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Are Thiopurines Always Contraindicated After Thiopurine-Induced Pancreatitis in Inflammatory Bowel Disease?

Ledder, Oren D.*; Lemberg, Daniel A.; Ooi, Chee Y.; Day, Andrew S.

Journal of Pediatric Gastroenterology & Nutrition: November 2013 - Volume 57 - Issue 5 - p 583–586
doi: 10.1097/MPG.0b013e31829f16fc
Original Articles: Gastroenterology

Background and Aims: Thiopurine use in inflammatory bowel disease (IBD) is well established for maintenance of disease remission. Approximately 3% of patients with IBD develop thiopurine-induced pancreatitis (TIP) as an idiosyncratic reaction. Patients diagnosed as having TIP are largely considered not to be candidates for future use of this drug. We hypothesize that previous TIP is not an absolute contraindication to retrialing a different thiopurine.

Methods: This case series is a retrospective chart review of those patients with IBD in whom thiopurines were successfully reintroduced following suspected TIP. The patients were all cared for in 2 Australasian pediatric IBD services. Four cases are presented of TIP appropriately related temporally to azathioprine commencement, with no other apparent cause of pancreatitis identified. All of these patients were trialled on 6-mercaptopurine according to clinical need and this was well tolerated in all cases.

Results and Conclusions: This report is the largest case series to date focusing on the reintroduction of a thiopurine following suspected thiopurine induced pancreatitis. All of the patients had a typical presentation of TIP. This case series should call into question the assumption that suspected TIP is an absolute contraindication for the future use of this class of drug. Cautious reintroduction of a thiopurine, in a controlled setting, should be considered in certain circumstances. The clinical relevance of this option is most marked in patients with complicated disease requiring long-term immunosuppression, in whom other therapies are poorly tolerated or contraindicated.

*Department of Pediatric Gastroenterology, Shaare Zedek Medical Centre, Jerusalem, Israel

Department of Gastroenterology, Sydney Children's Hospital, Sydney, Australia.

Address correspondence and reprint requests to Dr Oren D. Ledder, Department of Pediatric Gastroenterology, Shaare Zedek Medical Centre, 12 Shmuel Beyth, Jerusalem 91031, Israel (e-mail:

Received 6 March, 2013

Accepted 1 June, 2013

The authors report no conflicts of interest.

© 2013 by European Society for Pediatric Gastroenterology, Hepatology, and Nutrition and North American Society for Pediatric Gastroenterology,