias

• Serious or very serious limitation to study quality

Increase grade if

• Strong evidence of association—significant relative risk of > 2 ( < 0.5) based on consistent evidence from two or more observational studies, with no plausible confounders (+1)

• Very strong evidence of association—significant relative risk of > 5 ( < 0.2) based on direct evidence with no major threats to validity (+2)

• Evidence of a dose response gradient (+1)

• All plausible confounders would have reduced the effect (+1)

*Each quality criterion can reduce the quality by one or, if very serious, by two levels.



  • High = further research is very unlikely to change our confidence in the estimate of effect
  • Moderate = further research is likely to have an important impact on our confidence in the estimate of effect and may change the estimate
  • Low = further research is very likely to have an important impact on our confidence in the estimate of effect and is likely to change the estimate
  • Very low = any estimate of effect is very uncertain.


Development of the recommendations

For the development of a recommendation, other aspects than scientific evidence are also of importance, such as: patient preferences, availability of special techniques or expertise, organisational aspects, social consequences or costs. Known adverse events are also taken into account, as far as they were not already distilled from scientific literature. These aspects are discussed after the conclusion(s). On the basis of literature, the conclusion is here placed in the context of daily practice, and the pros and cons of the various treatments are balanced against each other. The final formulated recommendation is the result of the available evidence in combination with these considerations and can be formulated as a weak or strong recommendation in favour of a certain therapy or as a weak or strong recommendation against a certain therapy (see box below). The aim of this procedure and the formulation of the guideline using this ‘format’ is to enhance the transparency of the guideline. It leaves room for an efficient discussion during the meetings of the working group and moreover, it improves clarity for the user of the guideline.



  • Strong = if clinicians, based on the available evidence, are very certain that benefits do, or do not, outweigh risks or burdens, they will make a strong recommendation.
  • Weak = if clinicians, based on the available evidence, believe that benefits and risks or burdens are finely balanced, or if considerable uncertainty exists about the magnitude of benefits and risks, they must make a weak recommendation.


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