New Zealand Society of Gastroenterology Guidelines on Therapeutic Drug Monitoring in Inflammatory Bowel Disease

The incidence of inflammatory bowel disease (IBD) in New Zealand has increased over the last several decades. The management of IBD has been transformed since the introduction of monoclonal antibody drugs. Other medications used in the treatment of IBD include amino-salicylates, steroids, thiopurines and methotrexate. Therapeutic drug monitoring (TDM) involves the measurement of serum drug levels or active metabolites and anti-drug antibodies. TDM is essential for a personalised approach to the management of patients with IBD and is used to optimise drug efficacy and reduce the risk of toxicity. In IBD, TDM can be used for checking adherence, evaluating drug toxicity, identifying hypermethylators, assessing loss of response and in decisions regarding treatment escalation or de-escalation. Management decisions in patients on a thiopurine are facilitated by checking TPMT enzyme activity and thiopurine metabolite levels. Measurement of drug trough levels and anti-drug antibodies can result in individualised treatment decisions in patients on biologics. In addition to using TDM in patients who fail therapy, proactive TDM can potentially facilitate early treatment decisions, albeit more work is needed in this area. The clinical benefits of reactive TDM are well documented and this has been shown to be cost effective. Studies have shown that combination therapy in patients on a biologic leads to better clinical outcomes. Effective use of drugs in the treatment of IBD is even more imperative in the New Zealand setting due to relatively fewer options of funded treatment, and the limitations on the use of available drugs. This document represents the current guidelines of the New Zealand Society of Gastroenterology on TDM in IBD.

Determination of extracellular and intracellular thiopurines and methylthiopurines by high-performance liquid chromatography

The thiopurine antimetabolites 6-thioguanine and 6-mercaptopurine are important chemotherapeutic drugs in the treatment of childhood acute lymphoblastic leukaemia. Measurement of metabolites of these thiopurines is important because correlations exist between levels of these metabolites and the prognosis in childhood acute lymphoblastic leukaemia. The reversed-phase method for the determination of extracellular thiopurine nucleosides and bases was previously developed and has been modified such that methylthiopurine nucleosides, bases, thioxanthine and thiouric acid can be measured also. The anion-exchange method enables the determination of intracellular mono-, di- and triphosphate (methyl)thiopurine nucleotides in one run. Extraction on ice with perchloric acid and dipotassium hydrogenphosphate results in good recoveries for (methyl)thiopurine nucleotides in lymphoblasts and peripheral mononuclear cells and for methylthioinosine nucleotides in red blood cells. Measurement of the low concentrations of mono-, di- and triphosphate thioguanine nucleotides in red blood cells (detection limit 20 pmol/10(9) cells) is possible after extraction with methanol and methylene chloride, followed by oxidation of thioguanine nucleotides with permanganate and fluorimetric detection.

Chromatographic and radioimmunological methods for the determination of 5'-deoxy-5'-methylthioadenosine in biological fluids

Two specific methods for the determination of 5'-deoxy-5'-methylthioadenosine (MTA) in biological samples have been developed. The chromatographic procedure requires a preliminary step on a phenylboronate column to remove non-cis-diol compounds. The sample is then analysed using a high-performance liquid chromatography system equipped with a reversed-phase column. 5'-Deoxy-5'-methyl-thio[2-3H]adenosine with high specific activity was synthesized and employed as an internal standard. An alternative radioimmunoassay (RIA) procedure has also been developed. The RIA method is based on competition between the unlabelled thio-ether and 3H-labelled MTA for the binding to a specific antiserum. Anti-MTA antibodies were obtained from rabbits immunized with the nucleoside covalently linked to carrier proteins. Both the chromatographic and RIA procedures gave identical results when employed to determine MTA in human urine.

Influx of 5'-deoxy-5'-methylthioadenosine into HL-60 human leukemia cells and erythrocytes

The influx of 5'-deoxy-5'-methylthioadenosine (MeSAdo) into human HL-60 leukemia cells and erythrocytes was characterized in order to determine whether it is facilitated by the nonspecific nucleoside carrier system or by a separate transporter, as suggested by other reports. Initial velocities were measured at room temperature by means of inhibitor-stop and oil-stop assays. MeSAdo influx was strongly inhibited by Ado, dAdo, and nucleoside transport inhibitors including nitrobenzylthioinosine and dipyridamole. Ade was inhibitory only at concentrations in excess of 1 mM. Loss of nucleoside transport capacity during differentiation of HL-60 cells was accompanied by a corresponding decrease in MeSAdo influx rates. These results indicate that MeSAdo influx was mediated by the nonspecific nucleoside transport system. The kinetic data were consistent with a single saturable carrier and yielded Km values of 74 and 184 microM and Vmax values of 424 and 48 pmols/10(6) cells/min with HL-60 cells and erythrocytes, respectively, after correction for a substantial passive diffusion component, which accounted for over 50% of the influx of 1 mM MeSAdo. The passive diffusion of MeSAdo in the presence of a transport inhibitor was not rate-limiting for the salvage of 50 microM MeSAdo to methionine when HL-60 cells were cultured in methionine-deficient medium. The large contribution of passive diffusion to the influx of MeSAdo is consistent with its unusually high octanol/water partition ratio (5.7-fold greater than that of Ado).

Transport and metabolism of 5'-methylthioadenosine in human erythrocytes

The transport and metabolism of 5'-deoxy-5'-S-methylthioadenosine have been studied in intact human erythrocytes. The sulfur nucleoside is rapidly accumulated into red cells and the extent of uptake largely exceeds the theoretical equilibrium between inner and outer compartment owing to its conversion into a non-permeable compound, namely 5-methylthioribose 1-phosphate. To characterize the nucleoside transport, phosphate-depleted erythrocytes, in which the methylthioadenosine metabolism is negligible, have been employed. The results indicate that: (i) the transport occurs via a facilitated-diffusion mechanism; (ii) the process is not energy-dependent and (iii) no specific cation is required. The kinetic analyses of both the transport and the metabolism show that the uptake of methylthioadenosine is a result of the tandem action of a transport step of high capacity (Vmax = 604 +/- 51 pmol/10(6) cells per min) and low affinity (Km = 3270 +/- 321 microM) followed by a metabolic step of low capacity (Vmax = 6.6 pmol/10(6) cells per min) and high affinity (Km = 30 microM). Furthermore, a substrate inhibition exerted by methylthioadenosine at high concentration (over 200 microM) on its specific phosphorylase is reported for the first time. Experiments performed with several analogs of the thioether indicate that the adenine amino group and the hydrophobic substituent at the 5'-position are critical for the transport carrier recognition. Adenine is the most powerful inhibitor of methylthioadenosine transport.

Studies on 5'-methylthioadenosine uptake by human erythrocytes

The transport of 5'-methylthioadenosine across plasma membrane of human erythrocytes occurs by a carrier-mediated mechanism displaying a Km of congruent to 3 mM and a Vmax of congruent to 600 pmol/10(6) cells/min. Phosphate-depleted erythrocytes were employed to distinguish between 5'-methylthioadenosine transport and metabolic trapping. In phosphate medium, where 5'-methylthioadenosine phosphorylase is operative, the uptake of radioactivity increases over the theoretical calculated equilibrium owing principally to conversion of the molecular into 5-methylthioribose-1-phosphate. Newly developed HPLC techniques have been applied to analyze intracellular 5'-methylthioadenosine and its metabolites after exposure of the erythrocytes to [14C]-labelled 5'-methylthioadenosine.