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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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Arun B, Joshi M, Kakkar AK, Madki S, Ivaturi V, Chinnaswamy G, Banavali S, Gota V. Bioequivalence study followed by model-informed dose optimization of a powder for oral suspension of 6-mercaptopurine. Pediatr Blood Cancer 2024; 71:e30813. [PMID: 38110844 DOI: 10.1002/pbc.30813] [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: 07/03/2023] [Revised: 10/15/2023] [Accepted: 11/23/2023] [Indexed: 12/20/2023]
Abstract
BACKGROUND 6-Mercaptopurine (6MP) is the mainstay chemotherapy for acute lymphoblastic leukemia (ALL) and is conventionally available as 50 mg tablets. A new 6MP powder for oral suspension (PFOS 10 mg/mL) was developed recently by IDRS Labs, India, intended for pediatric use. A comparative pharmacokinetics of PFOS with T. mercaptopurine was conducted to determine the dose equivalence. METHODS An open-label, randomized, two-treatment, two-period, two-sequence, single oral dose, crossover, bioequivalence study was conducted on 51 healthy adult subjects. Post hoc, a population pharmacokinetic (PopPK) model was developed using the healthy volunteer data to perform simulations with various PFOS doses and select a bioequivalent dose. Further, to confirm the safety of PFOS in pediatrics, a simulation of 6MP and 6-thioguanine exposures was performed by incorporating the formulation-specific parameters derived from the healthy volunteer study into the PopPK model in childhood ALL available in literature. RESULTS The 6MP PFOS had 47% higher oral bioavailability compared to the reference product. Simulations using a two-compartmental PopPK model with dissolution and transit compartments showed that 40 mg of PFOS was found to be equivalent to 50 mg tablets. The simulated 6-thioguanine nucleotide concentrations in children using the dose adjusted for PFOS were between 114 and 703.6 pmol/8 × 108 RBC, which was within the range reported in pediatric ALL studies. CONCLUSION 6MP PFOS 10 mg/mL should be administered at a 20% lower dose than the tablet to achieve comparable exposure. 6MP PFOS addresses an unmet medical need for a liquid formulation of 6MP in the Indian subcontinent.
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Affiliation(s)
- Bhavatharini Arun
- Department of Clinical Pharmacology, Advanced Centre for Treatment, Research and Education in Cancer, Tata Memorial Centre, Navi Mumbai, Maharashtra, India
| | | | | | | | | | - Girish Chinnaswamy
- Department of Paediatric Oncology, Tata Memorial Hospital, Mumbai, Maharashtra, India
- Homi Bhabha National Institute, Anushakthinagar, Mumbai, Maharashtra, India
| | - Shripad Banavali
- Department of Paediatric Oncology, Tata Memorial Hospital, Mumbai, Maharashtra, India
- Homi Bhabha National Institute, Anushakthinagar, Mumbai, Maharashtra, India
| | - Vikram Gota
- Department of Clinical Pharmacology, Advanced Centre for Treatment, Research and Education in Cancer, Tata Memorial Centre, Navi Mumbai, Maharashtra, India
- Homi Bhabha National Institute, Anushakthinagar, Mumbai, Maharashtra, India
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Zhou Y, Wang L, Sun LR, Zhang L, Wang HM, Liu XT, Yang F, Wu KL, Liang YL, Zhao BB, Zhuang Y, Fu JQ, Song C, Li Y, Wang LZ, Xu HJ, Gu Y, van den Anker J, Ju XL, Zhu XF, Zhao W. Individualized Use of 6-Mercaptopurine in Chinese Children with ALL: A Multicenter Randomized Controlled Trial. Clin Pharmacol Ther 2024; 115:213-220. [PMID: 37753808 DOI: 10.1002/cpt.3061] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2023] [Accepted: 09/19/2023] [Indexed: 09/28/2023]
Abstract
Continuous 6-mercaptopurine (6-MP) dose titration is necessary because of its narrow therapeutic index and frequently encountered dose-limiting hematopoietic toxicity. However, evidence-based guidelines for gene-based 6-MP dosing have not been established for Chinese children with acute lymphoblastic leukemia (ALL). This multicenter, randomized, open-label, active-controlled clinical trial randomly assigned Chinese children with low- or intermediate-risk ALL in a 1:1 ratio to receive TPMT-NUDT15 gene-based dosing of 6-MP (N = 44, 10 to 50 mg/m2 /day) or standard dosing (N = 44, 50 mg/m2 /day) during maintenance therapy. The primary end point was the incidence of 6-MP myelosuppression in both groups. Secondary end points included frequencies of 6-MP hepatotoxicity, duration of myelosuppression and leukopenia, event-free survival, and steady-state concentrations of active metabolites (6-thioguaninenucleotides and 6-methylmercaptopurine nucleotides) in erythrocytes. A 2.2-fold decrease in myelosuppression, the primary end point, was observed in the gene-based-dose group using ~ 50% of the standard initial 6-MP dose (odds ratio, 0.26, 95% confidence interval, 0.11 to 0.64, P = 0.003). Patients in the gene-based-dose group had a significantly lower risk of developing thiopurine-induced myelosuppression and leukopenia (P = 0.015 and P = 0.022, respectively). No significant differences were observed in the secondary end points of the incidence of hepatotoxicity and steady-state concentrations of active metabolites in erythrocytes between the two groups. TPMT- and NUDT15-based dosing of 6-MP will significantly contribute toward further reducing the incidence of leukopenia in Chinese children with ALL. This trial is registered at www.clinicaltrial.gov as #NCT04228393.
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Affiliation(s)
- Yue Zhou
- Department of Clinical Pharmacy, Institute of Clinical Pharmacology, Key Laboratory of Chemical Biology (Ministry of Education), NMPA Key Laboratory for Clinical Research and Evaluation of Innovative Drug, School of Pharmaceutical Sciences, Cheeloo College of Medicine, Shandong University, Jinan, China
| | - Li Wang
- Department of Pediatric Hematology Oncology, Children's Hospital of Hebei Province affiliated to Hebei Medical University, Shijiazhuang, China
| | - Li-Rong Sun
- Department of Pediatrics Hematology, Affiliated Hospital of Qingdao University, Qingdao, China
| | - Li Zhang
- Department of Pediatrics, State Key Laboratory of Experimental Hematology, National Clinical Research Center for Blood Diseases, Haihe Laboratory of Cell Ecosystem, Institute of Hematology & Blood Diseases Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Tianjin, China
| | - Hong-Mei Wang
- Department of Pediatrics, The First Affiliated Hospital of Shandong, First Medical University & Shandong Provincial Qianfoshan Hospital, Jinan, China
| | - Xi-Ting Liu
- Department of Clinical Pharmacy, Institute of Clinical Pharmacology, Key Laboratory of Chemical Biology (Ministry of Education), NMPA Key Laboratory for Clinical Research and Evaluation of Innovative Drug, School of Pharmaceutical Sciences, Cheeloo College of Medicine, Shandong University, Jinan, China
- Department of Pharmacy, China-Japan Friendship Hospital, Beijing, China
| | - Fan Yang
- Department of Clinical Pharmacy, Institute of Clinical Pharmacology, Key Laboratory of Chemical Biology (Ministry of Education), NMPA Key Laboratory for Clinical Research and Evaluation of Innovative Drug, School of Pharmaceutical Sciences, Cheeloo College of Medicine, Shandong University, Jinan, China
| | - Ke-Liang Wu
- Department of Clinical Pharmacy, Institute of Clinical Pharmacology, Key Laboratory of Chemical Biology (Ministry of Education), NMPA Key Laboratory for Clinical Research and Evaluation of Innovative Drug, School of Pharmaceutical Sciences, Cheeloo College of Medicine, Shandong University, Jinan, China
| | - Yu-Li Liang
- Department of Pediatric Hematology Oncology, Children's Hospital of Hebei Province affiliated to Hebei Medical University, Shijiazhuang, China
| | - Bei-Bei Zhao
- Department of Pediatrics, State Key Laboratory of Experimental Hematology, National Clinical Research Center for Blood Diseases, Haihe Laboratory of Cell Ecosystem, Institute of Hematology & Blood Diseases Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Tianjin, China
| | - Yong Zhuang
- Department of Pediatrics, Qilu Hospital of Shandong University, Jinan, China
| | - Jin-Qiu Fu
- Department of Pediatrics, Qilu Hospital of Shandong University, Jinan, China
| | - Chao Song
- The State Key Laboratory of Translational Medicine and Innovative Drug Development, Jiangsu Simcere Diagnostics Co., Ltd., Nanjing, China
| | - Yun Li
- The State Key Laboratory of Translational Medicine and Innovative Drug Development, Jiangsu Simcere Diagnostics Co., Ltd., Nanjing, China
| | - Ling-Zhen Wang
- Department of Pediatrics Hematology, Affiliated Hospital of Qingdao University, Qingdao, China
| | - Hui-Juan Xu
- Department of Pediatrics Hematology, Affiliated Hospital of Qingdao University, Qingdao, China
| | - Yan Gu
- Department of Pediatrics, The First Affiliated Hospital of Shandong, First Medical University & Shandong Provincial Qianfoshan Hospital, Jinan, China
| | - John van den Anker
- Division of Clinical Pharmacology, Children's National Medical Center, Washington, DC, USA
- Departments of Pediatrics, Pharmacology & Physiology, School of Medicine and Health Sciences, George Washington University, Washington, DC, USA
- Department of Paediatric Pharmacology and Pharmacometrics, University Children's Hospital Basel, Basel, Switzerland
| | - Xiu-Li Ju
- Department of Pediatrics, Qilu Hospital of Shandong University, Jinan, China
| | - Xiao-Fan Zhu
- Department of Pediatrics, State Key Laboratory of Experimental Hematology, National Clinical Research Center for Blood Diseases, Haihe Laboratory of Cell Ecosystem, Institute of Hematology & Blood Diseases Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Tianjin, China
| | - Wei Zhao
- Department of Clinical Pharmacy, Institute of Clinical Pharmacology, Key Laboratory of Chemical Biology (Ministry of Education), NMPA Key Laboratory for Clinical Research and Evaluation of Innovative Drug, School of Pharmaceutical Sciences, Cheeloo College of Medicine, Shandong University, Jinan, China
- NMPA Key Laboratory for Clinical Research and Evaluation of Innovative Drug, Qilu Hospital of Shandong University, Shandong University, Jinan, China
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Chikondowa P, Munkombwe D, Chikwambi Z, Kuona P, Masimirembwa C. Pharmacogenetics of 6-mercaptopurine in a black Zimbabwean cohort treated for acute lymphoblastic leukaemia. Pharmacogenomics 2023; 24:449-457. [PMID: 37248698 PMCID: PMC10463210 DOI: 10.2217/pgs-2023-0026] [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: 02/18/2023] [Accepted: 05/16/2023] [Indexed: 05/31/2023] Open
Abstract
Background: 6-mercaptopurine usage is associated with myelotoxicity and increased risk in patients carrying metabolism-related genetic variations. This study aimed to determine the frequency of candidate gene polymorphisms and their association with 6-mercaptopurine intolerance. Methods: A total of 41 patients on acute lymphoblastic leukaemia treatment were genotyped for TPMT and NUDT15 (rs116855232) alleles, and their association with dose intensity was analyzed. Results: The defective TPMT*3C allele frequency was 9.8%. The median maintenance dose intensity for TPMT*1/*3C participants was considerably lower (47%) when compared with the TPMT*1/*1 wild-type (77%), although not statistically significant. Conclusion: This is the first pharmacogenetics study carried out in a black Zimbabwean leukemia patient cohort. The high defective TPMT*3C (9.8%) allele frequency points to the potential utility of pharmacogenetics testing for safe usage of 6-mercaptopurine in this population.
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Affiliation(s)
- Pageneck Chikondowa
- Department of Genomic Medicine, African Institute of Biomedical Science & Technology (AiBST), Harare, Zimbabwe
- Department of Biotechnology, School of Health Science & Technology, Chinhoyi University of Technology, Chinhoyi, Zimbabwe
| | - Derick Munkombwe
- Department of Genomic Medicine, African Institute of Biomedical Science & Technology (AiBST), Harare, Zimbabwe
- Department of Pharmacy, School of Health Sciences, University of Zambia, Lusaka, 10101, Zambia
| | - Zedias Chikwambi
- Department of Genomic Medicine, African Institute of Biomedical Science & Technology (AiBST), Harare, Zimbabwe
- Department of Biotechnology, School of Health Science & Technology, Chinhoyi University of Technology, Chinhoyi, Zimbabwe
| | - Patience Kuona
- Department of Paediatrics, Faculty of Medicine & Health Sciences, University of Zimbabwe, Harare, Zimbabwe
| | - Collen Masimirembwa
- Department of Genomic Medicine, African Institute of Biomedical Science & Technology (AiBST), Harare, Zimbabwe
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Huang S, Bian Y, Huang C, Miao L. Is Monitoring of the Intracellular Active Metabolite Levels of Nucleobase and Nucleoside Analogs Ready for Precision Medicine Applications? Eur J Drug Metab Pharmacokinet 2022; 47:761-775. [PMID: 35915365 DOI: 10.1007/s13318-022-00786-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/27/2022] [Indexed: 12/13/2022]
Abstract
Nucleobase and nucleoside analogs (NAs) play important roles in cancer therapy. Although there are obvious individual differences in NA treatments, most NAs lack direct relationships between their plasma concentration and efficacy or adverse effects. Accumulating evidence suggests that the intracellular active metabolite levels of NAs predict patient outcomes. This article reviewed the relationships between NA intracellular active metabolite levels and their efficacy or adverse effects. The factors affecting the formation of intracellular active metabolites and combination regimens that elevate intracellular active metabolite levels were also reviewed. Given the mechanism of NA cytotoxicity, NA intracellular active metabolite levels may be predictive of clinical outcomes. Many clinical studies support this hypothesis. Therefore, the monitoring of intracellular active metabolite levels is beneficial for individualized NA treatment. However, to perform clinical monitoring in practice, well-designed studies are needed to explore the optimal threshold or range and the appropriate regimen adjustment strategies based on these parameters.
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Affiliation(s)
- Shenjia Huang
- Department of Clinical Pharmacy, College of Pharmaceutical Science, Soochow University, Suzhou, China
- Institute for Interdisciplinary Drug Research and Translational Sciences, Soochow University, Suzhou, China
| | - Yicong Bian
- Department of Clinical Pharmacology, the First Affiliated Hospital of Soochow University, Suzhou, 215006, China
- Department of Clinical Pharmacy, College of Pharmaceutical Science, Soochow University, Suzhou, China
- Institute for Interdisciplinary Drug Research and Translational Sciences, Soochow University, Suzhou, China
| | - Chenrong Huang
- Department of Clinical Pharmacology, the First Affiliated Hospital of Soochow University, Suzhou, 215006, China.
- Department of Clinical Pharmacy, College of Pharmaceutical Science, Soochow University, Suzhou, China.
- Institute for Interdisciplinary Drug Research and Translational Sciences, Soochow University, Suzhou, China.
| | - Liyan Miao
- Department of Clinical Pharmacology, the First Affiliated Hospital of Soochow University, Suzhou, 215006, China.
- Department of Clinical Pharmacy, College of Pharmaceutical Science, Soochow University, Suzhou, China.
- Institute for Interdisciplinary Drug Research and Translational Sciences, Soochow University, Suzhou, China.
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Guo HL, Zhao YT, Wang WJ, Dong N, Hu YH, Zhang YY, Chen F, Zhou L, Li T. Optimizing thiopurine therapy in children with acute lymphoblastic leukemia: A promising “MINT” sequencing strategy and therapeutic “DNA-TG” monitoring. Front Pharmacol 2022; 13:941182. [PMID: 36238550 PMCID: PMC9552076 DOI: 10.3389/fphar.2022.941182] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2022] [Accepted: 08/02/2022] [Indexed: 11/13/2022] Open
Abstract
Thiopurines, including thioguanine (TG), 6-mercaptopurine (6-MP), and azathioprine (AZA), are extensively used in clinical practice in children with acute lymphoblastic leukemia (ALL) and inflammatory bowel diseases. However, the common adverse effects caused by myelosuppression and hepatotoxicity limit their application. Metabolizing enzymes such as thiopurine S-methyltransferase (TPMT), nudix hydrolase 15 (NUDT15), inosine triphosphate pyrophosphohydrolase (ITPA), and drug transporters like multidrug resistance-associated protein 4 (MRP4) have been reported to mediate the metabolism and transportation of thiopurine drugs. Hence, the single nucleotide polymorphisms (SNPs) in those genes could theoretically affect the pharmacokinetics and pharmacological effects of these drugs, and might also become one of the determinants of clinical efficacy and adverse effects. Moreover, long-term clinical practices have confirmed that thiopurine-related adverse reactions are associated with the systemic concentrations of their active metabolites. In this review, we mainly summarized the pharmacogenetic studies of thiopurine drugs. We also evaluated the therapeutic drug monitoring (TDM) research studies and focused on those active metabolites, hoping to continuously improve monitoring strategies for thiopurine therapy to maximize therapeutic efficacy and minimize the adverse effects or toxicity. We proposed that tailoring thiopurine dosing based on MRP4, ITPA, NUDT15, and TMPT genotypes, defined as “MINT” panel sequencing strategy, might contribute toward improving the efficacy and safety of thiopurines. Moreover, the DNA-incorporated thioguanine nucleotide (DNA-TG) metabolite level was more suitable for red cell 6-thioguanine nucleotide (6-TGNs) monitoring, which can better predict the efficacy and safety of thiopurines. Integrating the panel “MINT” sequencing strategy with therapeutic “DNA-TG” monitoring would offer a new insight into the precision thiopurine therapy for pediatric acute lymphoblastic leukemia patients.
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Affiliation(s)
- Hong-Li Guo
- Pharmaceutical Sciences Research Center, Department of Pharmacy, Children’s Hospital of Nanjing Medical University, Nanjing, China
| | - Yue-Tao Zhao
- School of Basic Medicine and Clinical Pharmacy, China Pharmaceutical University, Nanjing, China
- Visiting Graduate Student from School of Basic Medicine and Clinical Pharmacy, Pharmaceutical University, Nanjing, China
| | - Wei-Jun Wang
- School of Basic Medicine and Clinical Pharmacy, China Pharmaceutical University, Nanjing, China
- Visiting Graduate Student from School of Basic Medicine and Clinical Pharmacy, Pharmaceutical University, Nanjing, China
| | - Na Dong
- Institute of Pharmaceutical Science, China Pharmaceutical University, Nanjing, China
- School of Institute of Pharmaceutical Science, Pharmaceutical University, Nanjing, China
| | - Ya-Hui Hu
- Pharmaceutical Sciences Research Center, Department of Pharmacy, Children’s Hospital of Nanjing Medical University, Nanjing, China
| | - Yuan-Yuan Zhang
- Pharmaceutical Sciences Research Center, Department of Pharmacy, Children’s Hospital of Nanjing Medical University, Nanjing, China
| | - Feng Chen
- Pharmaceutical Sciences Research Center, Department of Pharmacy, Children’s Hospital of Nanjing Medical University, Nanjing, China
- *Correspondence: Feng Chen, ; Li Zhou, ; Tao Li,
| | - Li Zhou
- Hematology and Oncology Department, Children’s Hospital of Nanjing Medical University, Nanjing, China
- *Correspondence: Feng Chen, ; Li Zhou, ; Tao Li,
| | - Tao Li
- Department of Solid Oncology, Children’s Hospital of Nanjing Medical University, Nanjing, China
- *Correspondence: Feng Chen, ; Li Zhou, ; Tao Li,
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Tu M, Zhang A, Hu L, Wang F. A Retrospective Cohort Study of the Efficacy, Safety, and Clinical Value of 6-TG versus 6-MP Maintenance Therapy in Children with Acute Lymphoblastic Leukemia. BIOMED RESEARCH INTERNATIONAL 2022; 2022:7580642. [PMID: 36046443 PMCID: PMC9420618 DOI: 10.1155/2022/7580642] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/06/2022] [Revised: 06/23/2022] [Accepted: 07/12/2022] [Indexed: 11/29/2022]
Abstract
Objective To explore the efficacy, safety, and clinical value of 6-TG versus 6-MP when treating childhood acute lymphoblastic leukemia (ALL). Methods The study period was from January 2017 to June 2021. The subjects of this study were 100 children with ALL who were treated in our hospital. According to different intervention methods, the children who received 6-MP maintenance therapy were selected as the control group, with a total of 57 cases. Children with TG maintenance therapy were included in the research group, a total of 43 cases. The ICNS recurrence rate, non-ICNS recurrence rate, first remission mortality rate, secondary malignant tumor, and other indicators were compared. Results First of all, we compared the effective rate: complete remission (CR), partial remission, and nonremission in the study group, and the effective rate was 87.5%. In the control group, there were CR, partial remission, and no remission, and the effective rate was 65.5%. The effective rate of the study group was higher, and the difference between groups was statistically significant (P < 0.05). There were 55 cases of failure in the study group, with an incidence of 21.91%. There were 42 cases of total failure events in the control group, the incidence rate was 18.02%, and there exhibited no remarkable difference (P > 0.05). In the study group, 6 cases died in the first remission, with a fatality rate of 2.39%, while there exhibited no death in the control group. The mortality in the first remission period in the study group was lower (P < 0.05). The overall recurrence rate of the study group was 5.57%, while that of the control group was 11.15%. The overall recurrence rate of the study group was lower, and the difference between groups was statistically significant (P < 0.05). The recurrence rate of ICNS was 2.14% in the study group and 2.98% in the control group, and there exhibited no remarkable difference (P > 0.05). The non-ICNS recurrence rate was 3.43% in the study group and 7.17% in the control group. There exhibited no remarkable difference (P > 0.05). The incidence of secondary malignant tumor events was 0.85% in the study group and 1.59% in the control group. There exhibited no remarkable difference (P > 0.05). The incidence of hepatic vein occlusive disease was 7.29% in the study group and 2.39% in the control group. The incidence of hepatic vein occlusive disease in the study group was higher, and the difference between groups was statistically significant (P < 0.05). Finally, we compared the incidence of adverse reactions. In the study group, there were 12 cases of oral mucosal damage, 7 cases of liver function damage, 6 cases of infection, 10 cases of myelosuppression, 9 cases of gastrointestinal reaction, and 4 cases of skin damage; the incidence rate was 23.17%. In the control group, there were 12 cases of oral mucosal damage, 7 cases of liver function damage, 6 cases of infection, 10 cases of myelosuppression, 9 cases of gastrointestinal reaction, and 4 cases of skin damage, with an incidence of 19.12%. There exhibited no remarkable difference in the incidence of adverse reactions (P > 0.05). Conclusion 6-TG maintenance therapy in children with ALL can enhance the overall effective rate, can reduce the first remission mortality and the total recurrence rate, and will not increase the overall incidence of adverse reactions, but the incidence of reversible or irreversible hepatic veno-occlusive disease is remarkably increased, which has a certain clinical value. Background Treatment-related hepatotoxicity and myelosuppression remain formidable challenges for clinicians. Pharmacokinetic studies found that 6-TG has a more direct intracellular activation pathway, shorter cytotoxic time, and stronger potency than 6-MP. Therefore, this study investigated the efficacy, safety, and clinical value of 6-TG and 6-MP in the treatment of children with ALL.
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Affiliation(s)
- Minghui Tu
- Department of Pediatrics, Xiangyang No. 1 People's Hospital, Hubei University of Medicine, Xiangyang 441000, China
| | - Aiming Zhang
- Department of Pediatrics, Xiangyang No. 1 People's Hospital, Hubei University of Medicine, Xiangyang 441000, China
| | - Li Hu
- Department of Pediatrics, Xiangyang No. 1 People's Hospital, Hubei University of Medicine, Xiangyang 441000, China
| | - Feng Wang
- Department of Pediatrics, Xiangyang No. 1 People's Hospital, Hubei University of Medicine, Xiangyang 441000, China
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Khaeso K, Komvilaisak P, Chainansamit SO, Nakkam N, Suwannaying K, Kuwatjanakul P, Hikino K, Dornsena A, Kanjanawart S, Laoaroon N, Vannaprasaht S, Taketani T, Tassaneeyakul W. NUDT15 is a key genetic factor for prediction of hematotoxicity in pediatric patients who received a standard low dosage regimen of 6-mercaptopurine. Drug Metab Pharmacokinet 2021; 43:100436. [PMID: 35016134 DOI: 10.1016/j.dmpk.2021.100436] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2021] [Revised: 11/21/2021] [Accepted: 11/25/2021] [Indexed: 12/25/2022]
Abstract
6-Mercaptopurine (6-MP) is commonly used for treatment of acute lymphoblastic leukemia (ALL). The incidence of hematotoxicity caused by this drug is quite high in Asians even using a standard low dosage regimen. The present study was aimed to elucidate the impact of thiopurine S-methyltransferase (TPMT), a nucleoside diphosphate-linked moiety X-type motif 15 (NUDT15), inosine triphosphatase (ITPA) and ATP Binding Cassette Subfamily C Member 4 (ABCC4) polymorphisms on hematotoxicity in pediatric patients who received a standard low starting dose of 6-MP. One hundred and sixty-nine pediatric patients were enrolled and their genotypes were determined. Patients who carried NUDT15∗3 and NUDT15∗2 genotypes were at a 10-15 fold higher risk of severe neutropenia than those of the wild-type during the early months of the maintenance phase. Risk of neutropenia was not significantly increased in patients with other NUDT15 variants as well as in patients with TPMT, ITPA or ABCC4 variants. These results suggest that NUDT15 polymorphisms particularly, NUDT15∗3 and NUDT15∗2, play major roles in 6-MP-induced severe hematotoxicity even when using a standard low dosage of 6-MP and genotyping of these variants is necessary in order to obtain precise tolerance doses and avoid severe hematotoxicity in pediatric patients.
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Affiliation(s)
- Kanyarat Khaeso
- Department of Pharmacology, Faculty of Medicine, Khon Kaen University, Thailand
| | | | | | - Nontaya Nakkam
- Department of Pharmacology, Faculty of Medicine, Khon Kaen University, Thailand
| | - Kunanya Suwannaying
- Department of Pediatrics, Faculty of Medicine, Khon Kaen University, Thailand
| | | | - Keiko Hikino
- Laboratory for Pharmacogenomics, RIKEN Center for Integrative Medical Sciences, Yokohama City, Kanagawa, Japan
| | - Areerat Dornsena
- Department of Pharmacology, Faculty of Medicine, Khon Kaen University, Thailand
| | - Sirimas Kanjanawart
- Department of Pharmacology, Faculty of Medicine, Khon Kaen University, Thailand
| | - Napat Laoaroon
- Department of Pediatrics, Faculty of Medicine, Khon Kaen University, Thailand
| | - Suda Vannaprasaht
- Department of Pharmacology, Faculty of Medicine, Khon Kaen University, Thailand
| | - Takeshi Taketani
- Department of Pediatrics, Faculty of Medicine, Shimane University, Izumo, Japan
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9
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[Effect of genetic polymorphism of TPMT and NUDT15 on the tolerance of 6-mercaptopurine therapy in adult acute lymphoblastic leukemia]. ZHONGHUA XUE YE XUE ZA ZHI = ZHONGHUA XUEYEXUE ZAZHI 2021; 42:911-916. [PMID: 35045652 PMCID: PMC8763585 DOI: 10.3760/cma.j.issn.0253-2727.2021.11.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Objective: To investigate the effect of genetic polymorphisms of TPMT*2 rs1800462, TPMT*3B rs1800460, TPMT*3C rs1142345, and NUDT15 rs116855232 on the tolerance of 6-mercaptopurine (6-MP) therapy in adult acute lymphoblastic leukemia (ALL) . Methods: A total of 216 adult patients who were diagnosed with ALL and treated with cyclophosphamide, cytarabine, and 6-MP [complementary and alternative medicine (CAM) regimen] from September 2015 to December 2019 were included. Polymorphisms were detected by TaqMan SNP Genotyping Assay. Combined with clinical data, the influence of genetic polymorphism on the tolerance of 6-MP in the treatment of ALL was analyzed. Results: Among the 216 patients, 185 (85.65%) patients had B-ALL and 31 (14.35%) patients had T-ALL. 216 (100%) patients had CC genotype for both TPMT*2 rs1800462 and TPMT*3B rs1800460. The number of TT and TC genotypes for TPMT*3C rs1142345 was 209 (96.76%) and 7 (3.24%) , respectively. The allele frequency was 1.62% for TPMT*3C rs1142345. The number of CC, CT, and TT genotypes for NUDT15 rs116855232 was 166 (76.85%) , 48 (22.22%) , and 2 (0.93%) , respectively. The allele frequency was 12.04% for NUDT15 rs116855232. The TPMT*3C rs1142345 mutant group (TC+CC genotype) had less transfusion volume of packed red blood cell than the wild group (CC genotype) (P=0.036) , and the mutant group (TC+CC genotype) had a higher risk to develop hepatotoxicity (increased aspartate aminotransferase) than the wild group (CC genotype) (OR=9.559, 95% CI 1.135-80.475, P=0.038) . The durations of white blood cells (WBC) <1×10(9)/L and absolute neutrophil count (ANC) <0.5×10(9)/L in the NUDT15 rs116855232 mutation group (CT+TT genotype) were longer than that in the wild group (CC genotype) (P=0.005, P=0.007) , and the transfusion volume of apheresis-derived platelets in the mutant group (CT+TT type) was greater than that in the wild group (CC genotype) (P=0.014) . Conclusion: Genetic polymorphism of TMPT and NUDT15 has an effect on the tolerance of 6-MP in the treatment of adult ALL. Detecting genotypes of patients with ALL before treatment helps to optimize the dosage of 6-MP, which may help shorten the bone marrow suppression duration and reduce blood transfusion volume.
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10
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Tanaka Y, Saito Y. Importance of NUDT15 Polymorphisms in Thiopurine Treatments. J Pers Med 2021; 11:jpm11080778. [PMID: 34442422 PMCID: PMC8399029 DOI: 10.3390/jpm11080778] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2021] [Revised: 08/06/2021] [Accepted: 08/08/2021] [Indexed: 01/20/2023] Open
Abstract
Thiopurines, mercaptopurine, and azathioprine are used as immunosuppressants in the treatments of inflammatory bowel disease, rheumatoid arthritis, and organ transplantation and as chemotherapeutic drugs for the treatment of acute leukemia and chronic myeloid leukemia. This drug class sometimes causes severe adverse reactions, including bone marrow suppression and hair loss. Genetic polymorphisms of the metabolizing enzyme thiopurine S-methyltransferase have been used for predicting these reactions in Caucasians, but these allele frequencies are less frequently observed in Asian populations. Recently, nudix hydrolase 15 (NUDT15) polymorphisms have been shown to play an important role in thiopurine-induced adverse reactions in Asians. In this review, we summarize the NUDT15 studies, mainly in Asian countries, and their implementation in several countries.
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11
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Pu G, Wang Y, Duan S, Chen J, Yang C, Cui T, Fang C, Zhou Y, Zhang H, Tian X. NUDT15 polymorphism in healthy children with Bai nationality in Yunnan of China. Pediatr Int 2021; 63:790-796. [PMID: 32969567 DOI: 10.1111/ped.14480] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/22/2020] [Revised: 09/08/2020] [Accepted: 09/10/2020] [Indexed: 01/07/2023]
Abstract
BACKGROUND Thiopurine methyltransferase (TPMT) polymorphism is one of the causes of the toxicity of thiopurines, but this is rarely seen in Asian populations. Rather, the nucleoside diphosphate-linked X-component motif 15 (NUDT15) gene is frequently linked to mercaptopurine (MP) intolerance and myelotoxicity in children with acute lymphoblastic leukemia (ALL) in East Asians; however, little is known about the NUDT15 polymorphism in healthy children, especially in ethnic minorities in China. METHODS A total of 162 cases of healthy children with Bai nationality were enrolled for NUDT15 genotyping. RESULTS Three coding variants were identified in the NUDT15 gene including rs186364861, rs746071566 and rs116855232. Notably, the rs746071566 and rs116855232 in NUDT15 showed much higher frequencies in healthy children with Bai nationality compared with healthy East Asian populations, suggesting a concentrated distribution of these variants in the Bai ethnic group. CONCLUSIONS This finding reveals the genetic polymorphism of NUDT15 in children with Chinese Bai nationality, providing a biological genetic background for the individualized therapy of thiopurines for children with Bai nationality in China.
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Affiliation(s)
- Gangling Pu
- Department of Hematology and Oncology, Kunming Children's Hospital, Kunming, Yunnan, China.,Kunming Medical University, Kunming, Yunnan, China
| | - Yali Wang
- Department of Pediatrics, Rizhao People's Hospital, Rizhao, Shandong, China
| | - Shaoqin Duan
- Department of Hematology and Oncology, Kunming Children's Hospital, Kunming, Yunnan, China
| | - Jingpei Chen
- Wuhan Women and Children Medical Care Centre, Wuhan, Hubei, China
| | - Chunhui Yang
- Department of Hematology and Oncology, Kunming Children's Hospital, Kunming, Yunnan, China
| | - Tingting Cui
- Department of Hematology and Oncology, Kunming Children's Hospital, Kunming, Yunnan, China
| | - Chunlian Fang
- Department of Hematology and Oncology, Kunming Children's Hospital, Kunming, Yunnan, China.,Kunming Medical University, Kunming, Yunnan, China
| | - Yan Zhou
- Department of Hematology and Oncology, Kunming Children's Hospital, Kunming, Yunnan, China.,Kunming Medical University, Kunming, Yunnan, China
| | - Han Zhang
- Institute of Medical Biology, Chinese Academy of Medical Sciences and Peking Union Medical College, Kunming, Yunnan, China
| | - Xin Tian
- Department of Hematology and Oncology, Kunming Children's Hospital, Kunming, Yunnan, China.,Yunnan Key Laboratory of Children's Major Disease Research, Kunming, Yunnan, China
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12
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Genetic Polymorphisms of Drug-Metabolizing Enzymes Involved in 6-Mercaptopurine-Induced Myelosuppression in Thai Pediatric Acute Lymphoblastic Leukemia Patients. J Pediatr Genet 2021; 10:29-34. [PMID: 33552635 DOI: 10.1055/s-0040-1715818] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2020] [Accepted: 06/10/2020] [Indexed: 12/15/2022]
Abstract
Genetic polymorphisms of thiopurine S-methyltransferase (TPMT) and nucleoside diphosphate-linked moiety X-type motif 15 ( NUDT15 ) genes have been proposed as key determinants of 6-mercaptopurine (6-MP)-induced myelosuppression in pediatric acute lymphoblastic leukemia (ALL). In the present study, genotypes of TPMT and NUDT15 were investigated in 178 Thai pediatric patients with ALL by the TaqMan SNP genotyping assay and DNA sequencing. The frequency of TPMT*3C was 0.034. Among NUDT15 variants, NUDT15*3 is the most common variant with the allele frequency of 0.073, whereas those of NUDT15*2 , NUDT15*5 , and NUDT15*6 variants were 0.022, 0.011, and 0.039. These data suggest that a high proportion of Thai pediatric ALL patients may be at risk of thiopurine-induced myelosuppression.
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13
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Zhou Y, Wang L, Zhai XY, Wen L, Tang F, Yang F, Liu XT, Dong L, Zhi LJ, Shi HY, Hao GX, Zheng Y, Jacqz-Aigrain E, Wang TY, Zhao W. Precision therapy of 6-mercaptopurine in Chinese children with acute lymphoblastic leukaemia. Br J Clin Pharmacol 2020; 86:1519-1527. [PMID: 32077136 DOI: 10.1111/bcp.14258] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2019] [Revised: 01/27/2020] [Accepted: 01/29/2020] [Indexed: 01/02/2023] Open
Abstract
AIMS Chinese children are more susceptible to the development of thiopurine-induced leukopenia compared with Caucasian populations. The aim of our study was to establish a 6-mercaptopurine (6-MP) dose-concentration-response relationship through exploration of pharmacogenetic factors involved in the thiopurine-induced toxicities in Chinese paediatric patients afflicted by acute lymphoblastic leukaemia (ALL). METHODS Blood samples were obtained from ALL children treated with 6-MP. We determined the metabolite steady-state concentrations of 6-MP in red blood cells (RBCs) by using high-performance liquid chromatography. Pharmacogenetic analysis was carried out on patients' genomic DNA using the MassArray genotyping platform. RESULTS Sixty children afflicted by ALL who received 6-MP treatment were enrolled in this study. The median concentration of 6-thioguanine in patients afflicted by leukopenia was 235.83 pmol/8 × 108 RBCs, which was significantly higher than for patients unafflicted by leukopenia (178.90 pmol/8 × 108 RBCs; P = 0.029). We determined the population special target 6-thioguanine threshold to have equalled 197.50 pmol/8 × 108 RBCs to predict leukopenia risk in Chinese paediatric patients afflicted by ALL. Among 36 candidate single nucleotide polymorphisms, our results indicated that NUDT15 (rs116855232) and IMPDH1 (rs2278293) were correlated with a 5.50-fold and 5.80-fold higher risk of leukopenia, respectively. MTHFR rs1801133 variants were found to have had a 4.46-fold significantly higher risk of hepatotoxicity vs wild-type genotype. CONCLUSION Our findings support the idea that predetermination of genotypes and monitoring of thiopurine metabolism for Chinese paediatric patients afflicted by ALL is necessary to effectively predict the efficacy of treatments and to minimize the adverse effects of 6-MP maintenance therapy.
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Affiliation(s)
- Yue Zhou
- Department of Clinical Pharmacy, School of Pharmaceutical Sciences, Shandong University, Jinan, China
| | - Li Wang
- Department of Paediatric Haematology-Oncology, Children's Hospital of Hebei Province affiliated to Hebei Medical University, Shijiazhuang, China
| | - Xiao-Ying Zhai
- Department of Paediatric Haematology-Oncology, Children's Hospital of Hebei Province affiliated to Hebei Medical University, Shijiazhuang, China
| | - Li Wen
- Department of Paediatric Haematology-Oncology, Children's Hospital of Hebei Province affiliated to Hebei Medical University, Shijiazhuang, China
| | - Fang Tang
- Big data Center, Shandong Provincial Qianfoshan Hospital, the First Hospital Affiliated with Shandong First Medical University, Jinan, China
| | - Fan Yang
- Department of Clinical Pharmacy, School of Pharmaceutical Sciences, Shandong University, Jinan, China
| | - Xi-Ting Liu
- Department of Clinical Pharmacy, School of Pharmaceutical Sciences, Shandong University, Jinan, China
| | - Lei Dong
- Department of Pharmacy, Children's Hospital of Hebei Province affiliated to Hebei Medical University, Shijiazhuang, China
| | - Li-Juan Zhi
- Department of Paediatric Haematology-Oncology, Children's Hospital of Hebei Province affiliated to Hebei Medical University, Shijiazhuang, China
| | - Hai-Yan Shi
- Department of Pharmacy, Shandong Provincial Qianfoshan Hospital, the First Hospital Affiliated with Shandong First Medical University, Jinan, China
| | - Guo-Xiang Hao
- Department of Clinical Pharmacy, School of Pharmaceutical Sciences, Shandong University, Jinan, China
| | - Yi Zheng
- Department of Clinical Pharmacy, School of Pharmaceutical Sciences, Shandong University, Jinan, China
| | | | - Tian-You Wang
- Beijing Key Laboratory of Pediatric Hematology Oncology, National Key Discipline of Pediatrics (Capital Medical University), Key Laboratory of Major Diseases in Children, Ministry of Education, Beijing, China.,Hematology Oncology Center, Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, Beijing, China
| | - Wei Zhao
- Department of Clinical Pharmacy, School of Pharmaceutical Sciences, Shandong University, Jinan, China.,Department of Pharmacy, Shandong Provincial Qianfoshan Hospital, the First Hospital Affiliated with Shandong First Medical University, Jinan, China
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