Do you feel comfortable using azathioprine for dermatomyositis in patients with cirrhosis?

Azathioprine can cause liver damage, albeit this is a rare complication and usually asymptomatic. Therefore, I would probably avoid it in cases of liver cirrhosis and try other medications, like mycophenolate, IVIG, tofactinib. In either case, I would consult at the same time with the patient's hepatologist and decide together about what kind of medication would be allowed and the kind of follow-up indicated.

Great question! AZA hepatic toxicity is thought to be multifactorial but may be partially related to secondary glutathione reduction leading to mitochondrial damage. Glutathione levels are often already decreased in patients with notable hepatic dysfunction, which may theoretically increase the risk for AZA hepatic toxicity. As such, I agree with Dr. @Dr. First Last 's concerns about the risk of liver damage with AZA (even though we ironically do use it for autoimmune hepatitis).

AZA may also not be as effective in cirrhotic patients: AZA is a pro-drug which is metabolized in the liver to 6-MP and other active metabolites. Hepatic dysfunction may thus potentially decrease AZA conversion and make it less useful.

As such, I would strongly consi...