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Tonutti A, Pugliese N, Ceribelli A, Isailovic N, De Santis M, Colapietro F, De Nicola S, Polverini D, Selmi C, Aghemo A. The autoimmune landscape of Porto-sinusoidal vascular disorder: What the rheumatologist needs to know. Semin Arthritis Rheum 2024; 67:152467. [PMID: 38805899 DOI: 10.1016/j.semarthrit.2024.152467] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2024] [Revised: 04/23/2024] [Accepted: 04/29/2024] [Indexed: 05/30/2024]
Abstract
Porto-sinusoidal vascular disorder (PSVD) encompasses a group of vascular disorders characterized by lesions of the portal venules and sinusoids with clinical manifestations ranging from non-specific abnormalities in serum liver enzymes to clinically overt portal hypertension and related complications. Several reports have documented cases of PSVD in patients with systemic autoimmune conditions, such as systemic lupus erythematosus, systemic sclerosis, and rheumatoid arthritis. It is of note that these diseases share specific pathophysiological features with PSVD, including endothelial dysfunction, vascular inflammation, and molecular signatures. This narrative review aims to summarize the current knowledge on the association between PSVD and systemic autoimmune diseases, emphasizing the importance of promptly recognizing this condition in the rheumatological practice, and highlighting the key aspects where further research is necessary from both pathogenic and clinical perspectives.
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Affiliation(s)
- Antonio Tonutti
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Italy; Rheumatology and Clinical Immunology, IRCCS Humanitas Research Hospital, Rozzano, Italy
| | - Nicola Pugliese
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Italy; Division of Internal Medicine and Hepatology, Department of Gastroenterology, IRCCS Humanitas Research Hospital, Rozzano, Italy
| | - Angela Ceribelli
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Italy; Rheumatology and Clinical Immunology, IRCCS Humanitas Research Hospital, Rozzano, Italy
| | - Natasa Isailovic
- Rheumatology and Clinical Immunology, IRCCS Humanitas Research Hospital, Rozzano, Italy
| | - Maria De Santis
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Italy; Rheumatology and Clinical Immunology, IRCCS Humanitas Research Hospital, Rozzano, Italy
| | - Francesca Colapietro
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Italy; Division of Internal Medicine and Hepatology, Department of Gastroenterology, IRCCS Humanitas Research Hospital, Rozzano, Italy
| | - Stella De Nicola
- Division of Internal Medicine and Hepatology, Department of Gastroenterology, IRCCS Humanitas Research Hospital, Rozzano, Italy
| | - Davide Polverini
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Italy; Division of Internal Medicine and Hepatology, Department of Gastroenterology, IRCCS Humanitas Research Hospital, Rozzano, Italy
| | - Carlo Selmi
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Italy; Rheumatology and Clinical Immunology, IRCCS Humanitas Research Hospital, Rozzano, Italy.
| | - Alessio Aghemo
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Italy; Division of Internal Medicine and Hepatology, Department of Gastroenterology, IRCCS Humanitas Research Hospital, Rozzano, Italy
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Pugliese N, Giuli L, Mastrorocco E, Santopaolo F, Marcozzi G, Bezzio C, Dal Buono A, Gabbiadini R, Gasbarrini A, Ponziani FR, Armuzzi A, Aghemo A. Exploring the link: Porto-sinusoidal vascular disorder and inflammatory bowel disease - A comprehensive narrative review. Dig Liver Dis 2024; 56:964-970. [PMID: 38044225 DOI: 10.1016/j.dld.2023.11.021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/23/2023] [Revised: 11/15/2023] [Accepted: 11/16/2023] [Indexed: 12/05/2023]
Abstract
Porto-sinusoidal vascular disorder (PSVD) encompasses a group of vascular disorders characterized by lesions involving the portal venules and sinusoids, independent of the presence of portal hypertension (PH), and for which liver biopsy is essential for diagnosis. PSVD has been shown to be common in patients with immune-mediated diseases, including inflammatory bowel disease (IBD). The association between PSVD and the use of thiopurines and thioguanine in patients with IBD has been well established. In addition, research suggests an association between PSVD and IBD, even in cases where patients haven't been exposed to specific medications, probably related to changes in intestinal permeability. The identification and management of patients with known IBD and PSVD is a challenge for gastroenterologists. This narrative review aims to summarize the currently available data on the association between IBD and PSVD and provide practical suggestions for the management of this group of patients.
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Affiliation(s)
- Nicola Pugliese
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele (MI), Italy; Division of Internal Medicine and Hepatology, Department of Gastroenterology, IRCCS Humanitas Research Hospital, Rozzano (MI), Italy
| | - Lucia Giuli
- Hepatology Unit, CEMAD Centro Malattie dell'Apparato Digerente, Medicina Interna e Gastroenterologia, Fondazione Policlinico Universitario Gemelli IRCCS, Rome 00168, Italy
| | | | - Francesco Santopaolo
- Hepatology Unit, CEMAD Centro Malattie dell'Apparato Digerente, Medicina Interna e Gastroenterologia, Fondazione Policlinico Universitario Gemelli IRCCS, Rome 00168, Italy
| | - Giacomo Marcozzi
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele (MI), Italy
| | - Cristina Bezzio
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele (MI), Italy; IBD Center, Department of Gastroenterology, IRCCS Humanitas Research Hospital, Rozzano (MI), Italy
| | - Arianna Dal Buono
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele (MI), Italy; IBD Center, Department of Gastroenterology, IRCCS Humanitas Research Hospital, Rozzano (MI), Italy
| | - Roberto Gabbiadini
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele (MI), Italy; IBD Center, Department of Gastroenterology, IRCCS Humanitas Research Hospital, Rozzano (MI), Italy
| | - Antonio Gasbarrini
- Hepatology Unit, CEMAD Centro Malattie dell'Apparato Digerente, Medicina Interna e Gastroenterologia, Fondazione Policlinico Universitario Gemelli IRCCS, Rome 00168, Italy; Dipartimento di Medicina e Chirurgia Traslazionale, Università Cattolica del Sacro Cuore, Rome 00168, Italy
| | - Francesca Romana Ponziani
- Hepatology Unit, CEMAD Centro Malattie dell'Apparato Digerente, Medicina Interna e Gastroenterologia, Fondazione Policlinico Universitario Gemelli IRCCS, Rome 00168, Italy; Dipartimento di Medicina e Chirurgia Traslazionale, Università Cattolica del Sacro Cuore, Rome 00168, Italy
| | - Alessandro Armuzzi
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele (MI), Italy; IBD Center, Department of Gastroenterology, IRCCS Humanitas Research Hospital, Rozzano (MI), Italy
| | - Alessio Aghemo
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele (MI), Italy; Division of Internal Medicine and Hepatology, Department of Gastroenterology, IRCCS Humanitas Research Hospital, Rozzano (MI), Italy.
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de Boer NKH, Simsek M, Meijer B, Neurath MF, van Bodegraven A, Mulder CJJ. Drug rediscovery in gastroenterology: from off-label to on-label use of thioguanine in inflammatory bowel disease. Gut 2023; 72:1985-1991. [PMID: 37380330 DOI: 10.1136/gutjnl-2023-329679] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/09/2023] [Accepted: 06/16/2023] [Indexed: 06/30/2023]
Abstract
Drug rediscovery refers to the principle of using 'old' drugs outside the indications mentioned in the summary of product characteristics. In the past decades, several drugs were rediscovered in a wide variety of medical fields. One of the most recent examples is the unconditional registration of thioguanine (TG), a thiopurine derivative, in patients with inflammatory bowel disease in the Netherlands. In this paper, we aim to visualise potential hurdles that hamper drug rediscovery in general, emphasise the global need for optimal use and development of potentially useful drugs, and provide an overview of the registration process for TG in the Netherlands. With this summary, we aim to guide drug rediscovery trajectories in the near future.
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Affiliation(s)
- Nanne K H de Boer
- Gastroenterology and Hepatology, Amsterdam University Medical Centres, Amsterdam, The Netherlands
- Research Institute, Amsterdam Gastroenterology Endocrinology Metabolism, Amsterdam, Noord-Holland, The Netherlands
| | - Melek Simsek
- Gastroenterology and Hepatology, Amsterdam University Medical Centres, Amsterdam, The Netherlands
- School of Medicine, VU University, Amsterdam, The Netherlands
| | - Berrie Meijer
- Gastroenterology and Hepatology, Amsterdam University Medical Centres, Amsterdam, The Netherlands
- School of Medicine, VU University, Amsterdam, The Netherlands
| | - Markus F Neurath
- First Department of Medicine, Friedrich-Alexander-Universität Erlangen-Nürnberg, Erlangen, Germany
| | - Ad van Bodegraven
- Department of Gastroenterology, Geriatrics, Internal and Intensive Care Medicine (Co-MIK), Zuyderland Medical Centre, Heerlen-Sittard-Geleen, The Netherlands
| | - Chris J J Mulder
- Gastroenterology and Hepatology, Amsterdam University Medical Centres, Amsterdam, The Netherlands
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Nakafero G, Card T, Grainge MJ, Williams HC, Taal MW, Aithal GP, Fox CP, Mallen CD, van der Windt DA, Stevenson MD, Riley RD, Abhishek A. Risk-stratified monitoring for thiopurine toxicity in immune-mediated inflammatory diseases: prognostic model development, validation, and, health economic evaluation. EClinicalMedicine 2023; 64:102213. [PMID: 37745026 PMCID: PMC10514402 DOI: 10.1016/j.eclinm.2023.102213] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/16/2023] [Revised: 08/25/2023] [Accepted: 08/29/2023] [Indexed: 09/26/2023] Open
Abstract
Background Patients established on thiopurines (e.g., azathioprine) are recommended to undergo three-monthly blood tests for the early detection of blood, liver, or kidney toxicity. These side-effects are uncommon during long-term treatment. We developed a prognostic model that could be used to inform risk-stratified decisions on frequency of monitoring blood-tests during long-term thiopurine treatment, and, performed health-economic evaluation of alternate monitoring intervals. Methods This was a retrospective cohort study set in the UK primary-care. Data from the Clinical Practice Research Datalink Aurum and Gold formed development and validation cohorts, respectively. People age ≥18 years, diagnosed with an immune mediated inflammatory disease, prescribed thiopurine by their general practitioner for at-least six-months between January 1, 2007 and December 31, 2019 were eligible. The outcome was thiopurine discontinuation with abnormal blood-test results. Patients were followed up from six-months after first primary-care thiopurine prescription to up to five-years. Penalised Cox regression developed the risk equation. Multiple imputation handled missing predictor data. Calibration and discrimination assessed model performance. A mathematical model evaluated costs and quality-adjusted life years associated with lengthening the interval between blood-tests. Findings Data from 5982 (405 events over 16,117 person-years) and 3573 (269 events over 9075 person-years) participants were included in the development and validation cohorts, respectively. Fourteen candidate predictors (21 parameters) were included. The optimism adjusted R2 and Royston D statistic in development data were 0.11 and 0.76, respectively. The calibration slope and Royston D statistic (95% Confidence Interval) in the validation data were 1.10 (0.84-1.36) and 0.72 (0.52-0.92), respectively. A 2-year period between monitoring blood-test was most cost-effective in all deciles of predicted risk but the gain between monitoring annually or biennially reduced in higher risk deciles. Interpretation This prognostic model requires information that is readily available during routine clinical care and may be used to risk-stratify blood-test monitoring for thiopurine toxicity. These findings should be considered by specialist societies when recommending blood monitoring during thiopurine prescription to bring about sustainable and equitable change in clinical practice. Funding National Institute for Health and Care Research.
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Affiliation(s)
- Georgina Nakafero
- Academic Rheumatology, School of Medicine, University of Nottingham, Nottingham NG5 1PB, UK
| | - Tim Card
- Lifespan and Population Health, School of Medicine, University of Nottingham, Nottingham NG5 1PB, UK
| | - Matthew J. Grainge
- Lifespan and Population Health, School of Medicine, University of Nottingham, Nottingham NG5 1PB, UK
| | - Hywel C. Williams
- Lifespan and Population Health, School of Medicine, University of Nottingham, Nottingham NG5 1PB, UK
| | - Maarten W. Taal
- Centre for Kidney Research and Innovation, School of Medicine, Translational Medical Sciences, University of Nottingham, Derby DE22 3NE, UK
| | - Guruprasad P. Aithal
- Nottingham Digestive Diseases Centre, Translational Medical Sciences, School of Medicine, University of Nottingham, Nottingham NG7 2UH, UK
| | - Christopher P. Fox
- Translational Medical Sciences, School of Medicine, University of Nottingham, Nottingham, UK
| | - Christian D. Mallen
- Primary Care Centre Versus Arthritis, School of Medicine, Keele University, Keele ST5 5BJ, UK
| | | | - Matthew D. Stevenson
- School of Health and Related Research, University of Sheffield, Sheffield S1 4DA, UK
| | - Richard D. Riley
- Institute of Applied Health Research, College of Medical and Dental Sciences, University of Birmingham, Birmingham B15 2TT, UK
| | - Abhishek Abhishek
- Academic Rheumatology, School of Medicine, University of Nottingham, Nottingham NG5 1PB, UK
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Giuli L, Pallozzi M, Venturini G, Gasbarrini A, Ponziani FR, Santopaolo F. Molecular Mechanisms Underlying Vascular Liver Diseases: Focus on Thrombosis. Int J Mol Sci 2023; 24:12754. [PMID: 37628933 PMCID: PMC10454315 DOI: 10.3390/ijms241612754] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2023] [Revised: 08/07/2023] [Accepted: 08/11/2023] [Indexed: 08/27/2023] Open
Abstract
Vascular liver disorders (VLDs) comprise a wide spectrum of clinical-pathological entities that primarily affect the hepatic vascular system of both cirrhotic and non-cirrhotic patients. VLDs more frequently involve the portal and the hepatic veins, as well as liver sinusoids, resulting in an imbalance of liver homeostasis with serious consequences, such as the development of portal hypertension and liver fibrosis. Surprisingly, many VLDs are characterized by a prothrombotic phenotype. The molecular mechanisms that cause thrombosis in VLD are only partially explained by the alteration in the Virchow's triad (hypercoagulability, blood stasis, and endothelial damage) and nowadays their pathogenesis is incompletely described and understood. Studies about this topic have been hampered by the low incidence of VLDs in the general population and by the absence of suitable animal models. Recently, the role of coagulation imbalance in liver disease has been postulated as one of the main mechanisms linked to fibrogenesis, so a novel interest in vascular alterations of the liver has been renewed. This review provides a detailed analysis of the current knowledge of molecular mechanisms of VLD. We also focus on the promising role of anticoagulation as a strategy to prevent liver complications and to improve the outcome of these patients.
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Affiliation(s)
- Lucia Giuli
- Hepatology Unit, CEMAD Centro Malattie Dell’Apparato Digerente, Medicina Interna e Gastroenterologia, Fondazione Policlinico Universitario Gemelli IRCCS, 00168 Rome, Italy; (L.G.); (M.P.); (G.V.); (F.R.P.); (F.S.)
| | - Maria Pallozzi
- Hepatology Unit, CEMAD Centro Malattie Dell’Apparato Digerente, Medicina Interna e Gastroenterologia, Fondazione Policlinico Universitario Gemelli IRCCS, 00168 Rome, Italy; (L.G.); (M.P.); (G.V.); (F.R.P.); (F.S.)
| | - Giulia Venturini
- Hepatology Unit, CEMAD Centro Malattie Dell’Apparato Digerente, Medicina Interna e Gastroenterologia, Fondazione Policlinico Universitario Gemelli IRCCS, 00168 Rome, Italy; (L.G.); (M.P.); (G.V.); (F.R.P.); (F.S.)
| | - Antonio Gasbarrini
- Hepatology Unit, CEMAD Centro Malattie Dell’Apparato Digerente, Medicina Interna e Gastroenterologia, Fondazione Policlinico Universitario Gemelli IRCCS, 00168 Rome, Italy; (L.G.); (M.P.); (G.V.); (F.R.P.); (F.S.)
- Dipartimento di Medicina e Chirurgia Traslazionale, Università Cattolica del Sacro Cuore, 00168 Rome, Italy
| | - Francesca Romana Ponziani
- Hepatology Unit, CEMAD Centro Malattie Dell’Apparato Digerente, Medicina Interna e Gastroenterologia, Fondazione Policlinico Universitario Gemelli IRCCS, 00168 Rome, Italy; (L.G.); (M.P.); (G.V.); (F.R.P.); (F.S.)
| | - Francesco Santopaolo
- Hepatology Unit, CEMAD Centro Malattie Dell’Apparato Digerente, Medicina Interna e Gastroenterologia, Fondazione Policlinico Universitario Gemelli IRCCS, 00168 Rome, Italy; (L.G.); (M.P.); (G.V.); (F.R.P.); (F.S.)
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The prevalence of nodular regenerative hyperplasia of the liver in long-term thiopurine-treated inflammatory bowel disease patients. Eur J Gastroenterol Hepatol 2021; 33:e102-e107. [PMID: 33136726 DOI: 10.1097/meg.0000000000001980] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/10/2022]
Abstract
INTRODUCTION Nodular regenerative hyperplasia (NRH) has been associated with thiopurine therapy in patients with inflammatory bowel disease (IBD), but prevalence and prognosis of NRH remain unclear. This study is a cross-sectional search for NRH in IBD patients with long-term azathioprine or 6-mercaptopurine treatment. MATERIAL AND METHODS Thirty-three IBD patients with continuous azathioprine/6-mercaptopurine treatment for at least 5 years were included. Laboratory tests, thiopurine metabolite levels, liver histology, MRI were examined for NRH and signs of portal hypertension. RESULTS NRH was not observed in this cohort of 33 patients. Nevertheless, some possibly related signs of vascular changes were found by MRI in three patients. Also, splenomegaly, which may be associated with portal hypertension, was found in one patient. No high thiopurine dose neither high metabolite levels were found in these patients. CONCLUSION No NRH was found in this group of IBD patients with long-term azathioprine/6-mercaptopurine treatment. Larger multicenter studies are needed to determine the prevalence of NRH in thiopurine-treated IBD patients.
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Bayoumy AB, van Liere ELSA, Simsek M, Warner B, Loganayagam A, Sanderson JD, Anderson S, Nolan J, de Boer NK, Mulder CJJ, Ansari A. Efficacy, safety and drug survival of thioguanine as maintenance treatment for inflammatory bowel disease: a retrospective multi-centre study in the United Kingdom. BMC Gastroenterol 2020; 20:296. [PMID: 32917155 PMCID: PMC7488521 DOI: 10.1186/s12876-020-01441-6] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/06/2020] [Accepted: 09/03/2020] [Indexed: 12/19/2022] Open
Abstract
BACKGROUND Thioguanine (TG) is a thiopurine which has been used for patients with inflammatory bowel disease (IBD), who have failed azathioprine (AZA) or mercaptopurine (MP) due to adverse events or suboptimal response. Its widespread use has been hampered due to concerns about nodular regenerative hyperplasia (NRH) of the liver. The aim of this study was to investigate the long-term efficacy and safety of low-dose TG therapy in IBD patients failing AZA and MP. METHODS A retrospective multicentre study was performed in IBD patients who failed prior treatment with conventional thiopurines with or without following immunomodulation (thiopurine-allopurinol, biologicals, methotrexate, tacrolimus) and were subsequently treated with TG as rescue monotherapy between 2003 and 2019 at three hospitals in the United Kingdom. Clinical response, adverse events, laboratory results, imaging and liver biopsies were retrospectively collected. RESULTS A total of 193 patients (57% female and 64% Crohn's disease) were included, with a median daily TG dose of 20 mg (range: 20-40 mg), a median treatment duration of 23 months (IQR 10-47) and a median follow-up of 36 months (IQR 22-53). The clinical response rate at 12 months was 65 and 54% remained on TG until the end of follow-up. Adverse events consisted primarily of elevated liver tests (6%), myelotoxicity (7%) and rash (5%). NRH was histologically diagnosed in two patients and two other patients (1%) developed non-cirrhotic portal hypertension. The median 6-TGN and TPMT levels were 953 pmol/8 × 105 RBC (IQR 145-1761) and 47 mu/L (IQR 34.5-96). CONCLUSIONS Long-term follow-up suggests that TG can be an effective and well-tolerated therapy in more than half of difficult-to-treat and multi-therapy failing IBD patients. Findings of this study indicate that TG can be used safely and the occurrence of hepatotoxicity was low. The incidence rate of NRH was within the background incidence.
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Affiliation(s)
- Ahmed B Bayoumy
- Department of Gastroenterology and Hepatology, Amsterdam UMC, VU University Medical Centre, Amsterdam, The Netherlands. .,Department of Gastroenterology, Guy's and St Thomas' NHS Foundation Trust, London, UK. .,Department of Gastroenterology, Queen Elizabeth Hospital, Woolwich, UK. .,Department of Gastroenterology, Surrey and Sussex NHS, Easy Surrey Hospital, Surrey, UK.
| | - Elsa L S A van Liere
- Department of Gastroenterology and Hepatology, Amsterdam UMC, VU University Medical Centre, Amsterdam, The Netherlands.,Department of Gastroenterology, Guy's and St Thomas' NHS Foundation Trust, London, UK.,Department of Gastroenterology, Queen Elizabeth Hospital, Woolwich, UK.,Department of Gastroenterology, Surrey and Sussex NHS, Easy Surrey Hospital, Surrey, UK
| | - Melek Simsek
- Department of Gastroenterology and Hepatology, Amsterdam UMC, VU University Medical Centre, AG&M Research Institute, Amsterdam, The Netherlands
| | - Ben Warner
- Department of Gastroenterology, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | | | - Jeremy D Sanderson
- Department of Gastroenterology, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Simon Anderson
- Department of Gastroenterology, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Jonathan Nolan
- Department of Gastroenterology, Surrey and Sussex NHS, Easy Surrey Hospital, Surrey, UK
| | - Nanne K de Boer
- Department of Gastroenterology and Hepatology, Amsterdam UMC, VU University Medical Centre, AG&M Research Institute, Amsterdam, The Netherlands
| | - Chris J J Mulder
- Department of Gastroenterology and Hepatology, Amsterdam UMC, VU University Medical Centre, Amsterdam, The Netherlands
| | - Azhar Ansari
- Department of Gastroenterology, Surrey and Sussex NHS, Easy Surrey Hospital, Surrey, UK
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8
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Seo JW, Kim ES, Han MH, Kweon YO. Non-cirrhotic portal hypertension related to azathioprine therapy in a patient with Crohn's disease. Intest Res 2020; 19:247-251. [PMID: 32610890 PMCID: PMC8100374 DOI: 10.5217/ir.2020.00016] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/29/2020] [Accepted: 04/09/2020] [Indexed: 12/14/2022] Open
Abstract
Azathioprine is widely used for the treatment of Crohn’s disease (CD). Few cases from Western countries have reported idiopathic non-cirrhotic portal hypertension (NCPH) related to thiopurine therapy in patients with inflammatory bowel disease. Idiopathic NCPH is a rare hepatic condition with intrahepatic portal hypertension but no evidence of cirrhosis or chronic liver disease. Patients with idiopathic NCPH present with symptoms of portal hypertension such as thrombocytopenia, splenomegaly and esophageal varices. We report a case of idiopathic NCPH in a 51-year-old male patient with CD who had been taking azathioprine for 5 years. He was admitted due to esophageal variceal bleeding along with splenomegaly and thrombocytopenia. Evaluation of cirrhosis or chronic liver disease showed normal-range results as estimated by FibroScan evaluation, laboratory examination for autoimmune hepatitis or viral hepatitis, and liver biopsy. This case may suggest the need for careful monitoring for manifestations of portal hypertension in Asian patients with inflammatory bowel disease receiving thiopurine treatment.
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Affiliation(s)
- Jong Won Seo
- Department of Internal Medicine, School of Medicine, Kyungpook National University, Daegu, Korea
| | - Eun Soo Kim
- Department of Internal Medicine, School of Medicine, Kyungpook National University, Daegu, Korea
| | - Man-Hoon Han
- Department of Pathology, School of Medicine, Kyungpook National University, Daegu, Korea
| | - Young Oh Kweon
- Department of Internal Medicine, School of Medicine, Kyungpook National University, Daegu, Korea
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9
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Bayoumy AB, Simsek M, Seinen ML, Mulder CJJ, Ansari A, Peters GJ, De Boer NK. The continuous rediscovery and the benefit-risk ratio of thioguanine, a comprehensive review. Expert Opin Drug Metab Toxicol 2020; 16:111-123. [PMID: 32090622 DOI: 10.1080/17425255.2020.1719996] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Introduction: In the 1950s, thioguanine (TG), a thiopurine-derivative together with azathioprine (AZA) and mercaptopurine (MP), were developed for the treatment of childhood leukemia. Over the years, the use of TG was also explored for other, mainly immune-mediated and inflammatory, diseases such as in the field of dermatology and rheumatology (e.g. psoriasis, systemic lupus erythematosus (SLE)) and gastroenterology and hepatology (e.g. inflammatory bowel diseases (IBD), autoimmune hepatitis).Areas covered: This review provides a comprehensive overview of all the clinical uses of TG and describes its mechanism of action, pharmacokinetic/pharmacodynamic features, and toxicity.Expert opinion: Thioguanine has shown beneficial clinical effects in hematological (particularly leukemia) and several immune-inflammatory diseases including psoriasis, SLE, polycythemia vera, Churg-Strauss syndrome, IBD, collagenous sprue, refractory celiac disease, and autoimmune hepatitis. Thioguanine is not effective in treating solid-cancers. At relatively low dosages, i.e. 0.2- 0.3mg/kg/day or 20 mg/day, TG has a favorable risk-benefit ratio and is a safe and effective drug in the long-term treatment of amongst other IBD patients. Thioguanine toxicity, especially myelotoxicity, and hepatotoxicity, including nodular regenerative hyperplasia (NRH) of the liver, is limited when dosed adequately. The occurrence of NRH appears dose-dependent and has been especially described during high dose TG above 40 mg/day.
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Affiliation(s)
- Ahmed B Bayoumy
- Amsterdam UMC, Department of Gastroenterology and Hepatology, VU University Medical Center, Amsterdam, Netherlands
| | - Melek Simsek
- Amsterdam UMC, Department of Gastroenterology and Hepatology, VU University Medical Center, AG&M Research Institute, Amsterdam, Netherlands
| | - Margien L Seinen
- Amsterdam UMC, Department of Gastroenterology and Hepatology, VU University Medical Center, Amsterdam, Netherlands
| | - Chris J J Mulder
- Amsterdam UMC, Department of Gastroenterology and Hepatology, VU University Medical Center, Amsterdam, Netherlands
| | - Azhar Ansari
- Department of Gastroenterology, Surrey and Sussex NHS, Easy Surrey Hospital, Surrey, UK
| | - Godefridus J Peters
- Amsterdam UMC, VU University Medical Center, Laboratory Medical Oncology, Cancer Center Amsterdam, Amsterdam, Netherlands.,Department of Biochemistry, Medical University of Gdansk, Gdansk, Poland
| | - Nanne K De Boer
- Amsterdam UMC, Department of Gastroenterology and Hepatology, VU University Medical Center, AG&M Research Institute, Amsterdam, Netherlands
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10
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Luber RP, Honap S, Cunningham G, Irving PM. Can We Predict the Toxicity and Response to Thiopurines in Inflammatory Bowel Diseases? Front Med (Lausanne) 2019; 6:279. [PMID: 31850357 PMCID: PMC6892750 DOI: 10.3389/fmed.2019.00279] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2019] [Accepted: 11/14/2019] [Indexed: 12/21/2022] Open
Abstract
Thiopurines are a cheap, effective treatment option in the management of inflammatory bowel disease (IBD). However, with the growing choice of targeted therapies available, as well as the well-documented toxicities of thiopurines, the role of thiopurines has been questioned. Nevertheless, given their inexpense in an era of spiraling healthcare costs, thiopurines remain an attractive option in the right patients. In the age of personalized medicine, being able to predict patients who will respond as well as those that will develop toxicity to a treatment is vital to tailoring therapy. This review will summarize the available literature with respect to predictors of response and toxicity to thiopurines in order to guide management in IBD. Specifically, toxicities addressed will include myelotoxicity, hepatotoxicity, pancreatitis, alopecia, gastrointestinal and flu-like symptoms, and complications associated with Epstein-Barr virus. While more work needs to be done to further our ability to predict both response to and side effects from therapies, pharmacogenomic research shows significant promise in its ability to personalize our use of thiopurines.
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Affiliation(s)
- Raphael P Luber
- Department of Gastroenterology, Guy's and St. Thomas' NHS Foundation Trust, London, United Kingdom
| | - Sailish Honap
- Department of Gastroenterology, Guy's and St. Thomas' NHS Foundation Trust, London, United Kingdom
| | - Georgina Cunningham
- Department of Gastroenterology, Guy's and St. Thomas' NHS Foundation Trust, London, United Kingdom
| | - Peter M Irving
- Department of Gastroenterology, Guy's and St. Thomas' NHS Foundation Trust, London, United Kingdom
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Simsek M, Deben DS, Horjus CS, Bénard MV, Lissenberg‐Witte BI, Buiter HJC, van Luin M, Seinen ML, Mulder CJJ, Wong DR, de Boer NKH, van Bodegraven AA. Sustained effectiveness, safety and therapeutic drug monitoring of tioguanine in a cohort of 274 IBD patients intolerant for conventional therapies. Aliment Pharmacol Ther 2019; 50:54-65. [PMID: 31094013 PMCID: PMC6618772 DOI: 10.1111/apt.15280] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/05/2018] [Revised: 12/30/2018] [Accepted: 04/04/2019] [Indexed: 02/06/2023]
Abstract
BACKGROUND Tioguanine (or thioguanine) is an alternative drug for IBD patients who fail prior conventional immunomodulating therapy. AIM To report effectiveness, safety and therapeutic drug monitoring in a cohort of patients with prolonged tioguanine maintenance therapy. METHODS In this nationwide, multicentre study, medical records of tioguanine- using IBD patients were retrospectively reviewed. Response to therapy was defined as clinical effectiveness without (re)initiation of corticosteroids, concurrent biological therapy or surgical intervention. All adverse events that occurred during the follow-up were listed and graded according to the common terminology criteria (CTC). RESULTS Two hundred and seventy-four patients (female 63%, Crohn's disease in 68%) were included with median treatment duration of 51 months, 1567 patient-years of follow-up and median 20 mg/d tioguanine dosage. Tioguanine was tolerated in 79%, clinical effectiveness at 6 months was documented in 66% and sustained clinical effectiveness during 12 months in 51% of patients. Forty-one per cent of patients developed adverse events: 5% were graded as severe. Adverse events comprised infection requiring hospitalisation in three and skin cancer in eight patients (two melanomas). Asymptomatic nodular regenerative hyperplasia of the liver occurred in two out of 52 patients with liver biopsies (3.8%) and portal hypertension in three whereof one potentially associated with tioguanine (0.4%). Clinical effectiveness was correlated with 6-thioguanine nucleotide threshold concentrations >682 pmol/8×108 RBC (P < 0.05). CONCLUSIONS Long-term tioguanine therapy for at least 12 months was effective in 51% and well tolerated as a maintenance treatment for IBD in about 70% of patients. Adverse events were common, but mainly mild or moderate. 6-Thioguanine nucleotide threshold concentration ≥ 700 pmol/8×108 RBC is proposed as target level with higher odds for clinical effectiveness.
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Affiliation(s)
- Melek Simsek
- Department of Gastroenterology and HepatologyAmsterdam UMC, Vrije Universiteit Amsterdam, AG&M Research InstituteAmsterdamThe Netherlands
| | - Debbie S. Deben
- Department of Clinical Pharmacy, Clinical Pharmacology and Toxicology, Zuyderland Medical CentreSittard‐Geleen‐HeerlenThe Netherlands
| | - Carmen S. Horjus
- Department of Gastroenterology and HepatologyRijnstate HospitalArnhemThe Netherlands
| | - Melanie V. Bénard
- Department of Gastroenterology and HepatologyAmsterdam UMC, Vrije Universiteit AmsterdamAmsterdamThe Netherlands
| | - Birgit I. Lissenberg‐Witte
- Department of Epidemiology and BiostatisticsAmsterdam UMC, Vrije Universiteit AmsterdamAmsterdamThe Netherlands
| | - Hans J. C. Buiter
- Department of Clinical Pharmacology and PharmacyAmsterdam UMC, Vrije Universiteit AmsterdamAmsterdamThe Netherlands
| | - Matthijs van Luin
- Department of Clinical Pharmacology and PharmacyRijnstate HospitalArnhemThe Netherlands
| | - Margien L. Seinen
- Department of Gastroenterology and HepatologyAmsterdam UMC, Vrije Universiteit AmsterdamAmsterdamThe Netherlands
| | - Chris J. J. Mulder
- Department of Gastroenterology and HepatologyAmsterdam UMC, Vrije Universiteit AmsterdamAmsterdamThe Netherlands
| | - Dennis R. Wong
- Department of Clinical Pharmacy, Clinical Pharmacology and Toxicology, Zuyderland Medical CentreSittard‐Geleen‐HeerlenThe Netherlands
| | - Nanne K. H. de Boer
- Department of Gastroenterology and HepatologyAmsterdam UMC, Vrije Universiteit Amsterdam, AG&M Research InstituteAmsterdamThe Netherlands
| | - Adriaan A. van Bodegraven
- Department of Gastroenterology and HepatologyAmsterdam UMC, Vrije Universiteit AmsterdamAmsterdamThe Netherlands,Department of Gastroenterology, Geriatrics, Internal and Intensive Care Medicine (Co‐MIK)Zuyderland Medical Centre, Sittard‐Geleen‐HeerlenThe Netherlands
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12
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van Asseldonk DP, Simsek M, de Boer NKH, Jharap B, Bloemena E, den Hartog G, Westerveld DB, Becx MC, Russel MG, Lissenberg-Witte BI, van Nieuwkerk CM, Mulder CJJ, Verheij J, van Bodegraven AA. Limited relevance and progression of histological alterations in the liver during thioguanine therapy in inflammatory bowel disease patients. Scand J Gastroenterol 2019; 54:753-760. [PMID: 31203688 DOI: 10.1080/00365521.2019.1629006] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
Background: Thioguanine is associated with liver toxicity, especially nodular regenerative hyperplasia (NRH). We assessed if liver histology alters during long-term maintenance treatment with thioguanine in patients with inflammatory bowel disease (IBD). Methods: Liver specimens of thioguanine treated IBD patients with at least two liver biopsies were revised by two independent liver pathologists, blinded to clinical characteristics. Alterations in histopathological findings between first and sequential liver specimen were evaluated and associated clinical data, including laboratory parameters and abdominal imaging reports, were collected. Results: Twenty-five IBD patients underwent sequential liver biopsies prior to, at time of, or after cessation of thioguanine treatment. The median time between the first and second biopsy was 25 months (range: 14-54). Except for one normal liver specimen, any degree of irregularities including inflammation, steatosis, fibrosis and some vascular disturbances were observed in the biopsies. The rates of perisinusoidal fibrosis (91%), sinusoidal dilatation (68%) and nodularity (18%) were the same in the first and second liver biopsies. A trend towards statistical significance was observed for phlebosclerosis (36% of the first vs. 68% of the second biopsies, p = .092). Presence of histopathological liver abnormalities was not associated with clinical outcomes. Furthermore, two patients in this cohort had portal hypertension in presence of phlebosclerosis. In another two patients, nodularity of the liver resolved upon thioguanine withdrawal. Conclusion: Vascular abnormalities of the liver were commonly observed in thioguanine treated IBD patients, although these were not progressive and remained of limited clinical relevance over time.
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Affiliation(s)
- Dirk P van Asseldonk
- Department of Gastroenterology and Hepatology, Noordwest Ziekenhuis groep , Alkmaar , the Netherlands
| | - Melek Simsek
- Department of Gastroenterology and Hepatology, Amsterdam UMC, Vrije Universiteit Amsterdam , Amsterdam , the Netherlands
| | - Nanne K H de Boer
- Department of Gastroenterology and Hepatology, Amsterdam UMC, Vrije Universiteit Amsterdam , Amsterdam , the Netherlands
| | - Bindia Jharap
- Meander Medical Center, Department of Gastroenterology and Hepatology , Amersfoort , the Netherlands
| | - Elisabeth Bloemena
- Department of Pathology, Amsterdam UMC, Vrije Universiteit Amsterdam , Amsterdam , the Netherlands
| | - Gijsbert den Hartog
- Department of Gastroenterology and Hepatology, Rijnstate Hospital , Arnhem , the Netherlands
| | - Dik B Westerveld
- Isala Clinics, Department of Gastroenterology and Hepatology , Zwolle , the Netherlands
| | - Marco C Becx
- Department of Gastroenterology and Hepatology, Sint Antonius Hospital , Nieuwegein , the Netherlands
| | - Maurice G Russel
- Department of Gastroenterology and Hepatology, Medisch Spectrum Twente , Enschede , the Netherlands
| | - Birgit I Lissenberg-Witte
- Department of Epidemiology and Biostatistics, Amsterdam UMC, Vrije Universiteit Amsterdam , Amsterdam , the Netherlands
| | - Carin M van Nieuwkerk
- Department of Gastroenterology and Hepatology, Amsterdam UMC, Vrije Universiteit Amsterdam , Amsterdam , the Netherlands
| | - Chris J J Mulder
- Department of Gastroenterology and Hepatology, Amsterdam UMC, Vrije Universiteit Amsterdam , Amsterdam , the Netherlands
| | - Joanne Verheij
- Department of Pathology, Amsterdam UMC, Academical Medical Center , Amsterdam , the Netherlands
| | - Adriaan A van Bodegraven
- Department of Gastroenterology and Hepatology, Amsterdam UMC, Vrije Universiteit Amsterdam , Amsterdam , the Netherlands.,Zuyderland Medical Centre, Department of Gastroenterology, Geriatrics, Internal and Intensive Care Medicine (Co-MIK) , Sittard-Geleen-Heerlen , the Netherlands
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