Devastating diarrhoea caused by azathioprine: management difficulty in inflammatory bowel disease

Area of Science:

• Gastroenterology
• Clinical Pharmacology

Background:

• Inflammatory bowel disease (IBD) management often involves immunosuppressants like azathioprine.
• Corticosteroids are frequently used, with azathioprine as an adjunctive therapy for refractory cases.

Observation:

• Four IBD patients developed severe diarrhea and abdominal pain after azathioprine initiation.
• These symptoms were initially mistaken for disease exacerbation.
• Azathioprine rechallenge in three patients reproduced the adverse events.

Findings:

• Azathioprine toxicity presented with symptoms mimicking active inflammatory bowel disease.
• Drug-induced effects posed a diagnostic challenge, delaying appropriate management.
• Hospitalization and intravenous fluid resuscitation were necessary for severe reactions.

Implications:

• Clinicians must consider azathioprine toxicity in IBD patients presenting with worsening gastrointestinal symptoms.
• Diagnostic rechallenge with azathioprine should be conducted under controlled hospital conditions.
• Early recognition of azathioprine-induced toxicity is vital to prevent severe complications.