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van Liere ELSA, de Boer NKH. Editorial: Towards optimal thiopurine therapy for inflammatory bowel disease. Aliment Pharmacol Ther 2024; 59:792-793. [PMID: 38401141 DOI: 10.1111/apt.17876] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/26/2024]
Abstract
LINKED CONTENTThis article is linked to Vasudevan et al papers. To view these articles, visit https://doi.org/10.1111/apt.17831 and https://doi.org/10.1111/apt.17895
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Affiliation(s)
- Elsa L S A van Liere
- Department of Gastroenterology and Hepatology, Amsterdam University Medical Center location Vrije Universiteit Amsterdam, Amsterdam, the Netherlands
- Amsterdam Gastroenterology Endocrinology Metabolism Research Institute, Amsterdam, the Netherlands
| | - Nanne K H de Boer
- Department of Gastroenterology and Hepatology, Amsterdam University Medical Center location Vrije Universiteit Amsterdam, Amsterdam, the Netherlands
- Amsterdam Gastroenterology Endocrinology Metabolism Research Institute, Amsterdam, the Netherlands
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Gensmyr-Singer H, Werner M, Karling P. The drug-survival of low-dose thioguanine in patients with inflammatory bowel disease: a retrospective observational study. Therap Adv Gastroenterol 2024; 17:17562848241228064. [PMID: 38384282 PMCID: PMC10880529 DOI: 10.1177/17562848241228064] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/10/2023] [Accepted: 01/04/2024] [Indexed: 02/23/2024] Open
Abstract
Background Thiopurines are commonly used to treat inflammatory bowel disease but withdrawal due to side effects are common. Thioguanine has been suggested to be better tolerated than conventional thiopurines. Objectives We studied drug-survival of low dose of thioguanine in real-life clinical practice in comparison to conventional thiopurines. Design Retrospective observational study. Methods All patients born 1956 and later, and who at least once started thiopurine treatment between 2006 and 2022 were included. A medical chart review was performed that noted drug-survival for every thiopurine treatment attempt. The Mantel-Cox rank test was used to test differences in drug-survival for different thiopurines. Blood chemistry analysis and faecal calprotectin levels were registered for the first 5 years of treatment. Results In the study population, there was 379 initiated thiopurine treatments (210 for Crohn's disease and 169 for ulcerative colitis) in 307 patients with inflammatory bowel disease (IBD). Low-dose thioguanine (median dose 11 mg; 25-75th percentile 7-19 mg) had been initiated in 31 patients. Overall, when including all thiopurine attempts, thioguanine had the longest drug-survival [Mantel-Cox rank test: thioguanine versus azathioprine p = 0.014; thioguanine versus 6-mercaptopurine (6-MP) p < 0.001]. For second-line thiopurine treatment thioguanine had longer drug-survival than 6-MP (Mantel-Cox rank test: p = 0.006). At 60 months, 86% of the patients who started low-dose thioguanine were still on treatment compared to 42% of the patients who started 6-MP (p = 0.022). The median 6-thioguanine nucleotide levels in patients treated with thioguanine was 364 pmol/8 × 108. Patients on thioguanine treatment showed significantly lower values of median mean corpuscular volume at follow-up than patients treated with azathioprine and 6-MP. Patients treated with 6-MP showed significantly lower levels of FC in the third year of treatment compared to patient treated with azathioprine (59 versus 109 µg/g; p = 0.023), but there was no significant difference in FC levels for thioguanine compared to azathioprine (50 versus 109 µg/g; p = 0.33). Conclusion Treatment with a low dose of thioguanine is well-tolerated in patients with IBD and had a significantly higher drug-survival than conventional thiopurines.
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Affiliation(s)
| | - Mårten Werner
- Department of Public Health and Clinical Medicine, Umeå University, Umeå, Sweden
| | - Pontus Karling
- Department of Public Health and Clincal Medicine, Umeå University, Umeå S-90811, Sweden
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Vasudevan A, Con D, De Cruz P, Sparrow MP, Friedman AB, Garg M, Kashkooli S, Gibson PR, van Langenberg DR. Clinical trial: Combination allopurinol-thiopurine versus standard thiopurine in patients with IBD escalating to immunomodulators (the DECIDER study). Aliment Pharmacol Ther 2024; 59:504-514. [PMID: 38095246 DOI: 10.1111/apt.17831] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/11/2023] [Revised: 09/29/2023] [Accepted: 11/29/2023] [Indexed: 01/23/2024]
Abstract
BACKGROUND Thiopurines are established treatments for inflammatory bowel disease (IBD), yet concerns remain regarding their safety. AIM To evaluate the use of thiopurine-allopurinol combination therapy compared to standard thiopurine therapy in IBD. METHODS We performed a multicentre, randomised, placebo-controlled trial to compare the efficacy and safety of thiopurine-allopurinol versus thiopurine with placebo for adults commencing a thiopurine for IBD. Patients had active disease at baseline; dosing of therapy was based on a pre-specified regimen and subsequent metabolites. The primary outcome was the proportion of patients achieving a composite of symptomatic disease activity remission (Harvey Bradshaw Index <5 for Crohn's disease, Simple Clinical Colitis Activity Index <4 for ulcerative colitis) and a faecal calprotectin <150 μg/g after 26 weeks of treatment. RESULTS The trial was terminated early due to slow recruitment. We randomised 102 participants (54 thiopurine-allopurinol, 48 thiopurine with placebo) with similar age (median 42 vs 48 years) and sex distribution (46% women per group). A higher proportion achieved the primary outcome in the thiopurine-allopurinol group (50% vs 35%, p = 0.14) and fewer participants stopped their allocated therapy due to adverse events (11% vs 29%, p = 0.02). Also, within the thiopurine-allopurinol group, thiopurine dose adjustments were less frequent (69% vs 92%, p = 0.03), a higher proportion achieved an early therapeutic 6-TGN level at week 6 (71% vs 53%, p = 0.19), and adverse events attributed to therapy were less frequent (15% vs 44%, p = 0.002). CONCLUSION Thiopurine-allopurinol therapy is safe and mitigates thiopurine adverse effects, thus enhancing tolerability without compromising efficacy (ACTRN12613001347752).
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Affiliation(s)
- Abhinav Vasudevan
- Department of Gastroenterology and Hepatology, Eastern Health, Box Hill, Victoria, Australia
- Monash University, Eastern Health Clinical School, Box Hill, Victoria, Australia
| | - Danny Con
- Department of Gastroenterology, The Austin Hospital, Melbourne, Victoria, Australia
| | - Peter De Cruz
- Department of Gastroenterology, The Austin Hospital, Melbourne, Victoria, Australia
- Department of Medicine, Austin Academic Centre, University of Melbourne, Melbourne, Victoria, Australia
| | - Miles P Sparrow
- Department of Gastroenterology, Central Clinical School, Monash University and Alfred Health, Melbourne, Victoria, Australia
| | - Antony B Friedman
- Department of Gastroenterology, Central Clinical School, Monash University and Alfred Health, Melbourne, Victoria, Australia
| | - Mayur Garg
- Department of Gastroenterology, Northern Health, Epping, Victoria, Australia
- Department of Medicine, Melbourne University, Melbourne, Australia
| | - Soleiman Kashkooli
- Department of Gastroenterology, Northern Health, Epping, Victoria, Australia
| | - Peter R Gibson
- Department of Gastroenterology, Central Clinical School, Monash University and Alfred Health, Melbourne, Victoria, Australia
| | - Daniel R van Langenberg
- Department of Gastroenterology and Hepatology, Eastern Health, Box Hill, Victoria, Australia
- Monash University, Eastern Health Clinical School, Box Hill, Victoria, Australia
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Deben DS, Derijks LJJ, van den Bosch BJC, Creemers RH, van Nunen A, van Bodegraven AA, Wong DR. Implications of Tioguanine Dosing in IBD Patients with a TPMT Deficiency. Metabolites 2023; 13:1054. [PMID: 37887379 PMCID: PMC10608562 DOI: 10.3390/metabo13101054] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2023] [Revised: 09/29/2023] [Accepted: 10/04/2023] [Indexed: 10/28/2023] Open
Abstract
Tioguanine is metabolised by fewer enzymatic steps compared to azathioprine and mercaptopurine, without generating 6-methylmercaptopurine ribonucleotides. However, thiopurine S-methyl transferase (TPMT) plays a role in early toxicity in all thiopurines. We aimed to describe the hazards and opportunities of tioguanine use in inflammatory bowel disease (IBD) patients with aberrant TPMT metabolism and propose preventative measures to safely prescribe tioguanine in these patients. In this retrospective cohort study, all determined TPMT genotypes (2016-2021) were evaluated for aberrant metabolism (i.e., intermediate and poor TPMT metabolisers). Subsequently, all IBD patients on tioguanine with aberrant TPMT genotypes were evaluated for tioguanine dosages, adverse drug events, lab abnormalities, treatment duration and effectiveness. TPMT genotypes were determined in 485 patients, of whom, 50 (10.3%) and 4 patients (0.8%) were intermediate and poor metabolisers, respectively. Of these patients, 12 intermediate and 4 poor TPMT metabolisers had been prescribed tioguanine in varying doses. In one poor TPMT metaboliser, tioguanine 10 mg/day induced delayed pancytopenia. In general, reduced tioguanine dosages of 5 mg/day for intermediate TPMT metabolisers, and 10 mg two-weekly for poor TPMT metabolisers, resulted in a safe, long-term treatment strategy. Diminished or absent TPMT enzyme activity was related with a pharmacokinetic shift of tioguanine metabolism which is associated with relatively late-occurring myelotoxicity in patients on standard tioguanine dose. However, in strongly reduced dose regimens with strict therapeutic drug and safety monitoring, tioguanine treatment remained a safe and effective option in IBD patients with dysfunctional TPMT.
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Affiliation(s)
- Debbie S. Deben
- Department of Clinical Pharmacy, Clinical Pharmacology and Toxicology, Zuyderland Medical Centre, 6162 BG Sittard, The Netherlands;
| | - Luc J. J. Derijks
- Department of Clinical Pharmacy and Pharmacology, Máxima Medical Centre, 5504 DB Veldhoven, The Netherlands
| | - Bianca J. C. van den Bosch
- Department of Clinical Genetics, Maastricht University Medical Centre (MUMC+), 6229 HX Maastricht, The Netherlands
| | - Rob H. Creemers
- Department of Gastroenterology, Zuyderland Medical Centre, 6162 BG Sittard, The Netherlands
- Department of Gastro-Enterology, Maastricht University Medical Centre (MUMC+), 6229 HX Maastricht, The Netherlands
| | - Annick van Nunen
- Department of Gastroenterology, Zuyderland Medical Centre, 6162 BG Sittard, The Netherlands
| | - Adriaan A. van Bodegraven
- Department of Gastroenterology, Zuyderland Medical Centre, 6162 BG Sittard, The Netherlands
- Department of Gastro-Enterology, Maastricht University Medical Centre (MUMC+), 6229 HX Maastricht, The Netherlands
| | - Dennis R. Wong
- Department of Clinical Pharmacy, Clinical Pharmacology and Toxicology, Zuyderland Medical Centre, 6162 BG Sittard, The Netherlands;
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Crouwel F, Bayoumy AB, Mulder CJJ, Peters JHC, Boekema PJ, Derijks LJJ, de Boer SY, van de Meeberg PC, Ahmad I, Buiter HJC, de Boer NK. The Effectiveness and Safety of First-Line Thioguanine in Thiopurine-Naïve Inflammatory Bowel Disease Patients. Inflamm Bowel Dis 2023:izad197. [PMID: 37658804 DOI: 10.1093/ibd/izad197] [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: 03/10/2023] [Indexed: 09/05/2023]
Abstract
BACKGROUND Currently thioguanine is solely used as treatment for inflammatory bowel disease after azathioprine and/or mercaptopurine failure. This study aimed to determine the safety, effectiveness, and 12-month drug survival of thioguanine in thiopurine-naïve patients with inflammatory bowel disease. METHODS A retrospective cohort study was performed in thiopurine-naïve patients with inflammatory bowel disease treated with thioguanine as first thiopurine derivate. Clinical effectiveness was defined as the continuation of thioguanine without the (re)initiation of concurrent biological therapy, systemic corticosteroids, or a surgical intervention. All adverse events were categorized by the Common Terminology Criteria for Adverse Events. RESULTS A total of 114 patients (male 39%, Crohn's disease 53%) were included with a median treatment duration of 25 months and a median thioguanine dosage of 20 mg/d. Clinical effectiveness at 12 months was observed in 53% of patients, and 78% of these responding patients remained responsive until the end of follow-up. During the entire follow-up period, 26 patients were primary nonresponders, 8 had a secondary loss of response, and 11 patients were unable to cease therapy with systemic corticosteroids within 6 months and were therefore classified as nonresponders. After 12 months, thioguanine was still used by 86% of patients. Fifty (44%) patients developed adverse events (grade 1 or 2) and 9 (8%) patients ceased therapy due to the occurrence of adverse events. An infection was documented in 3 patients, none of them requiring hospitalization and pancytopenia occurred in 2 other patients. No signs of nodular regenerative hyperplasia or portal hypertension were observed. CONCLUSIONS At 12 months, first-line thioguanine therapy was clinically effective in 53% of thiopurine-naïve inflammatory bowel disease patients with an acceptable safety profile.
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Affiliation(s)
- Femke Crouwel
- Department of Gastroenterology and Hepatology, Amsterdam Gastroenterology Endocrinology Metabolism Research Institute, Amsterdam University Medical Centre, Vrije Universiteit Amsterdam, Amsterdam, the Netherlands
| | - Ahmed B Bayoumy
- Department of Gastroenterology and Hepatology, Amsterdam Gastroenterology Endocrinology Metabolism Research Institute, Amsterdam University Medical Centre, Vrije Universiteit Amsterdam, Amsterdam, the Netherlands
| | - Chris J J Mulder
- Department of Gastroenterology and Hepatology, Amsterdam Gastroenterology Endocrinology Metabolism Research Institute, Amsterdam University Medical Centre, Vrije Universiteit Amsterdam, Amsterdam, the Netherlands
| | - Job H C Peters
- Department of Gastroenterology and Hepatology, Rode Kruis hospital, Beverwijk, the Netherlands
| | - Paul J Boekema
- Department of Gastroenterology and Hepatology, Máxima Medical Centre, Veldhoven, the Netherlands
| | - Luc J J Derijks
- Department of Clinical Pharmacy and Pharmacology, Máxima Medical Centre, Veldhoven, the Netherlands
| | - Sybrand Y de Boer
- Department of Gastroenterology and Hepatology, Slingeland Hospital, Doetinchem, the Netherlands
| | - Paul C van de Meeberg
- Department of Gastroenterology and Hepatology, Slingeland Hospital, Doetinchem, the Netherlands
| | - Ishfaq Ahmad
- Department of Gastroenterology and Hepatology, Streekziekenhuis Koningin Beatrix, Winterswijk, the Netherlands
| | - Hans J C Buiter
- Department of Radiology and Nuclear Medicine, Amsterdam University Medical Centre, Vrije Universiteit Amsterdam, Amsterdam, the Netherlands
| | - Nanne K de Boer
- Department of Gastroenterology and Hepatology, Amsterdam Gastroenterology Endocrinology Metabolism Research Institute, Amsterdam University Medical Centre, Vrije Universiteit Amsterdam, Amsterdam, the Netherlands
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Jena A, Neelam PB, Telaprolu H, Mangipudi UK, Dutta U, Sebastian S, Sharma V. Effectiveness and safety of thioguanine as a maintenance therapy of inflammatory bowel disease: Systematic review, meta-analysis and meta-regression. Clin Res Hepatol Gastroenterol 2023; 47:102155. [PMID: 37301255 DOI: 10.1016/j.clinre.2023.102155] [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: 04/10/2023] [Revised: 05/28/2023] [Accepted: 06/05/2023] [Indexed: 06/12/2023]
Abstract
INTRODUCTION Thiopurines are an important therapy for the maintenance of remission in inflammatory bowel disease (IBD). However, the use of thioguanine has been limited by concerns regarding its toxicity. We performed a systematic review to evaluate its effectiveness and safety in IBD. METHODS Electronic databases were searched to identify studies reporting clinical responses and/or adverse events of thioguanine therapy in IBD. We calculated the pooled clinical response and clinical remission rates of thioguanine in IBD. Subgroup analyses were done for the dosage of thioguanine and the type of studies (prospective or retrospective). Meta-Regression was used to analyze the impact of dose on clinical efficacy and occurrence of nodular regenerative hyperplasia. RESULTS A total of 32 studies were included. The pooled clinical response rate of thioguanine therapy in IBD was 0.66 (95% C.I. 0.62 - 0.70; I2 = 16%). The pooled clinical response rate with low-dose was similar to high-dose thioguanine therapy [0.65 (95% C.I. 0.59 - 0.70; I2 = 24%) and 0.68 (95% C.I. 0.61 - 0.75; I2 = 18%) respectively]. The pooled remission maintenance rate was 0.71 (95% C.I. 0.58 - 0.81; I2 = 86%). The pooled rates of occurrence of nodular regenerative hyperplasia, liver function tests abnormalities and cytopenia were 0.04 (95% C.I. 0.02 - 0.08; I2 = 75%), 0.11 (95% C.I. 0.08 - 0.16; I2 = 72%) and 0.06 (95% C.I. 0.04 - 0.09; I2 = 62%) respectively. Meta-regression suggested that the risk of nodular regenerative hyperplasia is related to the dose of thioguanine. CONCLUSION TG is an efficacious and well-tolerated drug in most patients with IBD. Nodular regenerative hyperplasia, cytopenias, and liver function abnormalities occur in a small subset. Future studies should look into TG as primary therapy in IBD.
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Affiliation(s)
- Anuraag Jena
- Department of Gastroenterology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Pardhu B Neelam
- Department of Gastroenterology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Harshavardhan Telaprolu
- Department of Gastroenterology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Uday Kiran Mangipudi
- Department of Gastroenterology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Usha Dutta
- Department of Gastroenterology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Shaji Sebastian
- IBD Unit, Hull University Teaching Hospitals NHS Trust, Hull, UK
| | - Vishal Sharma
- Department of Gastroenterology, Postgraduate Institute of Medical Education and Research, Chandigarh, India.
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Low Dose Azathioprine with Allopurinol in IBD: Early Days to Call It a Recipe for Success. Dig Dis Sci 2022; 67:4263-4265. [PMID: 35244826 DOI: 10.1007/s10620-021-07375-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/15/2021] [Accepted: 12/20/2021] [Indexed: 12/09/2022]
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Cytotoxicity of Thiopurine Drugs in Patients with Inflammatory Bowel Disease. TOXICS 2022; 10:toxics10040151. [PMID: 35448412 PMCID: PMC9026123 DOI: 10.3390/toxics10040151] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/11/2022] [Revised: 03/11/2022] [Accepted: 03/17/2022] [Indexed: 02/04/2023]
Abstract
The effectiveness of thiopurine drugs in inflammatory bowel disease (IBD) was confirmed more than a half-century ago. It was proven that these can be essential immunomodulatory medications. Since then, they have been used routinely to maintain remission of Crohn’s disease (CD) and ulcerative colitis (UC). The cytotoxic properties of thiopurines and the numerous adverse effects of the treatment are controversial. However, the research subject of their pharmacology, therapy monitoring, and the search for predictive markers are still very relevant. In this article, we provide an overview of the current knowledge and findings in the field of thiopurines in IBD, focusing on the aspect of their cytotoxicity. Due to thiopurines’ benefits in IBD therapy, it is expected that they will still constitute an essential part of the CD and UC treatment algorithm. More studies are still required on the modulation of the action of thiopurines in combination therapy and their interaction with the gut microbiota.
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Savelkoul EHJ, Maas MHJ, Bourgonje AR, Crouwel F, Biemans VBC, den Broeder N, Russel MGVM, Römkens TEH, de Boer NK, Dijkstra G, Hoentjen F. Favourable Tolerability and Drug Survival of Tioguanine Versus Methotrexate After Failure of Conventional Thiopurines in Crohn's Disease. J Crohns Colitis 2022; 16:1372-1379. [PMID: 35303065 PMCID: PMC9455785 DOI: 10.1093/ecco-jcc/jjac044] [Citation(s) in RCA: 1] [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: 10/12/2021] [Revised: 12/06/2021] [Accepted: 03/16/2022] [Indexed: 02/08/2023]
Abstract
BACKGROUND AND AIMS Both methotrexate and tioguanine can be considered as treatment options in patients with Crohn's disease after failure of conventional thiopurines. This study aimed to compare tolerability and drug survival of methotrexate and tioguanine therapy after failure of conventional thiopurines in patients with Crohn's disease. METHODS We conducted a retrospective, multicentre study, including patients with Crohn's disease initiating monotherapy methotrexate or tioguanine after failure [all causes] of conventional thiopurines. Follow-up duration was 104 weeks or until treatment discontinuation. The primary outcome was cumulative therapy discontinuation incidence due to adverse events. Secondary outcomes included total number of [serious] adverse events, and ongoing monotherapy. RESULTS In total, 219 patients starting either methotrexate [n = 105] or tioguanine [n = 114] were included. In all 65 [29.7%] patients (methotrexate 43.8% [46/105 people], tioguanine 16.7% [19/114 people], p <0.001) discontinued their treatment due to adverse events during follow-up. Median time until discontinuation due to adverse events was 16 weeks (interquartile range [IQR] 7-38, p = 0.812). Serious adverse events were not significantly different. Patients treated with methotrexate experienced adverse events more often [methotrexate 83%, tioguanine 46%, p <0.001]. Total monotherapy drug survival after 104 weeks was 22% for methotrexate and 46% for tioguanine [p <0.001]. CONCLUSIONS We observed a higher cumulative discontinuation incidence due to adverse events for methotrexate [44%] compared with tioguanine [17%] in Crohn's disease patients after failure of conventional thiopurines. The total adverse events incidence during methotrexate use was higher, whereas serious adverse events incidence was similar. These favourable results for tioguanine treatment may guide the selection of immunosuppressive therapy after failure of conventional thiopurines.
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Affiliation(s)
- E H J Savelkoul
- Corresponding author: Edo H. J. Savelkoul, MD, Inflammatory Bowel Disease Centre, Department of Gastroenterology and Hepatology, Radboud University Medical Centre, PO Box 9101, code 455, 6500 HB Nijmegen, The Netherlands. Tel.: +31 24 3619190; fax: +31 24 3540103;
| | - M H J Maas
- Department of Gastroenterology and Hepatology, University Medical Centre Groningen, Groningen, The Netherlands
| | - A R Bourgonje
- Department of Gastroenterology and Hepatology, University Medical Centre Groningen, Groningen, The Netherlands
| | - F Crouwel
- Department of Gastroenterology and Hepatology, Amsterdam University Medical Centre, VU University, AGEM Research Institute, Amsterdam, The Netherlands
| | - V B C Biemans
- Department of Gastroenterology and Hepatology, University Medical CentreUtrecht, Utrecht, The Netherlands
| | - N den Broeder
- Department of Gastroenterology and Hepatology, Radboud University Medical Centre, Nijmegen, The Netherlands
| | - M G V M Russel
- Department of Gastroenterology and Hepatology, Medisch Spectrum Twente, Enschede, The Netherlands
| | - T E H Römkens
- Department of Gastroenterology and Hepatology, Jeroen Bosch Ziekenhuis, ‘s-Hertogenbosch, The Netherlands
| | - N K de Boer
- Department of Gastroenterology and Hepatology, Amsterdam University Medical Centre, VU University, AGEM Research Institute, Amsterdam, The Netherlands
| | - G Dijkstra
- Department of Gastroenterology and Hepatology, University Medical Centre Groningen, Groningen, The Netherlands
| | - F Hoentjen
- Department of Gastroenterology and Hepatology, Radboud University Medical Centre, Nijmegen, The Netherlands,Division of Gastroenterology, Department of Medicine, University of Alberta, Edmonton, AB, Canada
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Kiszka-Kanowitz M, Theede K, Thomsen SB, Bjerrum JT, Brynskov J, Gottschalck IB, Akimenko E, Hilsted KL, Neumann A, Wildt S, Larsen L, Munk JK, Ibsen PH, Janjua HGR, Gluud LL, Mertz-Nielsen A. Low-dose azathioprine and allopurinol versus azathioprine monotherapy in patients with ulcerative colitis (AAUC): An investigator-initiated, open, multicenter, parallel-arm, randomised controlled trial. EClinicalMedicine 2022; 45:101332. [PMID: 35274092 PMCID: PMC8902607 DOI: 10.1016/j.eclinm.2022.101332] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/14/2021] [Revised: 01/27/2022] [Accepted: 02/16/2022] [Indexed: 12/15/2022] Open
Abstract
Background Retrospective studies suggest that for patients with ulcerative colitis (UC) combination therapy with low-dose azathioprine and allopurinol (L-AZA/ALLO) may result in higher remission rates than monotherapy with azathioprine (AZA). We prospectively investigated the effects of these drugs for remission in patients with moderate-to-severe UC. Methods Open-label, unblinded, randomised, controlled, investigator-initiated, multicentre study conducted at eight hospital sites in Denmark. Adult patients with established UC, who were steroid dependent/refractory, thiopurine naïve, had a normal thiopurine methyltransferase, and achieved remission with steroids or infliximab were eligible for inclusion. Patients were randomly assigned by the investigators (1:1) to 52 weeks of treatment with once daily oral AZA (median dose 50 mg) combined with ALLO 100 mg versus AZA monotherapy (median dose 200 mg), using a computer-generated randomisation list with blocks of six. The trial was open without masking. All randomised patients who received at least one dose of study drug were included in primary and safety analyses (intention to treat population). The primary outcome was steroid and infliximab free remission after 52 weeks, defined as a Mayo Score of ≤1 and no rectal bleeding. The trial is completed and is registered in ClinicalTrials.gov (ClinicalTrials.gov NCT03101800). Findings Between January 9, 2017 and February 10, 2021, 47 patients were randomised to l-AZA/ALLO and 42 to AZA and received at least one dose of the study drug. After 52 weeks, 20 of 47 (43%) patients in the l-AZA/ALLO group and nine of 42 (21%) patients in the AZA group achieved remission (odds ratio 2·54 [95% CI 1·00 to 6.78, p < 0·048]). Fourteen patients (30%) in the l-AZA/ALLO group and 16 (38%) in the AZA group were withdrawn from the study due to adverse events. Interpretation This study suggests that after one year l-AZA/ALLO therapy may be associated with a beneficial effect on steroid- and infliximab-free clinical remission in patients with moderate-to-severe UC and should be considered as first line therapy. Funding Funding for AAUC was provided by The Capital Region of Denmark (Regionernes Medicinpulje (6062/16)).
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Affiliation(s)
- Marianne Kiszka-Kanowitz
- Gastro Unit, Copenhagen University Hospital Hvidovre, Kettegårds Alle 30, Hvidovre 2600 , Denmark
| | - Klaus Theede
- Gastro Unit, Copenhagen University Hospital Hvidovre, Kettegårds Alle 30, Hvidovre 2600 , Denmark
| | - Sandra Bohn Thomsen
- Gastro Unit, Copenhagen University Hospital Hvidovre, Kettegårds Alle 30, Hvidovre 2600 , Denmark
| | | | | | | | | | - Karen Lisa Hilsted
- Gastro Unit, Copenhagen University Hospital Hvidovre, Kettegårds Alle 30, Hvidovre 2600 , Denmark
| | | | | | - Lone Larsen
- Aalborg University Hospital, Aalborg, Denmark
| | - Jens Kristian Munk
- Gastro Unit, Copenhagen University Hospital Hvidovre, Kettegårds Alle 30, Hvidovre 2600 , Denmark
| | - Per Holger Ibsen
- Gastro Unit, Copenhagen University Hospital Hvidovre, Kettegårds Alle 30, Hvidovre 2600 , Denmark
| | - Huma Gul Rehana Janjua
- Gastro Unit, Copenhagen University Hospital Hvidovre, Kettegårds Alle 30, Hvidovre 2600 , Denmark
| | - Lise Lotte Gluud
- Gastro Unit, Copenhagen University Hospital Hvidovre, Kettegårds Alle 30, Hvidovre 2600 , Denmark
| | - Anette Mertz-Nielsen
- Gastro Unit, Copenhagen University Hospital Hvidovre, Kettegårds Alle 30, Hvidovre 2600 , Denmark
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11
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Rönnblom A, Ljunggren Ö, Karlbom U. Complications and adverse effects related to surgical and medical treatment in patients with inflammatory bowel disease in a prospectively recruited population-based cohort. Scand J Gastroenterol 2021; 56:1296-1303. [PMID: 34369245 DOI: 10.1080/00365521.2021.1961309] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
BACKGROUND Medical adverse effects and surgical complications have been reported during treatment of patients with inflammatory bowel diseases (IBDs). There is however a shortage of studies describing these in the same cohort of patients. AIM To describe medical adverse effects and surgical complications in a prospectively followed population-based cohort of patients followed for at least 10 years. METHODS All newly diagnosed patients with ulcerative colitis (UC) and Crohn's disease (CD) in the county of Uppsala between 2005 and 2009 were prospectively followed. At the end of 2019, the medical notes were scrutinised and all medical adverse effects and postoperative surgical complications were registered. RESULTS A total of 330 patients with UC and 153 patients with CD in all age groups were included in the cohort. Four hundred and forty-two of these (91.5%) could be followed for 10 years or until death. One hundred and twenty-two patients (26.9%) experienced one or more adverse effects during the pharmacological treatment, and 25 of these could be classified as serious. Fifty-seven malignancies were diagnosed during the observation time. Surgery was performed in 16/330 UC and 33/153 CD patients. Frequency of early postoperative complications was 31% for UC patients and 36% for CD patients. Most complications were minor but two patients were re-operated, two needed intensive care and one patient died postoperatively. CONCLUSIONS Adverse effects related to medical therapy were experienced by approximately every fourth patient, and by every third patient that was operated.
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Affiliation(s)
- Anders Rönnblom
- Section of Gastroenterology and Hepatology, Akademiska Hospital, Magtarmmottagningen, Uppsala, Sweden
| | - Östen Ljunggren
- Department of Medical Sciences, Uppsala University, Uppsala University Hospital, Uppsala, Sweden
| | - Urban Karlbom
- Department of Surgical Sciences, Uppsala University, University Hospital, Uppsala, Sweden
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12
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Andoh A, Kawahara M, Imai T, Tatsumi G, Inatomi O, Kakuta Y. Thiopurine pharmacogenomics and pregnancy in inflammatory bowel disease. J Gastroenterol 2021; 56:881-890. [PMID: 34287682 DOI: 10.1007/s00535-021-01805-z] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/26/2021] [Accepted: 06/18/2021] [Indexed: 02/04/2023]
Abstract
The thiopurine drugs azathioprine and 6-mercaptopurine are widely used for the maintenance of clinical remission in steroid-dependent inflammatory bowel disease (IBD). Thiopurines are recommended to be continued throughout pregnancy in IBD patients, but conclusive safety data in pregnant patients remain still insufficient. On the other hand, a strong association between a genetic variant of nucleoside diphosphate-linked moiety X-type motif 15 (NUDT15 p.Arg139Cys) and thiopurine-induced myelotoxicity has been identified. Pharmacokinetic studies have revealed that thiopurine metabolism is altered in pregnant IBD patients and suggested that the fetus may be exposed to the active-thiopurine metabolite, 6-thioguaninetriphosphate, in the uterus. A recent study using knock-in mice harboring the p.Arg138Cys mutation which corresponds to human p.Arg139Cys showed that oral administration of 6-MP at clinical dose induces a severe toxic effect on the fetus harboring the homozygous or heterozygous risk allele. This suggests that NUDT15 genotyping may be required in both women with IBD who are planning pregnancy (or pregnant) and their partner to avoid adverse outcomes for their infant. The risk to the fetus due to maternal thiopurine use is minimal but there are some concerns that are yet to be clarified. In particular, a pharmacogenomic approach to the fetus is considered necessary.
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Affiliation(s)
- Akira Andoh
- Division of Gastroenterology and Hematology, Shiga University of Medical Science, Seta-Tsukinowa, Otsu, Shiga, 520-2192, Japan.
| | - Masahiro Kawahara
- Division of Gastroenterology and Hematology, Shiga University of Medical Science, Seta-Tsukinowa, Otsu, Shiga, 520-2192, Japan
| | - Takayuki Imai
- Division of Gastroenterology and Hematology, Shiga University of Medical Science, Seta-Tsukinowa, Otsu, Shiga, 520-2192, Japan
| | - Goichi Tatsumi
- Division of Gastroenterology and Hematology, Shiga University of Medical Science, Seta-Tsukinowa, Otsu, Shiga, 520-2192, Japan
| | - Osamu Inatomi
- Division of Gastroenterology and Hematology, Shiga University of Medical Science, Seta-Tsukinowa, Otsu, Shiga, 520-2192, Japan
| | - Yoichi Kakuta
- Division of Gastroenterology, Tohoku University Graduate School of Medicine, Sendai, Miyagi, 980-8574, Japan
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13
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Bakulin IG, Skalinskaya MI, Maev IV, Skazyvaeva EV, Zhuravleva MS, Gaikovaya LB, Bakulina NV, Ermakov AI, Alekseenko ES, Ivanova KN, Solovev MV. Pharmacotherapy of inflammatory bowel diseases: efficacy performance and safety management. TERAPEVT ARKH 2021; 93:841-852. [DOI: 10.26442/00403660.2021.08.200982] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2021] [Accepted: 08/30/2021] [Indexed: 12/30/2022]
Abstract
Treatment of inflammatory bowel diseases IBD (Crohns disease, ulcerative colitis) is aimed at achieving clinical, endoscopic and histological remission, minimizing surgical complications, and ensuring a normal quality of life. However, the use of medical treatment is potentially associated with various adverse events, among which infectious complications, malignant neoplasms, as well as myelotoxicity, hepatotoxicity, skin lesions and others. The risk of side effects depends on the type of drug therapy (5-aminosalicylates, thiopurines, biologicals, etc.), the duration of treatment, the presence of extra-intestinal manifestations, etc. The article provides an overview of data on both the effectiveness and frequency of various side effects of the main classes of drugs in IBD, presents methods of investigation which can predict the effectiveness and development of side effects, the implementation of which can be considered as a variant of personalized therapy in IBD.
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14
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Gargallo-Puyuelo CJ, Laredo V, Gomollón F. Thiopurines in Inflammatory Bowel Disease. How to Optimize Thiopurines in the Biologic Era? Front Med (Lausanne) 2021; 8:681907. [PMID: 34336887 PMCID: PMC8322650 DOI: 10.3389/fmed.2021.681907] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2021] [Accepted: 06/23/2021] [Indexed: 12/18/2022] Open
Abstract
Thiopurines have been a cornerstone in the treatment of inflammatory bowel disease (IBD). Although they have been used for more than 50 years, there are still some unsolved issues about their efficacy and, also, some safety concerns, mainly the risk of myelosuppression and life-threatening lymphoproliferative disorders. Furthermore, the development of biological therapy raises the question whether there is still a role for thiopurines in the IBD treatment algorithm. On the other hand, limited cost and wide availability make thiopurines a reasonable option in settings of limited resources and increasing prevalence of IBD. In fact, there is a growing interest in optimizing thiopurine therapy, since pharmacogenomic findings suggest that a personalized approach based on the genotyping of some molecules involved in its metabolism could be useful to prevent side effects. Polymorphisms of thiopurine methyltransferase enzyme (TPMT) that result in low enzymatic activity have been associated with an increased risk of myelotoxicity, especially in Caucasians; however, in Asians it is assumed that the variants of nudix hydrolase 15 (NUDT15) are more relevant in the development of toxicity. Age is also important, since in elderly patients the risk of complications seems to be increased. Moreover, the primo-infection of Epstein Barr virus and cytomegalovirus under thiopurine treatment has been associated with severe lymphoproliferative disorders. In addition to assessing individual characteristics that may influence thiopurines treatment outcomes, this review also discusses other strategies to optimize the therapy. Low-dose thiopurines combined with allopurinol can be used in hypermethylators and in thiopurine-related hepatotoxicity. The measurement of metabolites could be useful to assess compliance, identify patients at risk of adverse events and also facilitating the management of refractory patients. Thioguanine is also a rescue therapy in patients with toxicity related to conventional thiopurine therapy. Finally, the current indications for thiopurines in monotherapy or in combination with biologics, as well as the optimal duration of treatment, are also reviewed.
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Affiliation(s)
| | - Viviana Laredo
- Department of Gastroenterology, University Clinic Hospital Lozano Blesa, Zaragoza, Spain
| | - Fernando Gomollón
- Department of Gastroenterology, University Clinic Hospital Lozano Blesa, Zaragoza, Spain.,Department of Medicine, Psychiatry and Dermatology, University of Zaragoza, Zaragoza, Spain.,Institute for Health Research Aragón (IIS Aragón), Zaragoza, Spain.,Centro de Investigación Biomédica en Red, Enfermedades Hepáticas y Digestivas, Madrid, Spain
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15
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Giraud EL, Thomas PWA, van Lint JA, van Puijenbroek EP, Römkens TEH, West RL, Russel MGVM, Jansen JM, Jessurun NT, Hoentjen F. Adverse Drug Reactions from Real-World Data in Inflammatory Bowel Disease Patients in the IBDREAM Registry. Drug Saf 2021; 44:581-588. [PMID: 33538994 PMCID: PMC8053178 DOI: 10.1007/s40264-021-01045-3] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/15/2021] [Indexed: 02/07/2023]
Abstract
Introduction Inflammatory bowel disease (IBD) frequently requires chronic immunosuppressive treatment and active involvement from patients during treatment decision making. Information about the risk of developing adverse drug reactions (ADRs) to IBD therapies is required in this process. Objective The aim of this study was to describe the ADRs reported in IBD patients from real-world data, using the Dutch nationwide IBDREAM registry, and compare the occurrence and cumulative incidences with the Summary of Product Characteristics (SmPC) of the associated drugs. Methods In this retrospective multicentre study, ADRs related to IBD medication were assessed. Only reports associated with the use of drugs used for the maintenance treatment of IBD were included. All ADRs were verified by healthcare professionals and coded by trained pharmacovigilance assessors. Results In total, 3080 ADRs were reported in 1179 patients. Twenty-three new drug–ADR associations related to the use of azathioprine, mercaptopurine, infliximab, oral mesalamine and thioguanine were reported in the IBDREAM registry that were not mentioned in the corresponding SmPCs. The most frequently reported new association was pyrexia for azathioprine (3.1%) and mercaptopurine (4.9%). In addition, there were seven ADRs with a higher cumulative incidence in IBDREAM compared with the SmPC, and included, among others, arthralgia during mercaptopurine use (2.5%), and diarrhoea (1.4%), alopecia (1.2%) and infections (1.6%) during azathioprine use. Conclusions Based on real-world data, ADR reporting demonstrated new ADRs and higher incidences of ADRs to IBD therapies. This information will contribute to drug safety by updating the SmPCs, allowing better risk assessment and communication towards patients. Supplementary Information The online version contains supplementary material available at 10.1007/s40264-021-01045-3.
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Affiliation(s)
- Eline L Giraud
- Netherlands Pharmacovigilance Centre Lareb, 's-Hertogenbosch, The Netherlands
| | - Pepijn W A Thomas
- Department of Gastroenterology and Hepatology, Radboud University Medical Centre, Nijmegen, The Netherlands.
| | - Jette A van Lint
- Netherlands Pharmacovigilance Centre Lareb, 's-Hertogenbosch, The Netherlands
| | | | - Tessa E H Römkens
- Department of Gastroenterology and Hepatology, Jeroen Bosch Ziekenhuis, 's-Hertogenbosch, The Netherlands
| | - Rachel L West
- Department of Gastroenterology and Hepatology, Franciscus Gasthuis en Vlietland, Rotterdam, The Netherlands
| | - Maurice G V M Russel
- Department of Gastroenterology and Hepatology, Medisch Spectrum Twente, Enschede, The Netherlands
| | - Jeroen M Jansen
- Department of Gastroenterology and Hepatology, Onze Lieve Vrouwe Gasthuis, Amsterdam, The Netherlands
| | - Naomi T Jessurun
- Netherlands Pharmacovigilance Centre Lareb, 's-Hertogenbosch, The Netherlands
| | - Frank Hoentjen
- Department of Gastroenterology and Hepatology, Radboud University Medical Centre, Nijmegen, The Netherlands
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