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Yamada S, Mizukoshi T, Sato A, Sakakibara SI. Purinosomes and Purine Metabolism in Mammalian Neural Development: A Review. Acta Histochem Cytochem 2024; 57:89-100. [PMID: 38988694 PMCID: PMC11231565 DOI: 10.1267/ahc.24-00027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2024] [Accepted: 05/19/2024] [Indexed: 07/12/2024] Open
Abstract
Neural stem/progenitor cells (NSPCs) in specific brain regions require precisely regulated metabolite production during critical development periods. Purines-vital components of DNA, RNA, and energy carriers like ATP and GTP-are crucial metabolites in brain development. Purine levels are tightly controlled through two pathways: de novo synthesis and salvage synthesis. Enzymes driving de novo pathway are assembled into a large multienzyme complex termed the "purinosome." Here, we review purine metabolism and purinosomes as spatiotemporal regulators of neural development. Notably, around postnatal day 0 (P0) during mouse cortical development, purine synthesis transitions from the de novo pathway to the salvage pathway. Inhibiting the de novo pathway affects mTORC1 pathway and leads to specific forebrain malformations. In this review, we also explore the importance of protein-protein interactions of a newly identified NSPC protein-NACHT and WD repeat domain-containing 1 (Nwd1)-in purinosome formation. Reduced Nwd1 expression disrupts purinosome formation, impacting NSPC proliferation and neuronal migration, resulting in periventricular heterotopia. Nwd1 interacts directly with phosphoribosylaminoimidazole-succinocarboxamide synthetase (PAICS), an enzyme involved in de novo purine synthesis. We anticipate this review will be valuable for researchers investigating neural development, purine metabolism, and protein-protein interactions.
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Affiliation(s)
- Seiya Yamada
- Laboratory for Molecular Neurobiology, Faculty of Human Sciences, Waseda University, Saitama, Japan
- Neuroscience Center, HiLIFE-Helsinki Institute of Life Science, University of Helsinki, Helsinki, Finland
| | - Tomoya Mizukoshi
- Laboratory for Molecular Neurobiology, Faculty of Human Sciences, Waseda University, Saitama, Japan
| | - Ayaka Sato
- Laboratory for Molecular Neurobiology, Faculty of Human Sciences, Waseda University, Saitama, Japan
| | - Shin-Ichi Sakakibara
- Laboratory for Molecular Neurobiology, Faculty of Human Sciences, Waseda University, Saitama, Japan
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Li L, Cheng R, Wu Y, Lin H, Gan H, Zhang H. Diagnosis and management of inflammatory bowel disease. J Evid Based Med 2024; 17:409-433. [PMID: 38934234 DOI: 10.1111/jebm.12626] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/01/2024] [Revised: 06/10/2024] [Accepted: 06/13/2024] [Indexed: 06/28/2024]
Abstract
Inflammatory bowel disease (IBD) is a chronic and relapsing immune-mediated disease of the gastrointestinal tract with a gradually increasing global incidence and prevalence. A prolonged course of IBD leads to a decline in patient quality of life and the creation of a substantial economic burden on society. Owing to the lack of specific diagnostic markers, the diagnosis of IBD still needs a gold standard based on a combination of clinical manifestations, imaging, laboratory, and endoscopic results. Accordingly, the current goals of IBD treatment are to alleviate clinical symptoms and reduce recurrence rates. Therefore, it is imperative to develop a standard set of procedures to diagnose and treat IBD. In this review, we summarize prominent and emerging studies, outline classical and contemporary approaches to diagnosing and managing IBD, and integrate multiple guidelines. Furthermore, we propose the possibility of establishing an early and comprehensive diagnostic workflow and personalized management strategy in the future. We aim to enhance the quality and standardization of diagnostic and treatment procedures for IBD.
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Affiliation(s)
- Lili Li
- Department of Gastroenterology, West China Hospital, Sichuan University, Chengdu, China
- Centre for Inflammatory Bowel Disease, West China Hospital, Sichuan University, Chengdu, China
- Lab of Inflammatory Bowel Disease, Frontiers Science Center for Disease-Related Molecular Network, West China Hospital, Sichuan University, Chengdu, China
| | - Rui Cheng
- Department of Gastroenterology, West China Hospital, Sichuan University, Chengdu, China
- Centre for Inflammatory Bowel Disease, West China Hospital, Sichuan University, Chengdu, China
- Lab of Inflammatory Bowel Disease, Frontiers Science Center for Disease-Related Molecular Network, West China Hospital, Sichuan University, Chengdu, China
| | - Yushan Wu
- Department of Gastroenterology, West China Hospital, Sichuan University, Chengdu, China
- Centre for Inflammatory Bowel Disease, West China Hospital, Sichuan University, Chengdu, China
- Lab of Inflammatory Bowel Disease, Frontiers Science Center for Disease-Related Molecular Network, West China Hospital, Sichuan University, Chengdu, China
| | - Hao Lin
- Department of Gastroenterology, West China Hospital, Sichuan University, Chengdu, China
- Centre for Inflammatory Bowel Disease, West China Hospital, Sichuan University, Chengdu, China
- Lab of Inflammatory Bowel Disease, Frontiers Science Center for Disease-Related Molecular Network, West China Hospital, Sichuan University, Chengdu, China
| | - Huatian Gan
- Department of Gastroenterology, West China Hospital, Sichuan University, Chengdu, China
- Centre for Inflammatory Bowel Disease, West China Hospital, Sichuan University, Chengdu, China
- Lab of Inflammatory Bowel Disease, Frontiers Science Center for Disease-Related Molecular Network, West China Hospital, Sichuan University, Chengdu, China
- The Center of Gerontology and Geriatrics, National Clinical Research Center for Geriatrics, West China Hospital, Sichuan University, Chengdu, China
| | - Hu Zhang
- Department of Gastroenterology, West China Hospital, Sichuan University, Chengdu, China
- Centre for Inflammatory Bowel Disease, West China Hospital, Sichuan University, Chengdu, China
- Lab of Inflammatory Bowel Disease, Frontiers Science Center for Disease-Related Molecular Network, West China Hospital, Sichuan University, Chengdu, China
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Kwan KR, Skokan S, Blesh-Boren T, Vogel J, Harter N, Ford JB. Chemotherapeutic metabolism presenting as a recalcitrant case of hand-foot syndrome and mucositis. J Oncol Pharm Pract 2024; 30:584-588. [PMID: 38204187 DOI: 10.1177/10781552241226595] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2024]
Abstract
INTRODUCTION Mercaptopurine (6MP) and methotrexate (MTX) are commonly used for maintenance chemotherapy for acute lymphoblastic leukemia (ALL). These medications have been associated with various side effects such as myelosuppression, colitis, and thyroiditis in addition to numerous cutaneous adverse events. Cutaneous side-effects most reported include mucositis, alopecia, xerosis, and pruritus. We report an interesting case of hand-foot syndrome to 6MP in a child on maintenance therapy for B-cell ALL from an alteration in medication metabolism. CASE We report a 10-year-old male on maintenance chemotherapy for pre-Bcell ALL who presented to the hospital with worsening oral lesions and erythematous, fissured plaques on the palms and soles. Maintenance therapy consisted of IV vincristine and 5-day pulse of steroids every 12 weeks, daily 6MP, and weekly MTX, which were increased to ≥ 150% of standard dosing due to persistent absolute neutrophil counts > 1500. Metabolites obtained on admission demonstrated elevated 6MMP metabolites at 35,761 (normal < 5700). TPMT and NUDT15 enzyme activity were normal and no alterations in genotyping were discovered. OUTCOME Patient's oral chemotherapy, including both 6MP and MTX, were stopped and allopurinol 100 mg daily was initiated, which lead to overall improvement. DISCUSSION Clinical findings of acute mucositis and worsening of hand-foot syndrome, in the setting of inadequate myelosuppression in a child on maintenance therapy for ALL should raise concerns to consider altered metabolism pathway leading to toxic metabolite buildup. Allopurinol can play in improving cutaneous manifestation and chemotherapeutic dosing in patients with altered metabolism.
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Affiliation(s)
- Kevin R Kwan
- Department of Dermatology, University of Nebraska Medical Center, Omaha, NE, USA
| | - Shayna Skokan
- Creighton University School of Pharmacy, Omaha, NE, USA
| | | | | | - Nicole Harter
- Department of Dermatology, University of Nebraska Medical Center, Omaha, NE, USA
- Children's Nebraska, Omaha, NE, USA
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Briki M, Murisier A, Guidi M, Seydoux C, Buclin T, Marzolini C, Girardin FR, Thoma Y, Carrara S, Choong E, Decosterd LA. Liquid chromatography coupled to tandem mass spectrometry (LC-MS/MS) methods for the therapeutic drug monitoring of cytotoxic anticancer drugs: An update. J Chromatogr B Analyt Technol Biomed Life Sci 2024; 1236:124039. [PMID: 38490042 DOI: 10.1016/j.jchromb.2024.124039] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2023] [Revised: 01/26/2024] [Accepted: 01/31/2024] [Indexed: 03/17/2024]
Abstract
In the era of precision medicine, there is increasing evidence that conventional cytotoxic agents may be suitable candidates for therapeutic drug monitoring (TDM)- guided drug dosage adjustments and patient's tailored personalization of non-selective chemotherapies. To that end, many liquid chromatography coupled to tandem mass spectrometry (LC-MS/MS) assays have been developed for the quantification of conventional cytotoxic anticancer chemotherapies, that have been comprehensively and critically reviewed. The use of stable isotopically labelled internal standards (IS) of cytotoxic drugs was strikingly uncommon, accounting for only 48 % of the methods found, although their use could possible to suitably circumvent patients' samples matrix effects variability. Furthermore, this approach would increase the reliability of cytotoxic drug quantification in highly multi-mediated cancer patients with complex fluctuating pathophysiological and clinical conditions. LC-MS/MS assays can accommodate multiplexed analyses of cytotoxic drugs with optimal selectivity and specificity as well as short analytical times and, when using stable-isotopically labelled IS for quantification, provide concentrations measurements with a high degree of certainty. However, there are still organisational, pharmacological, and medical constraints to tackle before TDM of cytotoxic drugs can be more largely adopted in the clinics for contributing to our ever-lasting quest to improve cancer treatment outcomes.
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Affiliation(s)
- M Briki
- Laboratory of Clinical Pharmacology, Department of Laboratory Medicine and Pathology, Lausanne University Hospital and University of Lausanne, 1011 Lausanne, Switzerland; Service of Clinical Pharmacology, Department of Medicine, Lausanne University Hospital and University of Lausanne, 1011 Lausanne, Switzerland; Bio/CMOS Interfaces Laboratory, École Polytechnique Fédérale de Lausanne-EPFL, 2002 Neuchâtel, Switzerland
| | - A Murisier
- Laboratory of Clinical Pharmacology, Department of Laboratory Medicine and Pathology, Lausanne University Hospital and University of Lausanne, 1011 Lausanne, Switzerland
| | - M Guidi
- Service of Clinical Pharmacology, Department of Medicine, Lausanne University Hospital and University of Lausanne, 1011 Lausanne, Switzerland; Institute of Pharmaceutical Sciences of Western Switzerland, University of Geneva, University of Lausanne, 1206 Geneva, Switzerland; Centre for Research and Innovation in Clinical Pharmaceutical Sciences, Lausanne University Hospital and University of Lausanne, 1011 Lausanne, Switzerland
| | - C Seydoux
- Internal Medicine Service, Department of Medicine, Lausanne University Hospital and University of Lausanne, 1011 Lausanne, Switzerland
| | - T Buclin
- Service of Clinical Pharmacology, Department of Medicine, Lausanne University Hospital and University of Lausanne, 1011 Lausanne, Switzerland
| | - C Marzolini
- Laboratory of Clinical Pharmacology, Department of Laboratory Medicine and Pathology, Lausanne University Hospital and University of Lausanne, 1011 Lausanne, Switzerland
| | - F R Girardin
- Laboratory of Clinical Pharmacology, Department of Laboratory Medicine and Pathology, Lausanne University Hospital and University of Lausanne, 1011 Lausanne, Switzerland; Service of Clinical Pharmacology, Department of Medicine, Lausanne University Hospital and University of Lausanne, 1011 Lausanne, Switzerland
| | - Y Thoma
- School of Engineering and Management Vaud, HES-SO University of Applied Sciences and Arts Western Switzerland, 1401 Yverdon-les-Bains, Switzerland
| | - S Carrara
- Bio/CMOS Interfaces Laboratory, École Polytechnique Fédérale de Lausanne-EPFL, 2002 Neuchâtel, Switzerland
| | - E Choong
- Laboratory of Clinical Pharmacology, Department of Laboratory Medicine and Pathology, Lausanne University Hospital and University of Lausanne, 1011 Lausanne, Switzerland
| | - L A Decosterd
- Laboratory of Clinical Pharmacology, Department of Laboratory Medicine and Pathology, Lausanne University Hospital and University of Lausanne, 1011 Lausanne, Switzerland.
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Cataletti G, Santagata F, Pastorelli L, Battezzati PM. Severe azathioprine-induced liver injury 22 months after initiation of treatment. Drug Ther Bull 2024; 62:60-63. [PMID: 38302287 DOI: 10.1136/dtb.2024.253505rep] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2024]
Affiliation(s)
- Giovanni Cataletti
- Liver and Gastroenterology Unit, ASST Santi Paolo e Carlo, Milan, Italy
- Department of Health Sciences, Università degli Studi di Milano, Milan, Italy
| | - Fabrizio Santagata
- Liver and Gastroenterology Unit, ASST Santi Paolo e Carlo, Milan, Italy
- Department of Health Sciences, Università degli Studi di Milano, Milan, Italy
| | - Luca Pastorelli
- Liver and Gastroenterology Unit, ASST Santi Paolo e Carlo, Milan, Italy
- Department of Health Sciences, Università degli Studi di Milano, Milan, Italy
| | - Pier Maria Battezzati
- Liver and Gastroenterology Unit, ASST Santi Paolo e Carlo, Milan, Italy
- Department of Health Sciences, Università degli Studi di Milano, Milan, Italy
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Chong KM, Jiang H, Lo EAG, Hong WZ, Wong ETY, Chan GC, Cho J. Therapeutic Drug Monitoring in Patients with Systemic Lupus Erythematosus: Utility and Gaps. J Clin Med 2024; 13:451. [PMID: 38256585 PMCID: PMC10816431 DOI: 10.3390/jcm13020451] [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: 11/27/2023] [Revised: 01/09/2024] [Accepted: 01/12/2024] [Indexed: 01/24/2024] Open
Abstract
Despite advances in the treatment of patients with systemic lupus erythematous (SLE), outcomes have remained suboptimal. Persistent disease activity, patient comorbidities and drug toxicities contribute to the accrual of progressive irreversible damage and high rates of morbidity and mortality. Currently, similar drug doses and regimens are promulgated in the treatment guidelines for all SLE patients, despite the vast differences in patient and environmental factors that affect the drugs' metabolism and blood concentrations. This causes a disconnect between drug dosing and drug blood concentrations, which can then result in unpredictability in drug toxicities and therapeutic effects. In this review, we discuss commonly used oral immunosuppressive medications in SLE, their pharmacogenomics, and factors affecting their metabolism and blood concentrations. Further, we highlight the role of therapeutic drug monitoring in SLE, which is the first accessible step to individualising therapy.
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Affiliation(s)
- Kar Mun Chong
- Division of Rheumatology, Department of Medicine, National University Hospital, Singapore 119074, Singapore;
| | - He Jiang
- Department of Pharmacy, National University Hospital, Singapore 119074, Singapore; (H.J.); (E.A.G.L.)
| | - Elaine Ah Gi Lo
- Department of Pharmacy, National University Hospital, Singapore 119074, Singapore; (H.J.); (E.A.G.L.)
| | - Wei-Zhen Hong
- Division of Nephrology, Department of Medicine, National University Hospital, Singapore 119074, Singapore; (W.-Z.H.); (E.T.-Y.W.); (G.C.C.)
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore 117597, Singapore
| | - Emmett Tsz-Yeung Wong
- Division of Nephrology, Department of Medicine, National University Hospital, Singapore 119074, Singapore; (W.-Z.H.); (E.T.-Y.W.); (G.C.C.)
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore 117597, Singapore
- National University Centre for Organ Transplantation, National University Hospital, Singapore 119074, Singapore
| | - Gek Cher Chan
- Division of Nephrology, Department of Medicine, National University Hospital, Singapore 119074, Singapore; (W.-Z.H.); (E.T.-Y.W.); (G.C.C.)
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore 117597, Singapore
| | - Jiacai Cho
- Division of Rheumatology, Department of Medicine, National University Hospital, Singapore 119074, Singapore;
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore 117597, Singapore
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De Castro F, Stefàno E, De Luca E, Benedetti M, Fanizzi FP. Platinum-Nucleos(t)ide Compounds as Possible Antimetabolites for Antitumor/Antiviral Therapy: Properties and Perspectives. Pharmaceutics 2023; 15:pharmaceutics15030941. [PMID: 36986802 PMCID: PMC10058173 DOI: 10.3390/pharmaceutics15030941] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2023] [Revised: 03/06/2023] [Accepted: 03/12/2023] [Indexed: 03/16/2023] Open
Abstract
Nucleoside analogues (NAs) are a family of compounds which include a variety of purine and pyrimidine derivatives, widely used as anticancer and antiviral agents. For their ability to compete with physiological nucleosides, NAs act as antimetabolites exerting their activity by interfering with the synthesis of nucleic acids. Much progress in the comprehension of their molecular mechanisms has been made, including providing new strategies for potentiating anticancer/antiviral activity. Among these strategies, new platinum-NAs showing a good potential to improve the therapeutic indices of NAs have been synthesized and studied. This short review aims to describe the properties and future perspectives of platinum-NAs, proposing these complexes as a new class of antimetabolites.
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Barnes A, Ooi SYJ, Lynch KD, Parthasarathy N, Bishara M, Gounder M, Grafton R, Leach P, Bampton P, Sechi A, Ng W, Connor S, van Langenberg D, Mountifield R, Andrews JM. Proactive Metabolite Testing in Patients on Thiopurine May Yield Long-Term Clinical Benefits in Inflammatory Bowel Disease. Dig Dis Sci 2023; 68:889-896. [PMID: 35687221 PMCID: PMC10011286 DOI: 10.1007/s10620-022-07556-y] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/11/2022] [Accepted: 05/04/2022] [Indexed: 01/06/2023]
Abstract
BACKGROUND The thiopurine medications are well established in the treatment of inflammatory bowel disease (IBD). There is significant variation in levels of toxic and therapeutic metabolites. Current data from small or short-term studies support therapeutic drug monitoring (TDM) in assessing azathioprine (AZA) and 6-mercaptopurine (6MP). TDM of thiopurines involves measurement and interpretation of metabolites 6-TGN and 6-MMPR. AIMS This study aimed to assess long-cterm outcomes of patients on thiopurines following therapeutic drug monitoring. METHODS A multicenter retrospective observational study of outcomes post thiopurine TDM was conducted. Demographics, disease characteristics, physician global assessment, IBD therapy at baseline TDM and again at 12 months were collected. Clinical outcomes were analyzed according to TDM result, and indication for TDM including proactive and other indications. RESULTS The study included 541 patients. Only 39% of patients had appropriate dosing of thiopurines. AZA/6MP TDM informed a management change in 61.9%, and enabled 88.8% of the cohort to continue AZA/6MP following TDM. At 12 months following TDM the majority (74.1%) of the cohort remained on AZA/6MP. Clinical remission was higher at 12-months following thiopurines TDM (68%) compared to baseline (37%), including proactive TDM. Post TDM, 13.0% of patients were identified as shunters and commenced on thiopurine-allopurinol co-therapy. CONCLUSION Thiopurine TDM resulted in a change in management for the majority of patients. Post TDM significantly more patients were in remission. TDM allowed the identification of non-adherence and shunters who, without intervention, would not reach therapeutic drug levels. Proactive TDM allowed identification and management of inappropriate dosing, and was associated with increased levels of clinical remission.
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Affiliation(s)
- Alex Barnes
- IBD Service, Department of Gastroenterology and Hepatology, Royal Adelaide Hospital Adelaide, Adelaide, Australia.
- Department of Gastroenterology and Hepatology, Flinders Medical Centre, Flinders Drive, Bedford Park, Adelaide, SA, 5042, Australia.
- College of Medicine and Public Health, Flinders University, Adelaide, Australia.
| | - Soong-Yuan J Ooi
- IBD Service, Department of Gastroenterology and Hepatology, Royal Adelaide Hospital Adelaide, Adelaide, Australia
- School of Medicine, University of Adelaide, Adelaide, Australia
| | - Kate D Lynch
- IBD Service, Department of Gastroenterology and Hepatology, Royal Adelaide Hospital Adelaide, Adelaide, Australia
- School of Medicine, University of Adelaide, Adelaide, Australia
| | - Nina Parthasarathy
- Department of Gastroenterology and Hepatology, Eastern Health, Melbourne, Australia
| | - Maria Bishara
- Department of Gastroenterology and Hepatology, Eastern Health, Melbourne, Australia
| | - Michael Gounder
- Department of Gastroenterology and Hepatology, Liverpool Hospital, Sydney, Australia
- South Western Sydney Clinical School, Faculty of Medicine, University of NSW, Sydney, Australia
| | - Rachel Grafton
- IBD Service, Department of Gastroenterology and Hepatology, Royal Adelaide Hospital Adelaide, Adelaide, Australia
| | - Peta Leach
- Department of Gastroenterology and Hepatology, Flinders Medical Centre, Flinders Drive, Bedford Park, Adelaide, SA, 5042, Australia
| | - Peter Bampton
- Department of Gastroenterology and Hepatology, Flinders Medical Centre, Flinders Drive, Bedford Park, Adelaide, SA, 5042, Australia
| | - Alexandra Sechi
- Department of Gastroenterology and Hepatology, Liverpool Hospital, Sydney, Australia
| | - Watson Ng
- Department of Gastroenterology and Hepatology, Liverpool Hospital, Sydney, Australia
- South Western Sydney Clinical School, Faculty of Medicine, University of NSW, Sydney, Australia
| | - Susan Connor
- Department of Gastroenterology and Hepatology, Liverpool Hospital, Sydney, Australia
- South Western Sydney Clinical School, Faculty of Medicine, University of NSW, Sydney, Australia
| | - Daniel van Langenberg
- Department of Gastroenterology and Hepatology, Eastern Health, Melbourne, Australia
- Eastern Health Clinical School, Monash University, Melbourne, Australia
| | - Réme Mountifield
- Department of Gastroenterology and Hepatology, Flinders Medical Centre, Flinders Drive, Bedford Park, Adelaide, SA, 5042, Australia
- College of Medicine and Public Health, Flinders University, Adelaide, Australia
| | - Jane M Andrews
- IBD Service, Department of Gastroenterology and Hepatology, Royal Adelaide Hospital Adelaide, Adelaide, Australia
- School of Medicine, University of Adelaide, Adelaide, Australia
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Deng C, Hu Y, Conceição M, Wood MJA, Zhong H, Wang Y, Shao P, Chen J, Qiu L. Oral delivery of layer-by-layer coated exosomes for colitis therapy. J Control Release 2023; 354:635-650. [PMID: 36634710 DOI: 10.1016/j.jconrel.2023.01.017] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2022] [Revised: 01/05/2023] [Accepted: 01/06/2023] [Indexed: 01/14/2023]
Abstract
Mesenchymal stem cell-derived exosomes (MSC-Exos) have attracted much attention as a potential cell-free therapy for ulcerative colitis (UC), mainly due to their anti-inflammatory, tissue repair, and immunomodulatory properties. Although intravenous injection of MSC-Exos is able to improve UC to a certain extent, oral administration of exosomes is the preferred method to treat gastrointestinal diseases such as UC. However, exosomes contain proteins and nucleic acids that are vulnerable to degradation by the gastrointestinal environment, making oral administration difficult to implement. Layer-by-layer (LbL) self-assembly technology provides a promising strategy for the oral delivery of exosomes. Therefore, an efficient LbL-Exos self-assembly system was constructed in this study for the oral delivery of exosomes targeted to the colon to improve UC treatment. Biocompatible and biodegradable N-(2-hydroxyl) propyl-3-trimethyl ammonium chitosan chloride (HTCC) and oxidized konjac glucomannan (OKGM) polysaccharides were used as the outer layers to provide colon targeting and to protect exosomes from degradation. Similar to plain exosomes, LbL-Exos had a similar structure and features, but LbL provided controlled release of exosomes in the inflammatory colon. Compared with intravenous administration, oral administration of LbL-Exos could effectively alleviate UC using half the number of exosomes. Mechanistic studies showed that LbL-Exos were internalized by macrophages and intestinal epithelial cells to exert anti-inflammatory and tissue repair effects and therefore alleviate UC. Furthermore, the LbL-Exos system was able to improve UC via MAPK/NF-κB signaling pathway inhibition. Overall, our data show that LbL-MSC-Exos can alleviate UC after oral administration and therefore may constitute a new strategy for UC treatment in the future.
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Affiliation(s)
- Chao Deng
- Wuxi School of Medicine, Jiangnan University, Wuxi 214122, China
| | - Yiwei Hu
- Wuxi School of Medicine, Jiangnan University, Wuxi 214122, China; Jiangyin Center for Disease Control and Prevention, Jiangyin 214434, China
| | | | - Matthew J A Wood
- Department of Paediatrics, University of Oxford, Oxford OX1 3QX, UK; MDUK Oxford Neuromuscular Centre, University of Oxford, Oxford, UK
| | - Hongyao Zhong
- Wuxi School of Medicine, Jiangnan University, Wuxi 214122, China
| | - Yan Wang
- Yixing Hospital of Traditional Chinese Medicine, Wuxi 214200, China
| | - Ping Shao
- Yixing Hospital of Traditional Chinese Medicine, Wuxi 214200, China.
| | - Jinghua Chen
- School of Life Sciences and Health Engineering, Jiangnan University, Wuxi 214122, China.
| | - Lipeng Qiu
- Department of Paediatrics, University of Oxford, Oxford OX1 3QX, UK; School of Life Sciences and Health Engineering, Jiangnan University, Wuxi 214122, China.
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Cataletti G, Santagata F, Pastorelli L, Battezzati PM. Severe azathioprine-induced liver injury 22 months after initiation of treatment. BMJ Case Rep 2022; 15:e253505. [PMID: 36543371 PMCID: PMC9772668 DOI: 10.1136/bcr-2022-253505] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
Drug-induced liver injury (DILI) is the leading cause of acute liver failure in high-income countries. Acute cholestasis is one of the most common forms of hepatotoxicity induced by azathioprine. It usually begins during the first year of treatment, with most cases reported during the first month. We describe an uncommon case of DILI that occurred after 22 months of drug administration. A woman in her 50s was hospitalised because of jaundice and asthenia. She had been treated with azathioprine for myasthenia gravis during the last 2 years. Acute cholestatic injury was diagnosed. After ruling out most common causes of cholestasis, azathioprine was withdrawn and subsequent histological findings in liver biopsy were consistent with drug-induced cholestatic liver damage. After discontinuation of azathioprine, biochemical parameters progressively normalised and remarkable clinical improvement was achieved. With this report, we suggest that azathioprine should be considered among the causes of liver injury, despite long treatment duration.
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Affiliation(s)
- Giovanni Cataletti
- Liver and Gastroenterology Unit, ASST Santi Paolo e Carlo, Milan, Italy
- Department of Health Sciences, Università degli Studi di Milano, Milan, Italy
| | - Fabrizio Santagata
- Liver and Gastroenterology Unit, ASST Santi Paolo e Carlo, Milan, Italy
- Department of Health Sciences, Università degli Studi di Milano, Milan, Italy
| | - Luca Pastorelli
- Liver and Gastroenterology Unit, ASST Santi Paolo e Carlo, Milan, Italy
- Department of Health Sciences, Università degli Studi di Milano, Milan, Italy
| | - Pier Maria Battezzati
- Liver and Gastroenterology Unit, ASST Santi Paolo e Carlo, Milan, Italy
- Department of Health Sciences, Università degli Studi di Milano, Milan, Italy
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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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12
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Late-Onset Acute Liver Injury From Azathioprine. ACG Case Rep J 2022; 9:e00847. [PMID: 36134121 PMCID: PMC9485461 DOI: 10.14309/crj.0000000000000847] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/06/2022] [Revised: 05/13/2022] [Accepted: 07/14/2022] [Indexed: 12/15/2022] Open
Abstract
Azathioprine is a widely prescribed immunosuppressant. Although hepatotoxicity is rare, it commonly presents as mild asymptomatic liver enzyme elevation or acute cholestatic liver injury. We report a case of a 46-year-old woman who presented with jaundice, abdominal pain, fatigue, and elevated aminotransferases in a cholestatic pattern. Endoscopic retrograde cholangiopancreatogram demonstrated no abnormalities, and recently started medications were discontinued without improvement. Liver biopsy was performed, which was consistent with drug-induced liver injury. Despite multiple years of treatment without issue, after azathioprine was discontinued, symptoms and laboratory abnormalities resolved. This case highlights azathioprine's potential for hepatotoxicity even multiple years after initiation.
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13
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Potęga A. Glutathione-Mediated Conjugation of Anticancer Drugs: An Overview of Reaction Mechanisms and Biological Significance for Drug Detoxification and Bioactivation. Molecules 2022; 27:molecules27165252. [PMID: 36014491 PMCID: PMC9412641 DOI: 10.3390/molecules27165252] [Citation(s) in RCA: 26] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2022] [Revised: 08/13/2022] [Accepted: 08/15/2022] [Indexed: 11/26/2022] Open
Abstract
The effectiveness of many anticancer drugs depends on the creation of specific metabolites that may alter their therapeutic or toxic properties. One significant route of biotransformation is a conjugation of electrophilic compounds with reduced glutathione, which can be non-enzymatic and/or catalyzed by glutathione-dependent enzymes. Glutathione usually combines with anticancer drugs and/or their metabolites to form more polar and water-soluble glutathione S-conjugates, readily excreted outside the body. In this regard, glutathione plays a role in detoxification, decreasing the likelihood that a xenobiotic will react with cellular targets. However, some drugs once transformed into thioethers are more active or toxic than the parent compound. Thus, glutathione conjugation may also lead to pharmacological or toxicological effects through bioactivation reactions. My purpose here is to provide a broad overview of the mechanisms of glutathione-mediated conjugation of anticancer drugs. Additionally, I discuss the biological importance of glutathione conjugation to anticancer drug detoxification and bioactivation pathways. I also consider the potential role of glutathione in the metabolism of unsymmetrical bisacridines, a novel prosperous class of anticancer compounds developed in our laboratory. The knowledge on glutathione-mediated conjugation of anticancer drugs presented in this review may be noteworthy for improving cancer therapy and preventing drug resistance in cancers.
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Affiliation(s)
- Agnieszka Potęga
- Department of Pharmaceutical Technology and Biochemistry, Faculty of Chemistry, Gdańsk University of Technology, Gabriela Narutowicza Str. 11/12, 80-233 Gdańsk, Poland
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14
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Bajaj AO, Kushnir MM, Kish-Trier E, Law RN, Zuromski LM, Molinelli AR, McMillin GA, Johnson-Davis KL. LC-MS/MS Method for Measurement of Thiopurine Nucleotides (TN) in Erythrocytes and Association of TN Concentrations With TPMT Enzyme Activity. Front Pharmacol 2022; 13:836812. [PMID: 35387339 PMCID: PMC8978547 DOI: 10.3389/fphar.2022.836812] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2021] [Accepted: 02/14/2022] [Indexed: 11/13/2022] Open
Abstract
Monitoring concentrations of thiopurine metabolites is used clinically to prevent adverse effects in patients on thiopurine drug therapy. We developed a LC-MS/MS method for the quantification of 6-thioguanine (6-TG) and 6-methylmercaptopurine (6-MMP) in red blood cells (RBCs). This method utilizes an automated cell washer for RBC separation from whole blood samples and washing of the separated RBCs. The lower limit of quantification of the method was 0.2 μmol/L for 6-TG (∼50 pmol/8 × 108 RBC) and 4 μmol/L for 6-MMP (∼1,000 pmol/8 × 108 RBC). The total imprecision of the assay was <3.0%. The upper limit of linearity for 6-TG and 6-MMP was 7.5 μmol/L and 150 μmol/L, respectively. The stability of the thiopurine metabolites under pre- and post-analytically relevant conditions was also evaluated. A good agreement was observed between this method and validated LC-MS/MS methods from three laboratories, except for ∼40% low bias for 6-MMP observed in one of the methods. The assessment of the association between 6-TG and 6-MMP concentrations with thiopurine S-methyltransferase (TPMT) phenotype and genotype demonstrated a statistically significant difference in the thiopurine metabolite concentrations between the TPMT groups with normal and intermediate activity of 6-MMP (p < 0.0001), while the difference in 6-TG concentrations was statistically not significant (p = 0.096). Among the samples with normal TPMT activity, higher concentrations of 6-MMP (p = 0.015) were observed in pediatric samples than in the samples of adults. No statistically significant differences were observed in the distributions of 6-TG and 6-MMP concentrations among the evaluated genotypes.
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Affiliation(s)
- Amol O Bajaj
- ARUP Institute for Clinical and Experimental Pathology, Salt Lake City, UT, United States
| | - Mark M Kushnir
- ARUP Institute for Clinical and Experimental Pathology, Salt Lake City, UT, United States.,University of Utah Health Sciences Center, Department of Pathology, Salt Lake City, UT, United States
| | - Erik Kish-Trier
- ARUP Institute for Clinical and Experimental Pathology, Salt Lake City, UT, United States
| | - Rachel N Law
- ARUP Institute for Clinical and Experimental Pathology, Salt Lake City, UT, United States
| | - Lauren M Zuromski
- ARUP Institute for Clinical and Experimental Pathology, Salt Lake City, UT, United States
| | - Alejandro R Molinelli
- Department of Pharmaceutical Sciences, St. Jude Children's Research Hospital, Memphis, TN, United States
| | - Gwendolyn A McMillin
- ARUP Institute for Clinical and Experimental Pathology, Salt Lake City, UT, United States.,University of Utah Health Sciences Center, Department of Pathology, Salt Lake City, UT, United States
| | - Kamisha L Johnson-Davis
- ARUP Institute for Clinical and Experimental Pathology, Salt Lake City, UT, United States.,University of Utah Health Sciences Center, Department of Pathology, Salt Lake City, UT, United States
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15
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Qin Y, Xu H, Zhou N, Chen X, Peng Z, Nie C, Tan J, Wu X. The first-principles study of BC 3 nanosheet as the delivery vehicle for 6-mercaptopurine drug. Mol Phys 2022. [DOI: 10.1080/00268976.2021.1992522] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Affiliation(s)
- Yong Qin
- School of Mathematics and Physics, University of South China, Hengyang, People’s Republic of China
| | - Haiting Xu
- School of Mathematics and Physics, University of South China, Hengyang, People’s Republic of China
| | - Nan Zhou
- School of Mathematics and Physics, University of South China, Hengyang, People’s Republic of China
| | - Xuekun Chen
- School of Mathematics and Physics, University of South China, Hengyang, People’s Republic of China
| | - Zhihua Peng
- School of Mathematics and Physics, University of South China, Hengyang, People’s Republic of China
| | - Changming Nie
- School of Chemistry and Chemical Engineering, University of South China, Hengyang, People’s Republic of China
| | - Jie Tan
- School of Mathematics and Physics, University of South China, Hengyang, People’s Republic of China
| | - Xijun Wu
- School of Mathematics and Physics, University of South China, Hengyang, People’s Republic of China
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16
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Balevic SJ, Sagcal-Gironella ACP. Precision Medicine: Towards Individualized Dosing in Pediatric Rheumatology. Rheum Dis Clin North Am 2021; 48:305-330. [PMID: 34798954 DOI: 10.1016/j.rdc.2021.09.010] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
Despite an increase in the number of available therapeutics, many children with rheumatic disease continue to experience active inflammatory disease and treatment failure. One reason for treatment failure is the lack of dosing paradigms to account for the wide between-patient variability in drug pharmacokinetics because of developmental changes or genetic polymorphisms that effect drug absorption, distribution, metabolism, and elimination. This review highlights several strategies to optimize dosing for biologic and nonbiologic disease-modifying antirheumatic drugs, including therapeutic drug monitoring, pharmacogenomics, and the use of pharmacokinetic/pharmacodynamic modeling.
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Affiliation(s)
- Stephen J Balevic
- Department of Pediatrics, Duke University, Durham, NC, USA; Duke Clinical Research Institute, Durham, NC, USA.
| | - Anna Carmela P Sagcal-Gironella
- Department of Pediatrics, Hackensack Meridian School of Medicine, Nutley, NJ, USA; Division of Pediatric Rheumatology, Joseph M. Sanzari Children's Hospital, 30 Prospect Avenue, WFAN 3rd Floor, Hackensack, NJ 07601, USA; K. HovnanianChildren's Hospital, Neptune, NJ, USA
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17
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Blom M, Pico-Knijnenburg I, van Montfrans JM, Bredius RGM, van der Burg M, Swen JJ, Berghuis D. Abnormal Results of Newborn Screening for SCID After Azathioprine Exposure In Utero: Benefit of TPMT Genotyping in Both Mother and Child. J Clin Immunol 2021; 42:199-202. [PMID: 34622388 DOI: 10.1007/s10875-021-01138-9] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2021] [Accepted: 08/29/2021] [Indexed: 11/30/2022]
Affiliation(s)
- Maartje Blom
- Willem-Alexander Children's Hospital, Laboratory for Pediatric Immunology, Leiden University Medical Center, Leiden, the Netherlands
| | - Ingrid Pico-Knijnenburg
- Willem-Alexander Children's Hospital, Laboratory for Pediatric Immunology, Leiden University Medical Center, Leiden, the Netherlands
| | - Joris M van Montfrans
- Department of Pediatric Immunology and Infectious Diseases, Wilhelmina Children's Hospital, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Robbert G M Bredius
- Willem-Alexander Children's Hospital, Department of Pediatrics, Division of Pediatric Immunology and Stem Cell Transplantation, Leiden University Medical Center, Albinusdreef 2, 2333 ZA, Leiden, the Netherlands
| | - Mirjam van der Burg
- Willem-Alexander Children's Hospital, Laboratory for Pediatric Immunology, Leiden University Medical Center, Leiden, the Netherlands
| | - Jesse J Swen
- Department of Clinical Pharmacy & Toxicology, Leiden University Medical Center, Leiden, the Netherlands
| | - Dagmar Berghuis
- Willem-Alexander Children's Hospital, Department of Pediatrics, Division of Pediatric Immunology and Stem Cell Transplantation, Leiden University Medical Center, Albinusdreef 2, 2333 ZA, Leiden, the Netherlands.
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18
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Morikubo H, Kobayashi T, Ozaki R, Okabayashi S, Kuronuma S, Takeuchi O, Shiba T, Kiyohara H, Matsubayashi M, Sagami S, Nakano M, Ikezaki O, Hisamatsu T, Tanaka Y, Hibi T. Differential effects of mesalazine formulations on thiopurine metabolism through thiopurine S-methyltransferase inhibition. J Gastroenterol Hepatol 2021; 36:2116-2124. [PMID: 33470487 DOI: 10.1111/jgh.15411] [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] [Received: 08/21/2020] [Revised: 12/08/2020] [Accepted: 01/05/2021] [Indexed: 12/30/2022]
Abstract
BACKGROUND AND AIM Thiopurines are often used in combination with mesalazine for the treatment of ulcerative colitis (UC). Mesalazine formulations are delivered to the digestive tract by various delivery systems and absorbed as 5-aminosalicylic acid (5-ASA). 5-ASA is known to inhibit thiopurine S-methyltransferase (TPMT) activity and to affect thiopurine metabolism. There have been no studies comparing TPMT inhibition by multimatrix mesalazine (MMX) with other formulations. We investigated the difference in TPMT inhibition by different mesalazine formulations and prospectively confirmed the clinical relevance. METHODS Plasma concentrations of 5-ASA, N-acetyl-5-aminosalicylic acid (N-Ac-5-ASA), and TPMT activities were measured in UC patients receiving various mesalazine formulations (time-dependent or pH-dependent mesalazine or MMX) as monotherapy. Patients already on both time-dependent or pH-dependent mesalazine and thiopurines switched their mesalazine to MMX, examining 6-thioguanine nucleotide (6-TGN) and 6-methylmercaptopurine (6-MMP) 0 and 8 weeks after switching. Clinical relapse after switching was also monitored for 24 weeks. RESULTS Plasma 5-ASA and N-Ac-5-ASA levels were significantly higher in patients receiving time-dependent mesalazine (n = 12) compared with pH-dependent mesalazine (n = 12) and MMX (n = 15), accompanied by greater TPMT inhibition. Prospective switching from time-dependent mesalazine to MMX decreased 6-TGN levels, increased those of 6-MMP, and increased 6-MMP/6-TGN ratios. Furthermore, this resulted in significantly more relapses than switching from pH-dependent mesalazine to MMX. CONCLUSIONS Time-dependent mesalazine has higher plasma 5-ASA and N-Ac-5-ASA levels and greater TPMT inhibition than MMX. Therefore, switching from time-dependent mesalazine to MMX may lead to an increase of 6-MMP/6-TGN, which may reduce the clinical effectiveness of thiopurines, warranting close monitoring after switch.
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Affiliation(s)
- Hiromu Morikubo
- Center for Advanced IBD Research and Treatment, Kitasato University Kitasato Institute Hospital, Tokyo, Japan.,Department of Gastroenterology and Hepatology, Kitasato University Kitasato Institute Hospital, Tokyo, Japan.,Department of Gastroenterology and Hepatology, Kyorin University School of Medicine, Tokyo, Japan
| | - Taku Kobayashi
- Center for Advanced IBD Research and Treatment, Kitasato University Kitasato Institute Hospital, Tokyo, Japan
| | - Ryo Ozaki
- Center for Advanced IBD Research and Treatment, Kitasato University Kitasato Institute Hospital, Tokyo, Japan.,Department of Gastroenterology and Hepatology, Kyorin University School of Medicine, Tokyo, Japan
| | - Shinji Okabayashi
- Center for Advanced IBD Research and Treatment, Kitasato University Kitasato Institute Hospital, Tokyo, Japan
| | - Satoshi Kuronuma
- Department of Research, BioMedical Laboratory, Kitasato University Kitasato Institute Hospital, Tokyo, Japan
| | - Osamu Takeuchi
- Department of Research, BioMedical Laboratory, Kitasato University Kitasato Institute Hospital, Tokyo, Japan
| | - Tenyo Shiba
- Division of Clinical Pharmacy, Research and Education Center for Clinical Pharmacy, School of Pharmacy, Kitasato University, Tokyo, Japan
| | - Hiroki Kiyohara
- Center for Advanced IBD Research and Treatment, Kitasato University Kitasato Institute Hospital, Tokyo, Japan.,Department of Gastroenterology and Hepatology, Kitasato University Kitasato Institute Hospital, Tokyo, Japan
| | - Mao Matsubayashi
- Center for Advanced IBD Research and Treatment, Kitasato University Kitasato Institute Hospital, Tokyo, Japan.,Department of Gastroenterology and Hepatology, Kitasato University Kitasato Institute Hospital, Tokyo, Japan
| | - Shintaro Sagami
- Center for Advanced IBD Research and Treatment, Kitasato University Kitasato Institute Hospital, Tokyo, Japan
| | - Masaru Nakano
- Center for Advanced IBD Research and Treatment, Kitasato University Kitasato Institute Hospital, Tokyo, Japan.,Department of Gastroenterology and Hepatology, Kitasato University Kitasato Institute Hospital, Tokyo, Japan
| | - Osamu Ikezaki
- Department of Gastroenterology and Hepatology, Kyorin University School of Medicine, Tokyo, Japan
| | - Tadakazu Hisamatsu
- Department of Gastroenterology and Hepatology, Kyorin University School of Medicine, Tokyo, Japan
| | - Yoichi Tanaka
- Division of Clinical Pharmacy, Research and Education Center for Clinical Pharmacy, School of Pharmacy, Kitasato University, Tokyo, Japan
| | - Toshifumi Hibi
- Center for Advanced IBD Research and Treatment, Kitasato University Kitasato Institute Hospital, Tokyo, Japan
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19
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Ribeiro AC, Barroso LHF, Mourao-Junior CA, Chebli JMF, Nascimento JWL. Simultaneous Monitoring of Azathioprine Metabolites in Erythrocytes of Crohn's Disease Patients by HPLC-UV. J Chromatogr Sci 2021; 60:518-524. [PMID: 34159374 DOI: 10.1093/chromsci/bmab084] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2021] [Indexed: 11/13/2022]
Abstract
The conversion of azathioprine (AZA) to active 6-thioguanine nucleotides (6-TGN) is essential for its clinical efficacy; however, another metabolite formed, 6-methylmercaptopurine (6-MMP), is related to hepatotoxicity. Blood samples were collected from 37 patients under AZA's treatment, and a new HPLC-UV method was validated and applied for simultaneous quantification of 6-TGN and 6-MMP in erythrocytes of Crohn's disease (CD) patients. The concentration of 6-TGN and 6-MMP found ranged from 4.5 to 2,456 ρmol/8 × 108 red blood cells (RBCs) for 6-TGN and from 170 to 53,951 ρmol/8 × 108 RBCs for 6-MMP. Reduced levels of 6-MMP in patients into combo therapy with AZA and allopurinol (2,031 ρmol/8 × 108 RBCs) have been observed when compared to patients undergoing monotherapy with AZA (9,098 ρmol/8 × 108 RBCs). Additionally, there was a negative correlation (r = -83.7%, P < 0.05) between lymphocyte count and 6-TGN levels. The method developed is reliable, accurate and reproducible and can be used as an important tool in the monitoring routine of patients with CD under AZA treatment, allowing the individualization of the dose, monitoring adherence to the treatment and the evaluation of the clinical outcome of these patients.
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Affiliation(s)
- Aline Correa Ribeiro
- Laboratory of Clinical and Experimental Pharmacology, Department of Pharmacology, Federal University of Juiz de Fora, José Lourenço Kelmer, s/n°, 36360-900, Juiz de Fora, Minas Gerais, Brazil
| | - Luciane Henriques Furtado Barroso
- Laboratory of Clinical and Experimental Pharmacology, Department of Pharmacology, Federal University of Juiz de Fora, José Lourenço Kelmer, s/n°, 36360-900, Juiz de Fora, Minas Gerais, Brazil
| | - Carlos Alberto Mourao-Junior
- Department of Physiology, Federal University of Juiz de Fora, José Lourenço Kelmer, s/n°, 36360-900, Juiz de Fora, Minas Gerais, Brazil
| | - Julio Maria Fonseca Chebli
- Division of Gastroenterology, Department of Internal Medicine, University Hospital of the Federal University of Juiz de Fora and Monte Sinai Hospital, Eugênio do Nascimento s/n°, 36038-330, Juiz de Fora, Minas Gerais, Brazil
| | - Jorge Willian Leandro Nascimento
- Laboratory of Clinical and Experimental Pharmacology, Department of Pharmacology, Federal University of Juiz de Fora, José Lourenço Kelmer, s/n°, 36360-900, Juiz de Fora, Minas Gerais, Brazil
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20
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Usefulness of Measuring Thiopurine Metabolites in Children with Inflammatory Bowel Disease and Autoimmunological Hepatitis, Treated with Azathioprine. Gastroenterol Res Pract 2021; 2021:9970019. [PMID: 34239556 PMCID: PMC8233083 DOI: 10.1155/2021/9970019] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/07/2021] [Revised: 04/30/2021] [Accepted: 05/31/2021] [Indexed: 11/18/2022] Open
Abstract
Introduction Thiopurines, such as azathioprine (AZA) and 6-mercaptopurine (6-MP), are immunomodulatory agents, used for the maintenance of remission in children with inflammatory bowel disease (IBD)—Crohn's disease (CD) and ulcerative colitis (UC), as well as with autoimmunological hepatitis (AIH). Measurements of thiopurine metabolites may allow identifying patients at risk for toxicity and nonadherence. It can also provide an explanation for the ineffectiveness of the treatment, observed in some patients. Patients and Methods. A retrospective analysis was carried out of sixty-eight patients (thirty-six patients with CD, eighteen with UC, and fourteen with AIH), treated with AZA. Thiopurine metabolites, 6-thioguanine nucleotide (6-TGN) and 6-methylmercaptopurine (6-MMP), were assayed by high-performance liquid chromatography (HPLC), and the AZA dose was adjusted when 6-TGN concentration was known. Result Only twenty-five (41%) children had therapeutic 6-TGN concentrations, ten (16%) subjects had suboptimal 6-TGN concentrations, and twenty-six subjects (43%) had 6-TGN concentrations above the recommended therapeutic range. 6-MMP was not above the therapeutic range in any case. Seven subjects revealed undetectable 6-TGN and 6-MMP levels, indicating nonadherence. The mean AZA dose after the 6-TGN concentration-related adjustment did not differ, in comparison to the initial dose, either in IBD or AIH groups. The mean AZA dose was lower in AIH than in IBD. The subjects with an optimal 6-TGN level presented with a higher ratio of remission (88%) than the under- or overdosed patients (60% and 69%), respectively (Chi − square test = 3.87, p < 0.05). Conclusion Timely measurements of thiopurine metabolites can be a useful tool to identify nonadherent patients before a decision is taken to switch to another drug. We may also spot the patients who receive either too low or too high doses, compensating dose deviations in an appropriate way. The patients with optimal 6-TGN levels presented a higher percentage of remission than the under- or overdosed patients. In most patients, both initial and adjusted AZA doses, lower than suggested in guidelines, appeared to be sufficient to maintain remission.
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21
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Zhou XS, Lu YY, Gao YF, Shao W, Yao J. Bone marrow inhibition induced by azathioprine in a patient without mutation in the thiopurine S-methyltransferase pathogenic site: A case report. World J Clin Cases 2021; 9:4230-4237. [PMID: 34141785 PMCID: PMC8173432 DOI: 10.12998/wjcc.v9.i17.4230] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/10/2020] [Revised: 01/20/2021] [Accepted: 03/24/2021] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Azathioprine (AZA) and its close analog 6-mercaptopurine are thiopurines widely used in the treatment of patients with cancer, organ transplantation, and autoimmune or inflammatory diseases, including systemic lupus erythematosus. Bone marrow inhibition is a common side effect of AZA, and severe bone marrow inhibition is related to decreased thiopurine S-methyltransferase (TPMT) activity.
CASE SUMMARY We herein report a patient with proliferative lupus nephritis who was using AZA for maintenance therapy, had no common TPMT pathogenic site mutations, and exhibited severe bone marrow inhibition on the 15th day after oral administration.
CONCLUSION This report alerts physicians to the fact that even though the TPMT gene has no common pathogenic site mutation, severe myelosuppression may also occur.
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Affiliation(s)
- Xiao-Shuang Zhou
- College of Biomedical Engineering, Taiyuan University of Technology, Taiyuan 030012, Shanxi Province, China
- Department of Nephrology, The Affiliated People's Hospital of Shanxi Medical University, Taiyuan 030032, Shanxi Province, China
| | - Yuan-Yue Lu
- Department of Nephrology, The Affiliated People's Hospital of Shanxi Medical University, Taiyuan 030032, Shanxi Province, China
| | - Yan-Fang Gao
- Department of Nephrology, The Affiliated People's Hospital of Shanxi Medical University, Taiyuan 030032, Shanxi Province, China
| | - Wen Shao
- Department of Gastroenterology, Shanxi Bethune Hospital, Taiyuan 030012, Shanxi Province, China
| | - Jia Yao
- Department of Gastroenterology, Shanxi Bethune Hospital, Taiyuan 030012, Shanxi Province, China
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22
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Therapeutic drug monitoring of immunosuppressive drugs in hepatology and gastroenterology. Best Pract Res Clin Gastroenterol 2021; 54-55:101756. [PMID: 34874840 DOI: 10.1016/j.bpg.2021.101756] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/03/2021] [Accepted: 06/11/2021] [Indexed: 01/31/2023]
Abstract
Immunosuppressive drugs have been key to the success of liver transplantation and are essential components of the treatment of inflammatory bowel disease (IBD) and autoimmune hepatitis (AIH). For many but not all immunosuppressants, therapeutic drug monitoring (TDM) is recommended to guide therapy. In this article, the rationale and evidence for TDM of tacrolimus, mycophenolic acid, the mammalian target of rapamycin inhibitors, and azathioprine in liver transplantation, IBD, and AIH is reviewed. New developments, including algorithm-based/computer-assisted immunosuppressant dosing, measurement of immunosuppressants in alternative matrices for whole blood, and pharmacodynamic monitoring of these agents is discussed. It is expected that these novel techniques will be incorporate into the standard TDM in the next few years.
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23
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Ding L, Zhang FB, Liu H, Gao X, Bi HC, Huang L, Wang XD, Chen BL, Zhang Y, Lv C, Hu PJ, Huang M. Xanthine oxidase activity in thiopurine curative Chinese inflammatory bowel disease patients. Pharmacol Res Perspect 2021; 9:e00764. [PMID: 33929082 PMCID: PMC8085934 DOI: 10.1002/prp2.764] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2020] [Accepted: 03/14/2021] [Indexed: 11/21/2022] Open
Abstract
Xanthine oxidase (XO) competes with thiopurine S‐methyltransferase (TPMT) and hypoxanthine guanine phosphoribosyltransferase (HPRT) to metabolize azathioprine (AZA)/6‐mercaptopurine (6‐MP) in vivo. A retrospective investigation was performed to detect the activity of XO in thiopurine curative Chinese inflammatory bowel disease (IBD) patients. We also evaluated whether a relationship between XO activity and incidence of thiopurine‐induced adverse effects (AEs) existed. Clinical data and blood samples were collected from 140 IBD patients before receiving AZA/6‐MP therapy, and the erythrocyte XO activity was measured. The XO activities of all patients were 20.29 ± 4.43 U/g Hb. No sex difference in XO activity was observed (p = .728), and the XO activity showed no difference between the UC and CD patients (p = .082). AEs were observed in 41 (29.3%) patients including leukopenia (26, 18.57%), gastrointestinal intolerance (11, 7.86%), flu‐like symptom (5, 3.57%), alopecia (5, 3.57%), and hepatotoxicity (1, 0.71%). XO activity was significantly lower in the patients with AEs than in those without AEs (18.40 ± 3.73 vs. 21.07 ± 4.48 U/g Hb, p = .001), especially in the patients with leukopenia (18.29 ± 3.68 vs. 21.07 ± 4.48 U/g Hb, p = .004). However, no significant difference in XO activity was found between patients with and without other AEs. Decreased XO activity was observed in the patients who developed flu‐like symptoms (17.58 ± 3.50 U/g Hb) and alopecia (18.67 ± 2.91 U/g Hb) compared to those who did not, although the differences did not reach statistical significance. These findings suggested that patients with low XO expression might have a high risk of thiopurine‐induced toxicity.
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Affiliation(s)
- Liang Ding
- Clinical Trial and Research Center, People's Hospital of Baoan Shenzhen, Shenzhen, PR China
| | - Fang-Bin Zhang
- Department of Gastroenterology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, PR China
| | - Hui Liu
- Department of Pharmacy, The First Affiliated Hospital of Jinan University, Guangzhou, PR China
| | - Xiang Gao
- Department of Gastroenterology, The Sixth Affiliated Hospital of Sun Yat-sen University, Guangzhou, PR China
| | - Hui-Chang Bi
- Institute of Clinical Pharmacology, School of Pharmaceutical Sciences, Sun Yat-sen University, Guangzhou, PR China
| | - Ling Huang
- Key Laboratory of Emergency and Trauma, Ministry of Education, College of Emergency and Trauma, Hainan Medical University, Haikou, China
| | - Xue-Ding Wang
- Institute of Clinical Pharmacology, School of Pharmaceutical Sciences, Sun Yat-sen University, Guangzhou, PR China
| | - Bai-Li Chen
- Department of Gastroenterology, First Affiliated Hospital, Sun Yat-sen University, Guangzhou, PR China
| | - Yu Zhang
- Institute of Clinical Pharmacology, School of Pharmaceutical Sciences, Sun Yat-sen University, Guangzhou, PR China
| | - Chuanzhu Lv
- Key Laboratory of Emergency and Trauma, Ministry of Education, College of Emergency and Trauma, Hainan Medical University, Haikou, China
| | - Pin-Jin Hu
- Department of Gastroenterology, The Sixth Affiliated Hospital of Sun Yat-sen University, Guangzhou, PR China
| | - Min Huang
- Institute of Clinical Pharmacology, School of Pharmaceutical Sciences, Sun Yat-sen University, Guangzhou, PR China
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Long-Term Treatment of Azathioprine in Rats Induces Vessel Mineralization. Biomedicines 2021; 9:biomedicines9030327. [PMID: 33806932 PMCID: PMC8004774 DOI: 10.3390/biomedicines9030327] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2021] [Revised: 03/14/2021] [Accepted: 03/17/2021] [Indexed: 12/31/2022] Open
Abstract
Medial vascular calcification (mVC) is closely related to cardiovascular disease, especially in patients suffering from chronic kidney disease (CKD). Even after successful kidney transplantation, cardiovascular mortality remains increased. There is evidence that immunosuppressive drugs might influence pathophysiological mechanisms in the vessel wall. Previously, we have shown in vitro that mVC is induced in vascular smooth muscle cells (VSMCs) upon treatment with azathioprine (AZA). This effect was confirmed in the current study in an in vivo rat model treated with AZA for 24 weeks. The calcium content increased in the aortic tissue upon AZA treatment. The pathophysiologic mechanisms involve AZA catabolism to 6-thiouracil via xanthine oxidase (XO) with subsequent induction of oxidative stress. Proinflammatory cytokines, such as interleukin (IL)-1ß and IL-6, increase upon AZA treatment, both systemically and in the aortic tissue. Further, VSMCs show an increased expression of core-binding factor α-1, alkaline phosphatase and osteopontin. As the AZA effect could be decreased in NLRP3−/− aortic rings in an ex vivo experiment, the signaling pathway might be, at least in part, dependent on the NLRP3 inflammasome. Although human studies are necessary to confirm the harmful effects of AZA on vascular stiffening, these results provide further evidence of induction of VSMC calcification under AZA treatment and its effects on vessel structure.
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Debnath P, Nair S, Jain S, Udgirkar S, Contractor Q, Rathi P. Thiopurine-induced Myelosuppression with Severe Sepsis in a Patient with Crohn's Disease: A Case Report. Indian J Crit Care Med 2021; 25:228-230. [PMID: 33707905 PMCID: PMC7922446 DOI: 10.5005/jp-journals-10071-23738] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Thiopurines by their glucocorticoid-sparing property help in maintaining remission for patients with inflammatory bowel disease (IBD), when glucocorticoids are reduced and withdrawn. However, due to bone marrow suppression, it cannot be used in various conditions where it is indicated. A 17-year-old patient presented with pancytopenia with neutropenic sepsis and alopecia after 3 weeks of starting azathioprine for her underlying Crohn's disease. Thiopurine S-methyltransferase (TPMT;*2, *3A, *3C) analysis resulted in a wild-type genotype, whereas homozygous Nudix hydrolase 15 (NUDT 15 C415T) variant was positive. Azathioprine was stopped immediately, and she was started on broad-spectrum antibiotics that led to some clinical improvements initially, but later on, the patient developed intestinal obstruction along with postoperative complications leading to death. In this report, we highlight a case of serious hematological toxicity associated with azathioprine use in a patient with Crohn's disease with homozygous NUDT 15 variant, thus favoring the implementation of a pharmacogenomic approach before starting azathioprine, particularly in the Asian population. How to cite this article Debnath P, Nair S, Jain S, Udgirkar S, Contractor Q, Rathi P. Thiopurine-induced Myelosuppression with Severe Sepsis in a Patient with Crohn's Disease: A Case Report. Indian J Crit Care Med 2021;25(2):228-230. Prior presentation of case report at professional meeting The case was presented in abstract form at the American College of Gastroenterology Annual Scientific Meeting, held at San Antonio, TX, USA 2019. Informed consent for publication of case details Obtained from patient's relatives.
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Affiliation(s)
| | - Sujit Nair
- TNMC & BYL Nair Charitable Hospital, Mumbai, Maharashtra, India
| | - Shubham Jain
- TNMC & BYL Nair Charitable Hospital, Mumbai, Maharashtra, India
| | - Suhas Udgirkar
- TNMC & BYL Nair Charitable Hospital, Mumbai, Maharashtra, India
| | - Qais Contractor
- TNMC & BYL Nair Charitable Hospital, Mumbai, Maharashtra, India
| | - Pravin Rathi
- TNMC & BYL Nair Charitable Hospital, Mumbai, Maharashtra, India
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26
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McNeill RP, Barclay ML. Cost-effectiveness of therapeutic drug monitoring in inflammatory bowel disease. Curr Opin Pharmacol 2020; 55:41-46. [DOI: 10.1016/j.coph.2020.09.006] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2020] [Revised: 09/16/2020] [Accepted: 09/18/2020] [Indexed: 12/18/2022]
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27
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Lin R, Lin W, Wang C, Dong J, Zheng W, Zeng D, Liu Y, Lin C, Jiao Z, Huang P. Population pharmacokinetics of azathioprine active metabolite in patients with inflammatory bowel disease and dosage regimens optimisation. Basic Clin Pharmacol Toxicol 2020; 128:482-492. [PMID: 33150655 DOI: 10.1111/bcpt.13530] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2020] [Revised: 10/12/2020] [Accepted: 11/02/2020] [Indexed: 12/25/2022]
Abstract
Azathioprine is a first-line drug used to maintain the remission of inflammatory bowel disease (IBD). As a prodrug, azathioprine is metabolised to produce active 6-thioguanine nucleotides (6-TGN). There are large individual variations in the pharmacokinetics/pharmacodynamics of 6-TGN in patients with IBD. Here, we aimed to develop a model to quantitatively investigate factors that affect 6-TGN pharmacokinetics to formulate a dosage guideline for azathioprine. Data were collected prospectively from 100 adult patients with IBD who were receiving azathioprine. Patients were genotyped for two single-nucleotide polymorphisms (TPMT*3C c.719A > G and NUDT15 c.415C > T). Using high-performance liquid chromatography, we measured 156 steady-state trough concentrations of 6-TGN within the range 0.09 to 1.16 mg/L (ie 133-1733 pmol per 8 × 108 RBC). The covariates analysed included sex, age, body-weight, laboratory tests and concomitant medications. A population pharmacokinetic model was established using "non-linear mixed-effects modelling" software and the "first-order conditional estimation method with interaction." Body-weight, TPMT*3C polymorphisms and co-therapy with mesalazine were found to be important factors influencing the clearance of 6-TGN. A dosage guideline for azathioprine was developed based on the PPK model that enables individualised azathioprine dosing in adult patients with different body-weights, TPMT*3C genotypes and co-administration with mesalazine.
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Affiliation(s)
- Rongfang Lin
- Department of Pharmacy, The First Affiliated Hospital, Fujian Medical University, Fuzhou, China
| | - Weiwei Lin
- Department of Pharmacy, The First Affiliated Hospital, Fujian Medical University, Fuzhou, China
| | - Changlian Wang
- Department of Pharmacy, The First Affiliated Hospital, Fujian Medical University, Fuzhou, China
| | - Jiashan Dong
- Department of Pharmacy, The First Affiliated Hospital, Fujian Medical University, Fuzhou, China
| | - Weiwei Zheng
- Department of Gastroenterology, The First Affiliated Hospital, Fujian Medical University, Fuzhou, China
| | - Dayong Zeng
- Department of Pharmacy, The First Affiliated Hospital, Fujian Medical University, Fuzhou, China
| | - Yiwei Liu
- Department of Pharmacy, The First Affiliated Hospital, Fujian Medical University, Fuzhou, China
| | - Cuihong Lin
- Department of Pharmacy, The First Affiliated Hospital, Fujian Medical University, Fuzhou, China
| | - Zheng Jiao
- Department of Pharmacy, Shanghai Chest Hospital, Shanghai Jiao Tong University, Shanghai, China
| | - Pinfang Huang
- Department of Pharmacy, The First Affiliated Hospital, Fujian Medical University, Fuzhou, China
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Thiopurines' Metabolites and Drug Toxicity: A Meta-Analysis. J Clin Med 2020; 9:jcm9072216. [PMID: 32668748 PMCID: PMC7408995 DOI: 10.3390/jcm9072216] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2020] [Revised: 07/06/2020] [Accepted: 07/09/2020] [Indexed: 12/13/2022] Open
Abstract
Many questions remain unanswered regarding therapeutic drug monitoring (TDM) utility with thiopurines. This study aims to establish a relationship between thiopurines' metabolites and drug toxicity. We performed a systematic review with inclusion of studies evaluating the relationship between thiopurines' metabolites and drug toxicity. Meta-analysis of mean difference (MD), correlations and odds ratio (OR) was performed. We identified 21,240 records, 72 of which were eligible for meta-analysis. Levels of 6-thioguanine nucleotides (6-TGN) were higher in patients with leukopenia (MD 127.06 pmol/8 × 108 RBC) and gastrointestinal intolerance (MD 201.46 pmol/8 × 108 RBC), and lower in patients with hepatotoxicity (MD -40.6 pmol × 108 RBC). We established a significant correlation between 6-TGN and leukocytes (r = -0.21), neutrophils (r = -0.24) and alanine aminotransferase levels (r = -0.24). OR for leukopenia in patients with elevated 6-TGN was 4.63 (95%CI 2.24; 9.57). An optimal cut-off of 135 pmol/8 × 108 RBC for leukopenia was calculated (sensitivity 75.4%; specificity 46.4%). 6-methylmercaptopurine ribonucleotides (6-MMPR) were significantly associated with hepatotoxicity (MD 3241.2 pmol/8 × 108 RBC; OR 4.28; 95%CI 3.20; 5.71). Levels of 6-MMPR measured in the first 8 weeks of treatment were associated with leukopenia. We conclude that TDM could be used to prevent thiopurines' toxicity. As optimal metabolites level may vary according to indication, physicians may adapt posology to decrease toxicity without compromising efficacy.
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Jonason DE, Sievers T, Trocke L, Abraham JM, Vaughn BP. Normal Ranges of Thiopurine Methyltransferase Activity Do Not Affect Thioguanine Nucleotide Concentrations With Azathioprine Therapy in Inflammatory Bowel Disease. CROHN'S & COLITIS 360 2020; 2:otaa058. [PMID: 36776499 PMCID: PMC9802184 DOI: 10.1093/crocol/otaa058] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/22/2020] [Indexed: 11/14/2022] Open
Abstract
Background Thiopurine methyltransferase (TPMT) activity influences azathioprine conversion into active metabolite 6-thioguanine nucleotide (6-TGN). Low TPMT activity correlates with high 6-TGN and risk for myelosuppression. Conversely, normal-to-high TPMT activity may be associated with low 6-TGN and drug resistance, the so-called hypermetabolizers. Our aim was to identify the effect of normal-to-high TPMT activity on 6-TGN concentrations in an inflammatory bowel disease population. Methods A retrospective chart review of patients aged ≥18 with inflammatory bowel disease, on azathioprine, with documented TPMT activity and 6-TGN concentration was performed. Correlations were evaluated via the Spearman rho correlation coefficient. Linear regression was used to determine the effect of TPMT activity on 6-TGN accounting for confounders. Relationships between TPMT activity, drug dose, and 6-TGN levels were defined via average causal mediation effects. Results One hundred patients were included. No correlation was observed between TPMT activity, azathioprine dosing, and metabolite concentrations. Overall, 39% of the cohort had a therapeutic 6-TGN level of >230 pmol/8 × 108 red blood cells (RBCs). No patient under 1 mg/kg achieved a therapeutic 6-TGN level, whereas 42% of patients taking 2.5 mg/kg did. The median 6-TGN concentration was higher for those in remission (254 pmol/8 × 108 RBCs, interquartile range: 174, 309) versus those not in remission (177 pmol/8 × 108 RBCs, interquartile range: 94.3, 287.8), though not significantly (P = 0.08). Smoking was the only clinical factor associated with 6-TGN level. On multivariate linear regression, only age, azathioprine dose, and obese body mass index were predictive of metabolite concentration. Conclusions Variations within the normal range of TPMT activity do not affect 6-TGN concentration.
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Affiliation(s)
- David E Jonason
- Department of Internal Medicine, University of Minnesota, Minneapolis, Minnesota, USA
| | - Tyson Sievers
- Inflammatory Bowel Disease Program, Division of Gastroenterology, Hepatology and Nutrition, Department of Medicine, University of Minnesota, Minneapolis, Minnesota, USA
| | - Lindsay Trocke
- Inflammatory Bowel Disease Program, M Health Fairview, Minneapolis, Minnesota, USA
| | - James M Abraham
- Inflammatory Bowel Disease Program, Division of Gastroenterology, Hepatology and Nutrition, Department of Medicine, University of Minnesota, Minneapolis, Minnesota, USA,Present address: Division of Gastroenterology and Hepatology, Department of Medicine, University of Michigan, Ann Arbor, Michigan, USA
| | - Byron P Vaughn
- Inflammatory Bowel Disease Program, Division of Gastroenterology, Hepatology and Nutrition, Department of Medicine, University of Minnesota, Minneapolis, Minnesota, USA,Address correspondence to: Byron P. Vaughn, MD, MS, Inflammatory Bowel Disease Program, Division of Gastroenterology, Hepatology and Nutrition, Department of Medicine, University of Minnesota, 420 Delaware Street MMC 36, Minneapolis, MN 55455 ()
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30
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Martín-Masot R, Ortiz Pérez MP, Ramos Rueda N, Serrano Nieto J, Blasco-Alonso J, Navas-López VM. Análisis de la determinación de niveles de tiopurínicos en pacientes pediátricos con enfermedad inflamatoria intestinal. An Pediatr (Barc) 2020; 93:34-40. [DOI: 10.1016/j.anpedi.2019.10.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2019] [Revised: 10/04/2019] [Accepted: 10/11/2019] [Indexed: 02/07/2023] Open
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Martín-Masot R, Ortiz Pérez MP, Ramos Rueda N, Serrano Nieto J, Blasco-Alonso J, Navas-López VM. Laboratory determination of thiopurine levels in paediatric patients with inflammatory bowel disease. ANALES DE PEDIATRÍA (ENGLISH EDITION) 2020. [DOI: 10.1016/j.anpede.2019.10.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
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32
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Czaja AJ. Review article: opportunities to improve and expand thiopurine therapy for autoimmune hepatitis. Aliment Pharmacol Ther 2020; 51:1286-1304. [PMID: 32363674 DOI: 10.1111/apt.15743] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/16/2020] [Revised: 03/07/2020] [Accepted: 03/31/2020] [Indexed: 12/14/2022]
Abstract
BACKGROUND Thiopurines in combination with glucocorticoids are used as first-line, second-line and maintenance therapies in autoimmune hepatitis and opportunities exist to improve and expand their use. AIMS To describe the metabolic pathways and key factors implicated in the efficacy and toxicity of the thiopurine drugs and to indicate the opportunities to improve outcomes by monitoring and manipulating metabolic pathways, individualising dosage and strengthening the response. METHODS English abstracts were identified in PubMed by multiple search terms. Full-length articles were selected for review, and secondary and tertiary bibliographies were developed. RESULTS Thiopurine methyltransferase activity and 6-tioguanine (6-thioguanine) nucleotide levels influence drug efficacy and safety, and they can be manipulated to improve treatment response and prevent myelosuppression. Methylated thiopurine metabolites are associated with hepatotoxicity, drug intolerance and nonresponse and their production can be reduced or bypassed. Universal pre-treatment assessment of thiopurine methyltransferase activity and individualisation of dosage to manipulate metabolite thresholds could improve outcomes. Early detection of thiopurine resistance by metabolite testing, accurate estimations of drug onset and strength by surrogate markers and adjunctive use of allopurinol could improve the management of refractory disease. Dose-restricted tioguanine (thioguanine) could expand treatment options by reducing methylated metabolites, increasing the bioavailability of 6-tioguanine nucleotides and ameliorating thiopurine intolerance or resistance. CONCLUSIONS The efficacy and safety of thiopurines in autoimmune hepatitis can be improved by investigational efforts that establish monitoring strategies that allow individualisation of dosage and prediction of outcome, increase bioavailability of the active metabolites and demonstrate superiority to alternative agents.
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Affiliation(s)
- Albert J Czaja
- Division of Gastroenterology and Hepatology, Mayo Clinic College of Medicine and Science, Rochester, MN, USA
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33
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Wilson L, Tuson S, Yang L, Loomes D. Real-World Use of Azathioprine Metabolites Changes Clinical Management of Inflammatory Bowel Disease. J Can Assoc Gastroenterol 2020; 4:101-109. [PMID: 34056527 PMCID: PMC8158651 DOI: 10.1093/jcag/gwaa005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Background Thiopurines such as 6-mercaptopurine and azathioprine have complex metabolism, resulting in significant inter-individual differences in clinical efficacy and risk of drug toxicity, making conventional weight-based dosing inaccurate and potentially unsafe. Therapeutic drug monitoring (TDM) of thiopurine metabolites improves clinical outcomes through dose optimization and toxicity monitoring. Despite evidence for TDM, use is limited, due in part to test availability and awareness. The objectives of this study were twofold: (1) to investigate how thiopurine TDM impacts clinical management of IBD patients and (2) to evaluate proportion of patients outside therapeutic 6TGN levels or exhibiting signs of toxicity Methods Patients who received thiopurine TDM as part of routine care underwent chart review of demographics, disease activity, medication dosing, metabolite levels, and adverse events. Changes in clinical management following TDM were measured. Additionally, we conducted a retrospective review of clinical decision making blinded and unblinded to TDM result. Results A total of 92 IBD patients were included. Levels of 6TGN were therapeutic in 29% of patients. 6TGN levels correlated weakly with weight-based dosing (r2 = 0.057, P = 0.02). Adverse reactions were observed in 6.5%. TDM informed clinical management in 64%. Significantly more changes to clinical management occurred in those with active disease than in remission (73% versus 48%; P = 0.02) and in those on mono- versus combination therapy (48% versus 27.5%; P = 0.03). Conclusions TDM informs clinical decision making in over two-thirds of patients. The demonstrated poor efficacy of weight-based dosing and impact of TDM on clinical management contributes to the evidence supporting the need for greater availability and uptake of thiopurine TDM.
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Affiliation(s)
- Laura Wilson
- Division of Gastroenterology, Vancouver Island IBD Clinic, Victoria, British Columbia, Canada
| | - Stephanie Tuson
- Division of Gastroenterology, Vancouver Island IBD Clinic, Victoria, British Columbia, Canada
| | - Lufang Yang
- Department of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
| | - Dustin Loomes
- Division of Gastroenterology, Vancouver Island IBD Clinic, Victoria, British Columbia, Canada.,Department of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
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Gibson DJ, Ward MG, Rentsch C, Friedman AB, Taylor KM, Sparrow MP, Gibson PR. Review article: determination of the therapeutic range for therapeutic drug monitoring of adalimumab and infliximab in patients with inflammatory bowel disease. Aliment Pharmacol Ther 2020; 51:612-628. [PMID: 31961001 DOI: 10.1111/apt.15643] [Citation(s) in RCA: 45] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/22/2019] [Revised: 10/14/2019] [Accepted: 01/07/2020] [Indexed: 12/11/2022]
Abstract
BACKGROUND Clinical application of therapeutic drug monitoring (TDM) to optimise anti-TNF therapies in patients with IBD depends upon target ranges. AIMS To review methodology used to determine therapeutic ranges and critically compare and contrast its application to infliximab and adalimumab. METHODS A systematic review was performed, and relevant literature was summarised and critically examined. RESULTS Upper limits of the therapeutic range are determined by toxicity, a plateau response and cost. Lower limits are determined by optimal concentration on the target of action in vitro and/or in vivo, or by correlation of drug levels with clinical efficacy using area-under-receiver-operator-curve (AUROC) analysis. In 43 studies, there were huge variations in time at which infliximab and adalimumab levels were measured, the end-points used (clinical remission to mucosal healing), the clinical setting (active disease vs maintenance phase) and the reason for TDM (proactive vs reactive). In the maintenance phase for infliximab, lower trough limits 2.8-5.7 µg/mL are reported depending upon end-points used, with consistent AUROC 0.68-0.77. Adalimumab TDM targets are even less consistent with a lower limit 5.9-11.8 µg/mL (AUROC 0.66-0.83) in some studies, but no cut-off can be identified that is significantly associated with outcome in others, related to inherent pharmacokinetic and pharmacodynamic differences, and heterogeneity of study design. CONCLUSIONS Evidence for exposure-response relationship is stronger for infliximab than adalimumab. Due to heterogeneity in settings for drug level measurements, therapeutic ranges vary. These factors need to be taken into account when interpreting the evidence and extending this to therapeutic strategies for IBD patients.
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Affiliation(s)
- David J Gibson
- Departments of Gastroenterology, The Alfred Hospital, Melbourne, VIC, Australia
| | - Mark G Ward
- Departments of Gastroenterology, The Alfred Hospital, Melbourne, VIC, Australia.,Monash University, Melbourne, VIC, Australia
| | | | - Antony B Friedman
- Departments of Gastroenterology, The Alfred Hospital, Melbourne, VIC, Australia.,Monash University, Melbourne, VIC, Australia
| | - Kirstin M Taylor
- Departments of Gastroenterology, The Alfred Hospital, Melbourne, VIC, Australia.,Monash University, Melbourne, VIC, Australia
| | - Miles P Sparrow
- Departments of Gastroenterology, The Alfred Hospital, Melbourne, VIC, Australia.,Monash University, Melbourne, VIC, Australia
| | - Peter R Gibson
- Departments of Gastroenterology, The Alfred Hospital, Melbourne, VIC, Australia.,Monash University, Melbourne, VIC, Australia
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Adherence to Azathioprine/6-Mercaptopurine in Children and Adolescents with Inflammatory Bowel Diseases: A Multimethod Study. Can J Gastroenterol Hepatol 2020; 2020:9562192. [PMID: 32185153 PMCID: PMC7060881 DOI: 10.1155/2020/9562192] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/21/2019] [Revised: 09/04/2019] [Accepted: 01/03/2020] [Indexed: 12/18/2022] Open
Abstract
BACKGROUND Measurement of the degree of adherence is a key element for the evaluation of treatment efficacy and safety; thus, adherence plays an important role in clinical research and practice. The aim of this study was to investigate medication adherence in children with inflammatory bowel disease (IBD) utilizing a multimethod assessment approach. A further aim was to examine factors that can influence adherence within this population. METHODS Medication adherence in 47 children (age range 3 to 17 years) with IBD in three centers in Northern Ireland and Jordan was assessed via subjective (parent and child versions of the Medication Adherence Report Scale (MARS) specific questionnaire) and objective methods, that is, high-performance liquid chromatography (HPLC) determination of the 6-mercaptopurine (6-MP) and azathioprine (AZA) metabolites in packed red blood cell samples taken during a clinic visit. Beliefs about prescribed medicines were also assessed in parents/guardians using the Beliefs about Medicines Questionnaire (BMQ). RESULTS An overall nonadherence to AZA/6-MP therapy in children with IBD was found to be 36.17% (17 out of 47 patients were classified as nonadherent using at least one of the assessment methods). A total of 41 patients (91.1%) were classified as adherent to AZA or 6-MP using the blood sampling, while adherence rates using the MARS questionnaire completed by children and parents/guardians were 60.6% and 72.7%, respectively. The latter provides a more longitudinal measure of adherence. Child self-reported nonadherence rates were significantly higher than parent/guardian reported rates (p=0.013). Binary logistic regression analysis identified age to be independently predictive of adherence, with adolescents (children aged ≥ 13 years old) more likely to be classified as nonadherent. Regarding the BMQ, when parental/guardian necessity beliefs outweighed concerns, that is, higher scores in the necessity-concern differential (NCD), adolescents were more likely to be classified as adherent. CONCLUSION Results provide evidence for ongoing adherence challenges in the paediatric population with IBD. It is recommended that parents/guardians (particularly of older children) and older children themselves, should receive enhanced counselling and education about their prescribed medicines.
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Gurram B, Patel AS. Recent advances in understanding and managing pediatric inflammatory bowel disease. F1000Res 2019; 8. [PMID: 31885858 PMCID: PMC6913196 DOI: 10.12688/f1000research.19609.1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 12/06/2019] [Indexed: 12/07/2022] Open
Abstract
The landscape of pediatric inflammatory bowel disease is rapidly evolving. The therapeutic advances seen in the adult arena are rapidly being adopted by pediatric gastroenterologists and evaluated in both controlled trials and real-world experience. Though anti-tumor necrosis factor agents have been the primary therapy over the last decade, recently there has been an expansion of therapeutic targets and alternative mechanism of action drugs with a focus on individualized and personalized therapy. By reviewing epidemiology, pathophysiology, and goals of treatment, we hope to frame the discussion of current and novel therapeutics for the pediatric gastroenterologist. As scientific discovery continues to push the envelope in defining our understanding of pediatric inflammatory bowel disease, the current era of therapeutics gives us hope that a cure may be realized soon.
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Affiliation(s)
- Bhaskar Gurram
- University of Texas Southwestern Medical Center, Dallas, TX, 75390, USA
| | - Ashish S. Patel
- University of Texas Southwestern Medical Center, Dallas, TX, 75390, USA
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Lampič K, Trontelj J, Prosen H, Drobne D, Šmid A, Vovk T. Determination of 6-thioguanine and 6-methylmercaptopurine in dried blood spots using liquid chromatography-tandem mass spectrometry: Method development, validation and clinical application. Clin Chim Acta 2019; 499:24-33. [DOI: 10.1016/j.cca.2019.08.024] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2019] [Revised: 08/22/2019] [Accepted: 08/22/2019] [Indexed: 02/08/2023]
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Landerholm K, Kalman D, Wallon C, Myrelid P. Immunomodulators: Friends or Enemies in Surgery for Crohn’s Disease? Curr Drug Targets 2019; 20:1384-1398. [DOI: 10.2174/1389450120666190617163919] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2019] [Revised: 04/18/2019] [Accepted: 04/25/2019] [Indexed: 02/08/2023]
Abstract
Crohn’s disease may severely impact the quality of life and being a chronic disease it requires
both medical and surgical treatment aimed at induction and maintenance of remission to prevent
relapsing symptoms and the need for further surgery. Surgery in Crohn’s disease often has to be
performed in patients with well-known risk factors of post-operative complications, particularly intraabdominal
septic complications. This review will look at the current knowledge of immunomodulating
therapies in the peri-operative phase of Crohn’s disease. The influence of immunomodulators on postoperative
complications is evaluated by reviewing available clinical reports and data from animal
studies. Furthermore, the effect of immunomodulators on preventing or deferring primary as well as
repeat surgery in Crohn’s disease is reviewed with particular consideration given to high-risk cohorts
and timing of prophylaxis.
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Affiliation(s)
- Kalle Landerholm
- Department of Clinical and Experimental Medicine, Linköping University and Department of Surgery, Ryhov County Hospital, Jonkoping, Sweden
| | - Disa Kalman
- Department of Clinical and Experimental Medicine, Linköping University and Department of Surgery, County Council of Ostergotland, Linkoping, Sweden
| | - Conny Wallon
- Department of Clinical and Experimental Medicine, Linköping University and Department of Surgery, County Council of Ostergotland, Linkoping, Sweden
| | - Pär Myrelid
- Department of Clinical and Experimental Medicine, Linköping University and Department of Surgery, County Council of Ostergotland, Linkoping, Sweden
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Bhamidimarri KR, Martin P. Are High-Dose Steroids Really Necessary in Treatment of Autoimmune Hepatitis? Clin Gastroenterol Hepatol 2019; 17:1948-1949. [PMID: 30885885 DOI: 10.1016/j.cgh.2019.03.018] [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: 02/22/2019] [Accepted: 03/10/2019] [Indexed: 02/07/2023]
Affiliation(s)
| | - Paul Martin
- University of Miami, School of Medicine, Miami, Florida
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40
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Shi X, Chen Q, Wang F. Mesenchymal stem cells for the treatment of ulcerative colitis: a systematic review and meta-analysis of experimental and clinical studies. Stem Cell Res Ther 2019; 10:266. [PMID: 31443677 PMCID: PMC6708175 DOI: 10.1186/s13287-019-1336-4] [Citation(s) in RCA: 44] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
OBJECTIVE To explore the promising use of mesenchymal stem cells (MSCs) for ulcerative colitis (UC). METHODS Studies reporting MSC treatment on UC were searched on five databases. Methodological quality was assessed based on the SYRCLE's Risk of Bias (RoB) tool and MINORS tool. Data analysis was conducted using Engauge Digitizer 10.8 and Stata 14.0. RESULTS A total of 15 studies met the inclusion criteria including 8 animal (n = 132) and 7 human (n = 216) trials. In animal studies, mice treated with MSCs had significantly lower disease activity index (DAI) than that in the control group: the 1st day (standardized mean difference (SMD) - 0.753, p = 0.027), the 3rd day (SMD - 1.634, p = 0.000), the 5th day (SMD - 2.124, p = 0.000), the 7th day (SMD - 5.327, p = 0.000), the 9th day (SMD - 2.979, p = 0.000), and the 14th day (SMD - 5.032, p = 0.000). Lower histopathological score (HS) (SMD - 5.15, p < 0.05) and longer colon length (SMD 2.147, p = 0.001) in mice treated with MSCs were also indicated. The main outcome in clinical trials showed, compared with control group, healing rate of patients accompanied by MSC therapy elevated obviously: MSCs vs 5-aminosalicylic acids (5-ASA) (RR = 2.317, p = 0.000) and MSCs + 5-ASA vs placebo + 5-ASA (RR = 5.118). The analytical data in 4 trials conducted with single-arm studies also demonstrated increased healing rate (0.787) after MSC treatment (p = 0.000). CONCLUSION Our meta-analysis results supported that MSCs could be an underlying method of treating UC.
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Affiliation(s)
- Xiao Shi
- Department of Gastroenterology, The Third Xiangya Hospital, Central South University, Changsha, 410013, Hunan, People's Republic of China
- Department of Gastroenterology, Hunan Key Laboratory of Non-Resolving Inflammation and Cancer, The Third Xiangya Hospital, Central South University, 138 Tongzi Road, Changsha, 410013, Hunan, People's Republic of China
| | - Qi Chen
- Department of Dermatology, Xiangya Hospital, Central South University, Changsha, 410008, Hunan, People's Republic of China
| | - Fen Wang
- Department of Gastroenterology, The Third Xiangya Hospital, Central South University, Changsha, 410013, Hunan, People's Republic of China.
- Department of Gastroenterology, Hunan Key Laboratory of Non-Resolving Inflammation and Cancer, The Third Xiangya Hospital, Central South University, 138 Tongzi Road, Changsha, 410013, Hunan, People's Republic of China.
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41
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Ooi CJ, Hilmi I, Banerjee R, Chuah SW, Ng SC, Wei SC, Makharia GK, Pisespongsa P, Chen MH, Ran ZH, Ye BD, Park DI, Ling KL, Ong D, Ahuja V, Goh KL, Sollano J, Lim WC, Leung WK, Ali RAR, Wu DC, Ong E, Mustaffa N, Limsrivilai J, Hisamatsu T, Yang SK, Ouyang Q, Geary R, De Silva JH, Rerknimitr R, Simadibrata M, Abdullah M, Leong RWL. Best practices on immunomodulators and biologic agents for ulcerative colitis and Crohn's disease in Asia. J Gastroenterol Hepatol 2019; 34:1296-1315. [PMID: 30848854 DOI: 10.1111/jgh.14648] [Citation(s) in RCA: 31] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/13/2018] [Revised: 02/05/2019] [Accepted: 03/02/2019] [Indexed: 02/05/2023]
Abstract
The Asia-Pacific Working Group on Inflammatory Bowel Disease was established in Cebu, Philippines, under the auspices of the Asia-Pacific Association of Gastroenterology with the goal of improving inflammatory bowel disease care in Asia. This consensus is carried out in collaboration with Asian Organization for Crohn's and Colitis. With biologic agents and biosimilars becoming more established, it is necessary to conduct a review on existing literature and establish a consensus on when and how to introduce biologic agents and biosimilars in conjunction with conventional treatments for ulcerative colitis and Crohn's disease in Asia. These statements also address how pharmacogenetics influences the treatments of ulcerative colitis and Crohn's disease and provides guidance on response monitoring and strategies to restore loss of response. Finally, the review includes statements on how to manage treatment alongside possible hepatitis B and tuberculosis infections, both common in Asia. These statements have been prepared and voted upon by members of inflammatory bowel disease workgroup employing the modified Delphi process. These statements do not intend to be all-encompassing, and future revisions are likely as new data continue to emerge.
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Affiliation(s)
- Choon Jin Ooi
- Department of Gastroenterology and Hepatology, Singapore General Hospital, Singapore.,Duke-NUS Medical School, Singapore
| | - Ida Hilmi
- Faculty of Medicine, University Malaya Medical Centre, Kuala Lumpur, Malaysia
| | - Rupa Banerjee
- Asian Institute of Gastroenterology, New Delhi, India
| | | | - Siew Chien Ng
- Department of Medicine and Therapeutics, The Chinese University of Hong Kong, Hong Kong
| | - Shu Chen Wei
- Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan
| | - Govind K Makharia
- Department of Gastroenterology and Human Nutrition, All India Institute of Medical Sciences, New Delhi, India
| | | | - Min Hu Chen
- Division of Gastroenterology, The First University Hospital, Sun Yat-sen University, Guangzhou, China
| | - Zhi Hua Ran
- Renji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Byong Duk Ye
- Department of Gastroenterology and IBD Center, University of Ulsan College of Medicine, Ulsan, Korea
| | - Dong Il Park
- Department of Internal Medicine, Kangbuk Samsung Hospital, Sungkyunkwan University School of Medicine, Seoul, Korea
| | | | - David Ong
- Division of Gastroenterology & Hepatology, University Medicine Cluster, National University Hospital of Singapore, Singapore
| | - Vineet Ahuja
- Department of Gastroenterology and Human Nutrition, All India Institute of Medical Sciences, New Delhi, India
| | - Khean Lee Goh
- University of Malaya Specialist Centre, Kuala Lumpur, Malaysia
| | - Jose Sollano
- Department of Medicine, University of Santo Tomas, Manila, Philippines
| | - Wee Chian Lim
- Department of Gastroenterology & Hepatology, Tan Tock Seng Hospital, Singapore
| | - Wai Keung Leung
- Division of Gastroenterology & Hepatology, Department of Medicine, University of Hong Kong, Hong Kong
| | | | - Deng Chyang Wu
- Department of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Evan Ong
- Department of Medicine, University of Santo Tomas, Manila, Philippines
| | - Nazri Mustaffa
- Department of Internal Medicine, School of Medical Sciences, Health Campus, Universiti Sains, George Town, Malaysia
| | - Julajak Limsrivilai
- Department of Medicine, Faculty of Medicine, Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Tadakazu Hisamatsu
- The Third Department of Internal Medicine, Kyorin University School of Medicine, Mitaka, Japan
| | - Suk Kyun Yang
- Department of Gastroenterology, University of Ulsan College of Medicine, Ulsan, Korea
| | - Qin Ouyang
- Department of Gastroenterology, West China Hospital, Sichuan University, Chengdu, China
| | - Richard Geary
- Department of Medicine, University of Otago, Christchurch, Christchurch, New Zealand
| | | | | | - Marcellus Simadibrata
- Department of Internal Medicine, Faculty of Medicine, Universitas Indonesia, Depok, Indonesia
| | - Murdani Abdullah
- Division of Gastroenterology, Department of Internal Medicine, Dr Cipto Mangankusumo National Hospital, Central Jakarta, Indonesia
| | - Rupert W L Leong
- Gastroenterology and Liver Services, Concord Hospital, Sydney, New South Wales, Australia
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42
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Ince MN, Elliott DE. Effective Use of the Laboratory in the Management of Patients with Inflammatory Bowel Diseases. Gastroenterol Clin North Am 2019; 48:237-258. [PMID: 31046973 DOI: 10.1016/j.gtc.2019.02.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Inflammatory bowel disease (IBD) comprises a group of chronic, intestinal inflammatory disorders, including ulcerative colitis and Crohn's disease. IBD is characterized by periods of relapse and remission. Long-term progressive intestinal inflammation can result in severe and devastating complications, such as intestinal strictures and/or fistulae. Immune suppressive medications with potent side effects are often used to control inflammation and limit disease activity. Laboratory tests guide various decisions in clinical management of IBD. We discuss tests used to diagnose IBD, assess for relapse or remission, monitor the effectiveness of therapeutic regimen, screen for the maintenance of health, and diagnose or prevent complications.
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Affiliation(s)
- M Nedim Ince
- Department of Internal Medicine, Division of Gastroenterology and Hepatology, University of Iowa, Carver College of Medicine, University of Iowa Hospitals and Clinics, 4546 JCP, 200 Hawkins Drive, Iowa City, IA 52242, USA.
| | - David E Elliott
- Department of Internal Medicine, Division of Gastroenterology and Hepatology, University of Iowa, Carver College of Medicine, University of Iowa Hospitals and Clinics, 4607 JCP, 200 Hawkins Drive, Iowa City, IA 52242, USA
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43
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Ooi CJ, Hilmi I, Banerjee R, Chuah SW, Ng SC, Wei SC, Makharia GK, Pisespongsa P, Chen MH, Ran ZH, Ye BD, Park DI, Ling KL, Ong D, Ahuja V, Goh KL, Sollano J, Lim WC, Leung WK, Ali RAR, Wu DC, Ong E, Mustaffa N, Limsrivilai J, Hisamatsu T, Yang SK, Ouyang Q, Geary R, De Silva JH, Rerknimitr R, Simadibrata M, Abdullah M, Leong RW. Best practices on immunomodulators and biologic agents for ulcerative colitis and Crohn's disease in Asia. Intest Res 2019; 17:285-310. [PMID: 31146509 PMCID: PMC6667368 DOI: 10.5217/ir.2019.00026] [Citation(s) in RCA: 65] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/20/2019] [Accepted: 04/15/2019] [Indexed: 02/07/2023] Open
Abstract
The Asia-Pacific Working Group on inflammatory bowel disease (IBD) was established in Cebu, Philippines, under the auspices of the Asian Pacific Association of Gastroenterology with the goal of improving IBD care in Asia. This consensus is carried out in collaboration with Asian Organization for Crohn’s and Colitis. With biologic agents and biosimilars becoming more established, it is necessary to conduct a review on existing literature and establish a consensus on when and how to introduce biologic agents and biosimilars in the conjunction with conventional treatments for ulcerative colitis (UC) and Crohn’s disease (CD) in Asia. These statements also address how pharmacogenetics influence the treatments of UC and CD and provide guidance on response monitoring and strategies to restore loss of response. Finally, the review includes statements on how to manage treatment alongside possible hepatitis B and tuberculosis infections, both common in Asia. These statements have been prepared and voted upon by members of IBD workgroup employing the modified Delphi process. These statements do not intend to be all-encompassing and future revisions are likely as new data continue to emerge.
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Affiliation(s)
- Choon Jin Ooi
- Department of Gastroenterology and Hepatology, Singapore General Hospital, Singapore
| | | | - Rupa Banerjee
- Asian Institute of Gastroenterology, New Delhi, India
| | | | - Siew Chien Ng
- Department of Medicine and Therapeutics, The Chinese University of Hong Kong, Hong Kong
| | - Shu Chen Wei
- Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan
| | - Govind K Makharia
- Department of Gastroenterology and Human Nutrition, All India Institute of Medical Sciences, New Delhi, India
| | - Pises Pisespongsa
- Gastroenterology and Hepatology, Bumrungrad International University, Bangkok, Thailand
| | - Min Hu Chen
- Division of Gastroenterology, The First University Hospital, Sun Yat-sen University, Guangzhou, China
| | - Zhi Hua Ran
- Department of Gastroenterology and Hepatology, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Byong Duk Ye
- Department of Gastroenterology and IBD Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Dong Il Park
- Department of Internal Medicine, Kangbuk Samsung Hospital, Sungkyunkwan University School of Medicine, Seoul, Korea
| | | | - David Ong
- Division of Gastroenterology and Hepatology, National University Hospital of Singapore, University Medicine Cluster, Singapore
| | - Vineet Ahuja
- Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan
| | - Khean Lee Goh
- University of Malaya Specialist Centre, Kuala Lumpur, Malaysia
| | - Jose Sollano
- Department of Medicine, University of Santo Tomas, Manila, Philippines
| | - Wee Chian Lim
- Department of Gastroenterology and Hepatology, Tan Tock Seng Hospital, Singapore
| | - Wai Keung Leung
- Division of Gastroenterology and Hepatology, Department of Medicine, University of Hong Kong, Hong Kong
| | - Raja Affendi Raja Ali
- Faculty of Medicine, UKM Medical and Specialist Centres, The National University of Malaysia, Kuala Lumpur, Malaysia
| | - Deng Chyang Wu
- Department of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Evan Ong
- Department of Medicine, University of Santo Tomas, Manila, Philippines
| | - Nazri Mustaffa
- Department of Internal Medicine, School of Medical Sciences, Health Campus, Sains University, Kubang Kerian, Malaysia
| | - Julajak Limsrivilai
- Department of Medicine, Faculty of Medicine, Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Tadakazu Hisamatsu
- The Third Department of Internal Medicine, Kyorin University School of Medicine, Mitaka, Japan
| | - Suk Kyun Yang
- Department of Gastroenterology, University of Ulsan College of Medicine, Seoul, Korea
| | - Qin Ouyang
- Department of Gastroenterology, West China Hospital, Sichuan University, Chengdu, China
| | - Richard Geary
- Department of Medicine, University of Otago, Christchurch, New Zealand
| | | | | | - Marcellus Simadibrata
- Department of Internal Medicine, Faculty of Medicine, University of Indonesia, Jakarta, Indonesia
| | - Murdani Abdullah
- Division of Gastroenterology, Department of Internal Medicine, Cipto Mangunkusumo National Hospital, Jakarta, Indonesia
| | - Rupert Wl Leong
- Gastroenterology and Liver Services, Concord Hospital, Sydney, Australia
| | -
- Department of Gastroenterology and Hepatology, Singapore General Hospital, Singapore
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44
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Weeramange C, Lansakara A, Dallman J, Nguyen T, Hulangamuwa W, Rafferty RJ. New methods to assess 6-thiopurine toxicity and expanding its therapeutic application to pancreatic cancer via small molecule potentiators. MEDCHEMCOMM 2019; 10:717-725. [PMID: 31191862 DOI: 10.1039/c9md00010k] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/08/2019] [Accepted: 03/14/2019] [Indexed: 01/16/2023]
Abstract
6-Thiopurine (6TP) is a potent cytotoxic agent that is a clinically prescribed anti-metabolite employed in the treatment of numerous blood cancers since 1952. However, its reported severe toxicities limit its general usage in the clinic. We previously have undertaken investigations into identifying the mode of toxicity for 6TP, and have found that the oxidative metabolites of 6TP, specifically 6-thiouric acid (6TU), is responsible for the in vitro inhibition of UDP-glucose dehydrogenase (UDPGDH) in a UV-vis method. In this method, inhibition was quantified through the quantification of NADH production, however, purines absorb at the same wavelength and thereby can interfere with the NADH detection. Herein, we report a HPLC method that allows for direct quantification of UDP-glucuronic acid, product from UDPGDH, for the assessment of inhibition towards UDPGDH with no interference from purines. In this method it was revealed that 6TP possesses a greater inhibitory properties than previously observed; 111 vs. 288 μM. Building upon the data collected from a previously performed rat hepatocyte study, which correlated our in vitro to in vivo inhibition theories about UDPGDH, we have developed a bio-mimic in vitro assay to aid in the inhibitory assessment of 6TP and analogs. In our efforts to expand the use of 6TP, and analogs constructed, our laboratory has undertaken a screening campaign to identify small molecule potentiators that work in synergy with 6TP in other types of cancers. Three chalcone-based compounds have been discovered through our total synthesis campaign of uvaretin, and it has been found that 11c has strong synergism with 6TP in the pancreatic cancer cell line MIA PaCa-2. Through the work presented herein, we reveal new methods to assess toxicity of 6TP and future analogs and new small molecules that work in synergy to expand the therapeutic applications of this neglected cytotoxic agent.
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Affiliation(s)
- Chamitha Weeramange
- Department of Chemistry , Kansas State University , 1212 Mid-Campus Drive North , Manhattan , KS 66506 , USA
| | - Ashabha Lansakara
- Department of Chemistry , Kansas State University , 1212 Mid-Campus Drive North , Manhattan , KS 66506 , USA
| | - Johnathan Dallman
- Department of Chemistry , Kansas State University , 1212 Mid-Campus Drive North , Manhattan , KS 66506 , USA
| | - Thi Nguyen
- Department of Chemistry , Kansas State University , 1212 Mid-Campus Drive North , Manhattan , KS 66506 , USA
| | - Wasundara Hulangamuwa
- Department of Chemistry , Kansas State University , 1212 Mid-Campus Drive North , Manhattan , KS 66506 , USA
| | - Ryan J Rafferty
- Department of Chemistry , Kansas State University , 1212 Mid-Campus Drive North , Manhattan , KS 66506 , USA
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45
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Walker GJ, Harrison JW, Heap GA, Voskuil MD, Andersen V, Anderson CA, Ananthakrishnan AN, Barrett JC, Beaugerie L, Bewshea CM, Cole AT, Cummings FR, Daly MJ, Ellul P, Fedorak RN, Festen EAM, Florin TH, Gaya DR, Halfvarson J, Hart AL, Heerasing NM, Hendy P, Irving PM, Jones SE, Koskela J, Lindsay JO, Mansfield JC, McGovern D, Parkes M, Pollok RCG, Ramakrishnan S, Rampton DS, Rivas MA, Russell RK, Schultz M, Sebastian S, Seksik P, Singh A, So K, Sokol H, Subramaniam K, Todd A, Annese V, Weersma RK, Xavier R, Ward R, Weedon MN, Goodhand JR, Kennedy NA, Ahmad T. Association of Genetic Variants in NUDT15 With Thiopurine-Induced Myelosuppression in Patients With Inflammatory Bowel Disease. JAMA 2019; 321:773-785. [PMID: 30806694 PMCID: PMC6439872 DOI: 10.1001/jama.2019.0709] [Citation(s) in RCA: 113] [Impact Index Per Article: 22.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
IMPORTANCE Use of thiopurines may be limited by myelosuppression. TPMT pharmacogenetic testing identifies only 25% of at-risk patients of European ancestry. Among patients of East Asian ancestry, NUDT15 variants are associated with thiopurine-induced myelosuppression (TIM). OBJECTIVE To identify genetic variants associated with TIM among patients of European ancestry with inflammatory bowel disease (IBD). DESIGN, SETTING, AND PARTICIPANTS Case-control study of 491 patients affected by TIM and 679 thiopurine-tolerant unaffected patients who were recruited from 89 international sites between March 2012 and November 2015. Genome-wide association studies (GWAS) and exome-wide association studies (EWAS) were conducted in patients of European ancestry. The replication cohort comprised 73 patients affected by TIM and 840 thiopurine-tolerant unaffected patients. EXPOSURES Genetic variants associated with TIM. MAIN OUTCOMES AND MEASURES Thiopurine-induced myelosuppression, defined as a decline in absolute white blood cell count to 2.5 × 109/L or less or a decline in absolute neutrophil cell count to 1.0 × 109/L or less leading to a dose reduction or drug withdrawal. RESULTS Among 1077 patients (398 affected and 679 unaffected; median age at IBD diagnosis, 31.0 years [interquartile range, 21.2 to 44.1 years]; 540 [50%] women; 602 [56%] diagnosed as having Crohn disease), 919 (311 affected and 608 unaffected) were included in the GWAS analysis and 961 (328 affected and 633 unaffected) in the EWAS analysis. The GWAS analysis confirmed association of TPMT (chromosome 6, rs11969064) with TIM (30.5% [95/311] affected vs 16.4% [100/608] unaffected patients; odds ratio [OR], 2.3 [95% CI, 1.7 to 3.1], P = 5.2 × 10-9). The EWAS analysis demonstrated an association with an in-frame deletion in NUDT15 (chromosome 13, rs746071566) and TIM (5.8% [19/328] affected vs 0.2% [1/633] unaffected patients; OR, 38.2 [95% CI, 5.1 to 286.1], P = 1.3 × 10-8), which was replicated in a different cohort (2.7% [2/73] affected vs 0.2% [2/840] unaffected patients; OR, 11.8 [95% CI, 1.6 to 85.0], P = .03). Carriage of any of 3 coding NUDT15 variants was associated with an increased risk (OR, 27.3 [95% CI, 9.3 to 116.7], P = 1.1 × 10-7) of TIM, independent of TPMT genotype and thiopurine dose. CONCLUSIONS AND RELEVANCE Among patients of European ancestry with IBD, variants in NUDT15 were associated with increased risk of TIM. These findings suggest that NUDT15 genotyping may be considered prior to initiation of thiopurine therapy; however, further study including additional validation in independent cohorts is required.
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Affiliation(s)
- Gareth J. Walker
- Department of Gastroenterology, Royal Devon and Exeter Hospital NHS Foundation Trust, Exeter, England
- IBD Pharmacogenetics Group, University of Exeter, Exeter, England
| | | | - Graham A. Heap
- Department of Gastroenterology, Royal Devon and Exeter Hospital NHS Foundation Trust, Exeter, England
- IBD Pharmacogenetics Group, University of Exeter, Exeter, England
| | - Michiel D. Voskuil
- Department of Gastroenterology and Hepatology, University Medical Center Groningen, Groningen, the Netherlands
| | - Vibeke Andersen
- Medical Department, Regional Hospital Viborg, Viborg, Denmark
| | | | | | | | - Laurent Beaugerie
- Department of Gastroenterology, Saint-Antoine Hospital and Sorbonne Universite, Paris, France
| | | | - Andy T. Cole
- Derby Digestive Diseases Centre, Royal Derby Hospital, Derby Teaching Hospitals NHS Foundation Trust, Derby, England
| | - Fraser R. Cummings
- Department of Gastroenterology, Southampton General Hospital, University Hospital Southampton NHS Foundation Trust, Southampton, England
| | - Mark J. Daly
- Broad Institute, Harvard University, Cambridge, Massachusetts
| | - Pierre Ellul
- Department of Gastroenterology, Mater Dei Hospital, Msida, Malta
| | | | - Eleonora A. M. Festen
- Department of Gastroenterology and Hepatology, University Medical Center Groningen, Groningen, the Netherlands
| | - Timothy H. Florin
- Mater Research Institute, University of Queensland, South Brisbane, Australia
| | - Daniel R. Gaya
- Department of Gastroenterology, Glasgow Royal Infirmary, NHS Greater Glasgow and Clyde, Glasgow, Scotland
| | | | - Ailsa L. Hart
- Department of Gastroenterology, St Mark’s Hospital, London North West Healthcare NHS Trust, Harrow, England
| | - Neel M. Heerasing
- Department of Gastroenterology, Royal Devon and Exeter Hospital NHS Foundation Trust, Exeter, England
- IBD Pharmacogenetics Group, University of Exeter, Exeter, England
| | - Peter Hendy
- Department of Gastroenterology, Royal Devon and Exeter Hospital NHS Foundation Trust, Exeter, England
- IBD Pharmacogenetics Group, University of Exeter, Exeter, England
| | - Peter M. Irving
- Department of Gastroenterology, Guy’s and St Thomas’ NHS Foundation Trust, London, England
| | | | - Jukka Koskela
- Broad Institute, Harvard University, Cambridge, Massachusetts
| | - James O. Lindsay
- Centre for Immunobiology, Blizard Institute, Barts and the London School of Medicine, Queen Mary University of London, London, England
| | - John C. Mansfield
- Department of Gastroenterology, Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, England
| | - Dermot McGovern
- F. Widjaja Foundation Inflammatory Bowel Disease and Immunobiology Research Institute, Cedars-Sinai Medical Center, Los Angeles, California
| | - Miles Parkes
- Department of Gastroenterology, Addenbrooke’s Hospital, Cambridge University Hospitals NHS Foundation Trust, Cambridge, England
| | - Richard C. G. Pollok
- Department of Gastroenterology, St George’s Healthcare NHS Trust, Tooting, England
| | - Subramaniam Ramakrishnan
- Gastrointestinal and Liver Services, Warrington and Halton Hospitals NHS Foundation Trust, Warrington, England
| | - David S. Rampton
- Department of Gastroenterology, Royal London Hospital, Barts Health NHS Trust, London, England
| | - Manuel A. Rivas
- Broad Institute, Harvard University, Cambridge, Massachusetts
| | - Richard K. Russell
- Department of Paediatric Gastroenterology, Royal Hospital for Children, NHS Greater Glasgow and Clyde, Glasgow, Scotland
| | | | - Shaji Sebastian
- Gastroenterology and Hepatology, Hull and East Yorkshire Hospitals NHS Trust, Hull, England
| | - Philippe Seksik
- Department of Gastroenterology, Saint-Antoine Hospital and Sorbonne Universite, Paris, France
| | - Abhey Singh
- Department of Gastroenterology, Royal Devon and Exeter Hospital NHS Foundation Trust, Exeter, England
| | - Kenji So
- Department of Gastroenterology, Royal Devon and Exeter Hospital NHS Foundation Trust, Exeter, England
| | - Harry Sokol
- Department of Gastroenterology, Saint-Antoine Hospital and Sorbonne Universite, Paris, France
| | | | - Anthony Todd
- Department of Haematology, Royal Devon and Exeter Hospital NHS Foundation Trust, Exeter, England
| | - Vito Annese
- Division of Gastroenterology, Azienda Ospedaliero Universitaria Careggi, Florence, Italy
| | - Rinse K. Weersma
- Department of Gastroenterology and Hepatology, University Medical Center Groningen, Groningen, the Netherlands
| | - Ramnik Xavier
- Broad Institute, Harvard University, Cambridge, Massachusetts
| | - Rebecca Ward
- University of Exeter Medical School, Exeter, England
| | | | - James R. Goodhand
- Department of Gastroenterology, Royal Devon and Exeter Hospital NHS Foundation Trust, Exeter, England
- IBD Pharmacogenetics Group, University of Exeter, Exeter, England
| | - Nicholas A. Kennedy
- Department of Gastroenterology, Royal Devon and Exeter Hospital NHS Foundation Trust, Exeter, England
- IBD Pharmacogenetics Group, University of Exeter, Exeter, England
| | - Tariq Ahmad
- Department of Gastroenterology, Royal Devon and Exeter Hospital NHS Foundation Trust, Exeter, England
- IBD Pharmacogenetics Group, University of Exeter, Exeter, England
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Torres Hernandez AX, Weeramange CJ, Desman P, Fatino A, Haney O, Rafferty RJ. Efforts in redesigning the antileukemic drug 6-thiopurine: decreasing toxic side effects while maintaining efficacy. MEDCHEMCOMM 2018; 10:169-179. [PMID: 30774864 DOI: 10.1039/c8md00463c] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/14/2018] [Accepted: 12/15/2018] [Indexed: 01/14/2023]
Abstract
6-Thiopurine (6TP) is a currently prescribed drug in the treatment of diseases ranging from Crohn's disease to acute lymphocytic leukemia. While its potent mode of action is through incorporation into DNA as a thiol mimic of deoxyguanosine, severe toxicities are associated with its administration which hinder the potential therapeutic application. We have previously reported in vitro that the oxidative metabolites of 6TP, specifically 6-thiouric acid (6TU, K i 7 μM), are potent inhibitors of UDP-glucose dehydrogenase (UDPGDH), an enzyme that is responsible for the formation of UDP-glucuronic acid (UDPGA), an essential substrate that is used in detoxification processes in the liver. An in vivo investigation was undertaken to probe if 6TU inhibits UDPGDH in rat hepatocytes, and it was observed that 6TU does greatly suppress the conjugation of bilirubin with UDPGA. The failed excretion of bilirubin is linked to a majority of the reported toxicities associated with 6TP administration. Efforts were undertaken for the construction of 6TP analogs, substituted at the C8 position, to reduce inhibition of UDPGDH while retaining therapeutic efficacy. Three new 6TP analogs bearing a halogen (Br, Cl, and F) at the C8 position have been achieved over five-synthetic steps in overall yields of 16 to 32%. Each of these analogs were shown to have reduced inhibition towards UDPGDH, with K i values of 192, 163, 215 μM, respectively. In addition, the bromine, chlorine, and fluorine analogs were shown to possess cytotoxicity towards the REH cell line (acute lymphocytic leukemia) having IC50 values of 9.54 μM (±0.97), 3.95 μM (±1.94), and 4.71 μM (±1.40), respectively. These three new 6TP analogs represent the first steps in the redesign of this potent anticancer agent into a better drug that possesses reduced toxic side effects while retaining therapeutic potency.
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Affiliation(s)
- Arnaldo X Torres Hernandez
- Department of Chemistry , Pontifical Catholic University of Puerto Rico , 2250 Boulevard Luis A. Ferré Aguayo, Suite 626 , Ponce , PR 00717-0777 , Puerto Rico.,Department of Chemistry , Kansas State University , 1212 Mid-Campus Drive North , Manhattan , KS 66506 , USA .
| | - Chamitha J Weeramange
- Department of Chemistry , Kansas State University , 1212 Mid-Campus Drive North , Manhattan , KS 66506 , USA .
| | - Prathibha Desman
- Department of Chemistry , Kansas State University , 1212 Mid-Campus Drive North , Manhattan , KS 66506 , USA .
| | - Anthony Fatino
- Department of Chemistry , Kansas State University , 1212 Mid-Campus Drive North , Manhattan , KS 66506 , USA .
| | - Olivia Haney
- Department of Chemistry , Kansas State University , 1212 Mid-Campus Drive North , Manhattan , KS 66506 , USA .
| | - Ryan J Rafferty
- Department of Chemistry , Kansas State University , 1212 Mid-Campus Drive North , Manhattan , KS 66506 , USA .
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47
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Pashazadeh P, Marjani A, Asadi J, Khoshnia M. Thiopurine Methyltransferase Genetic Polymorphisms and Activity and Metabolic Products of Azathioprine in Patients with Inflammatory Bowel Disease. Endocr Metab Immune Disord Drug Targets 2018; 19:541-547. [PMID: 30451123 DOI: 10.2174/1871530318666181119153522] [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: 06/12/2018] [Revised: 10/01/2018] [Accepted: 10/04/2018] [Indexed: 12/07/2022]
Abstract
BACKGROUND Thiopurine S-methyltransferase (TPMT) is a cytoplasmic enzyme that catalyzes thiopurine drugs such as 6-mercaptopurine, 6-thioguanine, and azathioprine. There is a correlation between thiopurine drug metabolism, response, and toxicity and genetic polymorphism of TPMT. The aim of this study is to assess TPMT genetic polymorphisms activity and metabolic products of AZA in patients with IBD. METHODS Blood samples were obtained from 50 IBD unrelated patients from a private laboratory. We used polymerase chain reaction-restriction length polymorphism (PCR-RFLP) and allele-specific PCRbased assays to determine the TPMT gene for the different variants. A high-performance liquid chromatography system (HPLC) was carried out to determine the whole blood 6-TGN concentration. Determination of serum TMPT activity was done by ELISA kit. RESULTS In IBD patients, 46/50 (92%) subjects were homozygous for the wild-type allele (TPMT*1/*1). Mutant TPMT*1/*2 and TPMT*1/*3C alleles were found in 4/46 (8%) and 3/47 (6%) of IBD patients, respectively. TPMT*1/*3B variant was not detected in any of the IBD patients. TPMT enzyme activity was higher in wild-type than that mutant variants TPMT*1/*2 and TPMT*1/*3C, suggesting that there are statistically significant differences between 6-TG levels and polymorphisms of TMPT enzyme. 6-TG levels significantly increased in IBD patients mutant variants TPMT*1/*2 and TPMT*1/*3C. CONCLUSIONS Our results showed that TPMT polymorphisms are associated with 6-TGN levels in patients using AZA. This study suggests that AZA dosage may be determined according to the high or low prevalence of a TPMT genotype. Moreover, the results present the determination of metabolite for assessing possible safe effective dosage of the drug.
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Affiliation(s)
- Paria Pashazadeh
- Metabolic Disorders Research Center, Department of Biochemistry and Biophysics, Gorgan Faulty of Medicine, Golestan University of Medical Sciences, Gorgan, Golestan Province, Iran
| | - Abdoljalal Marjani
- Metabolic Disorders Research Center, Department of Biochemistry and Biophysics, Gorgan Faulty of Medicine, Golestan University of Medical Sciences, Gorgan, Golestan Province, Iran
| | - Jahanbakhash Asadi
- Metabolic Disorders Research Center, Department of Biochemistry and Biophysics, Gorgan Faulty of Medicine, Golestan University of Medical Sciences, Gorgan, Golestan Province, Iran
| | - Masoud Khoshnia
- Golestan Research Center of Gasteroenterolgy and Hepatology, Golestan University of Medical Sciences, Gorgan, Golestan Province, Iran
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48
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Lim SZ, Chua EW. Revisiting the Role of Thiopurines in Inflammatory Bowel Disease Through Pharmacogenomics and Use of Novel Methods for Therapeutic Drug Monitoring. Front Pharmacol 2018; 9:1107. [PMID: 30349479 PMCID: PMC6186994 DOI: 10.3389/fphar.2018.01107] [Citation(s) in RCA: 37] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2018] [Accepted: 09/10/2018] [Indexed: 12/12/2022] Open
Abstract
Azathioprine and 6-mercaptopurine, often referred to as thiopurine compounds, are commonly used in the management of inflammatory bowel disease. However, patients receiving these drugs are prone to developing adverse drug reactions or therapeutic resistance. Achieving predefined levels of two major thiopurine metabolites, 6-thioguanine nucleotides and 6-methylmercaptopurine, is a long-standing clinical practice in ensuring therapeutic efficacy; however, their correlation with treatment response is sometimes unclear. Various genetic markers have also been used to aid the identification of patients who are thiopurine-sensitive or refractory. The recent discovery of novel Asian-specific DNA variants, namely those in the NUDT15 gene, and their link to thiopurine toxicity, have led clinicians and scientists to revisit the utility of Caucasian biomarkers for Asian individuals with inflammatory bowel disease. In this review, we explore the limitations associated with the current methods used for therapeutic monitoring of thiopurine metabolites and how the recent discovery of ethnicity-specific genetic markers can complement thiopurine metabolites measurement in formulating a strategy for more accurate prediction of thiopurine response. We also discuss the challenges in thiopurine therapy, alongside the current strategies used in patients with reduced thiopurine response. The review is concluded with suggestions for future work aiming at using a more comprehensive approach to optimize the efficacy of thiopurine compounds in inflammatory bowel disease.
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Affiliation(s)
| | - Eng Wee Chua
- Faculty of Pharmacy, Universiti Kebangsaan Malaysia, Kuala Lumpur, Malaysia
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Kishibe M, Nozaki H, Fujii M, Iinuma S, Ohtsubo S, Igawa S, Kanno K, Honma M, Kishibe K, Okamoto K, Ishida-Yamamoto A. Severe thiopurine-induced leukocytopenia and hair loss in Japanese patients with defectiveNUDT15 variant: Retrospective case-control study. J Dermatol 2018; 45:1160-1165. [DOI: 10.1111/1346-8138.14588] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2018] [Accepted: 07/03/2018] [Indexed: 02/06/2023]
Affiliation(s)
- Mari Kishibe
- Department of Dermatology; Asahikawa Medical University; Asahikawa Japan
| | - Hiroyoshi Nozaki
- Department of Dermatology; Asahikawa Medical University; Asahikawa Japan
| | - Mizue Fujii
- Department of Dermatology; Asahikawa Medical University; Asahikawa Japan
| | - Shin Iinuma
- Department of Dermatology; Asahikawa Medical University; Asahikawa Japan
| | - Sawa Ohtsubo
- Department of Dermatology; Asahikawa Medical University; Asahikawa Japan
| | - Satomi Igawa
- Department of Dermatology; Asahikawa Medical University; Asahikawa Japan
| | - Kyoko Kanno
- Department of Dermatology; Asahikawa Medical University; Asahikawa Japan
| | - Masaru Honma
- Department of Dermatology; Asahikawa Medical University; Asahikawa Japan
| | - Kan Kishibe
- Department of Otorhinolaryngology; Asahikawa Medical University; Asahikawa Japan
| | - Kensaku Okamoto
- Division of Metabolism and Biosystemic Science; Department of Medicine; Asahikawa Medical University; Asahikawa Japan
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50
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Yoo IY, Lee K, Ji OJ, Woo HI, Lee SY. Evaluation of Stability of Thiopurine Metabolites Using a Validated LC-MS/MS Method. Ann Lab Med 2018; 38:255-260. [PMID: 29401561 PMCID: PMC5820071 DOI: 10.3343/alm.2018.38.3.255] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2017] [Revised: 10/24/2017] [Accepted: 01/05/2018] [Indexed: 11/30/2022] Open
Abstract
Measurement of thiopurine metabolites is helpful to monitor adverse effects and assess compliance in patients on thiopurine treatment. The purpose of this study was to develop and validate an analytical method for measurement of thiopurine metabolites, thioguanine nucleotides (6-TGN) and 6-methylmercaptopurine nucleotide (6-MMPN), in RBCs. We developed and validated a liquid chromatography–tandem mass spectrometry (LC-MS/MS) method for the quantification of 6-TGN and 6-MMPN and evaluated the stability of the thiopurine metabolites in RBC and whole blood states without any preprocessing at various storage conditions. The linear range was 0.1–10 µmol/L and 0.5–100 µmol/L for 6-TGN and 6-MMPN, respectively. The mean extraction recovery at the two concentrations was 71.0% and 75.0% for 6-TGN, and 102.2% and 96.4% for 6-MMPN. Thiopurine metabolites in preprocessed RBC samples were stable at 25℃ and 4℃ after storage for 4 hours and at −70℃ for up to 6 months. However, 6-TGN decreased by 30% compared with the initial concentration when stored at −20℃ for 180 days. In whole blood states, 6-TGN decreased by about 20% at four days after storage at 4℃. We validated a reliable LC-MS/MS method and recommend that the patient's whole blood sample be preprocessed as soon as possible.
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Affiliation(s)
- In Young Yoo
- Department of Laboratory Medicine and Genetics, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Kyunghoon Lee
- Department of Laboratory Medicine and Genetics, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Ok Ja Ji
- Department of Laboratory Medicine and Genetics, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Hye In Woo
- Department of Laboratory Medicine, Samsung Changwon Hospital, Sungkyunkwan University School of Medicine, Changwon, Korea
| | - Soo Youn Lee
- Department of Laboratory Medicine and Genetics, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea.
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