Dosing & Uses
Dosage Forms & Strengths
tablet
- 50mg
oral suspension
- 20mg/mL
Acute Lymphatic Leukemia
Induction: 2.5 mg/kg PO qDay; usually 100-200 mg PO qDay in average adult (other agents preferred)
May increase by 5 mg/kg/day after 4 weeks
Maintenance: 1.5-2.5 mg/kg PO qDay
Reduce dose by 75% if concomitant allopurinol administration
Reduce dose in renal impairment
Crohn Disease (Off-label)
1-1.5 mg/kg PO qHS
Administration
Take on empty stomach to reduce risk of N/V
Other Information
Monitor: CBC, LFTs
Other Indications & Uses
AML
(Off-label): CML, Crohn's disease, ulcerative colitis, histiocytosis X
Dosage Forms & Strengths
tablet
- 50mg
oral suspension (Purixan)
- 20mg/mL
Acute Lymphatic Leukemia
Starting dose: 1.25-2.5 mg/kg (50-75 mg/m²) PO qDay
Maintenance: 1.5-2.5 mg/kg PO qDay in combination with methotrexate
Reduce dose by 75% if concomitant allopurinol administration
Reduce dose in renal impairment
Administration
Take on empty stomach to reduce risk of N/V
Other Information
Monitor: CBC, LFTs
Interactions
Interaction Checker
No Results
Contraindicated
Serious - Use Alternative
Significant - Monitor Closely
Minor
Contraindicated (1)
- febuxostat
febuxostat increases levels of mercaptopurine by decreasing metabolism. Contraindicated. Potential for increased myelosuppression.
Serious - Use Alternative (30)
- adenovirus types 4 and 7 live, oral
mercaptopurine decreases effects of adenovirus types 4 and 7 live, oral by pharmacodynamic antagonism. Avoid or Use Alternate Drug. Immunosuppressives may diminish therapeutic effects of vaccines and increase risk of adverse effects (increased risk of infection). Live-attenuated vaccines should be avoided for at least 3mo after cessation of immunosuppressive therapy.
- axicabtagene ciloleucel
mercaptopurine, axicabtagene ciloleucel. Either increases effects of the other by immunosuppressive effects; risk of infection. Avoid or Use Alternate Drug.
- BCG vaccine live
mercaptopurine decreases effects of BCG vaccine live by pharmacodynamic antagonism. Avoid or Use Alternate Drug. Immunosuppressants also increase risk of infection with concomitant live vaccines.
- brexucabtagene autoleucel
mercaptopurine, brexucabtagene autoleucel. Either increases effects of the other by immunosuppressive effects; risk of infection. Avoid or Use Alternate Drug.
- ciltacabtagene autoleucel
mercaptopurine, ciltacabtagene autoleucel. Either increases effects of the other by immunosuppressive effects; risk of infection. Avoid or Use Alternate Drug.
- deferiprone
deferiprone, mercaptopurine. Either increases toxicity of the other by pharmacodynamic synergism. Avoid or Use Alternate Drug. Avoid use of deferiprone with other drugs known to be associated with neutropenia or agranulocytosis; if an alternative is not possible, monitor absolute neutrophil count more frequently.
- human papillomavirus vaccine, nonavalent
mercaptopurine decreases effects of human papillomavirus vaccine, nonavalent by pharmacodynamic antagonism. Avoid or Use Alternate Drug. Immunosuppressive therapies, including irradiation, antimetabolites, alkylating agents, cytotoxic drugs, and corticosteroids (used in greater than physiologic doses), may reduce the immune responses to vaccines.
- human papillomavirus vaccine, quadrivalent
mercaptopurine decreases effects of human papillomavirus vaccine, quadrivalent by pharmacodynamic antagonism. Avoid or Use Alternate Drug. Immunosuppressive therapies, including irradiation, antimetabolites, alkylating agents, cytotoxic drugs, and corticosteroids (used in greater than physiologic doses), may reduce the immune responses to vaccines.
- idecabtagene vicleucel
mercaptopurine, idecabtagene vicleucel. Either increases effects of the other by immunosuppressive effects; risk of infection. Avoid or Use Alternate Drug.
- influenza virus vaccine quadrivalent, adjuvanted
mercaptopurine decreases effects of influenza virus vaccine quadrivalent, adjuvanted by pharmacodynamic antagonism. Avoid or Use Alternate Drug. Immunosuppressive drugs may reduce the immune response to influenza vaccine.
- influenza virus vaccine quadrivalent, intranasal
mercaptopurine decreases effects of influenza virus vaccine quadrivalent, intranasal by pharmacodynamic antagonism. Avoid or Use Alternate Drug. Immunosuppressants also increase risk of infection with concomitant live vaccines.
- influenza virus vaccine trivalent, adjuvanted
mercaptopurine decreases effects of influenza virus vaccine trivalent, adjuvanted by pharmacodynamic antagonism. Avoid or Use Alternate Drug. Immunosuppressive drugs may reduce the immune response to influenza vaccine.
- lisocabtagene maraleucel
mercaptopurine, lisocabtagene maraleucel. Either increases effects of the other by immunosuppressive effects; risk of infection. Avoid or Use Alternate Drug.
- measles (rubeola) vaccine
mercaptopurine decreases effects of measles (rubeola) vaccine by pharmacodynamic antagonism. Avoid or Use Alternate Drug. Immunosuppressants also increase risk of infection with concomitant live vaccines.
- measles mumps and rubella vaccine, live
mercaptopurine decreases effects of measles mumps and rubella vaccine, live by pharmacodynamic antagonism. Avoid or Use Alternate Drug. Immunosuppressants also increase risk of infection with concomitant live vaccines.
- measles, mumps, rubella and varicella vaccine, live
mercaptopurine decreases effects of measles, mumps, rubella and varicella vaccine, live by pharmacodynamic antagonism. Avoid or Use Alternate Drug. Immunosuppressants also increase risk of infection with concomitant live vaccines.
- meningococcal A C Y and W-135 polysaccharide vaccine combined
mercaptopurine decreases effects of meningococcal A C Y and W-135 polysaccharide vaccine combined by pharmacodynamic antagonism. Avoid or Use Alternate Drug. Immunosuppressants also increase risk of infection with concomitant live vaccines.
- palifermin
palifermin increases toxicity of mercaptopurine by Other (see comment). Avoid or Use Alternate Drug. Comment: Palifermin should not be administered within 24 hrbefore, during infusion of, or within 24 hr after administration of antineoplastic agents. Coadministration of palifermin within 24 hr of chemotherapy resulted in increased severity and duration of oral mucositis.
- pneumococcal vaccine 13-valent
mercaptopurine decreases effects of pneumococcal vaccine 13-valent by pharmacodynamic antagonism. Contraindicated. Immunosuppressants also increase risk of infection with concomitant live vaccines.
- ropeginterferon alfa 2b
ropeginterferon alfa 2b, mercaptopurine. Either increases toxicity of the other by Other (see comment). Avoid or Use Alternate Drug. Comment: Myelosuppressive agents can produce additive myelosuppression. Avoid use and monitor patients receiving the combination for effects of excessive myelosuppression.
- rotavirus oral vaccine, live
mercaptopurine decreases effects of rotavirus oral vaccine, live by pharmacodynamic antagonism. Avoid or Use Alternate Drug. Immunosuppressants also increase risk of infection with concomitant live vaccines.
- smallpox (vaccinia) vaccine, live
mercaptopurine decreases effects of smallpox (vaccinia) vaccine, live by pharmacodynamic antagonism. Avoid or Use Alternate Drug. Immunosuppressants also increase risk of infection with concomitant live vaccines.
- tisagenlecleucel
mercaptopurine, tisagenlecleucel. Either increases effects of the other by immunosuppressive effects; risk of infection. Avoid or Use Alternate Drug.
- tocilizumab
tocilizumab and mercaptopurine both increase immunosuppressive effects; risk of infection. Avoid or Use Alternate Drug.
- tofacitinib
mercaptopurine, tofacitinib. Either increases toxicity of the other by immunosuppressive effects; risk of infection. Avoid or Use Alternate Drug.
- tongkat ali
mercaptopurine and tongkat ali both increase immunosuppressive effects; risk of infection. Avoid or Use Alternate Drug.
- typhoid vaccine live
mercaptopurine decreases effects of typhoid vaccine live by pharmacodynamic antagonism. Avoid or Use Alternate Drug. Immunosuppressants also increase risk of infection with concomitant live vaccines.
- varicella virus vaccine live
mercaptopurine decreases effects of varicella virus vaccine live by pharmacodynamic antagonism. Avoid or Use Alternate Drug. Immunosuppressants also increase risk of infection with concomitant live vaccines.
- yellow fever vaccine
mercaptopurine decreases effects of yellow fever vaccine by pharmacodynamic antagonism. Avoid or Use Alternate Drug. Immunosuppressants also increase risk of infection with concomitant live vaccines.
- zoster vaccine live
mercaptopurine decreases effects of zoster vaccine live by pharmacodynamic antagonism. Avoid or Use Alternate Drug. Immunosuppressants also increase risk of infection with concomitant live vaccines.
Monitor Closely (70)
- acalabrutinib
acalabrutinib, mercaptopurine. Either increases toxicity of the other by pharmacodynamic synergism. Use Caution/Monitor. Coadministration may increase risk of myelosuppressive effects.
- adalimumab
adalimumab and mercaptopurine both increase immunosuppressive effects; risk of infection. Use Caution/Monitor.
- alefacept
alefacept and mercaptopurine both increase immunosuppressive effects; risk of infection. Use Caution/Monitor.
- allopurinol
allopurinol increases levels of mercaptopurine by decreasing metabolism. Use Caution/Monitor. Potential for increased myelosuppression.
- anakinra
anakinra and mercaptopurine both increase immunosuppressive effects; risk of infection. Use Caution/Monitor.
- anthrax vaccine
mercaptopurine decreases effects of anthrax vaccine by pharmacodynamic antagonism. Use Caution/Monitor. Immunosuppressants also increase risk of infection with concomitant live vaccines.
- antithymocyte globulin equine
antithymocyte globulin equine and mercaptopurine both increase immunosuppressive effects; risk of infection. Use Caution/Monitor.
- antithymocyte globulin rabbit
antithymocyte globulin rabbit and mercaptopurine both increase immunosuppressive effects; risk of infection. Use Caution/Monitor.
- astragalus
mercaptopurine increases and astragalus decreases immunosuppressive effects; risk of infection. Effect of interaction is not clear, use caution. Use Caution/Monitor.
- azathioprine
azathioprine and mercaptopurine both increase immunosuppressive effects; risk of infection. Use Caution/Monitor.
- basiliximab
basiliximab and mercaptopurine both increase immunosuppressive effects; risk of infection. Use Caution/Monitor.
- belatacept
belatacept and mercaptopurine both increase immunosuppressive effects; risk of infection. Use Caution/Monitor.
- canakinumab
canakinumab and mercaptopurine both increase immunosuppressive effects; risk of infection. Use Caution/Monitor.
- cholera vaccine
mercaptopurine decreases effects of cholera vaccine by immunosuppressive effects; risk of infection. Modify Therapy/Monitor Closely. Immunosuppressive therapies, including irradiation, antimetabolites, alkylating agents, cytotoxic drugs and corticosteroids (used in greater than physiologic doses), may reduce the immune response to cholera vaccine.
- cyclosporine
cyclosporine and mercaptopurine both increase immunosuppressive effects; risk of infection. Use Caution/Monitor.
- dengue vaccine
mercaptopurine decreases effects of dengue vaccine by immunosuppressive effects; risk of infection. Use Caution/Monitor. Immunosuppressive therapies (eg, irradiation, antimetabolites, alkylating agents, cytotoxic drugs, corticosteroids [greater than physiologic doses]) may reduce immune response to dengue vaccine.
- denosumab
mercaptopurine, denosumab. Other (see comment). Use Caution/Monitor. Comment: Caution should be taken in patients on concomitant immunosuppressants or with impaired immune systems because of increased risk for serious infections.
- diphtheria & tetanus toxoids
mercaptopurine decreases effects of diphtheria & tetanus toxoids by pharmacodynamic antagonism. Use Caution/Monitor. Immunosuppressants also increase risk of infection with concomitant live vaccines.
- diphtheria & tetanus toxoids/ acellular pertussis vaccine
mercaptopurine decreases effects of diphtheria & tetanus toxoids/ acellular pertussis vaccine by pharmacodynamic antagonism. Use Caution/Monitor. Immunosuppressants also increase risk of infection with concomitant live vaccines.
- diphtheria & tetanus toxoids/acellular pertussis/poliovirus, inactivated vaccine
mercaptopurine decreases effects of diphtheria & tetanus toxoids/acellular pertussis/poliovirus, inactivated vaccine by pharmacodynamic antagonism. Use Caution/Monitor. Immunosuppressants also increase risk of infection with concomitant live vaccines.
- doxorubicin
doxorubicin increases toxicity of mercaptopurine by pharmacodynamic synergism. Use Caution/Monitor. Increased risk of hepatotoxicity.
- doxorubicin liposomal
doxorubicin liposomal increases toxicity of mercaptopurine by pharmacodynamic synergism. Use Caution/Monitor. Increased risk of hepatotoxicity.
- echinacea
mercaptopurine, echinacea. immunosuppressive effects; risk of infection. Use Caution/Monitor. Theoretically echinacea may antagonize the effects of immunosuppressants.
- etanercept
etanercept and mercaptopurine both increase immunosuppressive effects; risk of infection. Use Caution/Monitor.
- everolimus
everolimus and mercaptopurine both increase immunosuppressive effects; risk of infection. Use Caution/Monitor.
- fingolimod
mercaptopurine increases effects of fingolimod by immunosuppressive effects; risk of infection. Modify Therapy/Monitor Closely. Concomitant therapy is expected to increase the risk of immunosuppression. Use caution when switching patients from long-acting therapies with immune effects. .
- glatiramer
glatiramer and mercaptopurine both increase immunosuppressive effects; risk of infection. Use Caution/Monitor.
- golimumab
golimumab and mercaptopurine both increase immunosuppressive effects; risk of infection. Use Caution/Monitor.
- haemophilus influenzae type b vaccine
mercaptopurine decreases effects of haemophilus influenzae type b vaccine by pharmacodynamic antagonism. Modify Therapy/Monitor Closely. Avoid vaccination during chemotherapy or radiation therapy if possible because antibody response might be suboptimal. Patients vaccinated within a 14-day period before starting or during immunosuppressive therapy should be revaccinated =3 months after therapy is discontinued if immune competence has been restored. .
- hepatitis A vaccine inactivated
mercaptopurine decreases effects of hepatitis A vaccine inactivated by pharmacodynamic antagonism. Use Caution/Monitor. Immunosuppressants also increase risk of infection with concomitant live vaccines.
- hepatitis a/b vaccine
mercaptopurine decreases effects of hepatitis a/b vaccine by pharmacodynamic antagonism. Use Caution/Monitor. Immunosuppressants also increase risk of infection with concomitant live vaccines.
- hepatitis b vaccine
mercaptopurine decreases effects of hepatitis b vaccine by pharmacodynamic antagonism. Use Caution/Monitor. Immunosuppressants also increase risk of infection with concomitant live vaccines.
- hydroxychloroquine sulfate
hydroxychloroquine sulfate and mercaptopurine both increase immunosuppressive effects; risk of infection. Use Caution/Monitor.
- hydroxyurea
mercaptopurine, hydroxyurea. Other (see comment). Use Caution/Monitor. Comment: Combination may increase risk of myelosuppression.
- infliximab
infliximab and mercaptopurine both increase immunosuppressive effects; risk of infection. Use Caution/Monitor.
- influenza A (H5N1) vaccine
mercaptopurine decreases effects of influenza A (H5N1) vaccine by Mechanism: pharmacodynamic antagonism. Use Caution/Monitor. Immunosuppressive therapies may reduce immune response to H5N1 vaccine.
- influenza virus vaccine (H5N1), adjuvanted
mercaptopurine decreases effects of influenza virus vaccine (H5N1), adjuvanted by Mechanism: pharmacodynamic antagonism. Use Caution/Monitor. Immunosuppressive therapies may reduce immune response to H5N1 vaccine.
- influenza virus vaccine quadrivalent
mercaptopurine decreases effects of influenza virus vaccine quadrivalent by pharmacodynamic antagonism. Use Caution/Monitor. Immunosuppressants also increase risk of infection with concomitant live vaccines.
- influenza virus vaccine quadrivalent, cell-cultured
mercaptopurine decreases effects of influenza virus vaccine quadrivalent, cell-cultured by pharmacodynamic antagonism. Use Caution/Monitor. Immunosuppressants also increase risk of infection with concomitant live vaccines.
- influenza virus vaccine quadrivalent, recombinant
mercaptopurine decreases effects of influenza virus vaccine quadrivalent, recombinant by pharmacodynamic antagonism. Use Caution/Monitor. Immune response to vaccine may be decreased in immunocompromised individuals.
- influenza virus vaccine trivalent
mercaptopurine decreases effects of influenza virus vaccine trivalent by pharmacodynamic antagonism. Use Caution/Monitor. Immunosuppressants also increase risk of infection with concomitant live vaccines.
- influenza virus vaccine trivalent, recombinant
mercaptopurine decreases effects of influenza virus vaccine trivalent, recombinant by pharmacodynamic antagonism. Use Caution/Monitor. Immune response to vaccine may be decreased in immunocompromised individuals.
- isavuconazonium sulfate
mercaptopurine and isavuconazonium sulfate both decrease immunosuppressive effects; risk of infection. Use Caution/Monitor.
- Japanese encephalitis virus vaccine
mercaptopurine decreases effects of Japanese encephalitis virus vaccine by pharmacodynamic antagonism. Use Caution/Monitor. Immunosuppressants also increase risk of infection with concomitant live vaccines.
- leflunomide
leflunomide and mercaptopurine both increase immunosuppressive effects; risk of infection. Use Caution/Monitor.
- maitake
mercaptopurine increases and maitake decreases immunosuppressive effects; risk of infection. Effect of interaction is not clear, use caution. Use Caution/Monitor.
- meningococcal group B vaccine
mercaptopurine decreases effects of meningococcal group B vaccine by pharmacodynamic antagonism. Use Caution/Monitor. Individuals with altered immunocompetence may have reduced immune responses to the vaccine.
- muromonab CD3
mercaptopurine and muromonab CD3 both increase immunosuppressive effects; risk of infection. Use Caution/Monitor.
- mycophenolate
mercaptopurine and mycophenolate both increase immunosuppressive effects; risk of infection. Use Caution/Monitor.
- ocrelizumab
mercaptopurine and ocrelizumab both increase immunosuppressive effects; risk of infection. Use Caution/Monitor. Coadministration of ocrelizumab with immunomodulators is expected to increase the risk of immunosuppression.
- ofatumumab SC
ofatumumab SC, mercaptopurine. Either increases effects of the other by immunosuppressive effects; risk of infection. Use Caution/Monitor. Consider the risk of additive immune system effects when coadministering immunosuppressive therapies with coadministration. When switching from therapies with immune effects, take into account the duration and mechanism of action of these therapies when initiating ofatumumab SC.
- olaparib
mercaptopurine and olaparib both increase pharmacodynamic synergism. Use Caution/Monitor. Coadministration with other other myelosuppressive anticancer agents, including DNA damaging agents, may potentiate and prolongate the myelosuppressive toxicity.
- oxaliplatin
oxaliplatin, mercaptopurine. Either increases toxicity of the other by pharmacodynamic synergism. Use Caution/Monitor. Combination may increase risk of myelosuppression.
- ozanimod
ozanimod, mercaptopurine. Either increases effects of the other by immunosuppressive effects; risk of infection. Use Caution/Monitor. Coadministration with immunosuppressive therapies may increase the risk of additive immune effects during therapy and in the weeks following administration. When switching from drugs with prolonged immune effects, consider the half-life and mode of action of these drugs in order to avoid unintended additive immunosuppressive effects.
- pneumococcal vaccine polyvalent
mercaptopurine decreases effects of pneumococcal vaccine polyvalent by pharmacodynamic antagonism. Use Caution/Monitor. Immunosuppressants also increase risk of infection with concomitant live vaccines.
- poliovirus vaccine inactivated
mercaptopurine decreases effects of poliovirus vaccine inactivated by pharmacodynamic antagonism. Modify Therapy/Monitor Closely. Avoid vaccination during chemotherapy or radiation therapy if possible because antibody response might be suboptimal. Patients vaccinated within a 14-day period before starting or during immunosuppressive therapy should be revaccinated =3 months after therapy is discontinued if immune competence has been restored. .
- rabies vaccine
mercaptopurine decreases effects of rabies vaccine by pharmacodynamic antagonism. Use Caution/Monitor. Immunosuppressants may interfere with development of active immunity.
- rabies vaccine chick embryo cell derived
mercaptopurine decreases effects of rabies vaccine chick embryo cell derived by pharmacodynamic antagonism. Use Caution/Monitor. Immunosuppressants also increase risk of infection with concomitant live vaccines.
- siponimod
siponimod and mercaptopurine both increase immunosuppressive effects; risk of infection. Use Caution/Monitor. Caution if coadministered because of additive immunosuppressive effects during such therapy and in the weeks following administration. When switching from drugs with prolonged immune effects, consider the half-life and mode of action of these drugs to avoid unintended additive immunosuppressive effects.
- sipuleucel-T
mercaptopurine decreases effects of sipuleucel-T by pharmacodynamic antagonism. Modify Therapy/Monitor Closely.
- sirolimus
mercaptopurine and sirolimus both increase immunosuppressive effects; risk of infection. Use Caution/Monitor.
- tacrolimus
mercaptopurine and tacrolimus both increase immunosuppressive effects; risk of infection. Use Caution/Monitor.
- temsirolimus
mercaptopurine and temsirolimus both increase immunosuppressive effects; risk of infection. Use Caution/Monitor.
- tetanus toxoid adsorbed or fluid
mercaptopurine decreases effects of tetanus toxoid adsorbed or fluid by pharmacodynamic antagonism. Use Caution/Monitor. Immunosuppressants also increase risk of infection with concomitant live vaccines.
- trastuzumab
trastuzumab, mercaptopurine. Either increases toxicity of the other by immunosuppressive effects; risk of infection. Use Caution/Monitor. Neutropenia or febrile neutropenia incidence were increased when trastuzumab was coadministered with myelosuppressive chemotherapy. .
- trastuzumab deruxtecan
trastuzumab deruxtecan, mercaptopurine. Either increases toxicity of the other by immunosuppressive effects; risk of infection. Use Caution/Monitor. Neutropenia or febrile neutropenia incidence were increased when trastuzumab was coadministered with myelosuppressive chemotherapy. .
- typhoid polysaccharide vaccine
mercaptopurine decreases effects of typhoid polysaccharide vaccine by pharmacodynamic antagonism. Use Caution/Monitor. Immunosuppressants also increase risk of infection with concomitant live vaccines.
- ublituximab
ublituximab and mercaptopurine both increase immunosuppressive effects; risk of infection. Modify Therapy/Monitor Closely. Owing to potential additive immunosuppressive effects, consider duration of effect and mechanism of action of these therapies if coadministered
- ustekinumab
mercaptopurine and ustekinumab both increase immunosuppressive effects; risk of infection. Use Caution/Monitor.
- zoster vaccine recombinant
mercaptopurine decreases effects of zoster vaccine recombinant by pharmacodynamic antagonism. Use Caution/Monitor. Immunosuppressive therapies may reduce the effectiveness of zoster vaccine recombinant.
Minor (5)
- benazepril
benazepril, mercaptopurine. Mechanism: pharmacodynamic synergism. Minor/Significance Unknown. Risk of neutropenia.
- maitake
maitake increases effects of mercaptopurine by pharmacodynamic synergism. Minor/Significance Unknown. Maitake mushroom has anti-tumor effects (animal/in vitro research).
- taurine
mercaptopurine decreases levels of taurine by unspecified interaction mechanism. Minor/Significance Unknown.
- vitamin A
vitamin A, mercaptopurine. Mechanism: pharmacodynamic synergism. Minor/Significance Unknown. Antioxidants such as vitamin A enhance the efficacy, and reduce toxicity, of antineoplastic drugs.
- vitamin E
vitamin E, mercaptopurine. Mechanism: pharmacodynamic synergism. Minor/Significance Unknown. Antioxidants such as vitamin E enhance the efficacy, and reduce toxicity, of antineoplastic drugs.
Adverse Effects
>10%
Elevated LFT's (15%)
1-10%
Nausea (10%)
Vomiting (10%)
Stomatitis (3-10%)
Thrombocytopenia (3-10%)
Rash (1-3%)
Diarrhea (1-3%)
Dizziness (1-3%)
Alopecia (1-3%)
Leukopenia (1-3%)
Frequency Not Defined
Fatigue
Anorexia
Headache
Chills and fever
Chest pain
Mucositis
Upper respiratory infection
Cough
Ulceration of intestine
Ulcerative stomatitis
Myelosuppression
Decreased hematocrit
Hepatotoxicity
Decreased resistance to infections
Hyperuricemia
Nephrotoxicity
Increased risk of pancreatitis in pts with IBD
Hyperpigmentation of skin
Arthralgias
Eye discomfort
Tinnitus
Postmarketing Reports
Photosensitivity
Hypoglycemia
Portal hypertension
Macrophage activation syndrome
Urticaria
Hyperbilirubinemia
Bone marrow toxicity
Hyperuricemia and/or hyperuricosuria
Skin rashes and hyperpigmentation
Alopecia
Fever (rare)
Warnings
Black Box Warnings
The drug should not be used unless a diagnosis of acute lymphatic leukemia has been adequately established, and the patient’s physician is knowledgeable in assessing response to chemotherapy
Contraindications
None
Cautions
Renal impairment
Recommended that evaluation of hemoglobin or hematocrit, total white blood cell count and differential count, and quantitative platelet count be obtained weekly while patient is on therapy
Macrophage activation syndrome (MAS) (hemophagocytic lymphohistiocytosis) a life-threatening disorder, may develop in patients with autoimmune conditions, in particular with inflammatory bowel disease (IBD); there could potentially be an increased susceptibility for developing the condition with the use of mercaptopurine (an unapproved use); if MAS occurs, or is suspected, discontinue therapy; monitor for and promptly treat infections such as EBV and cytomegalovirus (CMV), as these are known triggers for MAS
Drug fever very rarely reported; before attributing fever to drug, make every attempt to exclude more common causes of pyrexia, such as sepsis, in patients with acute leukemia
Mercaptopurine is immunosuppressive and may impair the immune response to infectious agents or vaccines; due to immunosuppression associated with maintenance chemotherapy for ALL, response to all vaccines may be diminished and there is a risk of infection with live virus vaccines; consult immunization guidelines for immunocompromised patients
Hepatotoxicity
- Mercaptopurine is hepatotoxic; there are reports of deaths attributed to hepatic necrosis associated with administration of the drug; hepatic injury can occur with any dosage but seems to occur with greater frequency when recommended dosage is exceeded; in some patients, jaundice has cleared following withdrawal of mercaptopurine and reappeared with rechallenge
- Usually, clinically detectable jaundice appears early in the course of treatment (1 to 2 months); however, jaundice has been reported as early as 1 week and as late as 8 years after starting mercaptopurine; the hepatotoxicity has been associated in some cases with anorexia, diarrhea, jaundice and ascites; hepatic encephalopathy has occurred; monitor serum transaminase levels, alkaline phosphatase, and bilirubin levels at weekly intervals when first beginning therapy and at monthly intervals thereafter
- Monitor liver tests more frequently in patients who are receiving therapy with other hepatotoxic products or with known pre-existing liver disease; withhold therapy at onset of hepatotoxicity
Myelosuppression
- The most consistent, dose-related adverse reaction is myelosuppression, manifested by anemia, leukopenia, thrombocytopenia, or any combination of these; monitor CBC and adjust dosage for excessive myelosuppression
- Bone marrow examination may be useful for evaluation of marrow status; decision to increase, decrease, continue, or discontinue a given dosage must be based upon degree of severity and rapidity with which changes are occurring; in many instances, particularly during induction phase of acute leukemia, complete blood counts will need to be done more frequently than once weekly in order to evaluate effect of therapy
- Myelosuppression can be exacerbated by coadministration with allopurinol, aminosalicylates or other products that cause myelosuppression; reduce dose by 75% (ie, give quarter dose) when used concurrently with allopurinol
- Increased risk of bone marrow toxicity; evaluate patients with repeated severe myelosuppression for thiopurine S-methyltransferase (TPMT) or nucleotide diphosphatase (NUDT15) deficiency; TPMT genotyping or phenotyping (red blood cell TPMT activity) and NUDT15 genotyping can identify patients who have reduced activity of these enzymes; patients with homozygous TPMT or NUDT15 deficiency require substantial dosage reductions of the drug
- Increased risk of developing lymphoproliferative disorders and other malignancies, notably skin cancers (melanoma and non-melanoma), sarcomas (Kaposi's and non-Kaposi's) and uterine cervical cancer in situ; increased risk appears to be related to degree and duration of immunosuppression; discontinuation of immunosuppression reported to provide partial regression of lymphoproliferative disorder; a treatment regimen containing multiple immunosuppressants (including thiopurines) should be used with caution as this could lead to lymphoproliferative disorders, some with reported fatalities; a combination of multiple immunosuppressants, given concomitantly increases risk of Epstein-Barr virus (EBV)-associated lymphoproliferative disorders
Hepatosplenic T-cell lymphomas
- Rare postmarketing cases reported primarily in adolescent and young adult patients with Crohn disease and ulcerative colitis treated with TNF blockers
- Reports have also included a patient being treated for psoriasis and 2 patients being treated for rheumatoid arthritis
- HSTCL is an aggressive, rare type of T-cell lymphoma (usually fatal)
- Most reported cases with TNF blockers have occurred with concomitant treatment with azathioprine or 6-mercaptopurine, although there have been cases reported receiving azathioprine or mercaptopurine alone
- The following HSTCL cases have been identified in the FDA Adverse Event Reporting System (AERS) database, the literature, and the HSTCL Cancer Survivors' Network: infliximab (20), etanercept (1), adalimumab (2), infliximab/adalimumab (5), certolizumab (0), golimumab (0), azathioprine (12), and mercaptopurine (3)
Pregnancy & Lactation
Pregnancy
Therapy can cause fetal harm when administered to a pregnant woman; pregnant women who receive mercaptopurine have an increased incidence of miscarriage and stillbirth; advise pregnant women of potential risk to fetus
Verify pregnancy status in females of reproductive potential prior to initiating therapy
Reproductive potential
- Females: Advise females of reproductive potential to use effective contraception during treatment and for 6 months after last dose
- Males: Based on genotoxicity findings, advise males with female partners of reproductive potential to use effective contraception during treatment with PURIXAN and for 3 months after the last dose
Infertility
- Females and males: Based on findings from animal studies, drug can impair female and male fertility; the long-term effects on female and male fertility, including the reversibility have not been studied
Animal data
- Drug was embryo-lethal and teratogenic in several animal species (rat, mouse, rabbit, and hamster) at doses less than recommended human dose
Lactation
There are no data on presence of mercaptopurine or metabolites in human milk, effects on breastfed child or on milk production; because of potential for serious adverse reactions in breastfed child, advise women not to breastfeed during treatment and for 1 week after last dose
Pregnancy Categories
A: Generally acceptable. Controlled studies in pregnant women show no evidence of fetal risk.
B: May be acceptable. Either animal studies show no risk but human studies not available or animal studies showed minor risks and human studies done and showed no risk. C: Use with caution if benefits outweigh risks. Animal studies show risk and human studies not available or neither animal nor human studies done. D: Use in LIFE-THREATENING emergencies when no safer drug available. Positive evidence of human fetal risk. X: Do not use in pregnancy. Risks involved outweigh potential benefits. Safer alternatives exist. NA: Information not available.Pharmacology
Mechanism of Action
Analog of naturally occurring purines hypoxanthine and guanine
Purine antagonist, antineoplastic
Absorption
Bioavailability: 5-37%
Peak Plasma Time: 2 hr
Onset: 2 hr
Duration: variable
Distribution
Protein Bound: 19%
Vd: 0.56-0.9 L/kg
Metabolism
GI mucosa, liver
Metabolites: 6-thiouric acid
Elimination
Half-Life: 21 minutes (children), 47 min (adult)
Clearance: 11 mL/min/kg
Excretion: urine
Dialyzable: no
Pharmacogenomics
6-mercaptopurine is activated by guanine phosphoribosyltransferase (HGPRT) to form thioinosine monophosphate (TIMP) and by kinase enzymatic pathways to form active 6-thioguanine nucleotides
Thiopurine S-methyltransferase (TPMT) inactivates 6-mercaptopurine
Although complete TPMT deficiency is rare in the general population (0.3%), TPMT screening should be performed prior to administration in all patients prescribed azathioprine or 6-mercaptopurine
With TPMT deficiency, a larger proportion of 6-mercaptopurine is converted to the cytotoxic 6-thioguanine nucleotide analogues, which can lead to bone marrow toxicity and myelosuppression
Alleles associated with decreased TPMT enzymatic activity are TPMT*2, TPMT*3A, and TPMT*3C
Genetic testing laboratories
- The following companies currently offer testing for TPMT variants
- Prometheus Labs (http://www.prometheuslabs.com/)
- Arup Laboratories (http://www.aruplab.com/)
Images
| BRAND | FORM. | UNIT PRICE | PILL IMAGE |
|---|---|---|---|
| mercaptopurine oral - | 50 mg tablet |  | |
| mercaptopurine oral - | 50 mg tablet |  | |
| mercaptopurine oral - | 50 mg tablet |  | |
| Purixan oral - | 20 mg/mL suspension |  |
Copyright © 2010 First DataBank, Inc.
Patient Handout
mercaptopurine oral
MERCAPTOPURINE - ORAL
(mer-KAP-toe-PURE-een)
COMMON BRAND NAME(S): Purinethol, Purixan
USES: This medication is used to treat a certain type of cancer (acute lymphocytic leukemia). It is a chemotherapy drug that works by slowing or stopping the growth of cancer cells.Talk to the doctor about the risks and benefits of mercaptopurine, especially when used by children and young adults.
HOW TO USE: Read the Patient Information Leaflet if available from your pharmacist before you start taking mercaptopurine and each time you get a refill. If you have any questions, ask your doctor or pharmacist.Take this medication by mouth with or without food as directed by your doctor, usually once daily. Drink plenty of fluids while taking this medication unless otherwise directed by your doctor. Doing so may help decrease the risk of certain side effects (kidney problems).If you are using the suspension, shake the bottle well for at least 30 seconds before each dose. Carefully measure the dose using the provided special measuring device. Do not use a household spoon because you may not get the correct dose. Avoid getting any of the suspension on your skin or in your eyes. If contact occurs, wash the affected skin area or rinse your eyes with water. Consult your pharmacist for details.The dosage is based on your medical condition, weight, and response to treatment. Do not increase your dose or use this drug more often or for longer than prescribed. Your condition will not improve any faster, and your risk of serious side effects will increase.Use this medication regularly to get the most benefit from it. To help you remember, take it at the same time each day.Since this drug can be absorbed through the skin and lungs and may harm an unborn baby, women who are pregnant or who may become pregnant should not handle this medication or breathe the dust from the tablets.
SIDE EFFECTS: Nausea, vomiting, diarrhea, and loss of appetite may occur. Temporary hair loss may also occur. If any of these effects last or get worse, tell your doctor or pharmacist promptly.People using this medication may have serious side effects. However, you have been prescribed this drug because your doctor has judged that the benefit to you is greater than the risk of side effects. Careful monitoring by your doctor may decrease your risk.Tell your doctor right away if you have any serious side effects, including: joint pain/swelling, black stools, vomit that looks like coffee grounds, signs of kidney problems (such as change in the amount of urine, pain in the lower back/side).Get medical help right away if you have any very serious side effects, including: symptoms of liver disease (such as nausea/vomiting that doesn't stop, stomach/abdominal pain, yellowing eyes/skin, dark urine).This medication may decrease bone marrow function, an effect that may lead to a low number of blood cells such as red cells, white cells, and platelets. This effect can cause anemia, decrease your body's ability to fight an infection, or cause easy bruising/bleeding. Tell your doctor right away if you develop any of the following symptoms: unusual tiredness, pale skin, signs of infection (such as sore throat that doesn't go away, fever, chills), easy bruising/bleeding.Mercaptopurine may rarely increase your risk of developing certain types of cancer (such as lymphoma, skin, cervical). This risk is higher in children/young adults being treated for certain bowel diseases (such as Crohn's disease, ulcerative colitis). Keep all medical and laboratory appointments. Tell your doctor right away if you develop any of the following symptoms: swollen abdomen, swollen lymph nodes, night sweats, unexplained weight loss, unusual skin changes (such as new skin lesion or bump, or change in size or color of a mole), unusual vaginal bleeding/discharge.A very serious allergic reaction to this drug is rare. However, get medical help right away if you notice any symptoms of a serious allergic reaction, including: rash, itching/swelling (especially of the face/tongue/throat), dizziness, trouble breathing.This is not a complete list of possible side effects. If you notice other effects not listed above, contact your doctor or pharmacist.In the US -Call your doctor for medical advice about side effects. You may report side effects to FDA at 1-800-FDA-1088 or at www.fda.gov/medwatch.In Canada - Call your doctor for medical advice about side effects. You may report side effects to Health Canada at 1-866-234-2345.
PRECAUTIONS: Before taking mercaptopurine, tell your doctor or pharmacist if you are allergic to it; or to azathioprine; or if you have any other allergies. This product may contain inactive ingredients, which can cause allergic reactions or other problems. Talk to your pharmacist for more details.Before using this medication, tell your doctor or pharmacist your medical history, especially of: kidney disease, liver disease, cancer, certain enzyme disorders (TPMT deficiency, NUDT15 deficiency).Mercaptopurine can make you more likely to get infections or may make current infections worse. Stay away from anyone who has an infection that may easily spread (such as chickenpox, COVID-19, measles, flu). Talk to your doctor if you have been exposed to an infection or for more details.Tell your health care professional that you are using mercaptopurine before having any immunizations/vaccinations. Avoid contact with people who have recently received live vaccines (such as flu vaccine inhaled through the nose).To lower the chance of getting cut, bruised, or injured, use caution with sharp objects like razors and nail cutters, and avoid activities such as contact sports.This medication may make you more sensitive to the sun. Limit your time in the sun. Avoid tanning booths and sunlamps. Use sunscreen and wear protective clothing when outdoors. Tell your doctor right away if you get sunburned or have skin blisters/redness.Before having surgery, tell your doctor or dentist about all the products you use (including prescription drugs, nonprescription drugs, and herbal products).Since this drug can be absorbed through the skin and lungs and may harm an unborn baby, women who are pregnant or who may become pregnant should not handle this medication or breathe the dust from the tablets.Tell your doctor if you are pregnant or plan to become pregnant. You should not become pregnant while using mercaptopurine. Mercaptopurine may harm an unborn baby, especially during the first 3 months of pregnancy. Your doctor should do a pregnancy test before you start this medication. Women of childbearing age should ask about reliable forms of birth control while using this medication and for 6 months after the last dose. Men with female partners of childbearing age should ask about reliable forms of birth control while using this medication and for 3 months after the last dose. If you or your partner become pregnant, or think you are pregnant, talk to your doctor right away about the risks and benefits of this medication.It is unknown if this drug passes into breast milk. Because of the possible risk to the infant, breast-feeding while using this drug and for 1 week after the last dose is not recommended. Consult your doctor before breast-feeding.
DRUG INTERACTIONS: Drug interactions may change how your medications work or increase your risk for serious side effects. This document does not contain all possible drug interactions. Keep a list of all the products you use (including prescription/nonprescription drugs and herbal products) and share it with your doctor and pharmacist. Do not start, stop, or change the dosage of any medicines without your doctor's approval.Some products that may interact with this drug are: febuxostat, other drugs that weaken the immune system/increase the risk of infection (such as rituximab, tofacitinib).This medication may interfere with certain lab tests (such as uric acid levels), possibly causing false test results. Make sure lab personnel and all your doctors know you use this drug.Mercaptopurine is very similar to azathioprine. Do not use medications containing azathioprine while using mercaptopurine.
OVERDOSE: If someone has overdosed and has serious symptoms such as passing out or trouble breathing, call 911. Otherwise, call a poison control center right away. US residents can call their local poison control center at 1-800-222-1222. Canada residents can call a provincial poison control center.
NOTES: Do not share this medication with others.Lab and/or medical tests (such as complete blood count, liver/kidney function) should be done while you are taking this medication. Keep all medical and lab appointments. Consult your doctor for more details.
MISSED DOSE: If you miss a dose, take it as soon as you remember. If it is near the time of the next dose, skip the missed dose. Take your next dose at the regular time. Do not double the dose to catch up.
STORAGE: Store at room temperature away from light and moisture. Do not store in the bathroom. Discard the suspension form of the medication 8 weeks after opening the bottle. Keep all medications away from children and pets.Do not flush medications down the toilet or pour them into a drain unless instructed to do so. Properly discard this product when it is expired or no longer needed. Consult your pharmacist or local waste disposal company.
MEDICAL ALERT: Your condition can cause complications in a medical emergency. For information about enrolling in MedicAlert, call 1-888-633-4298 (US) or 1-800-668-1507 (Canada).
Information last revised March 2023. Copyright(c) 2023 First Databank, Inc.
IMPORTANT: HOW TO USE THIS INFORMATION: This is a summary and does NOT have all possible information about this product. This information does not assure that this product is safe, effective, or appropriate for you. This information is not individual medical advice and does not substitute for the advice of your health care professional. Always ask your health care professional for complete information about this product and your specific health needs.
Formulary
Adding plans allows you to compare formulary status to other drugs in the same class.
To view formulary information first create a list of plans. Your list will be saved and can be edited at any time.
Adding plans allows you to:
- View the formulary and any restrictions for each plan.
- Manage and view all your plans together – even plans in different states.
- Compare formulary status to other drugs in the same class.
- Access your plan list on any device – mobile or desktop.
