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Crouwel F, Bayoumy AB, Mulder CJJ, Peters JHC, Boekema PJ, Derijks LJJ, de Boer SY, van de Meeberg PC, Ahmad I, Buiter HJC, de Boer NK. The Effectiveness and Safety of First-Line Thioguanine in Thiopurine-Naïve Inflammatory Bowel Disease Patients. Inflamm Bowel Dis 2023:izad197. [PMID: 37658804 DOI: 10.1093/ibd/izad197] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/10/2023] [Indexed: 09/05/2023]
Abstract
BACKGROUND Currently thioguanine is solely used as treatment for inflammatory bowel disease after azathioprine and/or mercaptopurine failure. This study aimed to determine the safety, effectiveness, and 12-month drug survival of thioguanine in thiopurine-naïve patients with inflammatory bowel disease. METHODS A retrospective cohort study was performed in thiopurine-naïve patients with inflammatory bowel disease treated with thioguanine as first thiopurine derivate. Clinical effectiveness was defined as the continuation of thioguanine without the (re)initiation of concurrent biological therapy, systemic corticosteroids, or a surgical intervention. All adverse events were categorized by the Common Terminology Criteria for Adverse Events. RESULTS A total of 114 patients (male 39%, Crohn's disease 53%) were included with a median treatment duration of 25 months and a median thioguanine dosage of 20 mg/d. Clinical effectiveness at 12 months was observed in 53% of patients, and 78% of these responding patients remained responsive until the end of follow-up. During the entire follow-up period, 26 patients were primary nonresponders, 8 had a secondary loss of response, and 11 patients were unable to cease therapy with systemic corticosteroids within 6 months and were therefore classified as nonresponders. After 12 months, thioguanine was still used by 86% of patients. Fifty (44%) patients developed adverse events (grade 1 or 2) and 9 (8%) patients ceased therapy due to the occurrence of adverse events. An infection was documented in 3 patients, none of them requiring hospitalization and pancytopenia occurred in 2 other patients. No signs of nodular regenerative hyperplasia or portal hypertension were observed. CONCLUSIONS At 12 months, first-line thioguanine therapy was clinically effective in 53% of thiopurine-naïve inflammatory bowel disease patients with an acceptable safety profile.
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Affiliation(s)
- Femke Crouwel
- Department of Gastroenterology and Hepatology, Amsterdam Gastroenterology Endocrinology Metabolism Research Institute, Amsterdam University Medical Centre, Vrije Universiteit Amsterdam, Amsterdam, the Netherlands
| | - Ahmed B Bayoumy
- Department of Gastroenterology and Hepatology, Amsterdam Gastroenterology Endocrinology Metabolism Research Institute, Amsterdam University Medical Centre, Vrije Universiteit Amsterdam, Amsterdam, the Netherlands
| | - Chris J J Mulder
- Department of Gastroenterology and Hepatology, Amsterdam Gastroenterology Endocrinology Metabolism Research Institute, Amsterdam University Medical Centre, Vrije Universiteit Amsterdam, Amsterdam, the Netherlands
| | - Job H C Peters
- Department of Gastroenterology and Hepatology, Rode Kruis hospital, Beverwijk, the Netherlands
| | - Paul J Boekema
- Department of Gastroenterology and Hepatology, Máxima Medical Centre, Veldhoven, the Netherlands
| | - Luc J J Derijks
- Department of Clinical Pharmacy and Pharmacology, Máxima Medical Centre, Veldhoven, the Netherlands
| | - Sybrand Y de Boer
- Department of Gastroenterology and Hepatology, Slingeland Hospital, Doetinchem, the Netherlands
| | - Paul C van de Meeberg
- Department of Gastroenterology and Hepatology, Slingeland Hospital, Doetinchem, the Netherlands
| | - Ishfaq Ahmad
- Department of Gastroenterology and Hepatology, Streekziekenhuis Koningin Beatrix, Winterswijk, the Netherlands
| | - Hans J C Buiter
- Department of Radiology and Nuclear Medicine, Amsterdam University Medical Centre, Vrije Universiteit Amsterdam, Amsterdam, the Netherlands
| | - Nanne K de Boer
- Department of Gastroenterology and Hepatology, Amsterdam Gastroenterology Endocrinology Metabolism Research Institute, Amsterdam University Medical Centre, Vrije Universiteit Amsterdam, Amsterdam, the Netherlands
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Dijkhuis LEJL, Crouwel F, Duijvestein M, Buiter HJC, de Boer NK, Hamer HM. The Reliability of Patient-Performed Fecal Calprotectin Testing in Inflammatory Bowel Disease. J Appl Lab Med 2023; 8:319-329. [PMID: 36512478 DOI: 10.1093/jalm/jfac078] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2022] [Accepted: 08/05/2022] [Indexed: 12/15/2022]
Abstract
BACKGROUND Home use of a buffer-containing extraction device for fecal calprotectin determination can bypass the labor-intensive extraction procedure and potentially prevent degradation at room temperature. METHODS In this prospective cross-sectional observational study, 2 CALiaGold tubes (extraction device) and one native tube were filled from the same bowel movement by patients with inflammatory bowel disease. Afterwards patients completed a questionnaire including whether they preferred the extraction device or the normal sampling method. All tubes were sent to the laboratory and when they arrived, 2 more CALiaGold tubes were filled at the laboratory from the native sample. The fecal calprotectin concentrations in all tubes were measured by a particle-enhanced turbidimetric immunoassay. RESULTS Fifty-three patients were included in the study. Fecal calprotectin levels were significantly higher in samples extracted by the patient compared to the analyst-performed extractions. When patients were divided into 3 groups (i.e., fecal calprotectin levels <50 ug/g, 50 to 200 µg/g, and >200 µg/g) a substantial concordance was found (Cohen kappa 0.654). Patients sampling imprecision was higher (P < 0.018, median CV 16%) compared to the analyst. Most patients preferred this extraction device. CONCLUSIONS Patient-performed fecal calprotectin extraction seems a realistic alternative sampling method and is preferred by most patients.
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Affiliation(s)
- Lies E J L Dijkhuis
- Department of Gastroenterology and Hepatology, Amsterdam Gastroenterology Endocrinology Metabolism research institute, Amsterdam University Medical Centers, Vrije Universiteit Amsterdam, Amsterdam, the Netherlands
| | - Femke Crouwel
- Department of Gastroenterology and Hepatology, Amsterdam Gastroenterology Endocrinology Metabolism research institute, Amsterdam University Medical Centers, Vrije Universiteit Amsterdam, Amsterdam, the Netherlands
| | - Marjolijn Duijvestein
- Department of Gastroenterology and Hepatology, Amsterdam Gastroenterology Endocrinology Metabolism research institute, Amsterdam University Medical Centers, Vrije Universiteit Amsterdam, Amsterdam, the Netherlands.,Department of Gastroenterology and Hepatology, Radboud University Medical Centre, Nijmegen, the Netherlands
| | - Hans J C Buiter
- Department of Radiology and Nuclear Medicine, Amsterdam University Medical Centers, Vrije Universiteit Amsterdam, Amsterdam, the Netherlands
| | - Nanne K de Boer
- Department of Gastroenterology and Hepatology, Amsterdam Gastroenterology Endocrinology Metabolism research institute, Amsterdam University Medical Centers, Vrije Universiteit Amsterdam, Amsterdam, the Netherlands
| | - Henrike M Hamer
- Department of Clinical Chemistry, Amsterdam University Medical Centers, Amsterdam Gastroenterology Endocrinology Metabolism Research Institute, Vrije Universiteit Amsterdam, Amsterdam, the Netherlands
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Crouwel F, Simsek M, de Boer MA, Mulder CJJ, van Andel EM, Creemers RH, van Asseldonk DP, van Bodegraven AA, Horjus CS, Visschedijk MC, Weusthuis ALM, Seinen ML, Jharap B, van Schaik FDM, Ahmad I, Boekema PJ, Tack GJ, Wormmeester L, Lutgens MWMD, van Boeckel PGA, Gilissen LPL, Kerkhof M, Russel MGVM, Hoentjen F, Bartelink ME, Kuijvenhoven JP, Maljaars JWJ, van Dop WA, Wonders J, van der Voorn MMPJA, Buiter HJC, de Boer NK. Exposure to thioguanine during 117 pregnancies in women with inflammatory bowel disease. J Crohns Colitis 2022; 17:738-745. [PMID: 36521000 PMCID: PMC10155742 DOI: 10.1093/ecco-jcc/jjac183] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/27/2022] [Indexed: 02/08/2023]
Abstract
BACKGROUND Safety of thioguanine in pregnant patients with inflammatory bowel disease (IBD) is sparsely recorded. This study was aimed to document the safety of thioguanine during pregnancy and in birth. METHODS In this multicenter case series, IBD patients treated with thioguanine during pregnancy were included. Data regarding disease and medication history, pregnancy course, obstetric complications and neonatal outcomes were collected. RESULTS Data on 117 thioguanine-exposed pregnancies in 99 women were collected. Most (78%) had Crohn's disease and the mean age at delivery was 31 years. In eighteen pregnancies (15%) IBD flared. Obstetric and infectious complications were seen in 15% (n=17) and 7% (n=8) of pregnancies, respectively. Ten pregnancies (8.5%) resulted in a first trimester miscarriage and one in a stillbirth at 22 weeks gestational age. Congenital abnormalities were observed in one induced abortion (trisomy 21) and in one of the live-born children (cleft palate) . In total 109 neonates were born from 101 singleton pregnancies and 4 twin pregnancies. In the singleton pregnancies, ten children were born prematurely and ten were born small for gestational age. Screening for myelosuppresion was performed in sixteen neonates (14.7%); two had anemia in umbilical cord blood. All outcomes were comparable to either the general Dutch population or to data from 3 Dutch cohort studies on the use of conventional thiopurines in pregnant IBD patients. CONCLUSION In this large case series the use of thioguanine during pregnancy is not associated in excess with adverse maternal or neonatal outcomes.
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Affiliation(s)
- Femke Crouwel
- Corresponding author: Femke Crouwel, MD, De Boelelaan 1117, 1081 HV Amsterdam, The Netherlands; Tel: +31204440799; Fax: +31204440554;
| | - Melek Simsek
- Department of Gastroenterology and Hepatology, Amsterdam Gastroenterology Endocrinology Metabolism Research Institute, Amsterdam University Medical Centre, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| | - Marjon A de Boer
- Department of Obstetrics and Gyneacology, Amsterdam Reproduction & Development Research Institute, Amsterdam University Medical Centre, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| | - Chris J J Mulder
- Department of Gastroenterology and Hepatology, Amsterdam Gastroenterology Endocrinology Metabolism Research Institute, Amsterdam University Medical Centre, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| | - Emma M van Andel
- Department of Gastroenterology and Hepatology, Noordwest Ziekenhuisgroep, Alkmaar, The Netherlands
| | - Rob H Creemers
- Department of Gastroenterology, Geriatrics, Internal and Intensive Care Medicine [Co-MIK], Zuyderland Medical Centre, Heerlen-Sittard-Geleen, The Netherlands
| | - Dirk P van Asseldonk
- Department of Gastroenterology and Hepatology, Noordwest Ziekenhuisgroep, Alkmaar, The Netherlands
| | - Ad A van Bodegraven
- Department of Gastroenterology and Hepatology, Amsterdam Gastroenterology Endocrinology Metabolism Research Institute, Amsterdam University Medical Centre, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
- Department of Gastroenterology, Geriatrics, Internal and Intensive Care Medicine [Co-MIK], Zuyderland Medical Centre, Heerlen-Sittard-Geleen, The Netherlands
| | - Carmen S Horjus
- Department of Gastroenterology and Hepatology, Rijnstate Hospital, Arnhem, The Netherlands
| | - Marijn C Visschedijk
- Department of Gastroenterology and Hepatology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | | | - Margien L Seinen
- Department of Gastroenterology and Hepatology, Onze Lieve Vrouwe Gasthuis, Amsterdam, The Netherlands
| | - Bindia Jharap
- Department of Gastroenterology and Hepatology, Meander Medical Centre, Amersfoort, The Netherlands
| | - Fiona D M van Schaik
- Department of Gastroenterology and Hepatology, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Ishfaq Ahmad
- Department of Gastroenterology and Hepatology, Streekziekenhuis Koningin Beatrix, Winterswijk, The Netherlands
| | - Paul J Boekema
- Department of Gastroenterology and Hepatology, Máxima Medical Centre, Veldhoven, The Netherlands
| | - Greetje J Tack
- Department of Gastroenterology and Hepatology, Medical Centre Leeuwarden, Leeuwarden, The Netherlands
| | - Louktje Wormmeester
- Department of Gastroenterology and Hepatology, Treant Zorggroep, Emmen-Hoogeveen-Stadskanaal, The Netherlands
| | - Maurice W M D Lutgens
- Department of Gastroenterology and Hepatology, Elisabeth-TweeSteden Hospital, Tilburg, The Netherlands
| | - Petra G A van Boeckel
- Department of Gastroenterology and Hepatology, Sint Antonius Hospital, Nieuwegein, The Netherlands
| | - Lennard P L Gilissen
- Department of Gastroenterology and Hepatology, Catharina Hospital, Eindhoven, The Netherlands
| | - Marjon Kerkhof
- Department of Gastroenterology and Hepatology, Groene Hart Hospital, Gouda, The Netherlands
| | - Maurice G V M Russel
- Department of Gastroenterology and Hepatology, Medical Spectrum Twente, Enschede, The Netherlands
| | - Frank Hoentjen
- Department of Gastroenterology, Radboud University Medical Center, Nijmegen, The Netherlands
- Division of Gastroenterology, Department of Medicine, University of Alberta, Edmonton, AB, Canada
| | - Maartje E Bartelink
- Department of Gastroenterology and Hepatology, Deventer Hospital, Deventer, The Netherlands
| | - Johan P Kuijvenhoven
- Department of Gastroenterology and Hepatology, Spaarne Gasthuis, Haarlem and Hoofddorp, The Netherlands
| | - Jeroen W J Maljaars
- Department of Gastroenterology and Hepatology, Leiden University Medical Center, Leiden, The Netherlands
| | - Willemijn A van Dop
- Department of Gastroenterology, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Janneke Wonders
- Department of Gastroenterology and Hepatology, HagaZiekenhuis, Den Haag, The Netherlands
| | | | - Hans J C Buiter
- Department of Radiology and Nuclear Medicine, Amsterdam University Medical Centre, Amsterdam, The Netherlands
| | - Nanne K de Boer
- Department of Gastroenterology and Hepatology, Amsterdam Gastroenterology Endocrinology Metabolism Research Institute, Amsterdam University Medical Centre, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
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Crouwel F, Simsek M, van Doorn AS, Mulder CJJ, Buiter HJC, Barclay ML, Florin TH, de Boer NK. Rectally Administrated Thioguanine for Distal Ulcerative Colitis: A Multicenter Case Series. Inflamm Bowel Dis 2022:6696694. [PMID: 36099056 DOI: 10.1093/ibd/izac195] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/28/2022] [Indexed: 01/06/2023]
Affiliation(s)
- Femke Crouwel
- Department of Gastroenterology and Hepatology, Amsterdam Gastroenterology Endocrinology Metabolism Research Institute, Amsterdam University Medical Centre, Vrije Universiteit Amsterdam, Amsterdam, the Netherlands
| | - Melek Simsek
- Department of Gastroenterology and Hepatology, Amsterdam Gastroenterology Endocrinology Metabolism Research Institute, Amsterdam University Medical Centre, Vrije Universiteit Amsterdam, Amsterdam, the Netherlands
| | - Amarylle S van Doorn
- Department of Gastroenterology and Hepatology, Amsterdam Gastroenterology Endocrinology Metabolism Research Institute, Amsterdam University Medical Centre, Vrije Universiteit Amsterdam, Amsterdam, the Netherlands.,Departments of Gastroenterology & Clinical Pharmacology, Christchurch Hospital, Canterbury District Health Board and University of Otago, Christchurch, New Zealand
| | - Chris J J Mulder
- Department of Gastroenterology and Hepatology, Amsterdam Gastroenterology Endocrinology Metabolism Research Institute, Amsterdam University Medical Centre, Vrije Universiteit Amsterdam, Amsterdam, the Netherlands
| | - Hans J C Buiter
- Department of Radiology and Nuclear Medicine, Amsterdam University Medical Centre, Vrije Universiteit Amsterdam, Amsterdam, the Netherlands
| | - Murray L Barclay
- Departments of Gastroenterology & Clinical Pharmacology, Christchurch Hospital, Canterbury District Health Board and University of Otago, Christchurch, New Zealand
| | - Timothy H Florin
- Inflammatory Bowel Diseases Group, Mater Research Institute, University of Queensland, Translational Research Institute, Woolloongabba, Queensland, Australia
| | - Nanne K de Boer
- Department of Gastroenterology and Hepatology, Amsterdam Gastroenterology Endocrinology Metabolism Research Institute, Amsterdam University Medical Centre, Vrije Universiteit Amsterdam, Amsterdam, the Netherlands
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Abstract
Exactly 70 years ago [1951] mercaptopurine was discovered by Gertrude Elion as a novel treatment option for acute leukaemia. A total of three thiopurines (also thioguanine [1950] and azathioprine [1957]) were developed over time. These immunosuppressive drugs were also successfully introduced a few decades later to prevent rejection of transplanted organs and to treat several autoimmune diseases. For her discovery of thiopurines and other antimetabolite drugs, in 1988 Elion was rewarded, together with George Hitchings and James Black, with the Nobel Prize in Physiology or Medicine. Important steps have been made in recent years to unravel its metabolism, mode of action and pharmacogenetics. Today thiopurine [based] therapy remains an essential immunosuppressive approach in treating patients with inflammatory bowel disease.
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Affiliation(s)
- Femke Crouwel
- Department of Gastroenterology and Hepatology, Amsterdam Gastroenterology Endocrinology Metabolism Research Institute, Amsterdam University Medical Centre, Vrije Universiteit Amsterdam, Amsterdam, the Netherland
| | - Hans J C Buiter
- Department of Radiology and Nuclear Medicine, Amsterdam University Medical Centers, Vrije Universiteit Amsterdam, Amsterdam, the Netherlands
| | - Nanne K de Boer
- Department of Gastroenterology and Hepatology, Amsterdam Gastroenterology Endocrinology Metabolism Research Institute, Amsterdam University Medical Centre, Vrije Universiteit Amsterdam, Amsterdam, the Netherland
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Jagt JZ, Pothof CD, Buiter HJC, van Limbergen JE, van Wijk MP, Benninga MA, de Boer NKH, de Meij TGJ. Adverse Events of Thiopurine Therapy in Pediatric Inflammatory Bowel Disease and Correlations with Metabolites: A Cohort Study. Dig Dis Sci 2022; 67:241-251. [PMID: 33532972 PMCID: PMC8741678 DOI: 10.1007/s10620-021-06836-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/06/2020] [Accepted: 01/07/2021] [Indexed: 01/18/2023]
Abstract
BACKGROUND In the recent era of growing availability of biological agents, the role of thiopurines needs to be reassessed with the focus on toxicity. AIMS We assessed the incidence and predictive factors of thiopurine-induced adverse events (AE) resulting in therapy cessation in pediatric inflammatory bowel disease (IBD), related to thiopurine metabolites and biochemical abnormalities, and determined overall drug survival. METHODS We performed a retrospective, single-center study of children diagnosed with IBD between 2000 and 2019 and treated with thiopurine therapy. The incidence of AE and overall drug survival of thiopurines were evaluated using the Kaplan-Meier method. Correlations between thiopurine metabolites and biochemical tests were computed using Spearman's correlation coefficient. RESULTS Of 391 patients with IBD, 233 patients (162 Crohn's disease, 62 ulcerative colitis, and 9 IBD-unclassified) were prescribed thiopurines (230 azathioprine and 3 mercaptopurine), of whom 50 patients (22%) discontinued treatment, at least temporary, due to thiopurine-induced AE (median follow-up 20.7 months). Twenty-six patients (52%) were rechallenged and 18 of them (70%) tolerated this. Sixteen patients (6%) switched to a second thiopurine agent after azathioprine intolerance and 10 of them (63%) tolerated this. No predictive factors for development of AE could be identified. Concentrations of 6-thioguanine nucleotides (6-TGN) were significantly correlated with white blood cell and neutrophil count, 6-methylmercaptopurine (6-MMP) concentrations with alanine aminotransferase and gamma-glutamyltranspeptidase. CONCLUSIONS Approximately 20% of pediatric patients with IBD discontinued thiopurine treatment due to AE. A rechallenge or switch to mercaptopurine is an effective strategy after development of AE. Concentrations of 6-TGN and 6-MMP are associated with biochemical abnormalities.
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Affiliation(s)
- Jasmijn Z. Jagt
- grid.12380.380000 0004 1754 9227Department of Pediatric Gastroenterology, Emma Children’s Hospital, Amsterdam, UMC, Vrije Universiteit Amsterdam, 1105 AZ Amsterdam, The Netherlands
| | - Christine D. Pothof
- grid.12380.380000 0004 1754 9227Department of Pediatric Gastroenterology, Emma Children’s Hospital, Amsterdam, UMC, Vrije Universiteit Amsterdam, 1105 AZ Amsterdam, The Netherlands
| | - Hans J. C. Buiter
- grid.12380.380000 0004 1754 9227Department of Clinical Pharmacology and Pharmacy, Amsterdam, UMC, Vrije Universiteit Amsterdam, 1105 AZ Amsterdam, The Netherlands
| | - Johan E. van Limbergen
- grid.5650.60000000404654431Department of Pediatric Gastroenterology, UMC, Emma Children’s Hospital, Amsterdam, Academic Medical Centre, 1081 HV Amsterdam, The Netherlands
| | - Michiel P. van Wijk
- grid.12380.380000 0004 1754 9227Department of Pediatric Gastroenterology, Emma Children’s Hospital, Amsterdam, UMC, Vrije Universiteit Amsterdam, 1105 AZ Amsterdam, The Netherlands ,grid.5650.60000000404654431Department of Pediatric Gastroenterology, UMC, Emma Children’s Hospital, Amsterdam, Academic Medical Centre, 1081 HV Amsterdam, The Netherlands
| | - Marc A. Benninga
- grid.5650.60000000404654431Department of Pediatric Gastroenterology, UMC, Emma Children’s Hospital, Amsterdam, Academic Medical Centre, 1081 HV Amsterdam, The Netherlands
| | - Nanne K. H. de Boer
- grid.12380.380000 0004 1754 9227Department of Gastroenterology and Hepatology, Amsterdam Gastroenterology and Metabolism Research Institute, Amsterdam, UMC, Vrije Universiteit Amsterdam, 1081 HV Amsterdam, The Netherlands
| | - Tim G. J. de Meij
- grid.12380.380000 0004 1754 9227Department of Pediatric Gastroenterology, Emma Children’s Hospital, Amsterdam, UMC, Vrije Universiteit Amsterdam, 1105 AZ Amsterdam, The Netherlands ,grid.5650.60000000404654431Department of Pediatric Gastroenterology, UMC, Emma Children’s Hospital, Amsterdam, Academic Medical Centre, 1081 HV Amsterdam, The Netherlands
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Affiliation(s)
- Femke Crouwel
- Department of Gastroenterology and Hepatology, AGEM Research Insitute, Amsterdam UMC Locatie VUmc, Amsterdam, The Netherlands
| | - Hans J C Buiter
- Department of Clinical Pharmacology and Pharmacy, Amsterdam UMC Locatie VUmc, Amsterdam, The Netherlands
| | - Nanne K H de Boer
- Department of Gastroenterology and Hepatology, AGEM Research Insitute, Amsterdam UMC Locatie VUmc, Amsterdam, The Netherlands
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Bayoumy AB, Crouwel F, Chanda N, Florin THJ, Buiter HJC, Mulder CJJ, de Boer NKH. Advances in Thiopurine Drug Delivery: The Current State-of-the-Art. Eur J Drug Metab Pharmacokinet 2021; 46:743-758. [PMID: 34487330 PMCID: PMC8599251 DOI: 10.1007/s13318-021-00716-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/22/2021] [Indexed: 02/07/2023]
Abstract
Thiopurines (mercaptopurine, azathioprine and thioguanine) are well-established maintenance treatments for a wide range of diseases such as leukemia, inflammatory bowel disease (IBD), systemic lupus erythematosus (SLE) and other inflammatory and autoimmune diseases in general. Worldwide, millions of patients are treated with thiopurines. The use of thiopurines has been limited because of off-target effects such as myelotoxicity and hepatotoxicity. Therefore, seeking methods to enhance target-based thiopurine-based treatment is relevant, combined with pharmacogenetic testing. Controlled-release formulations for thiopurines have been clinically tested and have shown promising outcomes in inflammatory bowel disease. Latest developments in nano-formulations for thiopurines have shown encouraging pre-clinical results, but further research and development are needed. This review provides an overview of novel drug delivery strategies for thiopurines, reviewing modified release formulations and with a focus on nano-based formulations.
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Affiliation(s)
- Ahmed B Bayoumy
- Faculty of Medicine, Amsterdam UMC, Location Academic Medical Centre, University of Amsterdam, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands.
| | - Femke Crouwel
- Department of Gastroenterology and Hepatology, AGEM Research Institute, Amsterdam University Medical Center, Location Vrije Universiteit Medical Center, Amsterdam, The Netherlands
| | - Nripen Chanda
- Micro System Technology Laboratory, CSIR, Central Mechanical Engineering Research Institute, Durgapur, India
| | - Timothy H J Florin
- Inflammatory Bowel Diseases Group, Mater Research Institute, University of Queensland, Translational Research Institute, Woolloongabba, QLD, Australia
| | - Hans J C Buiter
- Department of Radiology and Nuclear Medicine, Amsterdam University Medical Center, Location Vrije Universiteit Medical Center, Amsterdam, The Netherlands
| | - Chris J J Mulder
- Department of Gastroenterology and Hepatology, AGEM Research Institute, Amsterdam University Medical Center, Location Vrije Universiteit Medical Center, Amsterdam, The Netherlands
| | - Nanne K H de Boer
- Department of Gastroenterology and Hepatology, AGEM Research Institute, Amsterdam University Medical Center, Location Vrije Universiteit Medical Center, Amsterdam, The Netherlands
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Affiliation(s)
- Femke Crouwel
- Department of Gastroenterology and Hepatology, AGEM Research Institute, Amsterdam University Medical Centre, Vrije Universiteit Amsterdam, Amsterdam, the Netherlands,Corresponding Author: Femke Crouwel, De Boelelaan 1117, 1081 HV Amsterdam, Netherlands, Telephone number: +31204440799, Fax number: +31204440554,
| | - Petra Waaijenberg-Warmenhoven
- Department of Gastroenterology and Hepatology, Amsterdam University Medical Centre, Vrije Universiteit Amsterdam, Amsterdam, the Netherlands
| | - Hans J C Buiter
- Department of Clinical Pharmacology and Pharmacy, Amsterdam University Medical Centre, Vrije Universiteit Amsterdam, Amsterdam, the Netherlands
| | - Nanne K de Boer
- Department of Gastroenterology and Hepatology, AGEM Research Institute, Amsterdam University Medical Centre, Vrije Universiteit Amsterdam, Amsterdam, the Netherlands
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10
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Affiliation(s)
- Femke Crouwel
- Department of Gastroenterology and Hepatology, AG&M Research Institute, Amsterdam University Medical Centre, Vrije Universiteit Amsterdam, Amsterdam, the Netherlands
| | - Hans J C Buiter
- Department of Clinical Pharmacology and Pharmacy, Amsterdam University Medical Centre, Vrije Universiteit Amsterdam, Amsterdam, the Netherlands
| | - Nanne K de Boer
- Department of Gastroenterology and Hepatology, AG&M Research Institute, Amsterdam University Medical Centre, Vrije Universiteit Amsterdam, Amsterdam, the Netherlands
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Abstract
BACKGROUND AND AIMS The gut microbiota plays an important role in the metabolization and modulation of several types of drugs. With this study we aimed to review the literature about microbial drug metabolism of medication prescribed in inflammatory bowel disease practice. METHODS A systematic literature search was performed in Embase and PubMed from inception to October 2019. The search was conducted with predefined MeSH/Emtree and text terms. All studies about drug metabolism by microbiota of medication prescribed in inflammatory bowel disease practice were eligible. A total of 1018 records were encountered and 89 articles were selected for full text reading. RESULTS Intestinal bacterial metabolism or modulation is of influence in four specific drugs used in inflammatory bowel disease (mesalazines, methotrexate, glucocorticoids and thioguanine). The gut microbiota cleaves the azo-bond of sulfasalazine, balsalazide and olsalazine and releases the active moiety 5-aminosalicylic acid. It has an impact on the metabolization and potentially on the response of methotrexate therapy. Especially thioguanine can be converted by intestinal bacteria into the pharmacological active 6-thioguanine nucleotides without the requirement of host metabolism. Glucocorticoid compounds can be prone to bacterial degradation. CONCLUSION The human intestinal microbiota can have a major impact on drug metabolism and efficacy of medication prescribed in inflammatory bowel disease practice. A better understanding of these interactions between microbiota and drugs is needed and should be an integral part of the drug development pathway of new inflammatory bowel disease medication.
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Affiliation(s)
- Femke Crouwel
- Department of Gastroenterology and Hepatology, AG&M Research Institute, Amsterdam University Medical Centre, Vrije Universiteit Amsterdam, Amsterdam, the Netherlands
| | - Hans J C Buiter
- Department of Clinical Pharmacology and Pharmacy, Amsterdam University Medical Centre, Vrije Universiteit Amsterdam, Amsterdam, the Netherlands
| | - Nanne K de Boer
- Department of Gastroenterology and Hepatology, AG&M Research Institute, Amsterdam University Medical Centre, Vrije Universiteit Amsterdam, Amsterdam, the Netherlands
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12
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Affiliation(s)
- Hans J C Buiter
- Department of Clinical Pharmacology and Pharmacy, Amsterdam University Medical Centres, Amsterdam, The Netherlands
| | - Luc Derijks
- Department of Clinical Pharmacy and Pharmacology, Maxima Medical Centre, Veldhoven, The Netherlands
| | - Chris J J Mulder
- Department of Gastroenterology and Hepatology, Amsterdam University Medical Centres, Amsterdam, The Netherlands
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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: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [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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