title: Monitoring recommendations for oral azathioprine, methotrexate and cyclosporin in a paediatric dermatology clinic and literature review.
abstract: OBJECTIVE
  Systemic oral immunomodulators azathioprine, methotrexate and cyclosporin are widely used in paediatric dermatology. Routine blood tests are performed to minimise drug-related adverse events. However, the frequency of monitoring tests may lead to significant fearful experiences for patients. We reviewed haematological abnormalities and clinical side-effects in a paediatric clinic population commencing immunomodulators for dermatological conditions, where haematological profiles are monitored less frequently than in current recommendations.
  
  
  METHODS
  A retrospective chart review of children started on azathioprine, methotrexate or cyclosporin for a dermatological condition between 2001-2015 from a primarily paediatric, private dermatology practice was performed. Blood tests were done at baseline, 1 month, 2 months and then 3-monthly for children on azathioprine. Children on methotrexate and cyclosporin had tests done at baseline, after 1 month and then 3-monthly.
  
  
  RESULTS
  In total, 242 children were included in this study. Azathioprine, methotrexate and cyclosporin cohorts had 95, 97 and 50 patients treated for a mean duration of 656, 758 and 313 days, respectively. Isolated abnormal blood tests indicated the cessation of azathioprine in 3/95 (3%), methotrexate in 5/97 (5%) and cyclosporin in 2/50 (4%) of patients. Abnormal blood test results were not associated with any reported clinical side-effects in the azathioprine (P = 0.726), methotrexate (P = 0.06) or cyclosporin groups (P = 0.250).
  
  
  CONCLUSIONS
  In our experience, less frequent monitoring did not result in any significant adverse events over a 15-year period. We suggest that haematological monitoring during immunosuppressants use can be safely reduced from current recommendations.
authors.affiliation: Department of Dermatology, Royal Children's Hospital, Melbourne, Victoria, Australia.
authors.forename: Joy
authors.initials: J
authors.lastname: Yee
authors.affiliation: Department of Dermatology, Royal Children's Hospital, Melbourne, Victoria, Australia.|Department of Medicine, University of Melbourne, Melbourne, Victoria, Australia.
authors.forename: David
authors.initials: D
authors.lastname: Orchard
mesh_terms: D000284:Administration, Oral; D000293:Adolescent; D001379:Azathioprine / Q000008:administration & dosage / Q000009:adverse effects*; D001772:Blood Cell Count; D002648:Child; D002675:Child, Preschool; D003404:Creatinine / Q000097:blood; D016572:Cyclosporine / Q000008:administration & dosage / Q000009:adverse effects*; D016903:Drug Monitoring / Q000592:standards*; D004573:Electrolytes / Q000097:blood; D005260:Female; D006801:Humans; D007073:Immunoglobulin E / Q000097:blood; D007166:Immunosuppressive Agents / Q000008:administration & dosage / Q000009:adverse effects*; D008111:Liver Function Tests; D008297:Male; D008727:Methotrexate / Q000008:administration & dosage / Q000009:adverse effects*; D008780:Methyltransferases / Q000097:blood; D012189:Retrospective Studies; D012871:Skin Diseases / Q000188:drug therapy; D014508:Urea / Q000097:blood
chemical_list: D004573:Electrolytes; D007166:Immunosuppressive Agents; D007073:Immunoglobulin E; D016572:Cyclosporine; D014508:Urea; D003404:Creatinine; D008780:Methyltransferases; C022745:thiopurine methyltransferase; D001379:Azathioprine; D008727:Methotrexate
keywords: adverse effect; azathioprine; blood test monitoring; cyclosporin; immunomodulator; methotrexate; paediatric dermatology