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Chadli Z, Hannachi I, Ben Belgacem M, Guediche A, Ben Romdhane H, Kerkeni E, Hamdi L, Slama A, Chaabane A, Ben Fredj N, Boughattas NA, Safer L, Aouam K. Effects of genetic and clinical factors on thiopurine drugs pharmacokinetics in Tunisian patients. Pharmacogenomics 2024; 25:441-450. [PMID: 39382000 DOI: 10.1080/14622416.2024.2406739] [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: 07/10/2024] [Accepted: 09/17/2024] [Indexed: 10/10/2024] Open
Abstract
Aim: Thiopurine drugs are used in the treatment of various diseases including inflammatory bowel disease. Thiopurine-S-methyltransferase (TPMT) and inosine triphosphate pyrophosphatase (ITPA) are the crucial enzymes involved in thiopurines metabolism. The present study aims to investigate in Tunisian patients, the influence of genetic and nongenetic factors on thiopurine drugs pharmacokinetics.Experimental approach: We have included patients having received thiopurine drugs and have undergone 6-thioguanine nucleotides (6-TGN) concentration monitoring. The identification of TPMT and ITPA polymorphisms was performed using the polymerase chain reaction-restriction fragment length polymorphism method. The impact of both genetic and nongenetic factors on the variability of the 6-TGN C/D ratio was analyzed through a stepwise multiple regression model.Key results: One hundred and twenty-three patients were included in the study. For TPMT, the most frequent variant allele was TPMT*3B (3.3%). For ITPA, the predominant polymorphism was the c.IVS2 + 21A> C (7%). We have demonstrated that only gender, the TPMT*3A and TPMT*3C alleles are significantly involved on the variability of thiopurines pharmacokinetics.Conclusion: Our study is the first to evaluate, in African patients, the impact of both genetic and nongenetic factors on the thiopurine drugs pharmacokinetics. Considering the narrow therapeutic range of these drugs, TPMT genotyping combined with 6-TGN blood concentration monitoring may enhance their efficacy and safety.
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Affiliation(s)
- Zohra Chadli
- Laboratory of Pharmacology, University Hospital of Monastir, Faculty of Medicine, University of Monastir, Tunisia
| | - Ibtissem Hannachi
- Laboratory of Pharmacology, University Hospital of Monastir, Faculty of Medicine, University of Monastir, Tunisia
| | - Manel Ben Belgacem
- Laboratory of Pharmacology, University Hospital of Monastir, Faculty of Medicine, University of Monastir, Tunisia
| | - Arwa Guediche
- Gastroenterology Department, University Hospital of Monastir, Faculty of Medicine, University of Monastir, Tunisia
| | - Haifa Ben Romdhane
- Laboratory of Pharmacology, University Hospital of Monastir, Faculty of Medicine, University of Monastir, Tunisia
| | - Emna Kerkeni
- Laboratory of Pharmacology, University Hospital of Monastir, Faculty of Medicine, University of Monastir, Tunisia
| | - Lamia Hamdi
- Laboratory of Hematology, University Hospital of Monastir, Tunisia
| | - Ahlem Slama
- Laboratory of Pharmacology, University Hospital of Monastir, Faculty of Medicine, University of Monastir, Tunisia
| | - Amel Chaabane
- Laboratory of Pharmacology, University Hospital of Monastir, Faculty of Medicine, University of Monastir, Tunisia
| | - Nadia Ben Fredj
- Laboratory of Pharmacology, University Hospital of Monastir, Faculty of Medicine, University of Monastir, Tunisia
| | - Naceur A Boughattas
- Laboratory of Pharmacology, University Hospital of Monastir, Faculty of Medicine, University of Monastir, Tunisia
| | - Leila Safer
- Gastroenterology Department, University Hospital of Monastir, Faculty of Medicine, University of Monastir, Tunisia
| | - Karim Aouam
- Laboratory of Pharmacology, University Hospital of Monastir, Faculty of Medicine, University of Monastir, Tunisia
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Laredo V, García-Mateo S, Martínez-Domínguez SJ, López de la Cruz J, Gargallo-Puyuelo CJ, Gomollón F. Risk of Cancer in Patients with Inflammatory Bowel Diseases and Keys for Patient Management. Cancers (Basel) 2023; 15:871. [PMID: 36765829 PMCID: PMC9913122 DOI: 10.3390/cancers15030871] [Citation(s) in RCA: 21] [Impact Index Per Article: 21.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2023] [Revised: 01/26/2023] [Accepted: 01/27/2023] [Indexed: 02/01/2023] Open
Abstract
Chronic inflammation in patients with Inflammatory Bowel Disease (IBD) leads to an increased risk of colorectal cancer, small bowel cancer, intestinal lymphoma and cholangiocarcinoma. However, treatments for IBD have also been associated with an increased risk of neoplasms. Patients receiving Thiopurines (TPs) have an increased risk of hematologic malignancies, non-melanoma skin cancer, urinary tract neoplasms and cervical cancer. Anti-TNFs have been associated with a higher risk of neoplasms, mainly lymphomas and melanomas; however, the data are controversial, and some recent studies do not confirm the association. Nevertheless, other biologic agents, such as ustekinumab and vedolizumab, have not shown an increased risk of any neoplasm to date. The risk of malignancies with tofacitinib exists, but its magnitude and relationship with previous treatment with TPs is not defined, so more studies from daily clinical practice are needed. Although biologic therapy seems to be safe for patients with current cancer or a prior history of cancer, as has been demonstrated in other chronic inflammatory conditions, prospective studies in this specific population are needed. Until that time, it is crucial to manage such conditions via the combined clinical expertise of the gastroenterologist and oncologist.
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Affiliation(s)
- Viviana Laredo
- Department of Gastroenterology, Lozano Blesa University Hospital, 50009 Zaragoza, Spain
- Aragón Health Research Institute (IIS Aragón), 50009 Zaragoza, Spain
- School of Medicine, University of Zaragoza, 50009 Zaragoza, Spain
| | - Sandra García-Mateo
- Department of Gastroenterology, Lozano Blesa University Hospital, 50009 Zaragoza, Spain
- Aragón Health Research Institute (IIS Aragón), 50009 Zaragoza, Spain
- School of Medicine, University of Zaragoza, 50009 Zaragoza, Spain
| | - Samuel J. Martínez-Domínguez
- Department of Gastroenterology, Lozano Blesa University Hospital, 50009 Zaragoza, Spain
- Aragón Health Research Institute (IIS Aragón), 50009 Zaragoza, Spain
- School of Medicine, University of Zaragoza, 50009 Zaragoza, Spain
| | - Julia López de la Cruz
- Department of Gastroenterology, Lozano Blesa University Hospital, 50009 Zaragoza, Spain
- Aragón Health Research Institute (IIS Aragón), 50009 Zaragoza, Spain
| | - Carla J. Gargallo-Puyuelo
- Department of Gastroenterology, Lozano Blesa University Hospital, 50009 Zaragoza, Spain
- Aragón Health Research Institute (IIS Aragón), 50009 Zaragoza, Spain
- School of Medicine, University of Zaragoza, 50009 Zaragoza, Spain
| | - Fernando Gomollón
- Department of Gastroenterology, Lozano Blesa University Hospital, 50009 Zaragoza, Spain
- Aragón Health Research Institute (IIS Aragón), 50009 Zaragoza, Spain
- School of Medicine, University of Zaragoza, 50009 Zaragoza, Spain
- CIBER for Liver and Digestive Diseases (CIBERehd), 28029 Madrid, Spain
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3
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Gargallo-Puyuelo CJ, Laredo V, Gomollón F. Thiopurines in Inflammatory Bowel Disease. How to Optimize Thiopurines in the Biologic Era? Front Med (Lausanne) 2021; 8:681907. [PMID: 34336887 PMCID: PMC8322650 DOI: 10.3389/fmed.2021.681907] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2021] [Accepted: 06/23/2021] [Indexed: 12/18/2022] Open
Abstract
Thiopurines have been a cornerstone in the treatment of inflammatory bowel disease (IBD). Although they have been used for more than 50 years, there are still some unsolved issues about their efficacy and, also, some safety concerns, mainly the risk of myelosuppression and life-threatening lymphoproliferative disorders. Furthermore, the development of biological therapy raises the question whether there is still a role for thiopurines in the IBD treatment algorithm. On the other hand, limited cost and wide availability make thiopurines a reasonable option in settings of limited resources and increasing prevalence of IBD. In fact, there is a growing interest in optimizing thiopurine therapy, since pharmacogenomic findings suggest that a personalized approach based on the genotyping of some molecules involved in its metabolism could be useful to prevent side effects. Polymorphisms of thiopurine methyltransferase enzyme (TPMT) that result in low enzymatic activity have been associated with an increased risk of myelotoxicity, especially in Caucasians; however, in Asians it is assumed that the variants of nudix hydrolase 15 (NUDT15) are more relevant in the development of toxicity. Age is also important, since in elderly patients the risk of complications seems to be increased. Moreover, the primo-infection of Epstein Barr virus and cytomegalovirus under thiopurine treatment has been associated with severe lymphoproliferative disorders. In addition to assessing individual characteristics that may influence thiopurines treatment outcomes, this review also discusses other strategies to optimize the therapy. Low-dose thiopurines combined with allopurinol can be used in hypermethylators and in thiopurine-related hepatotoxicity. The measurement of metabolites could be useful to assess compliance, identify patients at risk of adverse events and also facilitating the management of refractory patients. Thioguanine is also a rescue therapy in patients with toxicity related to conventional thiopurine therapy. Finally, the current indications for thiopurines in monotherapy or in combination with biologics, as well as the optimal duration of treatment, are also reviewed.
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Affiliation(s)
| | - Viviana Laredo
- Department of Gastroenterology, University Clinic Hospital Lozano Blesa, Zaragoza, Spain
| | - Fernando Gomollón
- Department of Gastroenterology, University Clinic Hospital Lozano Blesa, Zaragoza, Spain.,Department of Medicine, Psychiatry and Dermatology, University of Zaragoza, Zaragoza, Spain.,Institute for Health Research Aragón (IIS Aragón), Zaragoza, Spain.,Centro de Investigación Biomédica en Red, Enfermedades Hepáticas y Digestivas, Madrid, Spain
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Zimdahl Kahlin A, Helander S, Wennerstrand P, Vikingsson S, Mårtensson LG, Appell ML. Pharmacogenetic studies of thiopurine methyltransferase genotype-phenotype concordance and effect of methotrexate on thiopurine metabolism. Basic Clin Pharmacol Toxicol 2020; 128:52-65. [PMID: 32865889 PMCID: PMC7821157 DOI: 10.1111/bcpt.13483] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2020] [Revised: 08/14/2020] [Accepted: 08/21/2020] [Indexed: 12/30/2022]
Abstract
The discovery and implementation of thiopurine methyltransferase (TPMT) pharmacogenetics has been a success story and has reduced the suffering from serious adverse reactions during thiopurine treatment of childhood leukaemia and inflammatory bowel disease. This MiniReview summarizes four studies included in Dr Zimdahl Kahlin's doctoral thesis as well as the current knowledge on this field of research. The genotype‐phenotype concordance of TPMT in a cohort of 12 663 individuals with clinically analysed TPMT status is described. Notwithstanding the high concordance, the benefits of combined genotyping and phenotyping for TPMT status determination are discussed. The results from the large cohort also demonstrate that the factors of gender and age affect TPMT enzyme activity. In addition, characterization of four previously undescribed TPMT alleles (TPMT*41, TPMT*42, TPMT*43 and TPMT*44) shows that a defective TPMT enzyme could be caused by several different mechanisms. Moreover, the folate analogue methotrexate (MTX), used in combination with thiopurines during maintenance therapy of childhood leukaemia, affects the metabolism of thiopurines and interacts with TPMT, not only by binding and inhibiting the enzyme activity but also by regulation of its gene expression.
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Affiliation(s)
- Anna Zimdahl Kahlin
- Division of Drug Research, Department of Biomedical and Clinical Sciences, Linköping University, Linköping, Sweden
| | - Sara Helander
- Division of Drug Research, Department of Biomedical and Clinical Sciences, Linköping University, Linköping, Sweden
| | - Patricia Wennerstrand
- Division of Chemistry, Department of Physics, Chemistry, and Biology, Linköping University, Linköping, Sweden
| | - Svante Vikingsson
- Division of Drug Research, Department of Biomedical and Clinical Sciences, Linköping University, Linköping, Sweden
| | - Lars-Göran Mårtensson
- Division of Chemistry, Department of Physics, Chemistry, and Biology, Linköping University, Linköping, Sweden
| | - Malin Lindqvist Appell
- Division of Drug Research, Department of Biomedical and Clinical Sciences, Linköping University, Linköping, Sweden
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5
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Biemans VBC, Savelkoul E, Gabriëls RY, Simsek M, Dijkstra G, Pierik MJ, West RL, de Boer NK, Hoentjen F. A comparative analysis of tioguanine versus low-dose thiopurines combined with allopurinol in inflammatory bowel disease patients. Aliment Pharmacol Ther 2020; 51:1076-1086. [PMID: 32339331 PMCID: PMC7318327 DOI: 10.1111/apt.15730] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/10/2020] [Revised: 03/02/2020] [Accepted: 03/25/2020] [Indexed: 12/20/2022]
Abstract
BACKGROUND Both tioguanine and low-dose thiopurines combined with allopurinol (LDTA) can be considered for the treatment of inflammatory bowel disease (IBD) when conventional thiopurines fail due to adverse events. AIM To compare the safety of tioguanine and LDTA in IBD patients. METHODS Inflammatory bowel disease patients who failed conventional thiopurines due to adverse events and initiated LDTA in standard care were identified in the prospective ICC Registry. IBD patients who failed conventional thiopurines due to adverse events and initiated tioguanine were enrolled in three university hospitals. Patients on concomitant biologicals were excluded. The primary outcome was discontinuation of therapy due to adverse events. Secondary outcomes included: safety outcomes and surgery-, biological- and corticosteroid-free clinical remission (physician global assessment = 0) after 104 weeks. Both multiple logistic regression and propensity score matching were used to correct for confounders. RESULTS In total, 182 IBD patients treated with tioguanine (n = 94) or LDTA (n = 88) were included with a median follow-up of 104 weeks (IQR 91-104). Of these, 19% (tioguanine: 20%, LDTA: 18%) of patients discontinued therapy due to adverse events. After adjusting for confounders, there were no differences in terms of discontinuation rate due to adverse events (OR 0.50, 95% CI 0.15-1.68, P = 0.26), adverse events (OR 0.89, 95% CI 0.44-1.81, P = 0.75), infections (OR 1.05, 95% CI 0.40-2.73, P = 0.93), hospitalisations (OR 2.00, 95% CI 0.64-6.23, P = 0.23) or clinical remission (OR 0.74, 95%CI 0.33-1.68, P = 0.48). All results are comparable with the propensity score matched cohort. CONCLUSION Nineteen percent of IBD patients with prior failure to conventional thiopurines due to adverse events discontinued therapy with tioguanine or LDTA due to adverse events. Either therapy may be considered before escalating to biological therapy.
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Affiliation(s)
- Vince B. C. Biemans
- Department of Gastroenterology and HepatologyRadboud University Medical CentreNijmegenThe Netherlands,Department of Gastroenterology and HepatologyMaastricht University Medical CentreMaastrichtThe Netherlands
| | - Edo Savelkoul
- Department of Gastroenterology and HepatologyRadboud University Medical CentreNijmegenThe Netherlands
| | | | - Melek Simsek
- Amsterdam University Medical CentreVrije UniversiteitAmsterdamThe Netherlands,Amsterdam Gastroenterology & Metabolism research instituteAmsterdamThe Netherlands
| | - Gerard Dijkstra
- University Medical Centre GroningenGroningenThe Netherlands,University of GroningenGroningenthe Netherlands
| | - Marieke J. Pierik
- Department of Gastroenterology and HepatologyMaastricht University Medical CentreMaastrichtThe Netherlands
| | | | - Nanne K.H. de Boer
- Amsterdam University Medical CentreVrije UniversiteitAmsterdamThe Netherlands,Amsterdam Gastroenterology & Metabolism research instituteAmsterdamThe Netherlands
| | - Frank Hoentjen
- Department of Gastroenterology and HepatologyRadboud University Medical CentreNijmegenThe Netherlands
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6
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Comprehensive study of thiopurine methyltransferase genotype, phenotype, and genotype-phenotype discrepancies in Sweden. Biochem Pharmacol 2019; 164:263-272. [PMID: 31005613 DOI: 10.1016/j.bcp.2019.04.020] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2019] [Accepted: 04/17/2019] [Indexed: 12/16/2022]
Abstract
Thiopurines are widely used in the treatment of leukemia and inflammatory bowel diseases. Thiopurine metabolism varies among individuals because of differences in the polymorphic enzyme thiopurine methyltransferase (TPMT, EC 2.1.1.67), and to avoid severe adverse reactions caused by incorrect dosing it is recommended that the patient's TPMT status be determined before the start of thiopurine treatment. This study describes the concordance between genotyping for common TPMT alleles and phenotyping in a Swedish cohort of 12,663 patients sampled before or during thiopurine treatment. The concordance between TPMT genotype and enzyme activity was 94.5%. Compared to the genotype, the first measurement of TPMT enzyme activity was lower than expected for 4.6% of the patients. Sequencing of all coding regions of the TPMT gene in genotype/phenotype discrepant individuals led to the identification of rare and novel TPMT alleles. Fifteen individuals (0.1%) with rare or novel genotypes were identified, and three TPMT alleles (TPMT*42, *43, and *44) are characterized here for the first time. These 15 patients would not have been detected as carrying a deviating TPMT genotype if only genotyping of the most common TPMT variants had been performed. This study highlights the benefit of combining TPMT genotype and phenotype determination in routine testing. More accurate dose recommendations can be made, which might decrease the number of adverse reactions and treatment failures during thiopurine treatment.
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7
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Cook JC, Wu H, Aleo MD, Adkins K. Principles of precision medicine and its application in toxicology. J Toxicol Sci 2018; 43:565-577. [PMID: 30298845 DOI: 10.2131/jts.43.565] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2022]
Abstract
Precision medicine is an approach to developing drugs that focuses on employing biomarkers to stratify patients in clinical trials with the goal of improving efficacy and/or safety outcomes, ultimately increasing the odds of clinical success and drug approval. Precision medicine is an important tool for toxicologists to utilize, because its principles can be used to decide whether to pursue a drug target, to understand interindividual differences in response to drugs in both nonclinical and clinical settings, to aid in selecting doses that optimize efficacy or reduce adverse events, and to facilitate understanding of a drug's mode-of-action. Nonclinical models such as the mouse and non-human primate can be used to understand genetic variation and its potential translation to humans, and are available for toxicologists to employ in advance of drugs moving into clinical development. Understanding interindividual differences in response to drugs and how these differences can influence the drug's risk-benefit profile and lead to the identification of biomarkers that enhance patient efficacy and safety is of critical importance for toxicologists today, and in the future, as the fields of pharmacogenomics and genetics continue to advance.
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Affiliation(s)
- Jon C Cook
- Pfizer Worldwide Research and Development, Groton, CT 06340
| | - Hong Wu
- Pfizer Worldwide Research and Development, Groton, CT 06340
| | - Michael D Aleo
- Pfizer Worldwide Research and Development, Groton, CT 06340
| | - Karissa Adkins
- Pfizer Worldwide Research and Development, Groton, CT 06340
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8
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Pecher D, Dokupilová S, Zelinková Z, Peppelenbosch M, Mikušová V, Mikuš P. Determination of thiopurine S-methyltransferase activity by hydrophilic interaction liquid chromatography hyphenated with mass spectrometry. J Pharm Biomed Anal 2017; 142:244-251. [PMID: 28525791 DOI: 10.1016/j.jpba.2017.05.016] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2017] [Revised: 05/05/2017] [Accepted: 05/08/2017] [Indexed: 12/18/2022]
Abstract
Thiopurine S-methyltransferase (TPMT) plays an important role in the metabolism of thiopurines used in the therapy of inflammatory bowel diseases (IBD). In this work a new progressive method for the determination of TPMT activity in red blood cells lysates was developed. Analysis was carried out by means of hydrophilic interaction liquid chromatography (HILIC) hyphenated with mass spectrometry (MS). In comparison with reversed-phase high-performance liquid chromatography (RP-HPLC), that has been typically applied in determination of TPMT activity, the HILIC significantly improved the analytical signal provided by MS, shortened analysis time, and improved chromatographic resolution. The HILIC-HPLC-MS method was optimized and validated, providing favorable parameters of detection and quantitation limits (5.5 and 16.5pmol/mL, respectively), linearity (coefficient of determination 0.9999 in the range of 0.01-1.0nmol/mL), recovery and precision (93.25-100.37% with RSD 1.06-1.32% in the whole concentration range of QC samples). Moreover, in contrast to the conventional RP-HPLC-UV approach, the complex phenotype TPMT profiles can be reliably and without interferences monitored using the HILIC-HPLC-MS method. Such advanced monitoring can provide valuable detail information on the thiopurines (e.g. evaluating ratio of methylated and non-methylated 6-mercaptopurine) and, by that, TPMT action in biological systems before and during the therapy of IBD.
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Affiliation(s)
- Daniel Pecher
- Department of Pharmaceutical Analysis and Nuclear Pharmacy, Faculty of Pharmacy, Comenius University in Bratislava, Odbojárov 10, SK-832 32 Bratislava, Slovak Republic; Toxicological and Antidoping center, Faculty of Pharmacy, Comenius University in Bratislava, Odbojárov 10, SK-832 32 Bratislava, Slovak Republic
| | - Svetlana Dokupilová
- Department of Pharmaceutical Analysis and Nuclear Pharmacy, Faculty of Pharmacy, Comenius University in Bratislava, Odbojárov 10, SK-832 32 Bratislava, Slovak Republic; Toxicological and Antidoping center, Faculty of Pharmacy, Comenius University in Bratislava, Odbojárov 10, SK-832 32 Bratislava, Slovak Republic
| | - Zuzana Zelinková
- Department of Gastroenterology, St Michael's Hospital, Bratislava, Slovak Republic
| | | | - Veronika Mikušová
- Toxicological and Antidoping center, Faculty of Pharmacy, Comenius University in Bratislava, Odbojárov 10, SK-832 32 Bratislava, Slovak Republic; Department of Cell and Molecular Biology of Drugs, Faculty of Pharmacy, Comenius University in Bratislava, Odbojárov 10, SK-832 32 Bratislava, Slovak Republic
| | - Peter Mikuš
- Department of Pharmaceutical Analysis and Nuclear Pharmacy, Faculty of Pharmacy, Comenius University in Bratislava, Odbojárov 10, SK-832 32 Bratislava, Slovak Republic; Toxicological and Antidoping center, Faculty of Pharmacy, Comenius University in Bratislava, Odbojárov 10, SK-832 32 Bratislava, Slovak Republic.
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9
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Dart RJ, Irving PM. Optimising use of thiopurines in inflammatory bowel disease. Expert Rev Clin Immunol 2017; 13:877-888. [DOI: 10.1080/1744666x.2017.1351298] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Affiliation(s)
- Robin J. Dart
- IBD Centre, Department of Gastroenterology, St Thomas’ Hospital, London, UK
- Immunosurveillance Lab, Francis Crick Institute, London, UK
- Immunobiology, DIIID, King’s College London, Guy’s Hospital, London, UK
| | - Peter M. Irving
- IBD Centre, Department of Gastroenterology, St Thomas’ Hospital, London, UK
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10
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Goel RM, Blaker P, Mentzer A, Fong SCM, Marinaki AM, Sanderson JD. Optimizing the use of thiopurines in inflammatory bowel disease. Ther Adv Chronic Dis 2015; 6:138-46. [PMID: 25954498 PMCID: PMC4416969 DOI: 10.1177/2040622315579063] [Citation(s) in RCA: 40] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
Immunomodulator drugs, of which thiopurines can be considered the backbone, are widely used in the treatment of inflammatory bowel disease. They have been shown to be highly effective and safe; however, a significant proportion of patients are deemed to have a poor response or suffer adverse reactions. Knowing how to monitor and optimize thiopurine therapy in these scenarios is crucial to effective management. We discuss the metabolism of thiopurines, the use of enzyme/metabolite testing to guide treatment, as well as strategies to circumvent toxicity and side effects, such as allopurinol coprescription. The indications, use in pregnancy, safety profile and duration of thiopurine therapy are also discussed.
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Affiliation(s)
- Rishi M Goel
- Guy's & St Thomas' Hospitals - Gastroenterology, Westminster Bridge Road, London SE1 7EH, UK
| | - Paul Blaker
- Guy's & St Thomas' Hospitals - Gastroenterology, London, UK
| | - Alex Mentzer
- Guy's & St Thomas' Hospitals - Gastroenterology, London, UK
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11
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Hullah EA, Blaker PA, Marinaki AM, Escudier MP, Sanderson JD. A practical guide to the use of thiopurines in oral medicine. J Oral Pathol Med 2014; 44:761-8. [PMID: 25529219 DOI: 10.1111/jop.12274] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/08/2014] [Indexed: 12/11/2022]
Abstract
Thiopurines are widely used as first-line immunosuppressive therapies in the management of chronic inflammatory oral disease. However, despite over half a century of clinical experience, the evidence base for their use is limited. The aims of this paper were to review the evidence for the use of thiopurines in oral medicine and provide a contemporary model of thiopurine metabolism and mechanism of action and a rationale for clinical use and safe practice.
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Affiliation(s)
- E A Hullah
- Oral Medicine, King's College London Dental Institute, London, UK
| | - P A Blaker
- Gastroenterology, Guy's & St Thomas' Hospitals NHS Foundation Trust, Guy's Hospital, Great Maze Pond, London, UK
| | - A M Marinaki
- Purine Research Laboratory, Viapath, Guy's & St Thomas' Hospitals NHS Foundation Trust, Guy's Hospital, Great Maze Pond, London, UK
| | - M P Escudier
- Oral Medicine, King's College London Dental Institute, London, UK
| | - J D Sanderson
- Gastroenterology, Guy's & St Thomas' Hospitals NHS Foundation Trust, Guy's Hospital, Great Maze Pond, London, UK
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12
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Gaio V, Nunes B, Fernandes A, Mendonça F, Horta Correia F, Beleza Á, Gil AP, Bourbon M, Vicente A, Dias CM, Barreto da Silva M. Genetic variation at the CYP2C19 gene associated with metabolic syndrome susceptibility in a South Portuguese population: results from the pilot study of the European Health Examination Survey in Portugal. Diabetol Metab Syndr 2014; 6:23. [PMID: 24548628 PMCID: PMC3932792 DOI: 10.1186/1758-5996-6-23] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/04/2013] [Accepted: 01/29/2014] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Metabolic syndrome (MetS) is a cluster of conditions that occur together, increasing the risk of heart disease, stroke and diabetes. Since pathways implicated in different diseases reveal surprising insights into shared genetic bases underlying apparently unrelated traits, we hypothesize that there are common genetic components involved in the clustering of MetS traits. With the aim of identifying these common genetic components, we have performed a genetic association study by integrating MetS traits in a continuous MetS score. METHODS A cross-sectional study developed in the context of the Portuguese Component of the European Health Examination Survey (EHES) was used. Data was collected through a detailed questionnaire and physical examination. Blood samples were collected and biochemical analyses were performed. Waist circumference, blood pressure, glucose, triglycerides and high density lipoprotein cholesterol (HDL) levels were used to compute a continuous MetS score, obtained by Principal Component Analysis. A total of 37 single nucleotide polymorphisms (SNPs) were genotyped and individually tested for association with the score, adjusting for confounding variables. RESULTS A total of 206 individuals were studied. Calculated MetS score increased progressively with increasing number of risk factors (P < 0.001). We found a significant association between CYP2C19 rs4244285 and the MetS score not detected using the MetS dichotomic approach. Individuals with the A allelic variant seem to be protected against MetS, displaying a lower MetS score (Mean difference: 0.847; 95%CI: 0.163-1.531; P = 0.015), after adjustment for age, gender, smoking status, excessive alcohol consumption and physical inactivity. An additive genetic effect of GABRA2 rs279871, NPY rs16147 and TPMT rs1142345 in the MetS score variation was also found. CONCLUSIONS This is the first report of a genetic association study using a continuous MetS score. The significant association found between the CYP2C19 polymorphism and the MetS score but not with the individual associated traits, emphasizes the importance of lipid metabolism in a MetS common etiological pathway and consequently on the clustering of different cardiovascular risk factors. Despite the sample size limitation of our study, this strategy can be useful to find genetic factors involved in the etiology of other disorders that are defined in a dichotomized way.
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Affiliation(s)
- Vânia Gaio
- Departamento de Epidemiologia, Instituto Nacional de Saúde Doutor Ricardo Jorge, Lisboa, Portugal
| | - Baltazar Nunes
- Departamento de Epidemiologia, Instituto Nacional de Saúde Doutor Ricardo Jorge, Lisboa, Portugal
| | - Aida Fernandes
- Laboratório de Saúde Pública Dra. Laura Ayres, Faro, Portugal
| | | | | | - Álvaro Beleza
- Laboratório de Saúde Pública Dra. Laura Ayres, Faro, Portugal
| | - Ana Paula Gil
- Departamento de Epidemiologia, Instituto Nacional de Saúde Doutor Ricardo Jorge, Lisboa, Portugal
| | - Mafalda Bourbon
- Departamento de Promoção da Saúde e Prevenção das Doenças Não Transmissíveis, Instituto Nacional de Saúde Doutor Ricardo Jorge, Lisboa, Portugal
| | - Astrid Vicente
- Departamento de Promoção da Saúde e Prevenção das Doenças Não Transmissíveis, Instituto Nacional de Saúde Doutor Ricardo Jorge, Lisboa, Portugal
| | - Carlos Matias Dias
- Departamento de Epidemiologia, Instituto Nacional de Saúde Doutor Ricardo Jorge, Lisboa, Portugal
| | - Marta Barreto da Silva
- Departamento de Epidemiologia, Instituto Nacional de Saúde Doutor Ricardo Jorge, Lisboa, Portugal
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Blaker PA, Arenas-Hernandez M, Smith MA, Shobowale-Bakre EA, Fairbanks L, Irving PM, Sanderson JD, Marinaki AM. Mechanism of allopurinol induced TPMT inhibition. Biochem Pharmacol 2013; 86:539-47. [PMID: 23770457 DOI: 10.1016/j.bcp.2013.06.002] [Citation(s) in RCA: 77] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2013] [Revised: 06/04/2013] [Accepted: 06/05/2013] [Indexed: 12/16/2022]
Abstract
Up to 1/5 of patients with wildtype thiopurine-S-methyltransferase (TPMT) activity prescribed azathioprine (AZA) or mercaptopurine (MP) demonstrate a skewed drug metabolism in which MP is preferentially methylated to yield methylmercaptopurine (MeMP). This is known as thiopurine hypermethylation and is associated with drug toxicity and treatment non-response. Co-prescription of allopurinol with low dose AZA/MP (25-33%) circumvents this phenotype and leads to a dramatic reduction in methylated metabolites; however, the biochemical mechanism remains unclear. Using intact and lysate red cell models we propose a novel pathway of allopurinol mediated TPMT inhibition, through the production of thioxanthine (TX, 2-hydroxymercaptopurine). In red blood cells pre-incubated with 250 μM MP for 2h prior to the addition of 250 μM TX or an equivalent volume of Earle's balanced salt solution, there was a significant reduction in the concentration of MeMP detected at 4h and 6h in cells exposed to TX (4 h, 1.68, p=0.0005, t-test). TX acts as a direct TPMT inhibitor with an apparent Ki of 0.329 mM. In addition we have confirmed that the mechanism is relevant to in vivo metabolism by demonstrating raised urinary TX levels in patients receiving combination therapy. We conclude that the formation of TX in patients receiving combination therapy with AZA/MP and allopurinol, likely explains the significant reduction of methylated metabolites due to direct TPMT inhibition.
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Affiliation(s)
- P A Blaker
- Department of Gastroenterology, Guy's and St Thomas' NHS Hospitals Foundation Trust, London, UK.
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