Dr Ramji Gupta

Azathioprine Pulse Therapy to Cure Psoriasis

(Developed by Dr.Ramji Gupta)

 

Various conventional therapy like coal tar, PUVA, methotrexate, methotrexate +betamethasone, azathioprine, cyclosporine and biologics to treat psoriasis clear the lesions partially or completely but are not able to prevent relapses or produce prolonged remission. Maximum remission period reported with these therapies is 1year.

 

The chief problem in the management of psoriasis is frequent relapses and subsequent need for repeated doses of systemic therapy leading to serious side effects. The goal of psoriasis treatment should be to control the disease process initially; to decrease percentage of involved body surface area, to achieve and maintain remission for prolonged period, to produce minimum adverse side effects and to improve patient’s quality of life.

 

Mechanism of action of Azathioprine in Psoriasis

Psoriasis is caused by activated T.lymphocyte cells which produce cytokines. Cytokines lead to the proliferation of keratinocyctes responsible for development of psoriasis. Azathioprine suppresses activated T lymphocyte cells which in turn stop production of cytokines leading to stoppage of proliferation of keratinocytes responsible for development of psoriasis.

 

Azathioprine in Psoriasis

Systemic azathioprine has been extensively investigated for the treatment of psoriasis since 1961.

 

Azathioprine pulse Therapy (APT) in Psoriasis 

The term pulse therapy has been used for administering a large dose of drug over a very short period then with drawing the drug completely till it is used again. In APT intermittent high dose (IHD) azathioprine i.e.500mg on 3 consecutive days is given which is repeated every month on same date, in combination with continuous low dose (CLD) azathioprine i.e.100 mg daily  orally in between IHD given. 

 

The regimen was divided into four phases. In phase I, treatment with IHD and CLD azathioprine was continued till clearance of psoriasis lesion. To clear the lesions fast, oral methotrexate (MTX) 15mg weekly/ MTX + betamethasone (BMT) 3mg weekly was also given after breakfast. Topical coal tar /corticosteroids ointment with salicylic acid was also used wherever needed till the lesions clear completely and stopped recurring when it enters into phase II. In phase II all the treatments was stopped except the azathioprine pulse and daily azathioprine which was given for another 9 months to stop any minor relapse. In the end of phase II if there was no recurrence of lesions, IHD azathioprine pulse was also  stopped and patients take only daily azathioprine 100 mg for another 9 months to prevent even any minor relapse (phase III). In phase IV if there was no recurrence daily azathioprine was also stopped and patients were followed-up for any relapse.

 

High dose azathioprine for 3 days in a month is used to get its maximum effect on psoriasis and to reduce the side effects of daily high dose azathioprine. 

Forty five patients who completed the study are in clinical remission without any treatment. Out  of 45 patients 12 are more than 5 years in continuous remission (64- 93months), 9 are in 3-5 years while13 patients are 1-3years and 11 are less than 1 year in continuous remission after all treatment was stopped.

 

Relapse: five patients out of 9, who were given 2nd course of APT after relapse in phase IV for 9.5-28 months, enter into remission and are in phase IV from 4-64 months. 

 

Adverse effects

Common side effects were nausea and vomiting (18 patients), weakness and fatigue (4 patients), giddiness and restlessness (2 patients each), loss of appetite, sleeplessness and generalized malaise (1 patient each). Most of these side effects were seen

in phase I.

 

References:

1. Gupta Ramji. Azathioprine pulse therapy in the treatment of psoriasis .J Pakistan Assoc Dermatol.2013;23(2):120-5

2. Gupta Ramji. Can psoriasis be cured? Delhi medical Assoc. News Bull May 10, 2013; 10:22.

3. Gupta Ramji. Prolonged remission of psoriasis with Azathioprine Pulse Therapy, India Journal of Dermatology( In Press ).