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Du S, Huang X, He X, Mao M, Chen M, Zhang R, Shao H, Lv Z, Liu X, Chuan J. Association of NUDT15 gene polymorphism with adverse reaction, treatment efficacy, and dose of 6-mercaptopurine in patients with acute lymphoblastic leukemia: a systematic review and meta-analysis. Haematologica 2024; 109:1053-1068. [PMID: 37794799 PMCID: PMC10985454 DOI: 10.3324/haematol.2023.282761] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2023] [Accepted: 10/26/2023] [Indexed: 10/06/2023] Open
Abstract
6-mercaptopurine (6-MP) serves as the backbone in the maintenance regimens of acute lymphoblastic leukemia (ALL). We aimed to evaluate the influence of NUDT15 gene polymorphism on the risk of myelosupression, hepatotoxicity and interruption of 6-MP, as well as treatment efficacy and dose of 6-MP in ALL patients. A total of 24 studies with 3,374 patients were included in this meta-analysis. We found 9-fold higher risk of 6-MP induced leukopenia (odds ratio [OR] =9.00, 95% confidence interval [CI]: 3.73-21.74) and 2.5-fold higher risk of 6-MP-induced neutropenia (OR=2.52, 95% CI: 1.72-3.69) for NUDT15 c.415C>T variant carriers in the dominant model. Moreover, we found that the dose intensity of 6-MP in ALL patients with one NUDT15 c.415C>T variant alleles (CT) was 19% less than that in wild-type patients (CC) (mean differences: 19.43%, 95% CI: -25.36 to -13.51). The tolerable dose intensity of 6-MP in NUDT15 c.415C>T homozygote variant (TT) and heterozygote variant (CT) carriers was 49% and 15% less than that in wild-type patients, respectively. The NUDT15 c.415C>T variant group (CT+TT) had seven times (OR=6.98, 95% CI: 2.83-17.22) higher risk of developing 6-MP intolerance than the CC group. However, NUDT15 c.415C>T polymorphism did not appear significantly associated with hepatotoxicity, treatment interruption or relapse incidence. We concluded that NUDT15 c.415C>T was a good predictor for 6-MP-induced myelosuppression in ALL patients. The dose intensity of 6-MP in ALL patients with NUDT15 c.415C>T variants was significantly lower than that in wild-type patients. This research provided a basis for further investigation into relations between NUDT15 gene and adverse reaction, treatment efficacy and dose intensity of 6-MP.
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Affiliation(s)
- Shan Du
- Department of Pharmacy, Sichuan Academy of Medical Sciences and Sichuan Provincial People's Hospital, Chengdu, China; Personalized Drug Therapy Key Laboratory of Sichuan Province, School of Medicine, University of Electronic Science and Technology of China, Chengdu
| | - Xuefei Huang
- Department of Pharmacy, Sichuan Academy of Medical Sciences and Sichuan Provincial People's Hospital, Chengdu, China; Personalized Drug Therapy Key Laboratory of Sichuan Province, School of Medicine, University of Electronic Science and Technology of China, Chengdu
| | - Xia He
- Department of Pharmacy, Sichuan Academy of Medical Sciences and Sichuan Provincial People's Hospital, Chengdu, China; Personalized Drug Therapy Key Laboratory of Sichuan Province, School of Medicine, University of Electronic Science and Technology of China, Chengdu
| | - Mian Mao
- Department of Pharmacy, Sichuan Cancer Hospital, Chengdu
| | - Min Chen
- Department of Pharmacy, Sichuan Academy of Medical Sciences and Sichuan Provincial People's Hospital, Chengdu, China; Personalized Drug Therapy Key Laboratory of Sichuan Province, School of Medicine, University of Electronic Science and Technology of China, Chengdu
| | - Rong Zhang
- Department of Pediatrics, Sichuan Academy of Medical Sciences and Sichuan Provincial People's Hospital, Chengdu
| | - Huikai Shao
- Department of Pharmacy, Sichuan Academy of Medical Sciences and Sichuan Provincial People's Hospital, Chengdu, China; Personalized Drug Therapy Key Laboratory of Sichuan Province, School of Medicine, University of Electronic Science and Technology of China, Chengdu
| | - Ziyan Lv
- Department of Pharmacy, Sichuan Academy of Medical Sciences and Sichuan Provincial People's Hospital, Chengdu, China; Personalized Drug Therapy Key Laboratory of Sichuan Province, School of Medicine, University of Electronic Science and Technology of China, Chengdu
| | - Xinxia Liu
- Department of Pharmacy, Sichuan Academy of Medical Sciences and Sichuan Provincial People's Hospital, Chengdu, China; Personalized Drug Therapy Key Laboratory of Sichuan Province, School of Medicine, University of Electronic Science and Technology of China, Chengdu.
| | - Junlan Chuan
- Department of Pharmacy, Sichuan Academy of Medical Sciences and Sichuan Provincial People's Hospital, Chengdu, China; Personalized Drug Therapy Key Laboratory of Sichuan Province, School of Medicine, University of Electronic Science and Technology of China, Chengdu.
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Leaviss J, Carroll C, Essat M, van der Windt D, Grainge MJ, Card T, Riley R, Abhishek A. Prognostic factors for liver, blood and kidney adverse events from glucocorticoid sparing immune-suppressing drugs in immune-mediated inflammatory diseases: a prognostic systematic review. RMD Open 2024; 10:e003588. [PMID: 38199851 PMCID: PMC10806492 DOI: 10.1136/rmdopen-2023-003588] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2023] [Accepted: 10/23/2023] [Indexed: 01/12/2024] Open
Abstract
BACKGROUND Immune-suppressing drugs can cause liver, kidney or blood toxicity. Prognostic factors for these adverse-events are poorly understood. PURPOSE To ascertain prognostic factors associated with liver, blood or kidney adverse-events in people receiving immune-suppressing drugs. DATA SOURCES MEDLINE, Web of Science, EMBASE and the Cochrane library (01 January 1995 to 05 January 2023), and supplementary sources. DATA EXTRACTION AND SYNTHESIS Data were extracted by one reviewer using a modified CHARMS-PF checklist and validated by another. Two independent reviewers assessed risk of bias using Quality in Prognostic factor Studies tool and assessed the quality of evidence using a Grading of Recommendations Assessment, Development and Evaluation-informed framework. RESULTS Fifty-six studies from 58 papers were included. High-quality evidence of the following associations was identified: elevated liver enzymes (6 studies) and folate non-supplementation (3 studies) are prognostic factors for hepatotoxicity in those treated with methotrexate; that mercaptopurine (vs azathioprine) (3 studies) was a prognostic factor for hepatotoxicity in those treated with thiopurines; that mercaptopurine (vs azathioprine) (3 studies) and poor-metaboliser status (4 studies) were prognostic factors for cytopenia in those treated with thiopurines; and that baseline elevated liver enzymes (3 studies) are a prognostic factor for hepatotoxicity in those treated with anti-tumour necrosis factors. Moderate and low quality evidence for several other demographic, lifestyle, comorbidities, baseline bloods/serologic or treatment-related prognostic factors were also identified. LIMITATIONS Studies published before 1995, those with less than 200 participants and not published in English were excluded. Heterogeneity between studies included different cut-offs for prognostic factors, use of different outcome definitions and different adjustment factors. CONCLUSIONS Prognostic factors for target-organ damage were identified which may be further investigated for their potential role in targeted (risk-stratified) monitoring. PROSPERO REGISTRATION NUMBER CRD42020208049.
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Affiliation(s)
- Joanna Leaviss
- SCHARR, The University of Sheffield, Sheffield, Yorkshire, UK
| | | | - Munira Essat
- SCHARR, The University of Sheffield, Sheffield, Yorkshire, UK
| | | | - Matthew J Grainge
- Academic Unit of Lifespan and Population Health, School of Medicine, University of Nottingham, Nottingham, UK
| | - Tim Card
- Division of Epidemiology and Public Health, University of Nottingham, Nottingham, UK
| | - Richard Riley
- Institute of Applied Health Research, College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK
- National Institute for Health and Care Research (NIHR) Birmingham Biomedical Research Centre, Birmingham, UK
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Singh AK, Sachdeva S, Srivastava S, Sonika U, Kumar A, Sharma BC, Puri AS, Dalal A. Comparing Myelosuppression Frequency in Indian Inflammatory Bowel Disease Patients: A Randomized Trial of Full Dose Versus Gradual Escalation of Thiopurines. Cureus 2023; 15:e50969. [PMID: 38259414 PMCID: PMC10801346 DOI: 10.7759/cureus.50969] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/22/2023] [Indexed: 01/24/2024] Open
Abstract
INTRODUCTION We aimed to compare the frequency of myelosuppression in patients initiating azathioprine (AZA) at full dose versus those undergoing gradual dose escalation. METHODS Forty patients with inflammatory bowel disease were recruited over one year and randomized into two groups of 20. Group A initiated AZA at a full dose of 2 mg/kg, while group B started at 1 mg/kg with subsequent dose increases at regular intervals. RESULTS Seventeen patients from each group were included in the final analysis. During follow-up, two patients (11.8%) from group A and four patients (23.5%) from group B experienced relapses (p=0.65). Myelosuppression occurred in two patients (11.8%) from each group. Absolute neutrophil counts in group A tended to have lower median values than those in group B, particularly four weeks after AZA initiation. Univariate analysis identified serum proteins, albumin, and bilirubin as significantly associated with leukopenia, but these factors were not significant according to multivariate analysis. CONCLUSIONS The incidence of myelosuppression was similar between the groups. Patients with full-dose initiation of AZA had numerically fewer relapses during the follow-up period.
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Affiliation(s)
- Alok Kumar Singh
- Department of Gastroenterology, G.B. Pant Hospital, New Delhi, IND
| | - Sanjeev Sachdeva
- Department of Gastroenterology, G.B. Pant Hospital, New Delhi, IND
| | | | - Ujjwal Sonika
- Department of Gastroenterology, G.B. Pant Hospital, New Delhi, IND
| | - Ajay Kumar
- Department of Gastroenterology, G.B. Pant Hospital, New Delhi, IND
| | - Barjesh C Sharma
- Department of Gastroenterology, G.B. Pant Hospital, New Delhi, IND
| | - Amarender S Puri
- Department of Gastroenterology, Medanta - The Medicity Hospital, Gurugram, IND
| | - Ashok Dalal
- Department of Gastroenterology, G.B. Pant Hospital, New Delhi, IND
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Lukose L, Shantaram PM, Raj A, Nair G, Shaju AM, K Subeesh V. Purine antimetabolites associated Pneumocystis jirovecii pneumonia. Pharmacoepidemiol Drug Saf 2023; 32:1244-1251. [PMID: 37265365 DOI: 10.1002/pds.5647] [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: 11/28/2022] [Revised: 04/06/2023] [Accepted: 05/28/2023] [Indexed: 06/03/2023]
Abstract
PURPOSE To detect the possible safety signal of purine antimetabolites associated with Pneumocystis jirovecii pneumonia through disproportionality analysis in the FDA Adverse Event Reporting System (FAERS) Database. METHODS A case/non-case retrospective disproportionality analysis was performed in the publicly available FAERS database using AERSmine (2004Q1-2021Q3). Four models were developed to explore the signal strength of PAs among different populations with possible confounding factors. Reporting odds ratio (ROR) and Proportional reporting ratio (PRR) was used as the data mining algorithm for the analysis. A value of ROR-1.96SE > 1 and PRR ≥ 2 with an associated X2 value of 4 or more was considered the threshold for a signal. RESULTS A total of 7073 reports associated with Pneumocystis jirovecii pneumonia were present in the database, of which 899 reports were associated with purine antimetabolites. A crude signal strength of ROR 15.76(14.70-16.91) was obtained for purine antimetabolites associated PJP, with the highest signal strength reported with fludarabine and thioguanine [ROR 19.63(17.42-22.13); 19.45(13.21-28.63)]. Stratifying the cases based on autoimmune disorders and the cancer population revealed an ROR of 3.33(2.46-4.50) and 2.93(2.26-3.79) respectively. The highest risk of PJP with use of PAs was observed amongst children with a higher risk of nearly 2 times than the adult population [ROR 11.57(9.16-14.62)]. CONCLUSIONS Our study provided evidence on the occurrence of PJP with the use of purine antimetabolites among the autoimmune and cancer population. We identified signals for PJP with azathioprine, mercaptopurine, thioguanine, cladribine, fludarabine, and clofarabine. More research with a superior epidemiological study design of a defined population is required to validate these findings.
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Affiliation(s)
- Lipin Lukose
- Department of Pharmacy Practice, Manipal College of Pharmaceutical Sciences, Manipal Academy of Higher Education, Manipal, Karnataka, India
| | - Pawar Mansi Shantaram
- Department of Pharmacy Practice, Manipal College of Pharmaceutical Sciences, Manipal Academy of Higher Education, Manipal, Karnataka, India
| | - Alan Raj
- Department of Pharmaceutical Biotechnology, Manipal College of Pharmaceutical Sciences, Manipal Academy of Higher Education, Manipal, Karnataka, India
| | - Gouri Nair
- Faculty of Pharmacy, Department of Pharmacology, MS Ramaiah University of Applied Sciences, Bengaluru, India
| | - Aina M Shaju
- Population Health Sciences Institute, Faculty of Medical Sciences, Newcastle University, Newcastle Upon Tyne, UK
| | - Viswam K Subeesh
- Department of Pharmacy Practice, Manipal College of Pharmaceutical Sciences, Manipal Academy of Higher Education, Manipal, Karnataka, India
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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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Jena A, Birda CL, Choudhury A, Sharma V. Safety and efficacy of personalized versus standard initial dosing of thiopurines: Systematic review and meta-analysis of randomized trials. Expert Opin Drug Saf 2023; 22:1253-1263. [PMID: 37436005 DOI: 10.1080/14740338.2023.2236554] [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: 03/14/2023] [Accepted: 06/22/2023] [Indexed: 07/13/2023]
Abstract
BACKGROUND Pretherapy assessment of specific genetic polymorphism (TPMT, NUDT15, FTO, RUNX1, etc) or enzyme levels (for TPMT) may help personalize the dose of thiopurines and avoid adverse effects. RESEARCH DESIGN AND METHODS A systematic review of randomized controlled trials (RCTs) comparing personalized versus standard strategy for initial thiopurine dosing was performed. The electronic databases were searched on 27 September 2022. The outcomes were overall adverse effects, myelotoxicity, drug interruptions, and therapeutic efficacy with either strategy. The certainty of evidence was assessed using GRADE methodology. RESULTS We included six randomized trials, done dominantly in patients with inflammatory bowel disease (IBD). The personalized strategies were genotype testing in 4 trials (TPMT in three trials, NUDT15 in two) and enzyme levels for TPMT in two trials. The pooled risk of myelotoxicity in personalized dosing was lower [RR = 0.72 (95%CI, 0.55-0.94, I2 = 0%)]. The pooled risk of pancreatitis (RR = 1.10I, 0.78-1.56, I2 = 0%), hepatotoxicity (RR = 1.13, 0.69-1.88, I2 = 45), and GI intolerance (RR = 1.01, 0.92-1.10, I2 = 0) were similar in two groups. The pooled risk of drug interruption in individualized dosing was similar to the standard dosing group (RR = 0.97, I2 = 68%). CONCLUSION Personalized testing-based initial thiopurine dosing is protective against myelotoxicity as compared to standard weight-based dosing.
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Affiliation(s)
- Anuraag Jena
- Department of Gastroenterology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Chhagan L Birda
- Department of Medical Gastroenterology, All India Institute of Medical Sciences, Jodhpur, India
| | - Arup Choudhury
- Department of Medicine, Nagaon Medical College, Nagaon, Assam, India
| | - Vishal Sharma
- Department of Gastroenterology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
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Ali AM, Adam H, Hailu D, Engidawork E, Howe R, Abula T, Coenen MJH. Genetic variants of genes involved in thiopurine metabolism pathway are associated with 6-mercaptopurine toxicity in pediatric acute lymphoblastic leukemia patients from Ethiopia. Front Pharmacol 2023; 14:1159307. [PMID: 37251339 PMCID: PMC10214954 DOI: 10.3389/fphar.2023.1159307] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2023] [Accepted: 04/12/2023] [Indexed: 05/31/2023] Open
Abstract
Introduction: Genetic variation in the thiopurine S-methyltransferase (TPMT) gene by and large predicts variability in 6-mercaptopurine (6-MP) related toxicities. However, some individuals without genetic variants in TPMT still develop toxicity that necessitates 6-MP dose reduction or interruption. Genetic variants of other genes in the thiopurine pathway have been linked to 6-MP related toxicities previously. Objective: The aim of this study was to evaluate the effect of genetic variants in ITPA, TPMT, NUDT15, XDH, and ABCB1 on 6-MP related toxicities in patients with acute lymphoblastic leukemia (ALL) from Ethiopia. Methods: Genotyping of ITPA, and XDH was performed using KASP genotyping assay, while that of TPMT, NUDT15, and ABCB1 with TaqMan® SNP genotyping assays. Clinical profile of the patients was collected for the first 6 months of the maintenance phase treatment. The primary outcome was the incidence of grade 4 neutropenia. Bivariable followed by multivariable cox regression analysis was performed to identify genetic variants associated with the development of grade 4 neutropenia within the first 6 months of maintenance treatment. Results: In this study, genetic variants in XDH and ITPA were associated with 6-MP related grade 4 neutropenia and neutropenic fever, respectively. Multivariable analysis revealed that patients who are homozygous (CC) for XDH rs2281547 were 2.956 times (AHR 2.956, 95% CI = 1.494-5.849, p = 0.002) more likely to develop grade 4 neutropenia than those with the TT genotype. Conclusion: In conclusion, in this cohort, XDH rs2281547 was identified as a genetic risk factor for grade 4 hematologic toxicities in ALL patients treated with 6-MP. Genetic polymorphisms in enzymes other than TPMT involved in the 6-mercaptopurine pathway should be considered during its use to avoid hematological toxicity.
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Affiliation(s)
- Awol Mekonnen Ali
- Department of Pharmacology and Clinical Pharmacy, School of Pharmacy, College of Health Sciences, Addis Ababa University, Addis Ababa, Ethiopia
| | - Haileyesus Adam
- Department of Pediatrics and Child Health, School of Medicine, College of Health Sciences, Addis Ababa University, Addis Ababa, Ethiopia
| | - Daniel Hailu
- Department of Pediatrics and Child Health, School of Medicine, College of Health Sciences, Addis Ababa University, Addis Ababa, Ethiopia
| | - Ephrem Engidawork
- Department of Pharmacology and Clinical Pharmacy, School of Pharmacy, College of Health Sciences, Addis Ababa University, Addis Ababa, Ethiopia
| | - Rawleigh Howe
- Armauer Hansen Research Institute, Addis Ababa, Ethiopia
| | - Teferra Abula
- Department of Pharmacology and Clinical Pharmacy, School of Pharmacy, College of Health Sciences, Addis Ababa University, Addis Ababa, Ethiopia
| | - Marieke J. H. Coenen
- Department of Human Genetics, Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen, Netherlands
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Jansen FM, Smits LJT, Thomas PWA, de Jong DJ, Kreijne JE, van Dop WA, den Broeder N, Hoentjen F. Feasibility of Reduced Clinical Monitoring in Patients with Inflammatory Bowel Disease Treated with Thiopurine Therapy. Dig Dis Sci 2023:10.1007/s10620-023-07950-0. [PMID: 37131100 DOI: 10.1007/s10620-023-07950-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/16/2022] [Accepted: 04/06/2023] [Indexed: 05/04/2023]
Abstract
BACKGROUND Outpatient visits and laboratory assessments are routinely scheduled every 3 to 4 months in thiopurine-treated patients with inflammatory bowel disease (IBD) to timely detect thiopurine-related adverse events (AEs). AEs that require therapy adjustment beyond 12 months of treatment are rare. AIM AND METHODS This single-center prospective cohort study evaluated the safety of a reduced 6-monthly monitoring strategy in steroid-free patients with quiescent IBD on stable dose of azathioprine, mercaptopurine, or thioguanine monotherapy. The primary outcome was thiopurine-related AEs requiring therapy adjustments during a follow-up period of 24 months. Secondary outcomes included all AEs including laboratory toxicity, disease flares until 12 months, and the net monetary benefit from this strategy concerning IBD-related health care use. RESULTS We enrolled 85 patients with IBD (median age 42 years, 61% Crohn's disease, 62% female), with a median disease duration of 12.5 years and median thiopurine treatment duration of 6.7 years. During follow-up, 3 patients (4%) ceased thiopurines due to AEs: recurrent infections, non-melanoma skin cancer, and gastrointestinal complaints (nausea, vomiting). At 12 months, 25 laboratory toxicities were observed (including 13% myelotoxicity, 17% hepatotoxicity); none required therapy adjustments and all were transient. A reduced monitoring strategy had a net benefit of €136 per patient. CONCLUSION Three patients (4%) ceased thiopurine therapy due to thiopurine-related AEs, while no laboratory toxicity required therapy adjustments. Monitoring frequency of every 6 months seems feasible in patients with stable IBD on long-term (median duration > 6 years) maintenance thiopurine therapy and may contribute to reduced patient-burden and health care costs.
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Affiliation(s)
- Fenna M Jansen
- Department of Gastroenterology and Hepatology, Radboud University Medical Center, Nijmegen, The Netherlands.
| | - Lisa J T Smits
- Department of Gastroenterology and Hepatology, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Pepijn W A Thomas
- Department of Gastroenterology and Hepatology, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Dirk J de Jong
- Department of Gastroenterology and Hepatology, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Joany E Kreijne
- Department of Gastroenterology and Hepatology, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Willemijn A van Dop
- Department of Gastroenterology and Hepatology, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Nathan den Broeder
- Department of Gastroenterology and Hepatology, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Frank Hoentjen
- Department of Gastroenterology and Hepatology, Radboud University Medical Center, Nijmegen, The Netherlands
- Division of Gastroenterology, Department of Medicine, University of Alberta, Edmonton, Canada
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Dickson AL, Daniel LL, Jackson E, Zanussi J, Yang W, Plummer WD, Dupont WD, Wei WQ, Nepal P, Hung AM, Cox NJ, Van Driest SL, Feng Q, Yang JJ, Stein CM, Mosley JD, Chung CP. Race, Genotype, and Azathioprine Discontinuation : A Cohort Study. Ann Intern Med 2022; 175:1092-1099. [PMID: 35724382 PMCID: PMC9378477 DOI: 10.7326/m21-4675] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023] Open
Abstract
BACKGROUND Thiopurines are an important class of immunosuppressants despite their risk for hematopoietic toxicity and narrow therapeutic indices. Benign neutropenia related to an ACKR1 variant (rs2814778-CC) is common among persons of African ancestries. OBJECTIVE To test whether rs2814778-CC was associated with azathioprine discontinuation attributed to hematopoietic toxicity and lower thiopurine dosing. DESIGN Retrospective cohort study. SETTING Two tertiary care centers. PATIENTS Thiopurine users with White or Black race. MEASUREMENTS Azathioprine discontinuation attributed to hematopoietic toxicity. Secondary outcomes included weight-adjusted final dose, leukocyte count, and change in leukocyte count. RESULTS The rate of azathioprine discontinuation attributed to hematopoietic toxicity was 3.92 per 100 person-years among patients with the CC genotype (n = 101) and 1.34 per 100 person-years among those with the TT or TC genotype (n = 1365) (hazard ratio [HR] from competing-risk model, 2.92 [95% CI, 1.57 to 5.41]). The risk remained significant after adjustment for race (HR, 2.61 [CI, 1.01 to 6.71]). The risk associated with race alone (HR, 2.13 [CI, 1.21 to 3.75]) was abrogated by adjustment for genotype (HR, 1.13 [CI, 0.48 to 2.69]). Lower last leukocyte count and lower dosing were significant among patients with the CC genotype. Lower dosing was validated in an external cohort of 94 children of African ancestries prescribed the thiopurine 6-mercaptopurine (6-MP) for acute lymphoblastic leukemia. The CC genotype was independently associated with lower 6-MP dose intensity relative to the target daily dose of 75 mg/m2 (median, 0.83 [IQR, 0.70 to 0.94] for the CC genotype vs. 0.94 [IQR, 0.72 to 1.13] for the TT or TC genotype; P = 0.013). LIMITATIONS Unmeasured confounding; data limited to tertiary centers. CONCLUSION Patients with the CC genotype had higher risk for azathioprine discontinuation attributed to hematopoietic toxicity and lower thiopurine doses. Genotype was associated with those risks, even after adjustment for race. PRIMARY FUNDING SOURCE National Institutes of Health.
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Affiliation(s)
- Alyson L Dickson
- Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee (A.L.D., L.L.D., E.J., J.Z., P.N., A.M.H., N.J.C., Q.F., C.M.S., C.P.C.)
| | - Laura L Daniel
- Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee (A.L.D., L.L.D., E.J., J.Z., P.N., A.M.H., N.J.C., Q.F., C.M.S., C.P.C.)
| | - Elise Jackson
- Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee (A.L.D., L.L.D., E.J., J.Z., P.N., A.M.H., N.J.C., Q.F., C.M.S., C.P.C.)
| | - Jacy Zanussi
- Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee (A.L.D., L.L.D., E.J., J.Z., P.N., A.M.H., N.J.C., Q.F., C.M.S., C.P.C.)
| | - Wenjian Yang
- Pharmacy and Pharmaceutical Sciences Department, St. Jude Children's Research Hospital, Memphis, Tennessee (W.Y., J.J.Y.)
| | - W Dale Plummer
- Department of Biostatistics, Vanderbilt University Medical Center, Nashville, Tennessee (W.D.P., W.D.D.)
| | - William D Dupont
- Department of Biostatistics, Vanderbilt University Medical Center, Nashville, Tennessee (W.D.P., W.D.D.)
| | - Wei-Qi Wei
- Department of Biomedical Informatics, Vanderbilt University Medical Center, Nashville, Tennessee (W.W.)
| | - Puran Nepal
- Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee (A.L.D., L.L.D., E.J., J.Z., P.N., A.M.H., N.J.C., Q.F., C.M.S., C.P.C.)
| | - Adriana M Hung
- Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee (A.L.D., L.L.D., E.J., J.Z., P.N., A.M.H., N.J.C., Q.F., C.M.S., C.P.C.)
| | - Nancy J Cox
- Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee (A.L.D., L.L.D., E.J., J.Z., P.N., A.M.H., N.J.C., Q.F., C.M.S., C.P.C.)
| | - Sara L Van Driest
- Departments of Medicine and Pediatrics, Vanderbilt University Medical Center, Nashville, Tennessee (S.L.V.)
| | - QiPing Feng
- Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee (A.L.D., L.L.D., E.J., J.Z., P.N., A.M.H., N.J.C., Q.F., C.M.S., C.P.C.)
| | - Jun J Yang
- Pharmacy and Pharmaceutical Sciences Department, St. Jude Children's Research Hospital, Memphis, Tennessee (W.Y., J.J.Y.)
| | - C Michael Stein
- Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee (A.L.D., L.L.D., E.J., J.Z., P.N., A.M.H., N.J.C., Q.F., C.M.S., C.P.C.)
| | - Jonathan D Mosley
- Departments of Medicine and Biomedical Informatics, Vanderbilt University Medical Center, Nashville, Tennessee (J.D.M.)
| | - Cecilia P Chung
- Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee (A.L.D., L.L.D., E.J., J.Z., P.N., A.M.H., N.J.C., Q.F., C.M.S., C.P.C.)
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10
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Zhou X, Cheng L, Wang Y, Gou H, Ju K, Lan T, Zhan T, Li G, Gu Y, Sun Y, Xu Y, Sun Y, Zhou Y, Li W. Effect of NUDT15 polymorphisms on early hematological safety of low-dose azathioprine in Chinese patients with pemphigus vulgaris: A prospective cohort study. J Dermatol 2021; 49:402-410. [PMID: 34866237 PMCID: PMC9299774 DOI: 10.1111/1346-8138.16265] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2021] [Revised: 11/18/2021] [Accepted: 11/19/2021] [Indexed: 02/05/2023]
Abstract
Azathioprine (AZA) is the preferred immunosuppressant for treating pemphigus vulgaris (PV), with discontinuation mainly attributed to hematological adverse events (AE). Reportedly, nucleoside diphosphate‐linked moiety X‐type motif 15 (NUDT15) polymorphisms have been strongly associated with thiopurine‐induced leukopenia. To investigate hematological AE of low‐dose AZA based on NUDT15 genotypes among patients with PV, a prospective cohort study was conducted in patients with PV, followed‐up for the first 8 weeks after AZA administration. All patients were divided into wild homozygous and heterozygous NUDT15 groups. Both groups initiated AZA at low dose (50 mg/day) and continued with different dose‐escalating approaches. Bone marrow suppression was considered the principal outcome. Overall, 62 patients with PV were enrolled (48 in the wild homozygous NUDT15 group vs. 14 in the heterozygous NUDT15 group). Except for median maintenance doses of AZA, no statistically significant differences were observed between the two groups in terms of age, sex, white blood cells, neutrophil count, platelet count, hemoglobin level, median final doses of corticosteroids (mg prednisone equivalent), pemphigus disease area index, and anti‐desmoglein 1/3 autoantibodies. In both groups, patients presented similar hematological AE and treatment responses after administration of different low‐dose AZA treatment strategies. Low‐dose AZA based on NUDT15 genotypes can reduce the risk of early hematological AE among patients with PV.
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Affiliation(s)
- Xingli Zhou
- Department of Dermatology, Rare Diseases Center, West China Hospital, Sichuan University, Chengdu, China
| | - Liangliang Cheng
- School of Public Health, Sun Yat-Sen University, Guangzhou, China
| | - Yiyi Wang
- Department of Dermatology, Rare Diseases Center, West China Hospital, Sichuan University, Chengdu, China
| | - Hui Gou
- Department of Dermatology, Rare Diseases Center, West China Hospital, Sichuan University, Chengdu, China
| | - Ke Ju
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia.,West China School of Public Health and West China Fourth Hospital, Sichuan University, Chengdu, China
| | - TianJiao Lan
- West China School of Public Health and West China Fourth Hospital, Sichuan University, Chengdu, China
| | - Tongying Zhan
- Department of Dermatology, Rare Diseases Center, West China Hospital, Sichuan University, Chengdu, China
| | - GaoJie Li
- Department of Dermatology, Rare Diseases Center, West China Hospital, Sichuan University, Chengdu, China
| | - Yuanxia Gu
- Department of Dermatology, Rare Diseases Center, West China Hospital, Sichuan University, Chengdu, China
| | - Yeting Sun
- West China School of Medicine, West China Hospital, Sichuan University, Chengdu, China
| | - Yan Xu
- West China School of Medicine, West China Hospital, Sichuan University, Chengdu, China
| | - Yukun Sun
- West China School of Medicine, West China Hospital, Sichuan University, Chengdu, China
| | - Yanhong Zhou
- Department of Laboratory Medicine, West China Hospital, Sichuan University, Chengdu, China
| | - Wei Li
- Department of Dermatology, Rare Diseases Center, West China Hospital, Sichuan University, Chengdu, China
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11
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Wu Y, Tan Y, Ou D, Wang X, Wang Y. Azathioprine-induced toxoplasma gondii infection in a patient with Crohn's disease with NUDT15 variation: A case report. Medicine (Baltimore) 2021; 100:e25781. [PMID: 33950972 PMCID: PMC8104275 DOI: 10.1097/md.0000000000025781] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/11/2021] [Accepted: 04/15/2021] [Indexed: 01/04/2023] Open
Abstract
INTRODUCTION Azathioprine (AZA) has been widely used for the treatment of various immune-related diseases and has become a mainstay in the treatment of inflammatory bowel disease. However, patients with genetic mutations may experience severe adverse events when treated with azathioprine. Most of the previous literature focused on the TPMP gene-related adverse reactions, herein, we report a case of Crohn's disease patient with nucleoside diphosphate-linked moiety X motif 15 gene (NUDT15) variation and wild-type TPMP gene who developed toxoplasma gondii infection after azathioprine treatment. PATIENT CONCERNS A 56-year-old Crohn's disease patient developed toxoplasma gondii infection within 2 months after the administration of azathioprine; however, he had no relevant high-risk factors. DIAGNOSIS Subsequent genetic testing revealed that the patient was heterozygous for NUDT15. Therefore, it was reasonable to consider that the patient's genetic mutation resulted in reduced tolerance to azathioprine, leading to low immunity and eventually toxoplasma infection. INTERVENTIONS AZA was then discontinued; after anti-infection, antipyretic and other supportive treatments were administered, the patient's condition gradually improved. OUTCOMES The patient was followed up at 1, 3, and 6 months after discharge; fortunately, he was in good health. CONCLUSION We report a case of Crohn's disease in a patient who developed severe pneumonia caused by toxoplasma gondii infection due to the administration of AZA, with normal TPMP gene but NUDT15 gene mutation. This indicates that NUDT15 variation may contribute to severe adverse events in patients treated with azathioprine, and we suggest that NUDT15 genotype be detected before the use of azathioprine in order to provide personalized therapy and reduce side effects.
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Affiliation(s)
- Yanan Wu
- Department of Gastroenterology, The Second Xiangya Hospital
- Research Center of Digestive Disease, Central South University, Changsha, Hunan 410011, China
| | - Yuyong Tan
- Department of Gastroenterology, The Second Xiangya Hospital
- Research Center of Digestive Disease, Central South University, Changsha, Hunan 410011, China
| | - Dalian Ou
- Department of Gastroenterology, The Second Xiangya Hospital
- Research Center of Digestive Disease, Central South University, Changsha, Hunan 410011, China
| | - Xuehong Wang
- Department of Gastroenterology, The Second Xiangya Hospital
- Research Center of Digestive Disease, Central South University, Changsha, Hunan 410011, China
| | - Yongjun Wang
- Department of Gastroenterology, The Second Xiangya Hospital
- Research Center of Digestive Disease, Central South University, Changsha, Hunan 410011, China
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12
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Jena A, Jha DK, Kumar-M P, Kasudhan KS, Kumar A, Sarwal D, Mishra S, Singh AK, Bhatia P, Patil A, Sharma V. Prevalence of polymorphisms in thiopurine metabolism and association with adverse outcomes: a South Asian region-specific systematic review and meta-analysis. Expert Rev Clin Pharmacol 2021; 14:491-501. [PMID: 33682590 DOI: 10.1080/17512433.2021.1900729] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Background: Prevalence and impact of thiopurine S-methyltransferase (TPMT) and Nudix hydrolase (NUDT15) minor allele frequencies in South Asian population is unclear.Methods: We searched PubMed and Embase with keywords-TPMT and NUDT15 combined with South Asian countries. We included studies reporting frequency of TPMT and NUDT15 polymorphisms. We estimated the pooled prevalence of TPMT and NUDT15 polymorphisms and their impact on pooled odds ratio of adverse events with thiopurines.Results: We included 26 studies in our analysis. The pooled prevalence of NUDT15 and TPMT polymorphisms was 16.5% (95% CI: 13.09-20.58) and 4.57% (95% CI: 3.66-5.68), respectively. In patients with adverse effects, the pooled prevalence of NUDT15 and TPMT polymorphism was 49.51% (95% C.I. 21.69-77.64) and 9.47% (95% C.I. 5.39-16.11), respectively. The odds ratio (OR) of adverse events with presence of TPMT polymorphisms was 3.65 (95% C.I., 1.43-9.28). The pooled OR for adverse events in presence of NUDT15 polymorphism was 12.63 (95% C.I., 3.68-43.26).Conclusion: NUDT15 were reported more frequently than the TPMT polymorphisms in South Asian population and were more frequently associated with adverse events. These findings may have implications for preemptive testing amongst South Asian population and immigrants prior to starting thiopurines.
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Affiliation(s)
- Anuraag Jena
- Department of Gastroenterology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Daya Krishna Jha
- Department of Gastroenterology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Praveen Kumar-M
- Department of Pharmacology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Kripa Shanker Kasudhan
- Department of Pharmacology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Ankit Kumar
- Department of Pharmacology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Dhruv Sarwal
- Government Medical College and hospital- Sector 32, Ex-intern, Chandigarh, India
| | - Shubhra Mishra
- Department of Gastroenterology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Anupam Kumar Singh
- Department of Gastroenterology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Prateek Bhatia
- Department of Pediatrics, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Amol Patil
- Department of Pharmacology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Vishal Sharma
- Department of Gastroenterology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
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13
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Rosdiana DS, Setiabudy R, Andalusia R, Gatot D, Louisa M, Bardosono S, Instiaty I. TPMT Genetic Variability and Its Association with Hematotoxicity in Indonesian Children with Acute Lymphoblastic Leukemia in Maintenance Therapy. Pharmgenomics Pers Med 2021; 14:199-210. [PMID: 33568932 PMCID: PMC7868246 DOI: 10.2147/pgpm.s288988] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2020] [Accepted: 12/29/2020] [Indexed: 11/23/2022] Open
Abstract
PURPOSE Hematotoxicity monitoring in children with acute lymphoblastic leukemia (ALL) is critical to preventing life-threatening infections and drug discontinuation. The primary drug that causes hematotoxicity in ALL children is 6-mercaptopurine (6-MP). Genetic variability of the drug-metabolizing enzymes of 6-MP, thiopurine S-methyltransferase (TPMT), is one factor that might increase the susceptibility of children to hematotoxicity. The present study aimed to determine the variability in TPMT genotypes and phenotypes and its association with the occurrence of hematotoxicity in ALL children in maintenance therapy. PATIENTS AND METHODS A cross-sectional study was conducted at Cipto Mangunkusumo and Dharmais National Cancer Hospital, Jakarta, Indonesia, from June 2017 to October 2018. We included ALL patients, 1-18 years, who were receiving at least one month of 6-MP during maintenance therapy according to the Indonesian protocol for ALL 2013. Direct sequencing was used to determine TPMT*3A, *3B, and *3C genotypes, and LC-MS/MS analysis was performed to measure the plasma concentrations of 6-MP and its metabolites. Association analysis between the TPMT genotype and hematotoxicity was evaluated using the unpaired t-test or Mann-Whitney's test. RESULTS The prevalence of neutropenia, anemia, and thrombocytopenia in ALL children during maintenance therapy was 51.9%, 44.3%, and 6.6%, respectively. We found a low frequency of TPMT*3C, which is 0.95%. No association was found between hematotoxicity and TPMT genotypes or age, nutritional status, serum albumin levels, risk stratification, the daily dose of 6-MP, and cotrimoxazole co-administration. However, hematotoxicity was associated with 6-methylmercaptopurine (6-MeMP) plasma concentrations and the ratio 6-MeMP/6-thioguanine (6-TGN). We also found no association between TPMT genotypes and TPMT phenotypes. CONCLUSION The 6-MeMP/6-TGN ratio is associated with hematotoxicity in ALL children during maintenance therapy but is not strong enough to predict hematotoxicity.
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Affiliation(s)
- Dewi Selvina Rosdiana
- Department of Pharmacology and Therapeutics, Faculty of Medicine, Universitas Indonesia, Jakarta, Indonesia
| | - Rianto Setiabudy
- Department of Pharmacology and Therapeutics, Faculty of Medicine, Universitas Indonesia, Jakarta, Indonesia
| | - Rizka Andalusia
- Dharmais National Cancer Hospital, Jakarta, Indonesia
- Drug Registration Directorate, National Agency for Drug and Food Control, Jakarta, Indonesia
| | - Djajadiman Gatot
- Division of Hematology-Oncology, Department of Pediatrics, Faculty of Medicine, Universitas Indonesia/Cipto Mangunkusumo Hospital, Jakarta, Indonesia
| | - Melva Louisa
- Department of Pharmacology and Therapeutics, Faculty of Medicine, Universitas Indonesia, Jakarta, Indonesia
| | - Saptawati Bardosono
- Department of Nutrition, Faculty of Medicine, University of Indonesia, Jakarta, Indonesia
| | - Instiaty Instiaty
- Department of Pharmacology and Therapeutics, Faculty of Medicine, Universitas Indonesia, Jakarta, Indonesia
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14
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Zalizko P, Stefanovics J, Sokolovska J, Paramonova N, Klavina E, Erts R, Rovite V, Klovins J, Pukitis A. Thiopurine S-methyltransferase genetic polymorphisms in adult patients with inflammatory bowel diseases in the Latvian population. Therap Adv Gastroenterol 2020; 13:1756284820937426. [PMID: 32704308 PMCID: PMC7361485 DOI: 10.1177/1756284820937426] [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: 08/18/2019] [Accepted: 05/29/2020] [Indexed: 02/04/2023] Open
Abstract
BACKGROUND Thiopurine methyltransferase (TPMT) plays a significant role in the metabolism of thiopurines, and, for patients with inflammatory bowel disease (IBD), it is useful to perform TPMT genotyping prior to azathioprine (AZA) treatment. In this study, we determined TPMT gene polymorphisms in a cohort of IBD patients in Latvia. METHODS DNA samples were obtained from 244 IBD patients, and qPCR was performed for detection of rs1800462, rs1800460, and rs1142345 single-nucleotide polymorphisms (SNPs). Three common, non-functional TPMT alleles (TPMT*2, *3B, and *3C) were identified (women, 51%; men, 49%). TPMT*2, *3A, *3B, and *3C allelic variants detected using qPCR were consistent with restriction fragment length polymorphism (RFLP) data. RESULTS Among patients, 78% had ulcerative colitis and 22% had Crohn's disease, with 93.9% of the former carrying a wild-type homozygous TPMT*1/*1 genotype and 6.1% carrying heterozygous genotypes. The most frequent polymorphisms were TPMT*1/*3A (5.3%: two variants: TPMT*3B and TPMT*3C), TPMT*1/*3C (0.4%), and TPMT*1/*2 (0.4%). None of the patients carried a TPMT*3B polymorphism and no patients were homozygous for any mutation. CONCLUSION This is the first study to identify TPMT gene polymorphisms in adult IBD patients in Latvia. The results indicate that the frequency of common TPMT alleles is similar to that of other European populations.
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Affiliation(s)
| | - Juris Stefanovics
- Pauls Stradins Clinical University Hospital, Riga, Latvia
- Faculty of Medicine, Laboratory of Personalized Medicine, University of Latvia, Riga, Latvia
| | - Jelizaveta Sokolovska
- Faculty of Medicine, Laboratory of Personalized Medicine, University of Latvia, Riga, Latvia
| | - Natalia Paramonova
- Genomics and Bioinformatics, Institute of Biology of the University of Latvia, Salaspils, Latvia
| | - Evija Klavina
- Pauls Stradins Clinical University Hospital, Riga, Latvia
| | - Renars Erts
- Faculty of Medicine, University of Latvia, Riga, Latvia
| | - Vita Rovite
- Latvian Biomedical Research and Study Centre, Riga, Latvia
| | - Janis Klovins
- Latvian Biomedical Research and Study Centre, Riga, Latvia
| | - Aldis Pukitis
- Pauls Stradins Clinical University Hospital, Riga, Latvia
- Faculty of Medicine, University of Latvia, Riga, Latvia
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Thiopurines' Metabolites and Drug Toxicity: A Meta-Analysis. J Clin Med 2020; 9:jcm9072216. [PMID: 32668748 PMCID: PMC7408995 DOI: 10.3390/jcm9072216] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2020] [Revised: 07/06/2020] [Accepted: 07/09/2020] [Indexed: 12/13/2022] Open
Abstract
Many questions remain unanswered regarding therapeutic drug monitoring (TDM) utility with thiopurines. This study aims to establish a relationship between thiopurines' metabolites and drug toxicity. We performed a systematic review with inclusion of studies evaluating the relationship between thiopurines' metabolites and drug toxicity. Meta-analysis of mean difference (MD), correlations and odds ratio (OR) was performed. We identified 21,240 records, 72 of which were eligible for meta-analysis. Levels of 6-thioguanine nucleotides (6-TGN) were higher in patients with leukopenia (MD 127.06 pmol/8 × 108 RBC) and gastrointestinal intolerance (MD 201.46 pmol/8 × 108 RBC), and lower in patients with hepatotoxicity (MD -40.6 pmol × 108 RBC). We established a significant correlation between 6-TGN and leukocytes (r = -0.21), neutrophils (r = -0.24) and alanine aminotransferase levels (r = -0.24). OR for leukopenia in patients with elevated 6-TGN was 4.63 (95%CI 2.24; 9.57). An optimal cut-off of 135 pmol/8 × 108 RBC for leukopenia was calculated (sensitivity 75.4%; specificity 46.4%). 6-methylmercaptopurine ribonucleotides (6-MMPR) were significantly associated with hepatotoxicity (MD 3241.2 pmol/8 × 108 RBC; OR 4.28; 95%CI 3.20; 5.71). Levels of 6-MMPR measured in the first 8 weeks of treatment were associated with leukopenia. We conclude that TDM could be used to prevent thiopurines' toxicity. As optimal metabolites level may vary according to indication, physicians may adapt posology to decrease toxicity without compromising efficacy.
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Daniel LL, Dickson AL, Chung CP. Precision medicine for rheumatologists: lessons from the pharmacogenomics of azathioprine. Clin Rheumatol 2020; 40:65-73. [PMID: 32617765 DOI: 10.1007/s10067-020-05258-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2020] [Revised: 06/16/2020] [Accepted: 06/22/2020] [Indexed: 12/13/2022]
Abstract
Precision medicine aims to personalize treatment for both effectiveness and safety. As a critical component of this emerging initiative, pharmacogenomics seeks to guide drug treatment based on genetics. In this review article, we give an overview of pharmacogenomics in the setting of an immunosuppressant frequently prescribed by rheumatologists, azathioprine. Azathioprine has a narrow therapeutic index and a high risk of adverse events. By applying candidate gene analysis and unbiased approaches, researchers have identified multiple variants associated with an increased risk for adverse events associated with azathioprine, particularly bone marrow suppression. Variants in two genes, TPMT and NUDT15, are widely recognized, leading drug regulatory agencies and professional organizations to adopt recommendations for testing before initiation of azathioprine therapy. As more gene-drug interactions are discovered, our field will continue to face the challenge of balancing benefits and costs associated with genetic testing. However, novel approaches in genomics and the integration of clinical and genetic factors into risk scores offer unprecedented opportunities for the application of pharmacogenomics in routine practice. Key Points • Pharmacogenomics can help us understand how individuals' genetics may impact their response to medications. • Azathioprine is a success story for the clinical implementation of pharmacogenomics, particularly the effects of TPMT and NUDT15 variants on myelosuppression. • As our knowledge advances, testing and dosing recommendations will continue to evolve, with our field striving to balance costs and benefits to patients. • As we aim toward the goals of precision medicine, future research may integrate increasingly individualized traits-including clinical and genetic characteristics-to predict the safety and efficacy of particular medications for individual patients.
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Affiliation(s)
- Laura L Daniel
- Department of Medicine, Division of Rheumatology, Vanderbilt University Medical Center (LLD, ALD, CPC), Nashville, TN, 37232, USA
| | - Alyson L Dickson
- Department of Medicine, Division of Rheumatology, Vanderbilt University Medical Center (LLD, ALD, CPC), Nashville, TN, 37232, USA
| | - Cecilia P Chung
- Department of Medicine, Division of Rheumatology, Vanderbilt University Medical Center (LLD, ALD, CPC), Nashville, TN, 37232, USA. .,Tennessee Valley Healthcare System-Nashville Campus (CPC), Nashville, TN, USA. .,Vanderbilt Genetics Institute, Vanderbilt University School of Medicine (CPC), Nashville, TN, USA.
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17
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Combining clinical and candidate gene data into a risk score for azathioprine-associated leukopenia in routine clinical practice. THE PHARMACOGENOMICS JOURNAL 2020; 20:736-745. [PMID: 32054992 PMCID: PMC7426242 DOI: 10.1038/s41397-020-0163-4] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/04/2019] [Revised: 01/22/2020] [Accepted: 01/30/2020] [Indexed: 02/06/2023]
Abstract
Leukopenia is a serious, frequent side effect associated with azathioprine use. Currently, we use thiopurine methyltransferase (TPMT) testing to predict leukopenia in patients taking azathioprine. We hypothesized that a risk score incorporating additional clinical and genetic variables would improve the prediction of azathioprine-associated leukopenia. In the discovery phase, we developed four risk score models: (1) age, sex, and TPMT metabolizer status; (2) model 1 plus additional clinical variables; (3) sixty candidate single nucleotide polymorphisms; and (4) model 2 plus model 3. The area under the receiver-operating-characteristic curve (AUC) of the risk scores was 0.59 (95%CI: 0.54-0.64), 0.75 (0.71-0.80), 0.66 (0.61-0.71), and 0.78 (0.74-0.82) for models one, two, three and four, respectively. During the replication phase, models two and four (AUC=0.64, 95%CI: 0.59-0.70 and AUC=0.63, 95%CI: 0.58-0.69, respectively) were significant in an independent group. Compared to TPMT testing alone, additional genetic and clinical variables improve the prediction of azathioprine-associated leukopenia.
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Lorenzoni PJ, Kay CSK, Zanlorenzi MF, Ducci RDP, Werneck LC, Scola RH. Myasthenia gravis and azathioprine treatment: Adverse events related to thiopurine S-methyl-transferase (TPMT) polymorphisms. J Neurol Sci 2020; 412:116734. [PMID: 32070863 DOI: 10.1016/j.jns.2020.116734] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2019] [Revised: 01/30/2020] [Accepted: 02/11/2020] [Indexed: 02/07/2023]
Abstract
Azathioprine (AZA) is the most common immunosuppressive drug used to treat myasthenia gravis (MG). To analyses the prevalence of thiopurine S-methyl-transferase (TPMT) genotypes and their association with adverse events due to azathioprine therapy in MG patients. Allele-specific polymerase chain reaction (PCR) and PCR with restriction fragment length polymorphism (RFLP) analysis were carried out to determine the prevalence of the most common TPMT genotypes (*2, *3A, *3B and *3C) in 50 MG patients from Southern Brazilian. The frequency of adverse reactions due to azathioprine therapy was analysed and correlated with different genotypes groups. The prevalence of TPMT gene variants was 12%. The allelic frequency of variant TPMT*2 (C238G), TPMT*3A (G460A/A719G), TPMT*3B (G460A), and TPMT*3C (A719G) genotypes was 1, 3, 2 and 1%, respectively. Adverse events occurred in 44%, of MG patients, of which 86% were minor and 14% were major. One patient, who presented a major adverse event (bone marrow suppression), was homozygous for the TPMT*3A genotype. Our study estimated the prevalence of TPMT genotypes for Brazilian MG patients. The profile of TPMT genotypes was different from other Brazilian populations. Hardy-Weinberg equilibrium and allelic frequencies of TPMT*3A and TPMT*3B, respectively, were different than expected, a finding that suggests a possible founder effect. Major adverse events were statistically significant for TPMT genotypes compared to wild-type. Although TPMT genotype has been associated with AZA-related adverse events, since no statistically significant difference among wild-type and other TPMT genotypes for minor adverse events, our study supports the view that TPMT genotype alone is not enough to adequately personalise the AZA therapy in MG patients. In conclusion, these results were important to characterise the prevalence of TPMT gene variants in MG patients treated with AZA and correlate the adverse events of this therapy in a real-world outpatient clinic from Southern Brazil.
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Affiliation(s)
- Paulo José Lorenzoni
- Service of Neuromuscular Disorders, Division of Neurology, Department of Internal Medicine, Hospital de Clínicas, Universidade Federal do Paraná (UFPR), Curitiba, Brazil.
| | - Cláudia Suemi Kamoi Kay
- Service of Neuromuscular Disorders, Division of Neurology, Department of Internal Medicine, Hospital de Clínicas, Universidade Federal do Paraná (UFPR), Curitiba, Brazil
| | - Marcelo Farago Zanlorenzi
- Service of Neuromuscular Disorders, Division of Neurology, Department of Internal Medicine, Hospital de Clínicas, Universidade Federal do Paraná (UFPR), Curitiba, Brazil
| | - Renata Dal-Prá Ducci
- Service of Neuromuscular Disorders, Division of Neurology, Department of Internal Medicine, Hospital de Clínicas, Universidade Federal do Paraná (UFPR), Curitiba, Brazil
| | - Lineu Cesar Werneck
- Service of Neuromuscular Disorders, Division of Neurology, Department of Internal Medicine, Hospital de Clínicas, Universidade Federal do Paraná (UFPR), Curitiba, Brazil
| | - Rosana Herminia Scola
- Service of Neuromuscular Disorders, Division of Neurology, Department of Internal Medicine, Hospital de Clínicas, Universidade Federal do Paraná (UFPR), Curitiba, Brazil
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20
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Wisniewski A, Kirchgesner J, Seksik P, Landman C, Bourrier A, Nion-Larmurier I, Marteau P, Cosnes J, Sokol H, Beaugerie L. Increased incidence of systemic serious viral infections in patients with inflammatory bowel disease associates with active disease and use of thiopurines. United European Gastroenterol J 2019; 8:303-313. [PMID: 32529821 DOI: 10.1177/2050640619889763] [Citation(s) in RCA: 65] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
Background The magnitude and drivers of the risk of serious viral infections in Inflammatory Bowel diseases (IBD) are unclear. Objective The objective of this study was to assess the incidence and risk factors for systemic serious viral infections in IBD patients. Methods Using MICISTA, a database detailing prospective characteristics and complications of IBD, we identified patients that were followed for IBD in 2005-2014 outside the context of organ transplantation, HIV infection or chronic viral hepatitis. We estimated incidences of systemic serious viral infections, defined by the need for hospitalization or permanent organ damage. Standardized incidence ratios (SIRs) were calculated using the French hospital database. We performed a case-control study nested in MICISTA for assessing the role of exposure to IBD drugs and IBD clinical activity in the risk of developing infection. Results We identified 31 patients with serious viral infections among 2645 patients followed for 15,383 person-years. We observed 13 cases of cytomegalovirus, 10 Epstein-Barr virus, 5 varicella zoster virus and 3 herpes simplex virus infections. No deaths occurred. The incidence rate of infections in patients with IBD was 2.02/1000 person-years, and the SIR was 3.09 (95% confidence interval (CI), 1.98-4.20; p = 0.0002) in the study population. By multivariate analysis, increased risk of infection was associated with exposure to thiopurines (odds ratio (OR), 3.48; 95% CI, 1.36-8.90; p = 0.009), and clinically active IBD at onset of infection (OR, 3.35; 95% CI, 1.23-9.23; p = 0.02). Conclusions The incidence of systemic serious viral infections in patients with IBD is tripled compared to general population. Clinically active IBD and exposure to thiopurines are the main drivers of the risk.
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Affiliation(s)
- Andrew Wisniewski
- Gastroenterology Department of Charles-Lemoyne hospital, Université de Sherbrooke, Montréal, Canada
| | - Julien Kirchgesner
- Department of Gastroenterology, INSERM, Institut Pierre Louis d'Epidémiologie et de Santé Publique, Sorbonne Université, AP-HP Hôpital Saint-Antoine, Paris, France
| | - Philippe Seksik
- Department of Gastroenterology, INSERM, Centre de recherche Saint-Antoine, Sorbonne Université, AP-HP Hôpital Saint-Antoine, Paris, France
| | - Cécilia Landman
- Department of Gastroenterology, AP-HP Hôpital Saint-Antoine, Paris, France
| | - Anne Bourrier
- Department of Gastroenterology, INSERM, Centre de recherche Saint-Antoine, Sorbonne Université, AP-HP Hôpital Saint-Antoine, Paris, France
| | | | - Philippe Marteau
- Department of Liver Diseases, INSERM, Centre de recherche Saint-Antoine, Sorbonne Université, AP-HP Hôpital Saint-Antoine, Paris, France
| | - Jacques Cosnes
- Department of Gastroenterology, AP-HP Hôpital Saint-Antoine, Paris, France
| | - Harry Sokol
- Department of Liver Diseases, INSERM, Centre de recherche Saint-Antoine, Sorbonne Université, AP-HP Hôpital Saint-Antoine, Paris, France
| | - Laurent Beaugerie
- Department of Gastroenterology, INSERM, Institut Pierre Louis d'Epidémiologie et de Santé Publique, Sorbonne Université, AP-HP Hôpital Saint-Antoine, Paris, France
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Derijks LJJ, Wong DR, Hommes DW, van Bodegraven AA. Clinical Pharmacokinetic and Pharmacodynamic Considerations in the Treatment of Inflammatory Bowel Disease. Clin Pharmacokinet 2019; 57:1075-1106. [PMID: 29512050 DOI: 10.1007/s40262-018-0639-4] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
According to recent clinical consensus, pharmacotherapy of inflammatory bowel disease (IBD) is, or should be, personalized medicine. IBD treatment is complex, with highly different treatment classes and relatively few data on treatment strategy. Although thorough evidence-based international IBD guidelines currently exist, appropriate drug and dose choice remains challenging as many disease (disease type, location of disease, disease activity and course, extraintestinal manifestations, complications) and patient characteristics [(pharmaco-)genetic predisposition, response to previous medications, side-effect profile, necessary onset of response, convenience, concurrent therapy, adherence to (maintenance) therapy] are involved. Detailed pharmacological knowledge of the IBD drug arsenal is essential for choosing the right drug, in the right dose, in the right administration form, at the right time, for each individual patient. In this in-depth review, clinical pharmacodynamic and pharmacokinetic considerations are provided for tailoring treatment with the most common IBD drugs. Development (with consequent prospective validation) of easy-to-use treatment algorithms based on these considerations and new pharmacological data may facilitate optimal and effective IBD treatment, preferably corroborated by effectiveness and safety registries.
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Affiliation(s)
- Luc J J Derijks
- Department of Clinical Pharmacy and Pharmacology, Máxima Medical Center, PO Box 7777, 5500 MB, Veldhoven, The Netherlands.
| | - Dennis R Wong
- Department of Clinical Pharmacy, Pharmacology and Toxicology, Zuyderland Medical Center, Sittard-Geleen, The Netherlands
| | - Daniel W Hommes
- Center for Inflammatory Bowel Diseases, UCLA, Los Angeles, CA, USA
| | - Adriaan A van Bodegraven
- Department of Gastroenterology, Zuyderland Medical Center, Sittard-Geleen, The Netherlands
- Department of Gastroenterology, VU University Medical Center, Amsterdam, The Netherlands
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22
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van Gennep S, Konté K, Meijer B, Heymans MW, D'Haens GR, Löwenberg M, de Boer NKH. Systematic review with meta-analysis: risk factors for thiopurine-induced leukopenia in IBD. Aliment Pharmacol Ther 2019; 50:484-506. [PMID: 31342537 DOI: 10.1111/apt.15403] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/31/2018] [Revised: 02/02/2019] [Accepted: 06/16/2019] [Indexed: 12/11/2022]
Abstract
BACKGROUND Thiopurine-induced leukopenia, a frequently observed and potentially life-threatening adverse event, complicates the clinical management of IBD patients. AIM To assess risk factors for thiopurine-induced leukopenia in IBD. METHODS MEDLINE, EMBASE, BIOSIS and Cochrane library were searched for studies reporting at least one risk factor for thiopurine-induced leukopenia. Pooled odds ratio (OR) was calculated for each potential risk factor using a random effects model. Studies that were not eligible for meta-analysis were described qualitatively. RESULTS Seventy articles were included, 34 (11 229 patients) were included in meta-analyses. A significantly higher thiopurine-induced leukopenia risk was found for TPMT (OR 3.9, 95% [CI] 2.5-6.1) and for NUDT15 R139C (OR 6.9, 95% CI 5.2-9.1), G52A (OR 3.2, 95% CI 1.3-7.9) and 36_37ins/delGGAGTC variant carriers (OR 5.6, 95% CI 2.8-11.4). A potential association between high 6-thioguanine nucleotides (6-TGN) or 6-methylmercaptopurine (6-MMP) levels and leukopenia was observed, since most studies reported higher metabolite levels in leukopenic patients (6-TGN: 204-308 (Lennard method) and 397 (Dervieux method), 6-MMP: 4020-10 450 pmol/8 x 108 RBC) compared to controls (6-TGN: 170-212 (Lennard method) and 269 (Dervieux method), 6-MMP: 1025-4550 pmol/8 x 108 RBC). CONCLUSIONS TPMT and NUDT15 variants predict thiopurine-induced leukopenia. High 6-TGN and 6-MMP levels might induce leukopenia, although exact cut-off values remain unclear. Potential preventive measures to reduce the risk of thiopurine-induced leukopenia include pre-treatment TPMT and NUDT15 genotyping. Routine thiopurine metabolite measurement might be efficient, yet cut-off levels must be validated in advance.
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Affiliation(s)
- Sara van Gennep
- Department of Gastroenterology and Hepatology, Amsterdam Gastroenterology and Metabolism Research Institute, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Kadère Konté
- Department of Gastroenterology and Hepatology, Amsterdam Gastroenterology and Metabolism Research Institute, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Berrie Meijer
- Department of Gastroenterology and Hepatology, Amsterdam Gastroenterology and Metabolism Research Institute, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| | - Martijn W Heymans
- Department of Clinical Epidemiology and Biostatistics, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| | - Geert R D'Haens
- Department of Gastroenterology and Hepatology, Amsterdam Gastroenterology and Metabolism Research Institute, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Mark Löwenberg
- Department of Gastroenterology and Hepatology, Amsterdam Gastroenterology and Metabolism Research Institute, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Nanne K H de Boer
- Department of Gastroenterology and Hepatology, Amsterdam Gastroenterology and Metabolism Research Institute, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
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23
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LeBlanc JF, Wiseman D, Lakatos PL, Bessissow T. Elderly patients with inflammatory bowel disease: Updated review of the therapeutic landscape. World J Gastroenterol 2019; 25:4158-4171. [PMID: 31435170 PMCID: PMC6700701 DOI: 10.3748/wjg.v25.i30.4158] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/19/2019] [Revised: 06/27/2019] [Accepted: 07/02/2019] [Indexed: 02/06/2023] Open
Abstract
High-quality data remains scarce in terms of optimal management strategies in the elderly inflammatory bowel disease (IBD) population. Indeed, available trials have been mostly retrospective, of small sample size, likely owing to under-representation of such a population in the major randomized controlled trials. However, in the last five years, there has been a steady increase in the number of published trials, helping clarify the estimated benefits and toxicity of the existing IBD armamentarium. In the Everhov trial, prescription strategies were recorded over an average follow-up of 4.2 years. A minority of elderly IBD patients (1%-3%) were treated with biologics within the five years following diagnosis, whilst almost a quarter of these patients were receiving corticosteroid therapy at year five of follow-up, despite its multiple toxicities. The low use of biologic agents in real-life settings likely stems from limited data suggesting lower efficacy and higher toxicity. This minireview will aim to highlight current outcome measurements as it portends the elderly IBD patient, as well as summarize the available therapeutic strategies in view of a growing body of evidence.
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Affiliation(s)
- Jean-Frédéric LeBlanc
- Department of Adult Gastroenterology, McGill University Health Centre, Montreal, QC H3G 1A4, Canada
| | - Daniel Wiseman
- Department of Medicine, McGill University Health Centre, Montreal, QC H3G 1A4, Canada
| | - Peter L Lakatos
- Department of Adult Gastroenterology, McGill University Health Centre, Montreal, QC H3G 1A4, Canada
- 1st Department of Medicine, Semmelweis University, Budapest 1083, Hungary
| | - Talat Bessissow
- Department of Adult Gastroenterology, McGill University Health Centre, Montreal, QC H3G 1A4, Canada
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Abstract
PURPOSE OF REVIEW With the advent of biologic therapies for the treatment of inflammatory bowel disease, the roles of thiopurines have continued to evolve. This review will focus on recent advances in pharmacology and the safety and efficacy of thiopurines as maintenance therapies for steroid-induced remissions and post-surgical maintenance of remission and as combination therapies to reduce immunogenicities of biologic agents. RECENT FINDINGS Due to pharmacogenetics of thiopurine S-methyltransferase, thiopurine dosing is more effectively based on monitoring of thiopurine metabolites rather than weight-based dosing. Thiopurines continue to have a role as maintenance therapy after steroid-induced remissions and in combination with biologics to induce and maintain remission. Safety monitoring includes measurements of blood counts, liver chemistries, and dermatologic evaluations and protection from sun exposure. Thiopurines appear to be safe during pregnancies and while very uncommon, lymphomas (including hepatosplenic T cell lymphomas) remain a recognized risk, particularly in younger and older males.
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Affiliation(s)
- Saurabh Kapur
- University of Kansas Medical Center (KUMC), Kansas City, KS, USA
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25
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Chen Y, Wang JC, Yang CM, Fan Q, Zheng J, Liu H. Positive acceleration adaptive training attenuates gastric ischemia-reperfusion injury through COX-2 and PGE2 expression. Exp Ther Med 2019; 17:2901-2906. [PMID: 30930978 PMCID: PMC6425289 DOI: 10.3892/etm.2019.7288] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2017] [Accepted: 03/02/2018] [Indexed: 12/19/2022] Open
Abstract
The mechanism involved in the effects of positive acceleration adaptive training (PAAT) on gastric ischemia-reperfusion injury (GI-RI) has not been fully characterized. The aim of the present study was to investigate the effects of PAAT in attenuating GI-RI in a rat model. The inflammatory factor and caspase-3 levels were measured using ELISA kits. A western blot assay was used to analyze tumor necrosis factor-α (TNF)-α, tumor necrosis factor receptor 1 (TNFR1), tumor necrosis factor-related apoptosis inducing ligand (TRAIL), death receptor (DR) 4, DR5, cyclooxygenase (COX)-2, COX-1 and prostaglandin E2 (PGE2) protein expression levels. It was revealed that PAAT could alleviate GI-RI and inflammatory factor levels in a rat model. PAAT suppressed TNF-α and TNFR1 protein expression levels, inhibited TRAIL, DR4, DR5, COX-2 and PGE2 protein expression levels; however, it did not have an effect on COX-1 protein expression in the model of GI-RI. The data indicated that the effects of PAAT attenuated GI-RI through the downregulation of COX-2 and PGE2 expression.
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Affiliation(s)
- Ying Chen
- Department of Gastroenterology and Research Center of Aeropathy, General Hospital of The Air Force, People's Liberation Army, Beijing 100036, P.R. China
| | - Jian-Chang Wang
- Department of Gastroenterology and Research Center of Aeropathy, General Hospital of The Air Force, People's Liberation Army, Beijing 100036, P.R. China
| | - Chun-Min Yang
- Department of Gastroenterology and Research Center of Aeropathy, General Hospital of The Air Force, People's Liberation Army, Beijing 100036, P.R. China
| | - Qin Fan
- Department of Gastroenterology and Research Center of Aeropathy, General Hospital of The Air Force, People's Liberation Army, Beijing 100036, P.R. China
| | - Jun Zheng
- Department of Gastroenterology and Research Center of Aeropathy, General Hospital of The Air Force, People's Liberation Army, Beijing 100036, P.R. China
| | - Hao Liu
- Department of Gastroenterology and Research Center of Aeropathy, General Hospital of The Air Force, People's Liberation Army, Beijing 100036, P.R. China
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26
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Drobne D, Kurent T, Golob S, Švegl P, Rajar P, Hanžel J, Koželj M, Novak G, Smrekar N, Ferkolj I, Štabuc B. Optimised infliximab monotherapy is as effective as optimised combination therapy, but is associated with higher drug consumption in inflammatory bowel disease. Aliment Pharmacol Ther 2019; 49:880-889. [PMID: 30784100 DOI: 10.1111/apt.15179] [Citation(s) in RCA: 30] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/08/2018] [Revised: 10/01/2018] [Accepted: 01/16/2019] [Indexed: 12/11/2022]
Abstract
BACKGROUND Combination treatment with azathioprine for 6-12 months is the preferred strategy for starting infliximab due to improved pharmacokinetics. However, optimised infliximab monotherapy with proactive dose escalations in case of low trough levels is a safer but under-studied alternative. AIM To compare the clinical success and infliximab consumption of combination vs optimised monotherapy strategies. METHODS We studied the clinical success and infliximab consumption of both strategies in 149 patients (94 Crohn's disease; 55 ulcerative colitis) starting infliximab and undergoing intensive drug monitoring assisted treatment optimisation. RESULTS The drug retention rates were similar for optimised monotherapy and combination treatment after induction (96% vs 97%, P = 0.73), after the first year (90% vs 83%, P = 0.23) and at the end of follow-up (74% vs 75%, P = 0.968). Similarly, no differences were observed for steroid use at year 1 (5% vs 14%, P = 0.08) or mucosal healing at the end of follow-up (64% vs 67%, P = 0.8). Higher infliximab consumption (7.6 mg/kg q8 weeks [interquartile range (IQR): 5.9-10.3] vs 6.4 mg/kg q8 weeks [IQR: 5.2-8.0], P = 0.019) combined with lower trough levels (1.7 µg/mL [IQR: 0.3-6.6] vs 5.0 µg/mL [2.5-8.7], P = 0.012) resulted in almost 3-fold higher drug-to-trough ratio (3.9 vs 1.5) in monotherapy compared to combination strategy at year 1. At the end of follow-up, when azathioprine had been discontinued for a median of 14 [IQR: 3-33] months, these differences disappeared. CONCLUSIONS In this study, optimised infliximab monotherapy was as clinically effective as combination therapy but was associated with significantly higher infliximab consumption. The infliximab-sparing effect disappeared after azathioprine withdrawal.
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Affiliation(s)
- David Drobne
- Department of Gastroenterology, University Medical Centre Ljubljana, Ljubljana, Slovenia.,Medical Faculty, University of Ljubljana, Ljubljana, Slovenia
| | - Tina Kurent
- Department of Gastroenterology, University Medical Centre Ljubljana, Ljubljana, Slovenia
| | - Saša Golob
- Department of Gastroenterology, University Medical Centre Ljubljana, Ljubljana, Slovenia
| | - Polona Švegl
- Department of Gastroenterology, University Medical Centre Ljubljana, Ljubljana, Slovenia
| | - Polona Rajar
- Department of Gastroenterology, University Medical Centre Ljubljana, Ljubljana, Slovenia
| | - Jurij Hanžel
- Department of Gastroenterology, University Medical Centre Ljubljana, Ljubljana, Slovenia
| | - Matic Koželj
- Department of Gastroenterology, University Medical Centre Ljubljana, Ljubljana, Slovenia
| | - Gregor Novak
- Department of Gastroenterology, University Medical Centre Ljubljana, Ljubljana, Slovenia
| | - Nataša Smrekar
- Department of Gastroenterology, University Medical Centre Ljubljana, Ljubljana, Slovenia
| | - Ivan Ferkolj
- Department of Gastroenterology, University Medical Centre Ljubljana, Ljubljana, Slovenia
| | - Borut Štabuc
- Department of Gastroenterology, University Medical Centre Ljubljana, Ljubljana, Slovenia.,Medical Faculty, University of Ljubljana, Ljubljana, Slovenia
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27
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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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28
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Broekman MMTJ, Wanten GJ, de Jong DJ. Editorial: thiopurine-induced myelosuppression and infections in inflammatory bowel disease patients with a normal TPMT genotype-the perils of ageing. Authors' reply. Aliment Pharmacol Ther 2018; 47:130-131. [PMID: 29226420 DOI: 10.1111/apt.14395] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/08/2022]
Affiliation(s)
- M M T J Broekman
- Department of Gastroenterology, Radboud Institute for Molecular Life Sciences, Radboud University Medical Center, Nijmegen, The Netherlands
| | - G J Wanten
- Department of Gastroenterology, Radboud Institute for Molecular Life Sciences, Radboud University Medical Center, Nijmegen, The Netherlands
| | - D J de Jong
- Department of Gastroenterology, Radboud Institute for Molecular Life Sciences, Radboud University Medical Center, Nijmegen, The Netherlands
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29
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Willington AJ, Gearry RB. Editorial: thiopurine-induced myelosuppression and infections in inflammatory bowel disease patients with a normal TPMT genotype-the perils of ageing. Aliment Pharmacol Ther 2018; 47:129-130. [PMID: 29226409 DOI: 10.1111/apt.14370] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Affiliation(s)
- A J Willington
- Department of Gastroenterology, Christchurch Hospital, Canterbury District Health Board, Christchurch, New Zealand
| | - R B Gearry
- Department of Gastroenterology, Christchurch Hospital, Canterbury District Health Board, Christchurch, New Zealand.,University of Otago, Dunedin, New Zealand
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