Antiproliferative immunosuppressants: azathioprine, mycophenolate and cyclophosphamide
How azathioprine, mycophenolate and cyclophosphamide stop lymphocytes dividing, why TPMT and NUDT15 genotype and allopurinol decide azathioprine dosing, why mycophenolate is lymphocyte selective and teratogenic, and why cyclophosphamide needs mesna, fertility planning and a cumulative dose count.
Tier 2Medical sciences concept
Written with AI assistance and fact-checked against the sources below. For exam study, not clinical decisions. How notes are made
At a glance
- All three drugs stop lymphocytes dividing. Azathioprine and mycophenolate block purine synthesis; cyclophosphamide cross-links DNA.
- Azathioprine: thiopurine prodrug. Check TPMT (and NUDT15 in people of Asian or Hispanic ancestry) before starting, and never combine with allopurinol at full dose.
- Mycophenolate: IMPDH inhibitor, relatively lymphocyte selective. First-line induction for lupus nephritis and maintenance after transplant. Teratogenic.
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Sources
- Clinical Pharmacogenetics Implementation Consortium guideline for thiopurine dosing based on TPMT and NUDT15 genotypes: 2018 updateClinical Pharmacology and Therapeutics (Relling et al., 2019;105:1095-105), 2018 update
- KDIGO 2021 clinical practice guideline for the management of glomerular diseasesKidney International (2021;100:S1-276), 2021
- KDIGO 2024 clinical practice guideline for the management of lupus nephritisKidney International (2024;105:S1-69), 2024
- Therapeutic Guidelines: Rheumatology (disease-modifying drugs)AU/NZTherapeutic Guidelines Limited (eTG complete), current online version, accessed November 2026
- Australian Medicines Handbook: azathioprine, mycophenolate and cyclophosphamide monographsAU/NZAustralian Medicines Handbook Pty Ltd, online, accessed November 2026
- Immunosuppressive therapy in lupus nephritis: the Euro-Lupus Nephritis Trial, a randomised trial of low-dose versus high-dose intravenous cyclophosphamideArthritis and Rheumatism (Houssiau et al., 2002;46:2121-31), 2002
- CellCept (mycophenolate mofetil): EU summary of product characteristics, sections 4.4 and 4.6 (contraception for men and their partners)European Medicines Agency, current at November 2026
- Last updated
- 14 November 2026
What changed
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