What adjustments should be made to Imuran (Azathioprine) 150 mg daily and Prednisone 7.5 mg daily for Behcet's syndrome with low neutrophil count?

Management of Neutrophilia in Behçet's Syndrome Patient on Imuran and Prednisone

Your patient has significant neutrophilia (84% neutrophils, absolute neutrophil count 8.0 × 10³/mm³) rather than neutropenia, which does not require dose adjustment of azathioprine or prednisone and likely reflects active Behçet's disease inflammation.

Understanding the Laboratory Values

• Neutrophil percentage of 84% with absolute count of 8.0 × 10³/mm³ represents neutrophilia, not neutropenia 1
• The lymphocyte percentage is low at 14.2%, creating a relative lymphopenia with elevated neutrophil-to-lymphocyte ratio (NLR) 2
• This pattern is commonly seen in active Behçet's syndrome and correlates with disease activity 2

No Dose Adjustment Required

Continue current doses of azathioprine 150 mg daily and prednisone 7.5 mg daily without modification, as neutrophilia does not trigger dose reduction protocols. 1

• Azathioprine dose reduction is only indicated when absolute neutrophil count falls below 4,000/mm³ (not when elevated) 1
• The threshold for holding azathioprine is ANC < 1,000/mm³, and for permanent discontinuation is ANC < 500/mm³ 1, 3
• Your patient's ANC of 8,000/mm³ is well above any concerning threshold 1

Clinical Significance of Neutrophilia in Behçet's

• Neutrophil hyperactivation is a hallmark pathogenic feature of Behçet's syndrome and elevated neutrophil counts often indicate active disease 4, 5
• Neutrophils in Behçet's produce excessive reactive oxygen species via NADPH oxidase, contributing to both inflammation and thrombosis risk 4
• The elevated NLR (approximately 5.6 in your patient) has been shown to correlate with Behçet's disease presence and may reflect disease activity 2

Recommended Actions

Assess for clinical signs of active Behçet's disease rather than adjusting immunosuppression:

• Evaluate for mucocutaneous lesions (oral/genital ulcers, erythema nodosum, papulopustular lesions) 1
• Screen for ocular inflammation, as posterior uveitis requires aggressive immunosuppression 1
• Assess for vascular involvement (deep vein thrombosis, arterial aneurysms) given neutrophil-mediated thrombotic risk 1, 4, 5
• Check for neurological or gastrointestinal manifestations 1

Monitoring Strategy

• Continue monthly complete blood counts to monitor for true azathioprine-induced cytopenias 1
• Monitor liver function tests monthly, as azathioprine hepatotoxicity (not neutrophilia) is a concern requiring dose adjustment if transaminases exceed 3× normal 1
• If neutrophilia persists with clinical disease activity, consider escalating immunosuppression rather than reducing it 1

Important Caveats

• Do not confuse neutrophilia with neutropenia—the management is completely opposite 1, 3
• The prednisone dose of 7.5 mg daily is appropriate maintenance therapy for Behçet's, though higher doses may be needed for acute flares 1
• Azathioprine 150 mg daily is within the recommended dosing range and should not exceed this dose even if neutrophil counts remain elevated 1
• Consider adding anti-TNF therapy (infliximab) if disease remains active despite current regimen, particularly for sight-threatening uveitis or refractory vascular disease 1