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Vasudevan A, Con D, De Cruz P, Sparrow MP, Friedman AB, Garg M, Kashkooli S, Gibson PR, van Langenberg DR. Clinical trial: Combination allopurinol-thiopurine versus standard thiopurine in patients with IBD escalating to immunomodulators (the DECIDER study). Aliment Pharmacol Ther 2024; 59:504-514. [PMID: 38095246 DOI: 10.1111/apt.17831] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/11/2023] [Revised: 09/29/2023] [Accepted: 11/29/2023] [Indexed: 01/23/2024]
Abstract
BACKGROUND Thiopurines are established treatments for inflammatory bowel disease (IBD), yet concerns remain regarding their safety. AIM To evaluate the use of thiopurine-allopurinol combination therapy compared to standard thiopurine therapy in IBD. METHODS We performed a multicentre, randomised, placebo-controlled trial to compare the efficacy and safety of thiopurine-allopurinol versus thiopurine with placebo for adults commencing a thiopurine for IBD. Patients had active disease at baseline; dosing of therapy was based on a pre-specified regimen and subsequent metabolites. The primary outcome was the proportion of patients achieving a composite of symptomatic disease activity remission (Harvey Bradshaw Index <5 for Crohn's disease, Simple Clinical Colitis Activity Index <4 for ulcerative colitis) and a faecal calprotectin <150 μg/g after 26 weeks of treatment. RESULTS The trial was terminated early due to slow recruitment. We randomised 102 participants (54 thiopurine-allopurinol, 48 thiopurine with placebo) with similar age (median 42 vs 48 years) and sex distribution (46% women per group). A higher proportion achieved the primary outcome in the thiopurine-allopurinol group (50% vs 35%, p = 0.14) and fewer participants stopped their allocated therapy due to adverse events (11% vs 29%, p = 0.02). Also, within the thiopurine-allopurinol group, thiopurine dose adjustments were less frequent (69% vs 92%, p = 0.03), a higher proportion achieved an early therapeutic 6-TGN level at week 6 (71% vs 53%, p = 0.19), and adverse events attributed to therapy were less frequent (15% vs 44%, p = 0.002). CONCLUSION Thiopurine-allopurinol therapy is safe and mitigates thiopurine adverse effects, thus enhancing tolerability without compromising efficacy (ACTRN12613001347752).
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Affiliation(s)
- Abhinav Vasudevan
- Department of Gastroenterology and Hepatology, Eastern Health, Box Hill, Victoria, Australia
- Monash University, Eastern Health Clinical School, Box Hill, Victoria, Australia
| | - Danny Con
- Department of Gastroenterology, The Austin Hospital, Melbourne, Victoria, Australia
| | - Peter De Cruz
- Department of Gastroenterology, The Austin Hospital, Melbourne, Victoria, Australia
- Department of Medicine, Austin Academic Centre, University of Melbourne, Melbourne, Victoria, Australia
| | - Miles P Sparrow
- Department of Gastroenterology, Central Clinical School, Monash University and Alfred Health, Melbourne, Victoria, Australia
| | - Antony B Friedman
- Department of Gastroenterology, Central Clinical School, Monash University and Alfred Health, Melbourne, Victoria, Australia
| | - Mayur Garg
- Department of Gastroenterology, Northern Health, Epping, Victoria, Australia
- Department of Medicine, Melbourne University, Melbourne, Australia
| | - Soleiman Kashkooli
- Department of Gastroenterology, Northern Health, Epping, Victoria, Australia
| | - Peter R Gibson
- Department of Gastroenterology, Central Clinical School, Monash University and Alfred Health, Melbourne, Victoria, Australia
| | - Daniel R van Langenberg
- Department of Gastroenterology and Hepatology, Eastern Health, Box Hill, Victoria, Australia
- Monash University, Eastern Health Clinical School, Box Hill, Victoria, Australia
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Mallick B, Malik S. Use of Azathioprine in Ulcerative Colitis: A Comprehensive Review. Cureus 2022; 14:e24874. [PMID: 35698683 PMCID: PMC9184176 DOI: 10.7759/cureus.24874] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/09/2022] [Indexed: 01/10/2023] Open
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Turbayne AK, Sparrow MP. Low-Dose Azathioprine in Combination with Allopurinol: The Past, Present and Future of This Useful Duo. Dig Dis Sci 2022; 67:5382-5391. [PMID: 36242689 PMCID: PMC9652213 DOI: 10.1007/s10620-022-07719-x] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/23/2022] [Accepted: 10/03/2022] [Indexed: 01/05/2023]
Abstract
The inflammatory bowel diseases (IBD) are complex immune-mediated inflammatory diseases that are associated with significant morbidity around the world. As our understanding of IBD, and other immune-mediated inflammatory diseases, advances the number of therapeutic targets has increased which has rapidly driven the development and introduction of new therapies. While these new therapies have shown promise they come with the significant drawback of high costs. For many IBD patients around the world the cost of newer therapies is prohibitive which means treating clinicians often need to turn to optimising simpler, older, and inexpensive medications. The concept of optimising well established cheaper medications is not unique to the management of IBD as health systems all over the world look to reduce costs while simultaneously improving patient outcomes. Despite thiopurines being used in the management IBD for over 60 years, many clinicians are still hesitant to use them due to perceptions around limited efficacy and poor tolerance. One method identified to potentially increase utilisation of thiopurines involves the coadministration of allopurinol. In this review we will explore the history, pharmacology, recent studies and give recommendations for the utilisation of the usual duo of azathioprine combined with allopurinol.
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Affiliation(s)
- Alexander Keith Turbayne
- grid.1623.60000 0004 0432 511XDepartment of Gastroenterology, Alfred Hospital, 55 Commercial Road, Melbourne, VIC 3004 Australia
| | - Miles Patrick Sparrow
- grid.1623.60000 0004 0432 511XDepartment of Gastroenterology, Alfred Hospital, 55 Commercial Road, Melbourne, VIC 3004 Australia ,grid.1002.30000 0004 1936 7857Monash University, Clayton, Melbourne, VIC 3800 Australia
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Belhocine M, Mourad A, Chapdelaine A, Mansour AM, Troyanov Y, Doré M. Optimizing Thiopurine Therapy with a Xanthine Oxidase Inhibitor in Patients with Systemic Autoimmune Diseases: A Single-Centre Experience. Can J Hosp Pharm 2021; 74:361-369. [PMID: 34602624 DOI: 10.4212/cjhp.v74i4.3199] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Abstract
Background Thiopurines are a mainstay of therapy for autoimmune diseases. However, up to 20% to 30% of patients experience overproduction of the methylated metabolites, known as 6-MMP, to the detriment of the active metabolite, 6-thioguanine nucleotide (6-TGN). These patients, commonly referred to as "shunters", are predisposed to thiopurine resistance and hepatotoxicity. In patients with inflammatory bowel diseases, the combination of thiopurine with a xanthine oxidase inhibitor (XOI) is used to reverse this skewed metabolism and to prevent treatment failure or hepatotoxicity. Data on the use of this strategy for patients with other diseases are limited. Objectives To investigate and describe the use of thiopurine-XOI combination therapy in shunters with systemic autoimmune diseases. Methods Shunters treated in the study hospital between January 1, 2005, and December 31, 2015, were identified using the hospital's laboratory database, and clinical data were collected retrospectively. For each patient with optimization of thiopurine therapy, clinical and laboratory data were assessed over a 6-month period. Results Thirty-four patients were identified as shunters; for 14 of these patients, thiopurine therapy was optimized with an XOI. In these 14 patients, the median dose of azathioprine was reduced from 1.95 to 0.78 mg/kg with combination therapy. In addition, median 6-TGN level increased from 135 to 385 pmol/8 × 108 erythrocytes (p = 0.001); furthermore, 6-TGN levels rose to above 235 pmol/8 ×108 erythrocytes for 11 of the 14 patients. Conversely, the median 6-MMP level decreased from 6267 to 271 pmol/8 × 108 erythrocytes (p = 0.001). Except for a 12% increase in mean corpuscular volume, no clinically significant changes in blood count were recorded. Notable infections were reported in 3 patients, and 1 patient had to discontinue treatment because of cytopenia. After 6 months, median prednisone daily dose was reduced by 74%, from 16.7 mg to 4.4 mg (p = 0.005), and 4 patients had been weaned off corticosteroids. Of the 14 patients, 11 (79%) were in full remission, and 2 (14%) were in partial remission. Conclusion Optimizing thiopurine therapy with an XOI may be a safe and effective strategy for patients with systemic autoimmune diseases.
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Affiliation(s)
- Mériem Belhocine
- , MD, FRCPC, is an internal medicine specialist with Hôpital du Sacré-Coeur de Montréal, and a Clinical Professor of Medicine in the Faculty of Medicine, Université de Montréal, Montréal, Quebec
| | - Alissar Mourad
- , PharmD, MSc, was, at the time of this study, a PharmD student in the Faculty of Pharmacy, Université de Montréal, Montréal, Quebec. She has now graduated and is a pharmacist with the Centre intégré universitaire de santé et services sociaux du Centre-sud-de-l'Ile-de-Montréal, Montréal, Quebec
| | - Aurélie Chapdelaine
- , MD, FRCPC, is an internal medicine specialist with the Department of Medicine, Hôpital Notre-Dame, Montréal, Quebec
| | - Anne-Marie Mansour
- , MD, MSc, FRCPC, is an internal medicine specialist with the Department of Medicine, Hôpital du Sacré-Coeur de Montréal, and a Clinical Professor of Medicine with the Faculty of Medicine, Université de Montréal, Montréal, Quebec
| | - Yves Troyanov
- , MD, FRCPC, is a rheumatologist with the Department of Medicine, Hôpital du Sacré-Coeur de Montréal, and a Clinical Professor of Medicine with the Faculty of Medicine, Université de Montréal, Montréal, Quebec
| | - Maxime Doré
- , BSc, BPharm, MSc, is a Clinical Pharmacist with the Hôpital du Sacré-Coeur de Montréal, Montréal, Quebec
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Ribeiro AC, Barroso LHF, Mourao-Junior CA, Chebli JMF, Nascimento JWL. Simultaneous Monitoring of Azathioprine Metabolites in Erythrocytes of Crohn's Disease Patients by HPLC-UV. J Chromatogr Sci 2021; 60:518-524. [PMID: 34159374 DOI: 10.1093/chromsci/bmab084] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2021] [Indexed: 11/13/2022]
Abstract
The conversion of azathioprine (AZA) to active 6-thioguanine nucleotides (6-TGN) is essential for its clinical efficacy; however, another metabolite formed, 6-methylmercaptopurine (6-MMP), is related to hepatotoxicity. Blood samples were collected from 37 patients under AZA's treatment, and a new HPLC-UV method was validated and applied for simultaneous quantification of 6-TGN and 6-MMP in erythrocytes of Crohn's disease (CD) patients. The concentration of 6-TGN and 6-MMP found ranged from 4.5 to 2,456 ρmol/8 × 108 red blood cells (RBCs) for 6-TGN and from 170 to 53,951 ρmol/8 × 108 RBCs for 6-MMP. Reduced levels of 6-MMP in patients into combo therapy with AZA and allopurinol (2,031 ρmol/8 × 108 RBCs) have been observed when compared to patients undergoing monotherapy with AZA (9,098 ρmol/8 × 108 RBCs). Additionally, there was a negative correlation (r = -83.7%, P < 0.05) between lymphocyte count and 6-TGN levels. The method developed is reliable, accurate and reproducible and can be used as an important tool in the monitoring routine of patients with CD under AZA treatment, allowing the individualization of the dose, monitoring adherence to the treatment and the evaluation of the clinical outcome of these patients.
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Affiliation(s)
- Aline Correa Ribeiro
- Laboratory of Clinical and Experimental Pharmacology, Department of Pharmacology, Federal University of Juiz de Fora, José Lourenço Kelmer, s/n°, 36360-900, Juiz de Fora, Minas Gerais, Brazil
| | - Luciane Henriques Furtado Barroso
- Laboratory of Clinical and Experimental Pharmacology, Department of Pharmacology, Federal University of Juiz de Fora, José Lourenço Kelmer, s/n°, 36360-900, Juiz de Fora, Minas Gerais, Brazil
| | - Carlos Alberto Mourao-Junior
- Department of Physiology, Federal University of Juiz de Fora, José Lourenço Kelmer, s/n°, 36360-900, Juiz de Fora, Minas Gerais, Brazil
| | - Julio Maria Fonseca Chebli
- Division of Gastroenterology, Department of Internal Medicine, University Hospital of the Federal University of Juiz de Fora and Monte Sinai Hospital, Eugênio do Nascimento s/n°, 36038-330, Juiz de Fora, Minas Gerais, Brazil
| | - Jorge Willian Leandro Nascimento
- Laboratory of Clinical and Experimental Pharmacology, Department of Pharmacology, Federal University of Juiz de Fora, José Lourenço Kelmer, s/n°, 36360-900, Juiz de Fora, Minas Gerais, Brazil
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Czaja AJ. Review article: opportunities to improve and expand thiopurine therapy for autoimmune hepatitis. Aliment Pharmacol Ther 2020; 51:1286-1304. [PMID: 32363674 DOI: 10.1111/apt.15743] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/16/2020] [Revised: 03/07/2020] [Accepted: 03/31/2020] [Indexed: 12/14/2022]
Abstract
BACKGROUND Thiopurines in combination with glucocorticoids are used as first-line, second-line and maintenance therapies in autoimmune hepatitis and opportunities exist to improve and expand their use. AIMS To describe the metabolic pathways and key factors implicated in the efficacy and toxicity of the thiopurine drugs and to indicate the opportunities to improve outcomes by monitoring and manipulating metabolic pathways, individualising dosage and strengthening the response. METHODS English abstracts were identified in PubMed by multiple search terms. Full-length articles were selected for review, and secondary and tertiary bibliographies were developed. RESULTS Thiopurine methyltransferase activity and 6-tioguanine (6-thioguanine) nucleotide levels influence drug efficacy and safety, and they can be manipulated to improve treatment response and prevent myelosuppression. Methylated thiopurine metabolites are associated with hepatotoxicity, drug intolerance and nonresponse and their production can be reduced or bypassed. Universal pre-treatment assessment of thiopurine methyltransferase activity and individualisation of dosage to manipulate metabolite thresholds could improve outcomes. Early detection of thiopurine resistance by metabolite testing, accurate estimations of drug onset and strength by surrogate markers and adjunctive use of allopurinol could improve the management of refractory disease. Dose-restricted tioguanine (thioguanine) could expand treatment options by reducing methylated metabolites, increasing the bioavailability of 6-tioguanine nucleotides and ameliorating thiopurine intolerance or resistance. CONCLUSIONS The efficacy and safety of thiopurines in autoimmune hepatitis can be improved by investigational efforts that establish monitoring strategies that allow individualisation of dosage and prediction of outcome, increase bioavailability of the active metabolites and demonstrate superiority to alternative agents.
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Affiliation(s)
- Albert J Czaja
- Division of Gastroenterology and Hepatology, Mayo Clinic College of Medicine and Science, Rochester, MN, USA
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Wilson L, Tuson S, Yang L, Loomes D. Real-World Use of Azathioprine Metabolites Changes Clinical Management of Inflammatory Bowel Disease. J Can Assoc Gastroenterol 2020; 4:101-109. [PMID: 34056527 PMCID: PMC8158651 DOI: 10.1093/jcag/gwaa005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Background Thiopurines such as 6-mercaptopurine and azathioprine have complex metabolism, resulting in significant inter-individual differences in clinical efficacy and risk of drug toxicity, making conventional weight-based dosing inaccurate and potentially unsafe. Therapeutic drug monitoring (TDM) of thiopurine metabolites improves clinical outcomes through dose optimization and toxicity monitoring. Despite evidence for TDM, use is limited, due in part to test availability and awareness. The objectives of this study were twofold: (1) to investigate how thiopurine TDM impacts clinical management of IBD patients and (2) to evaluate proportion of patients outside therapeutic 6TGN levels or exhibiting signs of toxicity Methods Patients who received thiopurine TDM as part of routine care underwent chart review of demographics, disease activity, medication dosing, metabolite levels, and adverse events. Changes in clinical management following TDM were measured. Additionally, we conducted a retrospective review of clinical decision making blinded and unblinded to TDM result. Results A total of 92 IBD patients were included. Levels of 6TGN were therapeutic in 29% of patients. 6TGN levels correlated weakly with weight-based dosing (r2 = 0.057, P = 0.02). Adverse reactions were observed in 6.5%. TDM informed clinical management in 64%. Significantly more changes to clinical management occurred in those with active disease than in remission (73% versus 48%; P = 0.02) and in those on mono- versus combination therapy (48% versus 27.5%; P = 0.03). Conclusions TDM informs clinical decision making in over two-thirds of patients. The demonstrated poor efficacy of weight-based dosing and impact of TDM on clinical management contributes to the evidence supporting the need for greater availability and uptake of thiopurine TDM.
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Affiliation(s)
- Laura Wilson
- Division of Gastroenterology, Vancouver Island IBD Clinic, Victoria, British Columbia, Canada
| | - Stephanie Tuson
- Division of Gastroenterology, Vancouver Island IBD Clinic, Victoria, British Columbia, Canada
| | - Lufang Yang
- Department of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
| | - Dustin Loomes
- Division of Gastroenterology, Vancouver Island IBD Clinic, Victoria, British Columbia, Canada.,Department of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
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Chavoushi SF, Jharap B, Friedrich P, Smid K, Peters GJ, Malingré M. Thiopurines with low-dose allopurinol (ThiLDA)-a prospective clinical one-way crossover trial. Eur J Clin Pharmacol 2019; 75:1669-1674. [PMID: 31587102 DOI: 10.1007/s00228-019-02760-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2019] [Accepted: 09/06/2019] [Indexed: 01/25/2023]
Abstract
PURPOSE Many patients with Crohn's disease (CD) and ulcerative colitis (UC) who have a high 6-methylmercaptopurine/6-thioguanine (6-MMP/6-TGN) ratio receive allopurinol 100 mg in addition to thiopurines to optimize metabolite concentrations. However, some patients do not tolerate allopurinol at this dosage. The aim of this study was to determine the intra-patient effect of reducing the allopurinol dosage from 100 to 50 mg, in terms of metabolite concentrations, enzyme activities, efficacy, and tolerability. METHODS A prospective non-inferiority one-way crossover study was performed. CD and UC patients with stable disease using a thiopurine and allopurinol 100 mg were switched to 50 mg for 1 month. Primary outcomes were thiopurine metabolite concentrations. Secondary outcomes were enzyme activities of xanthine oxidase, thiopurine methyltransferase and hypoxanthine-guanine phosphoribosyltransferase, disease activity, and tolerability. RESULTS Twenty-two patients were included. Treatment with allopurinol 50 mg compared with 100 mg resulted in a significant decrease in mean 6-TGN levels (761 to 625 pmol/8 × 108 RBC; p = 0.005) and a significant increase in mean 6-MMP levels (451 to 665 pmol/8 × 108 RBC; p = 0.01). However, the mean metabolite concentrations were still therapeutic. Enzyme activities, disease activity scores, and patient experiences did not alter significantly. Generally, UC patients were more positive about their improved treatment than CD patients. CONCLUSION Combination therapy with 50 mg allopurinol led to a decrease of 6-TGN levels compared with 100 mg allopurinol. Disease activity, side effects, and patient experience, however, were similar between allopurinol 100 and 50 mg. UC patients seem to benefit and prefer lower doses whereas the contrary is seen in CD patients. TRIAL REGISTRATION EudraCT trial registry - number 2016-001638-84.
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Affiliation(s)
- S Faraz Chavoushi
- Department of Clinical Pharmacy, Meander Medical Center, Amersfoort, The Netherlands.
| | - Bindia Jharap
- Department of Gastroenterology and Hepatology, Meander Medical Center, Amersfoort, The Netherlands
| | - Philip Friedrich
- Department of Gastroenterology and Hepatology, Meander Medical Center, Amersfoort, The Netherlands
| | - Kees Smid
- Department of Medical Oncology, Amsterdam UMC, VU University Medical Center, Amsterdam, The Netherlands
| | - Godefridus J Peters
- Department of Medical Oncology, Amsterdam UMC, VU University Medical Center, Amsterdam, The Netherlands
| | - Mirte Malingré
- Department of Clinical Pharmacy, Meander Medical Center, Amersfoort, The Netherlands
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Lim SZ, Chua EW. Revisiting the Role of Thiopurines in Inflammatory Bowel Disease Through Pharmacogenomics and Use of Novel Methods for Therapeutic Drug Monitoring. Front Pharmacol 2018; 9:1107. [PMID: 30349479 PMCID: PMC6186994 DOI: 10.3389/fphar.2018.01107] [Citation(s) in RCA: 37] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2018] [Accepted: 09/10/2018] [Indexed: 12/12/2022] Open
Abstract
Azathioprine and 6-mercaptopurine, often referred to as thiopurine compounds, are commonly used in the management of inflammatory bowel disease. However, patients receiving these drugs are prone to developing adverse drug reactions or therapeutic resistance. Achieving predefined levels of two major thiopurine metabolites, 6-thioguanine nucleotides and 6-methylmercaptopurine, is a long-standing clinical practice in ensuring therapeutic efficacy; however, their correlation with treatment response is sometimes unclear. Various genetic markers have also been used to aid the identification of patients who are thiopurine-sensitive or refractory. The recent discovery of novel Asian-specific DNA variants, namely those in the NUDT15 gene, and their link to thiopurine toxicity, have led clinicians and scientists to revisit the utility of Caucasian biomarkers for Asian individuals with inflammatory bowel disease. In this review, we explore the limitations associated with the current methods used for therapeutic monitoring of thiopurine metabolites and how the recent discovery of ethnicity-specific genetic markers can complement thiopurine metabolites measurement in formulating a strategy for more accurate prediction of thiopurine response. We also discuss the challenges in thiopurine therapy, alongside the current strategies used in patients with reduced thiopurine response. The review is concluded with suggestions for future work aiming at using a more comprehensive approach to optimize the efficacy of thiopurine compounds in inflammatory bowel disease.
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Affiliation(s)
| | - Eng Wee Chua
- Faculty of Pharmacy, Universiti Kebangsaan Malaysia, Kuala Lumpur, Malaysia
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Thiopurine Optimization Through Combination With Allopurinol in Children With Inflammatory Bowel Diseases. J Pediatr Gastroenterol Nutr 2018; 67:341-345. [PMID: 29601433 DOI: 10.1097/mpg.0000000000001986] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/10/2022]
Abstract
OBJECTIVES Thiopurines are commonly used in the maintenance of remission for children with inflammatory bowel diseases (IBDs). Variation in drug metabolism may affect hepatotoxicity or therapeutic effect. We aimed to describe our center's experience with thiopurine optimization through the use of reduced thiopurine dosing in combination with allopurinol upon hepatotoxicity, drug metabolite levels, and clinical outcomes in children with IBD. METHODS Patients aged 2 to 21 years with IBD treated with the combination of thiopurines/allopurinol between 2008 and 2015 were retrospectively reviewed. Patients previously treated with antitumor necrosis factor therapy were excluded. Demographic data, transaminase levels (aspartate transaminase, alanine transaminase), drug metabolites levels (6-thioguanine [6-TG], 6-methylmercaptopurine), physician global assessment, and corticosteroid use were recorded at baseline, 6, and 12 months. RESULTS Fifty-two patients (29 girls, 56%) met inclusion criteria. Thirty-two of 52 (62%) remained on the combination for 12 months. In those remaining on the thiopurine/allopurinol combination, median alanine transaminase and aspartate transaminase levels were reduced (P < 0.001) and median 6-TG levels were increased (P < 0.001) at both 6 and 12 months. Corticosteroid use was decreased at both 6 (P < 0.001) and 12 months (P < 0.001) compared to use at baseline. Remission rates also improved at both 6 (P = 0.013) and 12 months (P = 0.003). Twenty of the 52 patients (38%) had discontinued the thiopurine/allopurinol combination within 12 months of initiation with 17 of 52 (33%) initiating antitumor necrosis factor therapy. CONCLUSIONS Low-dose thiopurines in combination with allopurinol improved hepatotoxicity and increased 6-TG levels in children with IBD. Corticosteroid use was reduced and remission rates improved in those patients remaining on this combination for 1 year. However, approximately 40% of patients required a change in therapy within 12 months.
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Friedman AB, Brown SJ, Bampton P, Barclay ML, Chung A, Macrae FA, McKenzie J, Reynolds J, Gibson PR, Hanauer SB, Sparrow MP. Randomised clinical trial: efficacy, safety and dosage of adjunctive allopurinol in azathioprine/mercaptopurine nonresponders (AAA Study). Aliment Pharmacol Ther 2018; 47:1092-1102. [PMID: 29468701 DOI: 10.1111/apt.14571] [Citation(s) in RCA: 34] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/30/2017] [Revised: 09/26/2017] [Accepted: 01/25/2018] [Indexed: 02/06/2023]
Abstract
BACKGROUND Thiopurine hypermethylation towards 6-methylmercaptopurine (6MMP) instead of 6-thioguanine nucleotides (6TGN) is associated with inefficacy in patients with IBD. Allopurinol reverses such hypermethylation. AIMS To prospectively determine efficacy of allopurinol-thiopurine combination and to compare 2 doses of allopurinol. DESIGN In a multicentre, double-blind trial, patients with clinically active or steroid-dependent IBD and thiopurine shunting were randomised to 50 or 100 mg/d allopurinol and 25% of their screening thiopurine dose, which was subsequently optimised, aiming for 6TGN of 260-500 pmol/8x108 RBCs. The primary endpoint was steroid-free clinical remission at 24 weeks. RESULTS Of 73 patients, 39 (53% [95% CI 42-65]) achieved steroid-free remission, (54% with 50 mg/d and 53% with 100 mg/d). 81% were able to discontinue steroids. Therapeutic 6TGN levels were achieved in both groups. Final thiopurine doses were lower with 100 mg/d allopurinol (P < 0.005). 6MMP: 6TGN ratio decreased from mean 64 to 4 (P < 0.001), being higher with 50 mg/d (6 ± 1.83) than for 100 mg/d ([1 ± 0.16], P = 0.003). Three patients on 50 mg/d failed to sustain low ratios at 24 weeks. Toxicity was minimal; three patients on 50 mg/d allopurinol developed transient leukopenia. Alanine aminotransferase concentrations decreased (P < 0.001) similarly in both arms. Faecal calprotectin levels at study end were lower in patients who achieved the primary endpoint (median 171 [85-541] vs 821[110-5892] ug/g, P = 0.03). CONCLUSIONS Low-dose allopurinol-thiopurine combination safely reverses shunting and optimises 6TGN with associated improvement in disease activity. 100 mg/d allopurinol is preferable due to greater metabolite profile stability and lower thiopurine dose without additional toxicity.
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Affiliation(s)
- A B Friedman
- Department of Gastroenterology, The Alfred Hospital and Monash University, Melbourne, Australia
| | - S J Brown
- St Vincent's Hospital, Melbourne, Australia
| | - P Bampton
- Flinders medical Centre, Adelaide, Australia
| | - M L Barclay
- Christchurch Hospital, Christchurch, New Zealand
| | - A Chung
- Eastern Health and Monash University, Melbourne, Australia
| | - F A Macrae
- Royal Melbourne Hospital, Melbourne, Australia
| | - J McKenzie
- The Alfred Hospital and Monash University, Melbourne, Australia
| | - J Reynolds
- The Alfred Hospital and Monash University, Melbourne, Australia
| | - P R Gibson
- The Alfred Hospital and Monash University, Melbourne, Australia
| | | | - M P Sparrow
- The Alfred Hospital and Monash University, Melbourne, Australia
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12
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Wall GC, Muktar H, Effken C, Mahajan PB. Addition of Allopurinol for Altering Thiopurine Metabolism to Optimize Therapy in Patients with Inflammatory Bowel Disease. Pharmacotherapy 2018; 38:259-270. [PMID: 29197117 DOI: 10.1002/phar.2067] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Thiopurine drugs, including azathioprine and 6-mercaptopurine, are used commonly in patients with inflammatory bowel disease for maintenance of remission. Although generally well tolerated, adverse effects lead to discontinuation in a significant minority of patients. Pharmacogenomic studies have suggested that metabolic breakdown of azathioprine in an individual is genetically determined. Coupled with the fact that certain thiopurine metabolites, notably 6-thioguanine nucleotide and 6-methylmercaptopurine, are associated with antiinflammatory effects and adverse effects, respectively, some investigators have examined intentionally shunting the metabolism of azathioprine toward increasing 6-thioguanine nucleotide levels by using low doses of the xanthine oxidoreductase inhibitor allopurinol to improve efficacy and decrease toxicity of azathioprine in patients with inflammatory bowel disease. We performed a search of the MEDLINE and Embase databases for basic and clinical research reports of this modality. Pertinent articles were retrieved, reviewed, and assessed by the authors. Case series, cohort studies, and one randomized trial have investigated adding allopurinol to azathioprine therapy in patients with inflammatory bowel disease. Most reports primarily examined metabolite levels in these patients. In general, the literature suggests that this modality was successful at significantly increasing 6-thioguanine nucleotide levels while decreasing 6-methylmercaptopurine levels. Several small reports have suggested that patients with increased 6-thioguanine nucleotide levels had improved symptoms or symptom remission. Adverse effects and discontinuation rates remained similar or were improved in patients who were taking a thiopurine and started allopurinol. In conclusion, the addition of allopurinol may be an option for optimizing thiopurine metabolite production in select patients with low 6-thioguanine nucleotide levels. Appropriate care and monitoring of these patients are mandatory to prevent neutropenia or other adverse effects.
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Affiliation(s)
- Geoffrey C Wall
- Drake University College of Pharmacy and Health Sciences, Des Moines, Iowa.,Iowa Methodist Medical Center-University of Iowa Medical Residency Program, Des Moines, Iowa
| | - Hamid Muktar
- Iowa Methodist Medical Center-University of Iowa Medical Residency Program, Des Moines, Iowa
| | - Cassandra Effken
- Drake University College of Pharmacy and Health Sciences, Des Moines, Iowa
| | - Pramod B Mahajan
- Drake University College of Pharmacy and Health Sciences, Des Moines, Iowa
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Azathioprine with Allopurinol: Lower Deoxythioguanosine in DNA and Transcriptome Changes Indicate Mechanistic Differences to Azathioprine Alone. Inflamm Bowel Dis 2017; 23:946-955. [PMID: 28452864 PMCID: PMC5436732 DOI: 10.1097/mib.0000000000001131] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
BACKGROUND Use of azathioprine (AZA) for inflammatory bowel disease is limited by side effects or poor efficacy. Combining low-dose azathioprine with allopurinol (LDAA) bypasses side effects, improves efficacy, and may be appropriate as first-line therapy. We test the hypothesis that standard-dose azathioprine (AZA) and LDAA treatments work by similar mechanisms, using incorporation of the metabolite deoxythioguanosine into patient DNA, white-blood cell counts, and transcriptome analysis as biological markers of drug effect. METHODS DNA was extracted from peripheral whole-blood from patients with IBD treated with AZA or LDAA, and analyzed for DNA-incorporated deoxythioguanosine. Measurement of red-blood cell thiopurine metabolites was part of usual clinical practice, and pre- and on-treatment (12 wk) blood samples were used for transcriptome analysis. RESULTS There were no differences in reduction of white-cell counts between the 2 treatment groups, but patients on LDAA had lower DNA-incorporated deoxythioguanosine than those on AZA; for both groups, incorporated deoxythioguanosine was lower in patients on thiopurines for 24 weeks or more (maintenance of remission) compared to patients treated for less than 24 weeks (achievement of remission). Patients on LDAA had higher levels of red-blood cell thioguanine nucleotides than those on AZA, but there was no correlation between these or their methylated metabolites, and incorporated deoxythioguanosine. Transcriptome analysis suggested down-regulation of immune responses consistent with effective immunosuppression in patients receiving LDAA, with evidence for different mechanisms of action between the 2 therapies. CONCLUSIONS LDAA is biologically effective despite lower deoxythioguanosine incorporation into DNA, and has different mechanisms of action compared to standard-dose azathioprine.
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Sturm A, Maaser C, Mendall M, Karagiannis D, Karatzas P, Ipenburg N, Sebastian S, Rizzello F, Limdi J, Katsanos K, Schmidt C, Jeuring S, Colombo F, Gionchetti P. European Crohn's and Colitis Organisation Topical Review on IBD in the Elderly. J Crohns Colitis 2017; 11:263-273. [PMID: 27797918 DOI: 10.1093/ecco-jcc/jjw188] [Citation(s) in RCA: 30] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/01/2016] [Revised: 09/17/2016] [Accepted: 10/18/2016] [Indexed: 12/12/2022]
Abstract
This ECCO topical review of the European Crohn's and Colitis Organisation [ECCO] focuses on the epidemiology, pathophysiology, diagnosis, management and outcome of the two most common forms of inflammatory bowel disease, Crohn's disease and ulcerative colitis, in elderly patients. The objective was to reach expert consensus to provide evidence-based guidance for clinical practice.
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Affiliation(s)
- Andreas Sturm
- Department of Gastroenterology, DRK Kliniken Berlin I Westend. Akademisches Lehrkrankenhaus der Charite, Spandauer Damm 130, 14050 Berlin, Germany
| | - Christian Maaser
- Outpatients Department of Gastroenterology and Department of Geriatrics, Hospital Lüneburg, Bögelstraße 1, 21339 Lüneburg, Germany
| | - Michael Mendall
- Croydon University Hospital, Mayday Road, CR4 7YE Thornton Heath; & St George's Medical School, Cranmer Terrace SW17 ORE, UK
| | - Dimitrios Karagiannis
- Department of Gastroenterology, Iatriko Kentro Athinon, Dervenakion St. 3, 14572 Athens, Greece
| | - Pantelis Karatzas
- Department of Gastroenterology, Evangelismos Hospital, 45-47 Ypsilantou Street, 10676 Athens, Greece
| | - Nienke Ipenburg
- Department of Gastroenterology and Hepatology, Leiden University Medical Center, Albinusdreef 2, PO Box 9600, 2300 RC Leiden, The Netherlands
| | - Shaji Sebastian
- IBD Unit, Hull & East Yorkshire NHS Trust, Anlaby Road, Hull HU3 2JZ, UK
| | - Fernando Rizzello
- IBD Unit, DIMEC, University of Bologna, Via Massarenti, 9, 40138 Bologna, BO, Italy
| | - Jimmy Limdi
- Department of Gastroenterology, Pennine Acute Hospitals NHS Trust, Manchester M8 5RB, Institute of Inflammation and Repair, Manchester Academic Health Sciences, University of Manchester, UK
| | - Konstantinos Katsanos
- Department of Gastroenterology and Hepatology, Division of Internal Medicine, University and Medical School of Ioannina, PO Box 1186, 45110 Ioannina, Greece
| | - Carsten Schmidt
- Department of Internal Medicine IV, Jena University Hospital, Am Klinikum 1, 07747 Jena, Germany
| | - Steven Jeuring
- Division of Gastroenterology-Hepatology, Department of Internal Medicine, Maastricht University Medical Center (MUMC), PO Box 5800, 6202 AZ Maastricht, The Netherlands
| | - Francesco Colombo
- Dipartimento di Area Chirurgica, Ospedale "Luigi Sacco"- Polo Universitario, ASST Fatebenefratelli Sacco, Milano, Italy
| | - Paolo Gionchetti
- IBD Unit, DIMEC, University of Bologna, Via Massarenti, 9, 40138 Bologna, BO, Italy
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Khan I, Samson SE, Grover AK. Antioxidant Supplements and Gastrointestinal Diseases: A Critical Appraisal. Med Princ Pract 2017; 26:201-217. [PMID: 28278495 PMCID: PMC5588418 DOI: 10.1159/000468988] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/31/2016] [Accepted: 03/08/2017] [Indexed: 12/21/2022] Open
Abstract
The gastrointestinal tract digests and absorbs dietary nutrients, protects the body against physical and chemical damage from contents in its lumen, provides immunity against external antigens, and keeps an optimum environment for the gut microbiota. These functions cannot be performed normally in several diseases of which the following are discussed here: irritable bowel syndrome and inflammatory bowel disease, which includes Crohn's disease and ulcerative colitis. Because these diseases are associated with oxidative stress, a host of antioxidant supplements are used for maintenance and recovery of the gut functions. However, the benefits of these supplements have not been established. The available 80 human trials were rated for levels of confidence and for benefits of the antioxidant supplements. For Crohn's disease, the supplements for which clear benefits occurred in at least 2 studies were allopurinol, Boswellia serrata (frankincense or shallaki), Artemesia species (wormwood), Tripterygium wilfordii (léi gōng téng), and omega-3 fatty acids. Similar beneficial supplements for ulcerative colitis were allopurinol, Matricaria chamomilla (chamomile), Curcuma longa (curcumin in turmeric), and omega-3 fatty acids. There was also a clear benefit for ulcerative colitis in 2 studies where a multiherbal Chinese medicine preparation and an Ayurvedic medicine preparation were used. For irritable bowel syndrome, there was only a marginal benefit of some of the antioxidant supplements. Thus, some antioxidant supplements may be beneficial at certain stages of specific diseases. This is consistent with the current concept that antioxidants act by inhibiting oxidative stress pathways in a tissue- and environment-specific manner and not by simply acting as scavengers.
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Affiliation(s)
- Islam Khan
- Department of Biochemistry, Kuwait University, Kuwait, Kuwait
| | - Sue E. Samson
- Department of Medicine, McMaster University, Hamilton, ON, Canada
| | - Ashok Kumar Grover
- Department of Medicine, McMaster University, Hamilton, ON, Canada
- *Dr. Ashok Kumar Grover, Department of Medicine, McMaster University, 1280 Main Street W., Hamilton, ON L8S 4K1 (Canada), E-Mail
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Coskun M, Steenholdt C, de Boer NK, Nielsen OH. Pharmacology and Optimization of Thiopurines and Methotrexate in Inflammatory Bowel Disease. Clin Pharmacokinet 2016; 55:257-74. [PMID: 26255287 DOI: 10.1007/s40262-015-0316-9] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
Improving the efficacy and reducing the toxicity of thiopurines and methotrexate (MTX) have been areas of intense basic and clinical research. An increased knowledge on pharmacodynamics and pharmacokinetics of these immunomodulators has optimized treatment strategies in inflammatory bowel disease (IBD). This review focuses on the metabolism and mode of action of thiopurines and MTX, and provides an updated overview of individualized treatment strategies in which efficacy in IBD can be increased without compromising safety. The patient-based monitoring instruments adapted into clinical practice include pretreatment thiopurine S-methyltransferase testing, thiopurine metabolite monitoring, and blood count measurements that may help guiding the dosage to improve clinical outcome. Other approaches for optimizing thiopurine therapy in IBD include combination therapy with allopurinol, 5-aminosalicylates, and/or biologics. Similar strategies are yet to be proven effective in improving the outcome of MTX therapy. Important challenges for the management of IBD in the future relate to individualized dosing of immunomodulators for maximal efficacy with minimal risk of side effects. As low-cost conventional immunomodulators still remain a mainstay in pharmacotherapy of IBD, more research remains warranted, especially to substantiate these tailored management strategies in controlled clinical trials.
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Affiliation(s)
- Mehmet Coskun
- Department of Gastroenterology, Herlev Hospital, University of Copenhagen, Herlev, Denmark. .,Department of Biology and Biotech Research and Innovation Centre (BRIC), The Bioinformatics Centre, University of Copenhagen, Copenhagen, Denmark.
| | - Casper Steenholdt
- Department of Gastroenterology, Herlev Hospital, University of Copenhagen, Herlev, Denmark
| | - Nanne K de Boer
- Department of Gastroenterology and Hepatology, VU University Medical Center, Amsterdam, The Netherlands
| | - Ole Haagen Nielsen
- Department of Gastroenterology, Herlev Hospital, University of Copenhagen, Herlev, Denmark
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17
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González-Lama Y, Gisbert JP. Monitoring thiopurine metabolites in inflammatory bowel disease. Frontline Gastroenterol 2016; 7:301-307. [PMID: 28839871 PMCID: PMC5369498 DOI: 10.1136/flgastro-2015-100681] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/30/2015] [Revised: 03/09/2016] [Accepted: 03/16/2016] [Indexed: 02/04/2023] Open
Abstract
Thiopurines (azathioprine and mercaptopurine) are one of the immunosuppressive mainstays for the treatment of inflammatory bowel disease. In spite of its widespread use, thiopurine metabolism is still not fully understood, and a significant proportion of patients suffer toxicity or lack of efficacy. Different enzymatic pathways with individual variations constitute a pharmacogenetic model that seems to be suitable for monitoring and therapeutic intervention. This review is focused on current concepts and recent research that may help clinicians to rationally optimise thiopurine treatment in patients with inflammatory bowel disease.
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Affiliation(s)
- Yago González-Lama
- Gastroenterology and Hepatology Department, Puerta de Hierro University Hospital, Majadahonda, Madrid, Spain
| | - Javier P Gisbert
- Gastroenterology Unit, Hospital Universitario de La Princesa and Instituto de Investigación Sanitaria Princesa (IIS-IP), Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBEREHD), Madrid, Madrid, Spain
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18
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Update 2014: advances to optimize 6-mercaptopurine and azathioprine to reduce toxicity and improve efficacy in the management of IBD. Inflamm Bowel Dis 2015; 21:445-52. [PMID: 25248004 DOI: 10.1097/mib.0000000000000197] [Citation(s) in RCA: 53] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
BACKGROUND The thiopurine drugs, 6-mercaptopurine (6-MP) and azathioprine (AZA), remain as a mainstay therapy in inflammatory bowel disease (IBD). Differences in metabolism of these drugs lead to individual variation in thiopurine metabolite levels that can determine its therapeutic efficacy and development of adverse reactions. In this update, we will review thiopurine metabolic pathway along with the up-to-date approaches in administering thiopurine medications based on the current literature. METHODS A search of the PubMed database by 2 independent reviewers identifying 98 articles evaluating thiopurine metabolism and IBD management. RESULTS Monitoring thiopurine metabolites can assist physicians in optimizing 6-MP and AZA therapy in treating patients with IBD. Of the dosing strategies reviewed, we found evidence for monitoring thiopurine metabolite level, use of allopurinol with thiopurine, use of mesalamine with thiopurine, combination therapy with thiopurine and anti-tumor necrosis factor agents, and split dosing of AZA or 6-MP to optimize thiopurine therapy and minimize adverse effects in IBD. CONCLUSIONS Based on the currently available literature, various dosing strategies to improve therapeutic response and reduce adverse reactions can be considered, including use of allopurinol with thiopurine, use of mesalamine with thiopurine, combination therapy with thiopurine and anti-tumor necrosis factor agents, and split dosing of thiopurine.
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Renna S, Cottone M, Orlando A. Optimization of the treatment with immunosuppressants and biologics in inflammatory bowel disease. World J Gastroenterol 2014; 20:9675-90. [PMID: 25110407 PMCID: PMC4123358 DOI: 10.3748/wjg.v20.i29.9675] [Citation(s) in RCA: 63] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/29/2013] [Revised: 01/18/2014] [Accepted: 04/28/2014] [Indexed: 02/06/2023] Open
Abstract
Many placebo controlled trials and meta-analyses evaluated the efficacy of different drugs for the treatment of inflammatory bowel disease (IBD), including immunosuppressants and biologics. Their use is indicated in moderate to severe disease in non responders to corticosteroids and in steroid-dependent patients, as induction and maintainance treatment. Infliximab, as well as cyclosporine, is considered a second line therapy in the case of severe ulcerative colitis, or non-responders to intravenous corticosteroids. An adequate dosage and duration of therapy with thiopurines should be reached before evaluating their efficacy. Methotrexate is a valid option in patients with Crohn's disease but its use is confined to patients who are intolerant or non-responders to thiopurines. Evidence for the use of methotrexate in ulcerative colitis is insufficient. The use of thalidomide and mycophenolate mofetil is not recommended in patients with inflammatory bowel disease, these treatments could be considered in case of failure of all other therapeutic options. In patients with moderately active ulcerative colitis, refractory to thiopurines, the use of tacrolimus is considered an alternative to biologics. An increase of the dose or a decrease in the interval of administration of biological treatment could be useful in the presence of an incomplete clinical response. In the case of primary failure of an anti-tumor necrosis factor alpha a switch to another one should be considered. Data on the efficacy of combination therapy are up to now insufficient to consider this strategy in all IBD patients. The final outcome of the treatment should be considered the clinical remission, with mucosa healing, and not the clinical response. The evaluation of serum concentration of thiopurine methyl transferase activity, thiopurine metabolites, biologic serum levels and antibiologic antibodies could be useful for the management of the treatment but it has not been routinely applied in clinical practice. The evidence of high risk development of lymphoma and cutaneous malignancies should be considered in patients treated with immunosuppressants and biologics for a long period.
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Weiler S, Aellig N, Fauchère I, Jetter A, Corti N. Treatment of gout in a renal transplant patient leading to severe thrombocytopenia. J Clin Pharm Ther 2014; 39:571-2. [PMID: 25040676 DOI: 10.1111/jcpt.12190] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2014] [Accepted: 06/16/2014] [Indexed: 12/27/2022]
Abstract
WHAT IS KNOWN AND OBJECTIVE Allopurinol (AP) inhibits the xanthine oxidase, which may indirectly lead to myelotoxicity when used in combination with azathioprine (AZA). CASE SUMMARY A 79-year-old female developed symptomatic thrombocytopenia after combination therapy with AZA (75 mg/day) and AP (100 mg/day) - after AP had been stopped. Concentrations of the myelotoxic 6-thioguanine-nucleotides metabolite of AZA were increased. Thrombocyte counts normalized within 8 days of discontinuation of AZA. WHAT IS NEW AND CONCLUSION The effect of a drug interaction in a patient with decreased elimination capacity may take several weeks to become apparent and may in fact do so even after the drug has been stopped. Concurrent AZA and AP therapy demands cautious use.
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Affiliation(s)
- S Weiler
- Department of Clinical Pharmacology and Toxicology, University Hospital Zurich, Zurich, Switzerland
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Abstract
Ulcerative colitis (UC) is a chronic inflammatory disorder of the gastrointestinal tract of unknown etiology that frequently presents in the pediatric population. The evaluation of pediatric UC involves excluding infection, and a colonoscopy that documents the clinical and histologic features of chronic colitis. Initial management of mild UC is typically with mesalamine therapy for induction and maintenance. Moderate UC is often initially treated with oral prednisone. Depending on disease severity and response to prednisone, maintenance options include mesalamine, mercaptopurine, azathioprine, infliximab, or adalimumab. Severe UC is typically treated with intravenous corticosteroids. Corticosteroid nonresponders should either undergo a colectomy or be treated with second-line medical rescue therapy (infliximab or calcineurin inhibitors). The severe UC patients who respond to medical rescue therapy can be maintained on infliximab or thiopurine, but 1-year remission rates for such patients are under 50 %. These medications are discussed in detail along with the initial work-up and a treatment algorithm.
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Affiliation(s)
- Brian P Regan
- Department of Gastroenterology, Inflammatory Bowel Disease Center, GI Division-Hunnewell Ground, Harvard Medical School, Boston Children's Hospital, 300 Longwood Avenue, Boston, MA, 02115, USA,
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Kanbay M, Solak Y, Gaipov A, Takir M, Weiner DE. Allopurinol as a kidney-protective, cardioprotective, and antihypertensive agent: hype or reality? Blood Purif 2014; 37:172-8. [PMID: 24903910 DOI: 10.1159/000360520] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2013] [Accepted: 02/07/2014] [Indexed: 11/19/2022]
Abstract
Numerous experimental and clinical studies suggest that uric acid might have pathobiologic implications in the development and progression of hypertension, kidney disease, and coronary heart disease, among others, resulting in renewed interest in uric acid as a potential pathogenic mediator in these clinical conditions. Despite encouraging animal studies showing beneficial roles of allopurinol, clinical studies and randomized controlled trials remain scarce, and, despite available clinical evidence supporting a therapeutic role for allopurinol, multiple issues remain before routine use of allopurinol can be recommended for use in patients with hyperuricemia and hypertension, kidney disease, or coronary heart disease. These include a need for more robust clinical trial data that evaluate efficacy on hard clinical outcomes, optimal dose, duration of treatment, and the potential for serious allergic reactions. In this article we review the current available evidence describing the effects of allopurinol in hypertension, kidney disease, and coronary heart disease, highlighting unresolved issues surrounding allopurinol use for uric acid lowering in individuals without gout.
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Affiliation(s)
- Mehmet Kanbay
- Division of Nephrology, Department of Medicine, Istanbul Medeniyet University School of Medicine, Istanbul, Turkey
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