Although azathioprine is the most popular cytotoxic drug used for immunosuppression, others have been employed. Among these is cyclophosphamide, a cycle-specific agent that acts by cross-linking and alkylating DNA, thereby preventing correct duplication during cell divisions. Methotrexate is a phase-specific agent that acts by inhibiting folate metabolism. It is highly toxic and appears to offer no advantages over azathio-prine. Chlorambucil, an alkylating agent, has actions similar to those of cyclophosphamide. In contrast, its adverse effects are fewer in that alopecia and GI intolerance are almost never encountered. See Chapter 56 for further details of these agents.
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