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Dr PG (M.D.)
Dr PG (M.D.), Doctor
Category: Medical
Satisfied Customers: 2337
Experience:  MD since 1997
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Hi, My 15-year old son has had severe and extentive pancolitis

Resolved Question:

Hi,
My 15-year old son has had severe and extentive pancolitis for 3+ years. He takes 6 Asacol/day. He also has severe acid reflux that he takes Prevacid for. After a long, stubborn flare last year (he took a combination of prednisone and hydrocortisone enemas for about 5 mos), his doctor put him on 6MP in addition to the Asacol. 6 mos ago, our son began having colitis pain again. He started Asacol enemas in addition to his other meds. That lost its effect after a few months. He has now been on a hydrocortisone foam for 3 weeks. He isn't pain-free, but is not getting worse. His doctor is considering switching from 6MP to Remicade without a waiting period in between. My concern is the small percentage of young males who develop a lethal form of lymphoma from being on Remicade and 6MP. I would like our son to wait a few months of being off of 6MP before starting Remicade. Is there a known safe period of time to wait? His doctor thinks that the risk is so small of developing the lethal lymphoma that no waiting is necessary. I am not willing to taking any risk. Any suggestions?
Submitted: 5 years ago.
Category: Medical
Expert:  Dr PG (M.D.) replied 5 years ago.

Dr PG (M.D.) :

Your concern while quite understandable is ill founded

Dr PG (M.D.) :

There is little evidence that Remicade or 6mp increase the chances of this by any sizeable percentage.

Dr PG (M.D.) :

In fact there are many UC / IBD patients who are on BOTH these medications too with prolonged remission

Dr PG (M.D.) :

No long term study has conclusively proven the link of increased lymphoma,

Dr PG (M.D.) :

and most doctors (just like yours) are very comfortable using these drugs without a waiting period, since this can be detrimental to the child's health

Dr PG (M.D.) :

especially in a case such as yours, where control is very difficult to achieve

Customer:

However, there is a disclaimer for Remicade that states that there is a certain group of young males who contracted a lethal lymphoma. The only ones that got this lymphoma were young males who were on both Remicade and 6 MP. All I want to know is how long you would have to be off of the 6MP for this not to pose a risk of this specific lymphoma. How long would it take for the 6MP to be out of your body?

Dr PG (M.D.) :

Yes, the risk was in fact investigated by FDA too, and no significant change of usage was suggested

Customer:

Unfortunately, that does not answer my question.

Dr PG (M.D.) :

Well alright,

Customer:

Is there a quantitative answer available?

Dr PG (M.D.) :

Yes

Dr PG (M.D.) :

According to my drug reference, the half-life of 6 mercaptopurine is very short - on the order of hours.

Customer:

Will you be able to tell me shortly?

Dr PG (M.D.) :

The half life is around 60-120 minutes onlu

Dr PG (M.D.) :

only

Dr PG (M.D.) :

Hence a wash off period of days to weeks would suffice in this situation

Dr PG (M.D.) :

Sorry for the delay, needed to check the exact time of the half life of the drug

Customer:

OK, thanks. So, the way I understand it is that even though the risk is very minimal, do you think that the only patients who died from that specific lymphoma were young males who were taking the medications concurrently--NOT spaced at all apart? So, if we waited a few weeks in between the 6MP and the Remicade, although there would be associated risks with taking Remicade, there would be no risk of the lethal lymphoma from taking both drugs?

Dr PG (M.D.) :

The fact of the matter is..

Dr PG (M.D.) :

1. The risk of increased lymphoma are NOT quantified in any study

Dr PG (M.D.) :

2. FDA has not found any need to change the recommendation of medicine usage on the basis of its investigation in 2008

Dr PG (M.D.) :

3. The risk is probably related to immunosuppresion per se, which would be more when a large number of immunomodulators are used.

Dr PG (M.D.) :

4. The risk will be very minimal, and a wash out period may not make any significant clinical difference to the same

Dr PG (M.D.) :

Bottomline:

Dr PG (M.D.) :

I would like to NOT wait in this situation since the risk of stopping therapy is far greater in this situation as compared to the essentially theoretical long term concern of lymphoma

Customer:

Thank you--you have helped with a difficult question.

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