What to expect when "toxicity" becomes an issue?

[Daggar]

Just wondering what happens when cytoxan lives up to its name and begins to cause toxic damage rather than keeping WG at bay? Do they lower the dosage or stop it completely to see how lab work responds? Is there usually a lapse in treatment while switching to an alternative drug?

The concern is liver damage.

[Sangye]

Depending on how high the liver enzymes are, they will either lower the dose or stop it to allow them to normalize. If the enzymes don't go down or they increase again once the dose is raised, they will probably not be able to continue using ctx. Rtx (rituximab/ rituxan) is the only other power-hitter and is not linked to liver problems.

[NicShaf]

Out of curiosity, do everyone's liver enzymes fluctuate while on Cytoxan?

[Daggar]

Holly's has made a steady increase since starting treatment -- from low-to-mid range "normal" to twice the normal level now (after 3½ months). They've also been as high as 3 times the normal level in the past few weeks.

Her Nephrologist has told us that only 2% of Cytoxan patients experience liver damage from the treatment -- if correct, she's one of the unfortunate few.

There is still a chance that the "cotrimoxazole/sulfatrim" med could be causing it as well.

This raises the question - which is harder to control WG or the drug side effects??

[Psyborg]

I have liver issues before treatment. And CTX is considered to be actually safer for the liver than some of the other treatments. The biggest risk was for the liver is MTX as I understand it. But I'm on that now. Just hoping I don't have another part of my body break down on me

At any rate the biggest issue as I understood it with CTX was with the bladder and urinary tract if you didn't take in sufficient water.

[Daggar]

Has anyone been switched from Cytoxan to Imuran? Is this dangerous after 4 months of treatment?

[JanW]

I was told that mtx was the biggest risk to the liver, which is one of the major reasons to limit drinking when on the drug. Which is how I learned that what I call moderate drinking and what my rheumy call moderate drinking are different things! :-). No matter, I have a few drinks a week and my liver enzymes have been in normal range for a year now.

At the Symposium they talked about being treated with pred and an initial immunosuppressant for three to six months before stepping down to imuran, mtx or cellcept.

[Sangye]

Daggar, elevated liver enzymes do not necessarily indicate permanent liver damage. They indicate liver stress which, if prolonged, will result in damage. Ctx is chemo and all forms of chemo are hard on the liver.

Imuran is not strong enough to get Wegs into remission unless she has mild involvement. They need to induce remission with rtx or ctx and then they can transition her to imuran, mtx or cellcept. However, since she's been on ctx for a bit, it may be that the Wegs is sufficiently under control to consider transitioning her to another drug.

As far as which being harder to control (Wegs vs side effects) it's probably a draw. It's very common to have problems with drug side effects or complications from Wegs.

[Daggar]

Anyone here have an adverse reaction to their liver from Imuran?

[Sangye]

I haven't been on imuran, but it's quite common to have liver problems with it. Before using it they do a blood test to make sure you can take it (forgot the name of the test--TPT or something?). The test only rules out those who definitely can't tolerate imuran, but some people have a bad reaction to it and can't stay on it.