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Mu H, Ye L, Wang B. Detailed resume of S-methyltransferases: Categories, structures, biological functions and research advancements in related pathophysiology and pharmacotherapy. Biochem Pharmacol 2024; 226:116361. [PMID: 38876259 DOI: 10.1016/j.bcp.2024.116361] [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: 03/05/2024] [Revised: 05/19/2024] [Accepted: 06/10/2024] [Indexed: 06/16/2024]
Abstract
Methylation is a vital chemical reaction in the metabolism of many drugs, neurotransmitters, hormones, and exogenous compounds. Among them, S-methylation plays a significant role in the biotransformation of sulfur-containing compounds, particularly chemicals with sulfhydryl groups. Currently, only three S-methyltransferases have been reported: thiopurine methyltransferase (TPMT), thiol methyltransferase (TMT), and thioether methyltransferase (TEMT). These enzymes are involved in various biological processes such as gene regulation, signal transduction, protein repair, tumor progression, and biosynthesis and degradation reactions in animals, plants, and microorganisms. Furthermore, they play pivotal roles in the metabolic pathways of essential drugs and contribute to the advancement of diseases such as tumors. This paper reviews the research progress on relevant structural features, metabolic mechanisms, inhibitor development, and influencing factors (gene polymorphism, S-adenosylmethionine level, race, sex, age, and disease) of S-methyltransferases. We hope that a better comprehension of S-methyltransferases will help to provide a reference for the development of novel strategies for related disorders and improve long-term efficacy.
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Affiliation(s)
- Hongfei Mu
- Department of Drug Metabolism, Beijing Key Laboratory of Non-Clinical Drug Metabolism and PK/PD Study, State Key Laboratory of Bioactive Substance and Function of Natural Medicines, Institute of Materia Medica, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, PR China.
| | - Lisha Ye
- Department of Drug Metabolism, Beijing Key Laboratory of Non-Clinical Drug Metabolism and PK/PD Study, State Key Laboratory of Bioactive Substance and Function of Natural Medicines, Institute of Materia Medica, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, PR China.
| | - Baolian Wang
- Department of Drug Metabolism, Beijing Key Laboratory of Non-Clinical Drug Metabolism and PK/PD Study, State Key Laboratory of Bioactive Substance and Function of Natural Medicines, Institute of Materia Medica, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, PR China.
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2
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Yeo JQ, Cheen HHM, Wong A, Lim TG, Chowbay B, Leong WF, Wang C, Salazar E, Chan WPW, Kong SC, Ong WC. Clinical utility of thiopurine metabolite monitoring in inflammatory bowel disease and its impact on healthcare utilization in Singapore. JGH Open 2022; 6:658-666. [PMID: 36262537 PMCID: PMC9575318 DOI: 10.1002/jgh3.12798] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2022] [Revised: 07/01/2022] [Accepted: 07/10/2022] [Indexed: 01/05/2023]
Abstract
Background and Aim Thiopurines are recommended for maintenance of steroid‐free remission (SFR) in inflammatory bowel disease (IBD). Thiopurine metabolite monitoring (MM) is increasingly used in the West but remains novel in Singapore, with limited information on its therapeutic and economic benefits. Hence, this study aims to investigate MM's clinical utility and its impact on healthcare resource utilization in Singaporean IBD patients. Methods A retrospective observational study was conducted at Singapore General Hospital outpatient IBD Centre. Patients with IBD, baseline MM during 2014–2017, and weight‐based thiopurine doses for ≥4 weeks were followed up for 1 year. Actions were taken to optimize therapy, and metabolite levels before and after the first action were documented. Outcomes assessed included SFR, no therapy escalation or surgery, healthcare resource utilization, and direct healthcare costs. Results Ninety IBD patients (50 Crohn's disease, 40 ulcerative colitis) were included. Among them, 40% had baseline metabolite levels within therapeutic range, 31.1% sub‐therapeutic, 21.1% supra‐therapeutic, and 7.8% shunters. Repeated MM with subsequent dose optimization helped 67.2% of patients achieve therapeutic levels after 1 year. Overall, 87.8% of patients achieved SFR and 90% had no therapy escalation or surgery. Despite greater outpatient visits and laboratory investigations with MM, the median total healthcare costs at 1 year only increased marginally (S$6407.66 [shunters] vs S$5215.20 [supra‐therapeutic] vs S$4970.80 [sub‐therapeutic] vs S$4370.48 [control (within therapeutic range)], P = 0.592). Conclusion MM guided timely therapy escalation for non‐responders, identification of non‐adherence, and reversal of shunting. Therefore, it is a useful clinical tool to optimize thiopurines without significantly increasing healthcare costs.
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Affiliation(s)
- Jia Qi Yeo
- National Healthcare Group Pharmacy Singapore
| | | | - Amanda Wong
- Department of Pharmacy Singapore General Hospital Singapore
| | - Teong Guan Lim
- Department of Pharmacy Singapore General Hospital Singapore
| | - Balram Chowbay
- Clinical Pharmacology Laboratory National Cancer Centre Singapore Singapore
- Centre for Clinician‐Scientist Development Duke‐NUS Medical School Singapore
- Singapore Immunology Network (SIgN) A*STAR (Agency for Science, Technology and Research), Biopolis Singapore
| | - Wai Fook Leong
- Singapore Immunology Network (SIgN) A*STAR (Agency for Science, Technology and Research), Biopolis Singapore
| | | | - Ennaliza Salazar
- Department of Gastroenterology and Hepatology Singapore General Hospital Singapore
| | - Webber Pak Wo Chan
- Department of Gastroenterology and Hepatology Singapore General Hospital Singapore
| | - San Choon Kong
- Department of Gastroenterology and Hepatology Sengkang General Hospital Singapore
| | - Wan Chee Ong
- Department of Pharmacy Singapore General Hospital Singapore
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3
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Venner JM, Bernstein CN. Immunomodulators: still having a role? Gastroenterol Rep (Oxf) 2022; 10:goac061. [PMID: 36381225 PMCID: PMC9642324 DOI: 10.1093/gastro/goac061] [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: 07/26/2022] [Revised: 09/08/2022] [Accepted: 10/09/2022] [Indexed: 11/09/2022] Open
Abstract
Immunomodulators, particularly the thiopurines and to a lesser extent methotrexate, were standard of care for inflammatory bowel diseases, including Crohn’s disease and ulcerative colitis, for >40 years. While there has been a renaissance in available therapies with the advent of biologics and small molecules, an impetus remains for the ongoing use of thiopurines and methotrexate. This is particularly true for the maintenance of remission and when used in combination therapy with infliximab to suppress anti-biologic antibodies. This article summarizes the data behind immunomodulator use in Crohn’s disease, focusing on the beneficial role these drugs still have while acknowledging their clinical limitations.
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Affiliation(s)
- Jeffery M Venner
- University of Manitoba IBD Clinical and Research Centre , Winnipeg, Manitoba, Canada
- Department of Internal Medicine, Max Rady College of Medicine, Rady Faculty of Health Sciences, University of Manitoba , Winnipeg, Manitoba, Canada
| | - Charles N Bernstein
- University of Manitoba IBD Clinical and Research Centre , Winnipeg, Manitoba, Canada
- Department of Internal Medicine, Max Rady College of Medicine, Rady Faculty of Health Sciences, University of Manitoba , Winnipeg, Manitoba, Canada
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4
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Singh A, Mahajan R, Kedia S, Dutta AK, Anand A, Bernstein CN, Desai D, Pai CG, Makharia G, Tevethia HV, Mak JW, Kaur K, Peddi K, Ranjan MK, Arkkila P, Kochhar R, Banerjee R, Sinha SK, Ng SC, Hanauer S, Verma S, Dutta U, Midha V, Mehta V, Ahuja V, Sood A. Use of thiopurines in inflammatory bowel disease: an update. Intest Res 2021; 20:11-30. [PMID: 33845546 PMCID: PMC8831775 DOI: 10.5217/ir.2020.00155] [Citation(s) in RCA: 32] [Impact Index Per Article: 10.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/04/2020] [Accepted: 03/01/2021] [Indexed: 12/11/2022] Open
Abstract
Inflammatory bowel disease (IBD), once considered a disease of the Western hemisphere, has emerged as a global disease. As the disease prevalence is on a steady rise, management of IBD has come under the spotlight. 5-Aminosalicylates, corticosteroids, immunosuppressive agents and biologics are the backbone of treatment of IBD. With the advent of biologics and small molecules, the need for surgery and hospitalization has decreased. However, economic viability and acceptability is an important determinant of local prescription patterns. Nearly one-third of the patients in West receive biologics as the first/initial therapy. The scenario is different in developing countries where biologics are used only in a small proportion of patients with IBD. Increased risk of reactivation of tuberculosis and high cost of the therapy are limitations to their use. Thiopurines hence become critical for optimal management of patients with IBD in these regions. However, approximately one-third of patients are intolerant or develop adverse effects with their use. This has led to suboptimal use of thiopurines in clinical practice. This review article discusses the clinical aspects of thiopurine use in patients with IBD with the aim of optimizing their use to full therapeutic potential.
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Affiliation(s)
- Arshdeep Singh
- Department of Gastroenterology, Dayanand Medical College and Hospital, Ludhiana, India
| | - Ramit Mahajan
- Department of Gastroenterology, Dayanand Medical College and Hospital, Ludhiana, India
| | - Saurabh Kedia
- Department of Gastroenterology and Human Nutrition, All India Institute of Medical Sciences, New Delhi, India
| | - Amit Kumar Dutta
- Department of Gastroenterology, Christian Medical College, Vellore, India
| | - Abhinav Anand
- Department of Gastroenterology and Human Nutrition, All India Institute of Medical Sciences, New Delhi, India
| | - Charles N Bernstein
- University of Manitoba IBD Clinical and Research Centre, Max Rady College of Medicine, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, MB, Canada
| | - Devendra Desai
- P. D. Hinduja Hospital and Medical Research Centre, Mumbai, India
| | - C Ganesh Pai
- Department of Gastroenterology, Kasturba Medical College, Manipal, India
| | - Govind Makharia
- Department of Gastroenterology and Human Nutrition, All India Institute of Medical Sciences, New Delhi, India
| | | | - Joyce Wy Mak
- Department of Medicine and Therapeutics, Faculty of Medicine, The Chinese University of Hong Kong, Shatin, Hong Kong
| | - Kirandeep Kaur
- Department of Pharmacology, Dayanand Medical College and Hospital, Ludhiana, India
| | - Kiran Peddi
- Citizens Centre for Digestive Disorders, Hyderabad, India
| | - Mukesh Kumar Ranjan
- Department of Gastroenterology and Human Nutrition, All India Institute of Medical Sciences, New Delhi, India
| | - Perttu Arkkila
- Department of Gastroenterology, Helsinki University Central Hospital, Helsinki, Finland
| | - Rakesh Kochhar
- Department of Gastroenterology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Rupa Banerjee
- Asian Institute of Gastroenterology Hyderabad, Hyderabad, India
| | - Saroj Kant Sinha
- Department of Gastroenterology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Siew Chien Ng
- Department of Medicine and Therapeutics, Faculty of Medicine, The Chinese University of Hong Kong, Shatin, Hong Kong
| | - Stephen Hanauer
- Department of Medicine, Northwestern University, Chicago, IL, USA
| | - Suhang Verma
- Department of Gastroenterology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Usha Dutta
- Department of Gastroenterology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Vandana Midha
- Department of Internal Medicine, Dayanand Medical College, Ludhiana, India
| | - Varun Mehta
- Department of Gastroenterology, Dayanand Medical College and Hospital, Ludhiana, India
| | - Vineet Ahuja
- Department of Gastroenterology and Human Nutrition, All India Institute of Medical Sciences, New Delhi, India
| | - Ajit Sood
- Department of Gastroenterology, Dayanand Medical College and Hospital, Ludhiana, India
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Miele E, Benninga MA, Broekaert I, Dolinsek J, Mas E, Orel R, Pienar C, Ribes-Koninckx C, Thomassen RA, Thomson M, Tzivinikos C, Thapar N. Safety of Thiopurine Use in Paediatric Gastrointestinal Disease. J Pediatr Gastroenterol Nutr 2020; 71:156-162. [PMID: 32520827 DOI: 10.1097/mpg.0000000000002802] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/10/2022]
Abstract
Thiopurines, alone or in combination with other agents, have a pivotal role in the treatment of specific gastrointestinal and hepatological disorders. In inflammatory bowel disease and autoimmune hepatitis thiopurines have proven their value as steroid sparing agents for the maintenance of remission and may be considered for preventing postoperative Crohn disease recurrence where there is moderate risk of this occurring. Their use with infliximab therapy reduces antibody formation and increases biologic drug levels. The routine clinical use of thiopurines has, however, been questioned due to a number of potential adverse effects. The aim of this article is to provide information regarding the use, and in particular, safety of these agents in clinical practice in the light of such potentially severe, albeit rare, effects.
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Affiliation(s)
- Erasmo Miele
- Department of Translational Medical Science, Section of Paediatrics, University of Naples "Federico II", Italy
| | - Marc A Benninga
- Department of Paediatric Gastroenterology, Hepatology and Nutrition, Emma Children's Hospital/Amsterdam UMC, Amsterdam, The Netherlands
| | - Ilse Broekaert
- Faculty of Medicine and University Hospital Cologne, Department of Pediatrics, University of Cologne, Cologne, Germany
| | - Jernej Dolinsek
- Department of Pediatrics, Gastroenterology Unit, University Medical Centre Maribor.,Department of Paediatrics, Medical Faculty of University of Maribor, Maribor, Slovenia
| | - Emmanuel Mas
- IRSD, Université de Toulouse, INSERM, INRA, ENVT, UPS.,Unité de Gastroentérologie, Hépatologie, Nutrition, Diabétologie et Maladies Héréditaires du Métabolisme, Hôpital des Enfants, CHU de Toulouse, Toulouse, France
| | - Rok Orel
- Department of Gastroenterology, Hepatology and Nutrition, Children's Hospital, University Medical Centre Ljubljana, Ljubljana, Slovenia
| | - Corina Pienar
- Paediatrics Department, "Victor Babes" University of Medicine and Pharmacy, Timisoara, Romania
| | - Carmen Ribes-Koninckx
- Pediatric Gastroenterolgy, Hepatology and Nutrition, La Fe University Hospital, Valencia, Spain
| | - Rut A Thomassen
- Pediatric Nutrition and Dietetics Unit, Department of Paediatric and Adolescent Medicine, Oslo University Hospital, Oslo, Norway
| | - Mike Thomson
- Department of Paediatric Gastroenterology, Sheffield Children's NHS Foundation Trust, Sheffield
| | - Christos Tzivinikos
- Department of Paediatric Gastroenterology, Hepatology and Nutrition, Al Jalila Children's Specialty Hospital, Dubai, United Arab Emirates
| | - Nikhil Thapar
- Neurogastroenterology and Motility Unit, UCL Great Ormond Street Institute for Child Health and Great Ormond Street Hospital, London, United Kingdom.,Gastroenterology, Hepatology and Liver Transplant, Queensland Children's Hospital, Brisbane, Australia
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6
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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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Miao Q, Bai YJ, Zhang JL, Li Y, Su ZZ, Yan L, Wang LL, Zou YG. Highly sensitive and rapid determination of azathioprine metabolites in whole blood lysate by liquid chromatography-tandem mass spectrometry. J Chromatogr B Analyt Technol Biomed Life Sci 2019; 1136:121802. [PMID: 31809961 DOI: 10.1016/j.jchromb.2019.121802] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2019] [Revised: 09/10/2019] [Accepted: 09/11/2019] [Indexed: 02/05/2023]
Abstract
Individualized therapy involves genetic test of drug metabolism, which provides information about the initial dose and therapeutic drug monitoring for adjusting the subsequent dose. Consequently, toxic side effects are expected to be minimized and therapeutic effects to be maximized. In this study, an ultra-performance liquid chromatography tandem mass spectrometry method that was specific, accurate and sensitive was developed to simultaneously determine azathioprine two metabolites, 6-thioguanine nucleotides (6-TGN) and 6-methyl-mercaptopurine riboside (6-MMPr) in the whole blood lysate. We precipitated the sample by trifluoroacetic acid under the protection of dithiothreitol, with 6-MMPr and 6-TGN being hydrolyzed to produce 6-methymercaptopurine and 6-thioguanine. In the chromatographic separation, Waters ACQUITY BEH C18 (2.1 × 100 mm, 1.7 μm) chromatographic column was applied and gradient elution was conducted with 0.02 mol/L ammonium acetate buffer (which contains 0.3% formic acid) and acetonitrile at a flow rate of 0.4 ml/min. Tandem mass spectrometry in multiple reaction monitoring mode was applied for detection via electrospray ionization source in positive ionization mode. The analyzing process lasted for no more than 2 min. The calibration curve for each metabolite fitted a least squares model (weighed 1/X) from 1.25 to 5000 ng/ml (r2 > 0.99). The ion pairs were detected as 6-MMP m/z 167.07 → 152.15, 6-TG m/z 168.06 → 134.13, and internal standard m/z 171.07 → 137.14. Under the guidance of FDA guidelines for bioanalytical method validation, we carried out validation and obtained satisfactory results. The method was successfully utilized for monitoring the concentrations of each metabolite from 65 affected patients who had received azathioprine maintenance therapy and achieved optimal results.
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Affiliation(s)
- Qiang Miao
- Department of Laboratory Medicine/Research Center of Clinical Laboratory Medicine, West China Hospital of Sichuan University, Chengdu, China
| | - Yang-Juan Bai
- Department of Laboratory Medicine/Research Center of Clinical Laboratory Medicine, West China Hospital of Sichuan University, Chengdu, China
| | - Jun-Long Zhang
- Department of Laboratory Medicine/Research Center of Clinical Laboratory Medicine, West China Hospital of Sichuan University, Chengdu, China
| | - Yi Li
- Department of Laboratory Medicine/Research Center of Clinical Laboratory Medicine, West China Hospital of Sichuan University, Chengdu, China
| | - Zhen-Zhen Su
- Department of Laboratory Medicine/Research Center of Clinical Laboratory Medicine, West China Hospital of Sichuan University, Chengdu, China
| | - Lin Yan
- Department of Laboratory Medicine/Research Center of Clinical Laboratory Medicine, West China Hospital of Sichuan University, Chengdu, China
| | - Lan-Lan Wang
- Department of Laboratory Medicine/Research Center of Clinical Laboratory Medicine, West China Hospital of Sichuan University, Chengdu, China
| | - Yuan-Gao Zou
- Department of Laboratory Medicine/Research Center of Clinical Laboratory Medicine, West China Hospital of Sichuan University, Chengdu, China.
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Simsek M, Deben DS, Horjus CS, Bénard MV, Lissenberg‐Witte BI, Buiter HJC, van Luin M, Seinen ML, Mulder CJJ, Wong DR, de Boer NKH, van Bodegraven AA. Sustained effectiveness, safety and therapeutic drug monitoring of tioguanine in a cohort of 274 IBD patients intolerant for conventional therapies. Aliment Pharmacol Ther 2019; 50:54-65. [PMID: 31094013 PMCID: PMC6618772 DOI: 10.1111/apt.15280] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/05/2018] [Revised: 12/30/2018] [Accepted: 04/04/2019] [Indexed: 02/06/2023]
Abstract
BACKGROUND Tioguanine (or thioguanine) is an alternative drug for IBD patients who fail prior conventional immunomodulating therapy. AIM To report effectiveness, safety and therapeutic drug monitoring in a cohort of patients with prolonged tioguanine maintenance therapy. METHODS In this nationwide, multicentre study, medical records of tioguanine- using IBD patients were retrospectively reviewed. Response to therapy was defined as clinical effectiveness without (re)initiation of corticosteroids, concurrent biological therapy or surgical intervention. All adverse events that occurred during the follow-up were listed and graded according to the common terminology criteria (CTC). RESULTS Two hundred and seventy-four patients (female 63%, Crohn's disease in 68%) were included with median treatment duration of 51 months, 1567 patient-years of follow-up and median 20 mg/d tioguanine dosage. Tioguanine was tolerated in 79%, clinical effectiveness at 6 months was documented in 66% and sustained clinical effectiveness during 12 months in 51% of patients. Forty-one per cent of patients developed adverse events: 5% were graded as severe. Adverse events comprised infection requiring hospitalisation in three and skin cancer in eight patients (two melanomas). Asymptomatic nodular regenerative hyperplasia of the liver occurred in two out of 52 patients with liver biopsies (3.8%) and portal hypertension in three whereof one potentially associated with tioguanine (0.4%). Clinical effectiveness was correlated with 6-thioguanine nucleotide threshold concentrations >682 pmol/8×108 RBC (P < 0.05). CONCLUSIONS Long-term tioguanine therapy for at least 12 months was effective in 51% and well tolerated as a maintenance treatment for IBD in about 70% of patients. Adverse events were common, but mainly mild or moderate. 6-Thioguanine nucleotide threshold concentration ≥ 700 pmol/8×108 RBC is proposed as target level with higher odds for clinical effectiveness.
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Affiliation(s)
- Melek Simsek
- Department of Gastroenterology and HepatologyAmsterdam UMC, Vrije Universiteit Amsterdam, AG&M Research InstituteAmsterdamThe Netherlands
| | - Debbie S. Deben
- Department of Clinical Pharmacy, Clinical Pharmacology and Toxicology, Zuyderland Medical CentreSittard‐Geleen‐HeerlenThe Netherlands
| | - Carmen S. Horjus
- Department of Gastroenterology and HepatologyRijnstate HospitalArnhemThe Netherlands
| | - Melanie V. Bénard
- Department of Gastroenterology and HepatologyAmsterdam UMC, Vrije Universiteit AmsterdamAmsterdamThe Netherlands
| | - Birgit I. Lissenberg‐Witte
- Department of Epidemiology and BiostatisticsAmsterdam UMC, Vrije Universiteit AmsterdamAmsterdamThe Netherlands
| | - Hans J. C. Buiter
- Department of Clinical Pharmacology and PharmacyAmsterdam UMC, Vrije Universiteit AmsterdamAmsterdamThe Netherlands
| | - Matthijs van Luin
- Department of Clinical Pharmacology and PharmacyRijnstate HospitalArnhemThe Netherlands
| | - Margien L. Seinen
- Department of Gastroenterology and HepatologyAmsterdam UMC, Vrije Universiteit AmsterdamAmsterdamThe Netherlands
| | - Chris J. J. Mulder
- Department of Gastroenterology and HepatologyAmsterdam UMC, Vrije Universiteit AmsterdamAmsterdamThe Netherlands
| | - Dennis R. Wong
- Department of Clinical Pharmacy, Clinical Pharmacology and Toxicology, Zuyderland Medical CentreSittard‐Geleen‐HeerlenThe Netherlands
| | - Nanne K. H. de Boer
- Department of Gastroenterology and HepatologyAmsterdam UMC, Vrije Universiteit Amsterdam, AG&M Research InstituteAmsterdamThe Netherlands
| | - Adriaan A. van Bodegraven
- Department of Gastroenterology and HepatologyAmsterdam UMC, Vrije Universiteit AmsterdamAmsterdamThe Netherlands,Department of Gastroenterology, Geriatrics, Internal and Intensive Care Medicine (Co‐MIK)Zuyderland Medical Centre, Sittard‐Geleen‐HeerlenThe Netherlands
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9
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Vasudevan A, Beswick L, Friedman AB, Moltzen A, Haridy J, Raghunath A, Sparrow M, van Langenberg D. Low-dose thiopurine with allopurinol co-therapy overcomes thiopurine intolerance and allows thiopurine continuation in inflammatory bowel disease. Dig Liver Dis 2018. [PMID: 29525182 DOI: 10.1016/j.dld.2018.02.001] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
AIMS To assess the utility and tolerability of thiopurine-allopurinol co-therapy in inflammatory bowel disease (IBD) patients with intolerance to thiopurine monotherapy. METHODS A retrospective observational study assessed cases of thiopurine intolerance then switched to thiopurine allopurinol co-therapy between 2011 and 2015 at two centres. Indications for switch, dosing and subsequent clinical outcomes (including thiopurine persistence) were recorded. RESULTS Of 767 patients on thiopurines for IBD, 89 (12%) were switched to co-therapy for intolerance. 64/89 (72%) had Crohn's disease, 38 (43%) were males, median age at switch was 40y (range 17-78), median IBD duration 6y (0-29). Median follow-up was 1.9y (0-5). Reasons for switching to co-therapy included fatigue (37%), hepatotoxicity (23%), nausea (23%), arthralgia (10%), headache (12%) and hypersensitivity reaction (4%). Overall, 66 (74%) patients remained on co-therapy until most recent review and achieved a clinical response. High rates of overcoming intolerance (62-100%) occurred with co-therapy for all reasons above, although fatigue was less amenable to switching than non-fatigue indications (62% vs 91%, p = <0.001). Of 34 patients not escalated to biologics with endoscopic data, 15 were in remission (44%) at most recent review. CONCLUSION Low-dose thiopurine combined with allopurinol appears safe and effective in overcoming intolerances to thiopurine monotherapy in many cases.
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Affiliation(s)
- Abhinav Vasudevan
- Department of Gastroenterology and Hepatology, Eastern Health and Monash University, Box Hill Hospital, Box Hill, Victoria, Australia.
| | - Lauren Beswick
- Department of Gastroenterology and Hepatology, Eastern Health and Monash University, Box Hill Hospital, Box Hill, Victoria, Australia; Department of Gastroenterology, Alfred Health and Monash University, Victoria, Australia.
| | - Antony B Friedman
- Department of Gastroenterology, Alfred Health and Monash University, Victoria, Australia.
| | - Alicia Moltzen
- Department of Gastroenterology and Hepatology, Eastern Health and Monash University, Box Hill Hospital, Box Hill, Victoria, Australia.
| | - James Haridy
- Department of Gastroenterology and Hepatology, Eastern Health and Monash University, Box Hill Hospital, Box Hill, Victoria, Australia.
| | - Ajay Raghunath
- Department of Gastroenterology and Hepatology, Eastern Health and Monash University, Box Hill Hospital, Box Hill, Victoria, Australia.
| | - Miles Sparrow
- Department of Gastroenterology, Alfred Health and Monash University, Victoria, Australia.
| | - Daniel van Langenberg
- Department of Gastroenterology and Hepatology, Eastern Health and Monash University, Box Hill Hospital, Box Hill, Victoria, Australia.
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10
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Parkar SP, Dherai AJ, Desai DC, Ashavaid TF. Thiopurine metabolite level and toxicity in Indians with inflammatory bowel disease. JGH OPEN 2017; 1:25-31. [PMID: 30483529 PMCID: PMC6206977 DOI: 10.1002/jgh3.12004] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/23/2017] [Accepted: 08/07/2017] [Indexed: 11/06/2022]
Abstract
Background and Aim A lower dose requirement and higher toxicity of thiopurine is reported in Asian patients with inflammatory bowel disease (IBD) as compared with Caucasian patients. These reports are based on thiopurine methyltransferase measurement studies rather than metabolite estimation.We studied the utility of thiopurine metabolite estimation in Indian patients with IBD and compared dose and toxicity with Asian and Caucasian patients. Methods In this prospective study, 6-thioguanine nucleotide (6-TGN) and 6-methylmercaptopurine levels were determined by HPLC in 76 IBD patients treated with thiopurines. The levels were correlated with dose, disease activity, and toxicity. The dose-related metabolite levels and toxicity were compared with Caucasian and Asian patients reported in literature. Results Of the 76 patients (32 women, mean age: 35.9 [SD: 14.54] years, 36 Crohn's disease and 40 ulcerative colitis), 1 non-compliant patient had undetectable level of metabolites. Of the 75 patients, 21(28%) had therapeutic level of 6-TGN, 37(49%) had subtherapeutic level and 17(23%) had supratherapeutic level. The 6-methylmercaptopurine levels ranged up to 4971 pmol/8 × 108 red blood cells. Six (8%) patients showed toxicity. Thiopurine dose was optimized in 20 (26.31%) patients. Dose-based metabolite levels were comparable to Asian and Caucasian patients. The toxicity (8%) observed in our patients was less than that reported (12-39%). Conclusion Half of the patients in this study had low and a quarter had high 6-TGN levels. One-fourth of the patients needed dose modification. The dose-based metabolite levels were comparable and the toxicity was less than that reported in Asian and Caucasian patients.
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Affiliation(s)
- Suruchi P Parkar
- Department of Laboratory Medicine, Division of Gastroenterology P. D. Hinduja Hospital and Medical Research Centre Mumbai India
| | - Alpa J Dherai
- Department of Laboratory Medicine, Division of Gastroenterology P. D. Hinduja Hospital and Medical Research Centre Mumbai India
| | - Devendra C Desai
- Department of Laboratory Medicine, Division of Gastroenterology P. D. Hinduja Hospital and Medical Research Centre Mumbai India
| | - Tester F Ashavaid
- Department of Laboratory Medicine, Division of Gastroenterology P. D. Hinduja Hospital and Medical Research Centre Mumbai India
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Hvas C, Kodjabashia K, Nixon E, Hayes S, Farrer K, Abraham A, Lal S. Reversal of intestinal failure-associated liver disease (IFALD): emphasis on its multifactorial nature. Frontline Gastroenterol 2016; 7:114-117. [PMID: 27103984 PMCID: PMC4819675 DOI: 10.1136/flgastro-2015-100560] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/06/2015] [Revised: 03/05/2015] [Accepted: 03/14/2015] [Indexed: 02/04/2023] Open
Abstract
Patients with intestinal failure (IF) and home parenteral nutrition commonly develop abnormal liver function tests. The presentations of IF-associated liver disease (IFALD) range from mild cholestasis or steatosis to cirrhosis and decompensated liver disease. We describe the reversal of IFALD in an adult patient with IF secondary to severe Crohn's disease and multiple small bowel resections. The patient developed liver dysfunction and pathology consistent with IFALD. Multiple causal factors were implicated, including nutrition-related factors, catheter sepsis and the use of hepatotoxic medications. Multidisciplinary treatment in a tertiary IF referral centre included aggressive sepsis management, discontinuation of hepatotoxic medications and a reduction of parenteral nutrition dependency through optimisation of enteral nutrition via distal enteral tube feeding. Upon this, liver function tests normalised.
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Affiliation(s)
- Christian Hvas
- Department of Hepatology and Gastroenterology, Aarhus University Hospital, Aarhus C, Denmark,Intestinal Failure Unit, Salford Royal NHS Foundation Trust, Salford, UK
| | | | - Emma Nixon
- Intestinal Failure Unit, Salford Royal NHS Foundation Trust, Salford, UK
| | - Stephen Hayes
- Intestinal Failure Unit, Salford Royal NHS Foundation Trust, Salford, UK
| | - Kirstine Farrer
- Intestinal Failure Unit, Salford Royal NHS Foundation Trust, Salford, UK,Department of Dietetics, Salford Royal, Salford, UK
| | - Arun Abraham
- Intestinal Failure Unit, Salford Royal NHS Foundation Trust, Salford, UK
| | - Simon Lal
- Intestinal Failure Unit, Salford Royal NHS Foundation Trust, Salford, UK
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12
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Gallego-Gutiérrez S, Navas-López VM, Kolorz M, Bartosova L, Lukac K, Luque-Pérez S, Núñez-Caro L, García-Galán P, Fernández-Crehuet FG, Blasco-Alonso J, Serrano-Nieto MJ, Sierra-Salinas C. Successful Mercaptopurine Usage despite Azathioprine-Induced Pancreatitis in Paediatric Crohn's Disease. J Crohns Colitis 2015; 9:676-9. [PMID: 25968582 DOI: 10.1093/ecco-jcc/jjv086] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/03/2015] [Accepted: 05/07/2015] [Indexed: 01/15/2023]
Abstract
BACKGROUND Azathioprine [AZA] and mercaptopurine [MP] are recommended for maintenance of steroid-free remission in children with Crohn`s disease [CD]. Azathioprine-induced pancreatitis, an idiosyncratic and major side effect, has been considered as an absolute contraindication for the use of a second thiopurine in IBD patients. MATERIALS AND METHODS We describe two children with CD in whom MP were successfully trialled after a confirmed azathioprine-induced pancreatitis, being well tolerated in both cases. RESULTS Two boys [13 and 10 years old] started exclusive enteral nutrition after diagnosis of moderate (Pediatric Crohn's Disease Activity Index [wPCDAI] = 45) and mild [wPCDAI = 35] CD. Both developed an acute mild to moderate pancreatitis after 2 and 3 weeks, respectively, of AZA treatment but recovered fully in hospital after AZA withdrawal. They started on MP treatment without any adverse effect. They were tested for the presence of polymorphisms 238G>C, 460G>A, and 719A>G in the TPMT gene and 94C>A and 21>C in the ITPase. Both patients were wild-type for all tested polymorphisms. CONCLUSIONS Azathioprine-induced acute pancreatitis should not be considered as an absolute contraindication for the use of MP. Further investigation is required to create a better understanding of the mechanism underlying the adverse events and to allow more possibilities for personalised therapy.
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Affiliation(s)
- Silvia Gallego-Gutiérrez
- Pediatric Gastroenterology and Nutrition Unit, UGC de Pediatría, Hospital Regional Universitario de Málaga, Málaga, Spain
| | - Víctor Manuel Navas-López
- Pediatric Gastroenterology and Nutrition Unit, UGC de Pediatría, Hospital Regional Universitario de Málaga, Málaga, Spain Biomedical Institute of Malaga [IBIMA], Hopsital General de Málaga, Málaga, Spain
| | - Michal Kolorz
- Department of Human Pharmacology and Toxicology, Faculty of Pharmacy, UVPS Brno, Czech Republic Department of Clinical Pharmacy, Hospital Pharmacy, Faculty Hospital, Brno, Bohunice, Czech Republic
| | - Ladislava Bartosova
- Department of Human Pharmacology and Toxicology, Faculty of Pharmacy, UVPS Brno, Czech Republic
| | - Katerina Lukac
- Department of Human Pharmacology and Toxicology, Faculty of Pharmacy, UVPS Brno, Czech Republic
| | - Silvia Luque-Pérez
- Pediatric Gastroenterology and Nutrition Unit, UGC de Pediatría, Hospital Regional Universitario de Málaga, Málaga, Spain
| | - Leticia Núñez-Caro
- Pediatric Gastroenterology and Nutrition Unit, UGC de Pediatría, Hospital Regional Universitario de Málaga, Málaga, Spain
| | - Paloma García-Galán
- Pediatric Gastroenterology and Nutrition Unit, UGC de Pediatría, Hospital Regional Universitario de Málaga, Málaga, Spain
| | | | - Javier Blasco-Alonso
- Pediatric Gastroenterology and Nutrition Unit, UGC de Pediatría, Hospital Regional Universitario de Málaga, Málaga, Spain Biomedical Institute of Malaga [IBIMA], Hopsital General de Málaga, Málaga, Spain
| | - María Juliana Serrano-Nieto
- Pediatric Gastroenterology and Nutrition Unit, UGC de Pediatría, Hospital Regional Universitario de Málaga, Málaga, Spain
| | - Carlos Sierra-Salinas
- Pediatric Gastroenterology and Nutrition Unit, UGC de Pediatría, Hospital Regional Universitario de Málaga, Málaga, Spain Biomedical Institute of Malaga [IBIMA], Hopsital General de Málaga, Málaga, Spain
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