{"Azathioprine can be affected by a patient's TPMT and NUDT15 phenotype. This patient is predicted to be a TPMT poor metabolizer and NUDT15 poor metabolizer. This patient is at high risk for life threatening myelosuppression with normal doses of azathioprine and should receive greatly reduced doses. For non-malignant conditions, consider alternative non-thiopurine immunosuppressant therapy. For malignant conditions, start with drastically reduced normal daily doses (reduce daily dose by 10 fold and dose thrice weekly instead of daily) and adjust doses of azathioprine based on degree of myelosuppression and disease-specific guidelines. Allow 4-6 weeks to reach steady-state after each dose adjustment. Please consult a clinical pharmacist for more information."}