What is the recommendation for continuing Imuran (azathioprine) at 150mg daily in a patient with Behçet's disease who contracts COVID-19?

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Management of Azathioprine (Imuran) 150mg Daily in Behçet's Disease Patients with COVID-19

For patients with Behçet's disease on azathioprine 150mg daily who contract COVID-19, the medication should be continued if the patient remains asymptomatic, but temporarily withheld if symptomatic COVID-19 develops, with decisions made on a case-by-case basis considering disease severity and risk of flare. 1

Asymptomatic COVID-19 (Positive Test, No Symptoms)

  • Continue azathioprine at current dose if the patient tests positive for SARS-CoV-2 but has no clinical symptoms 1
  • Conventional DMARDs (including azathioprine) may be continued in asymptomatic COVID-19 to maintain disease control and prevent flares 1
  • The risk of Behçet's disease flare from stopping immunosuppression may outweigh theoretical COVID-19 risks in asymptomatic patients 2

Symptomatic COVID-19 (Mild to Moderate Symptoms)

  • Temporarily withhold or delay azathioprine when symptomatic COVID-19 develops 1

  • The decision should be individualized based on:

    • Severity of COVID-19 symptoms 1
    • Risk of Behçet's disease flare if treatment is interrupted 2
    • Presence of life-threatening or organ-threatening manifestations of Behçet's disease 1

  • For mild COVID-19 symptoms, discuss potential treatment changes on a case-by-case basis, considering patient concerns and disease stability 1

  • Immunosuppressive effects of azathioprine may persist for weeks after cessation, so stopping may not provide immediate benefit 1

Critical Considerations for Behçet's Disease Specifically

  • Behçet's disease patients may be particularly vulnerable to disease flares when immunosuppression is interrupted 2, 3
  • Case reports document severe exacerbations of Behçet's disease following COVID-19 infection, requiring aggressive treatment escalation 3
  • In a retrospective study of 54 Behçet's patients during the pandemic, 44 continued previous treatment without developing COVID-19 or life-threatening activations 4

Medications to Continue Regardless of COVID-19 Status

  • Colchicine should be continued even with symptomatic COVID-19, as it may have beneficial effects on COVID-19 outcomes and is critical for Behçet's control 1, 2
  • Corticosteroids must be continued at the lowest effective dose to prevent adrenal insufficiency, even with symptomatic COVID-19 1
  • Topical treatments and NSAIDs can be continued safely 2

Monitoring and Follow-up

  • Patients who have azathioprine temporarily withheld should be monitored closely for signs of Behçet's disease flare 2
  • If COVID-19 symptoms worsen, immediately seek consultation with infectious disease or pulmonology specialists 1
  • Resume azathioprine as soon as COVID-19 symptoms resolve to minimize risk of disease flare 2

Common Pitfalls to Avoid

  • Do not automatically discontinue azathioprine based solely on positive COVID-19 test without considering symptom status 1
  • Do not abruptly stop corticosteroids if patient is on concurrent prednisone, as this risks adrenal crisis 1
  • Do not delay restarting azathioprine after COVID-19 resolution, as Behçet's disease can flare dramatically post-infection 3
  • Be aware that stopping immunosuppression does not provide immediate protection, as drug effects persist for weeks 1

References

1
Guideline

Guideline Directed Topic Overview

Dr.Oracle Medical Advisory Board & Editors, 2025

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Professional Medical Disclaimer

This information is intended for healthcare professionals. Any medical decision-making should rely on clinical judgment and independently verified information. The content provided herein does not replace professional discretion and should be considered supplementary to established clinical guidelines. Healthcare providers should verify all information against primary literature and current practice standards before application in patient care. Dr.Oracle assumes no liability for clinical decisions based on this content.

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