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Bayoumy AB, D'Agnolo HMA, de Boer NKH, Mulder CJJ, Derijks LJJ. The fate of thiopurine metabolites after switching to low-dose thiopurine with allopurinol or thioguanine in IBD patients: A retrospective analysis. Br J Clin Pharmacol 2025. [PMID: 40421668 DOI: 10.1002/bcp.70112] [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: 01/21/2025] [Revised: 05/06/2025] [Accepted: 05/12/2025] [Indexed: 05/28/2025] Open
Abstract
AIMS Shunting (hypermethylating) thiopurine metabolism, characterized by excessive 6-MMPR production and (sub)therapeutic 6-TGN levels, poses a significant challenge in the treatment of inflammatory bowel disease (IBD). This study evaluates the metabolic outcomes of switching to low-dose thiopurine with allopurinol (LDTA) or thioguanine (TG) in IBD patients with shunting metabolism. METHODS This retrospective study analysed demographic data, thiopurine metabolite profiles, and adverse event rates in shunting IBD patients before and after switching to LDTA or TG therapy. Metabolite variability was assessed by examining alterations in 6-MMPR and 6-TGN levels and their correlation before and after therapy switch. RESULTS Both therapies significantly reduced toxic 6-MMPR levels, with 100% of patients achieving non-toxic levels (6-MMPR-level below 7000 pmol/8 × 10E8 RBC) post-therapy. For TG, 93% of patients attained non-toxic 6-TGN levels (6-TGN < 1000 pmol/8 × 10E8 RBC). In contrast, LDTA showed greater variability in 6-TGN outcomes, with 50% of patients reaching therapeutic levels, 31% remaining subtherapeutic, and 19% within toxic range. The slope for LDTA was significantly positive (1.044, R2 = 0.4515, P = 0.004), reflecting proportional increases in 6-TGN levels. CONCLUSIONS Switching to LDTA or TG therapy in shunting IBD patients resulted in favourable alterations in thiopurine metabolism. However, LDTA appears to have a slightly less favourable metabolite profile, with some residual 6-MMPR formation and fewer patients achieving normal 6-TGN levels compared to TG. Given the challenges associated with achieving optimal thiopurine metabolite levels with LDTA and the need for closer monitoring of 6-TGN levels, TG appears a more suitable option for thiopurine shunting IBD patients.
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Affiliation(s)
- Ahmed B Bayoumy
- Department of Gastroenterology and Hepatology, Amsterdam University Medical Center, Amsterdam, The Netherlands
- Amsterdam Gastroenterology Endocrinology Metabolism Research Institute, Amsterdam, The Netherlands
- Department of Clinical Pharmacy and Pharmacology, Máxima Medical Center, Veldhoven, The Netherlands
| | - Hedwig M A D'Agnolo
- Department of Gastroenterology and Hepatology, Máxima Medical Center, Veldhoven, The Netherlands
| | - Nanne K H de Boer
- Department of Gastroenterology and Hepatology, Amsterdam University Medical Center, Amsterdam, The Netherlands
- Amsterdam Gastroenterology Endocrinology Metabolism Research Institute, Amsterdam, The Netherlands
| | - Chris J J Mulder
- Department of Gastroenterology and Hepatology, Amsterdam University Medical Center, Amsterdam, The Netherlands
- Amsterdam Gastroenterology Endocrinology Metabolism Research Institute, Amsterdam, The Netherlands
| | - Luc J J Derijks
- Department of Clinical Pharmacy and Pharmacology, Máxima Medical Center, Veldhoven, The Netherlands
- Department of Clinical Pharmacy and Toxicology and NUTRIM, School of Nutrition and Translational Research in Metabolism, Maastricht University Medical Center, Maastricht, The Netherlands
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2
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Rathi G, Shamkuwar PB, Rathi K, Ranazunjare R, Kulkarni S. Contemporary and prospective use of azathioprine (AZA) in viral, rheumatic, and dermatological disorders: a review of pharmacogenomic and nanotechnology applications. NAUNYN-SCHMIEDEBERG'S ARCHIVES OF PHARMACOLOGY 2025; 398:3183-3197. [PMID: 39495265 DOI: 10.1007/s00210-024-03569-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/26/2024] [Accepted: 10/23/2024] [Indexed: 11/05/2024]
Abstract
Azathioprine (AZA) has been extensively used for immunomodulatory effects in autoimmune disorders and transplantation. This article is proposed to review the contemporary and prospective use of AZA in viral, rheumatic, and dermatological disorders. The primary objective is to draw attention to possible developments in regards to AZA application in recent years, with an emphasis on the use of pharmacogenomics and nanotechnology to improve its efficacy in practice. This study reveals that AZA, having the active metabolites 6-mercaptopurine (6-MP) and 6-thioguanine (6-TG), may be useful in the treatment of systemic lupus erythematosus (SLE), pemphigus vulgaris, and psoriasis. Pharmacogenomic testing of thiopurine methyltransferase (TPMT) and Nudix hydrolase 15 (NUDT15) genotypes minimizes the occurrence of myelosuppression. Furthermore, new formulations of AZA using biocompatible polymers and nanoparticles for drug delivery were reported to improve its efficacy and lower systemic toxicity. This paper aims to establish the multifunctional nature of AZA in modern medicine, thus emphasizing its potential for other applications. Through the combination of pharmacogenomic analysis along with nanotechnology application, AZA makes the promise of enhancing patients' treatment efficacy and extending the stock of medical information available. These advancements offer new possibilities for application of precision medicine and improvements in the use of AZA therapy.
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Affiliation(s)
- Gulshan Rathi
- Department of Pharmaceutics, VSS Institute of Pharmacy, Badnapur, Maharashtra, India.
| | - Prashant B Shamkuwar
- Department of Pharmacognosy, Government College of Pharmacy, Chhatrapati Sambhajinagar, Maharashtra, India
| | - Karishma Rathi
- Department of Pharmacy Practice, Dr. D.Y. Patil Institute of Pharmaceutical Sciences and Research Pimpri, Pune, Maharashtra, India
| | - Ruchita Ranazunjare
- Department of Pharmacy Practice, Dr. D.Y. Patil Institute of Pharmaceutical Sciences and Research Pimpri, Pune, Maharashtra, India
| | - Soham Kulkarni
- Department of Pharmacy Practice, Dr. D.Y. Patil Institute of Pharmaceutical Sciences and Research Pimpri, Pune, Maharashtra, India
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3
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Li R, Yang L. Research progress in the combined treatment of ulcerative colitis. REVISTA ESPANOLA DE ENFERMEDADES DIGESTIVAS 2025; 117:129-135. [PMID: 37073706 DOI: 10.17235/reed.2023.9444/2022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 04/20/2023]
Abstract
In recent years, more and more drugs have been used in the treatment of ulcerative colitis, but the efficacy of monotherapy is limited, especially for patients with refractory moderate to severe ulcerative colitis (UC). Combination therapy is mainly used for patients with a poor response or partial efficacy of monotherapy and has become a new direction for exploring the treatment strategy of ulcerative colitis. Therefore, the authors review the combined treatment options of ulcerative colitis in the context of the existing literature and discuss considerations for the practical application of combination therapy, hoping to provide new ideas for clinicians in the treatment of ulcerative colitis.
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Affiliation(s)
- Rui Li
- Gastroenterology, China-Japan Union Hospital of Jilin University
| | - Lei Yang
- Gastroenterology, China-Japan Union Hospital of Jilin University, China
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4
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Engel B, Assis DN, Bhat M, Clusmann J, Drenth JPH, Gerussi A, Londoño MC, Oo YH, Schregel I, Sebode M, Taubert R, the International Autoimmune Hepatitis Group (IAIHG) collaborators, the European Reference Network for Rare Liver Diseases (ERN RARE-LIVER). Quo vadis autoimmune hepatitis? - Summary of the 5 th international autoimmune hepatitis group research workshop 2024. JHEP Rep 2025; 7:101265. [PMID: 39897612 PMCID: PMC11783120 DOI: 10.1016/j.jhepr.2024.101265] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/17/2024] [Revised: 10/28/2024] [Accepted: 10/30/2024] [Indexed: 02/04/2025] Open
Abstract
Autoimmune hepatitis (AIH) is a rare chronic liver disease with an increasing incidence in many countries. Chronic autoimmune responses against the liver can cause hepatic and extrahepatic symptoms, decreased quality of life and reduced liver transplant-free survival if inadequately treated. Although standard treatment with corticosteroids and thiopurines improves the life expectancy of patients with AIH, remission rates and tolerability are generally overestimated and the development of alternative first-line and salvage therapies has been disappointingly slow compared to in rheumatological diseases or inflammatory bowel disease. Other gaps include the lack of disease-specific diagnostic markers for AIH. Similarly, the new entity of drug-induced autoimmune-like hepatitis underscores the need to re-evaluate previous diagnostic criteria. The International AIH Group (IAIHG) has initiated a series of research workshops over the last decade to promote the identification of research gaps and subsequently improve the pace of scientific progress by stimulating collaboration between expert centres. This review reports on the results of the 5th Research Workshop, held in Hannover, Germany in June 2024, and summarises the progress made since the 4th Workshop in 2022. Patient representatives from the European Reference Network (ERN) Rare Liver Youth Panel participated in the workshop. The specific objectives of this year's 5th Workshop were: (1) To further improve diagnostics. (2) Initiate clinical trials including knowledge transfer on drugs from extrahepatic immune-mediated diseases, including B cell-depleting CAR T cells. (3) Utilisation of multi-omics approaches to improve the understanding of disease pathogenesis. (4) Application of machine learning-based approaches established in oncology or transplantation medicine to improve diagnosis and outcome prediction in AIH.
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Affiliation(s)
- Bastian Engel
- Department of Gastroenterology, Hepatology, Infectious Diseases and Endocrinology, Hannover Medical School, Hannover, Germany
| | | | - Mamatha Bhat
- Ajmera Transplant Centre, University Health Network, Toronto, Ontario, Canada
| | - Jan Clusmann
- Else Kroener Fresenius Center for Digital Health, Technical University Dresden, Dresden, Germany
- Department of Medicine III, University Hospital RWTH Aachen, Aachen, Germany
| | - Joost PH. Drenth
- Department of Gastroenterology and Hepatology, Amsterdam University Medical Center, The Netherlands
| | - Alessio Gerussi
- Department of Medicine and Surgery, University of Milano-Bicocca, Monza, Italy
- Centre for Autoimmune Liver Diseases & Division of Gastroenterology, Fondazione IRCCS San Gerardo dei Tintori, Monza, Italy
| | - María-Carlota Londoño
- Liver Unit, Hospital Clínic Barcelona, Fundació de Recerca Clínic Barcelona-Institut d’Investigacions Biomèdiques August Pi i Sunyer (FRCB-IDIBAPS), Universitat de Barcelona, Centro de investigación biomédica en red Enfermedades Hepáticas y Digestivas (CIBEREHD), Barcelona, Spain
| | - Ye Htun Oo
- Liver Transplant and Hepatobiliary Unit, Queen Elizabeth Hospital, University Hospital of Birmingham NHS Foundation Trust & Centre for Liver and Gastro Research, NIHR Biomedical Research Centre, Institute of Immunology and Immunotherapy, University of Birmingham, Birmingham, UK
| | - Ida Schregel
- I. Department of Medicine, University Medical Centre Hamburg-Eppendorf, Hamburg, Germany
| | - Marcial Sebode
- I. Department of Medicine, University Medical Centre Hamburg-Eppendorf, Hamburg, Germany
| | - Richard Taubert
- Department of Gastroenterology, Hepatology, Infectious Diseases and Endocrinology, Hannover Medical School, Hannover, Germany
| | - the International Autoimmune Hepatitis Group (IAIHG) collaborators
- Department of Gastroenterology, Hepatology, Infectious Diseases and Endocrinology, Hannover Medical School, Hannover, Germany
- Yale School of Medicine, New Haven, CT USA
- Ajmera Transplant Centre, University Health Network, Toronto, Ontario, Canada
- Else Kroener Fresenius Center for Digital Health, Technical University Dresden, Dresden, Germany
- Department of Medicine III, University Hospital RWTH Aachen, Aachen, Germany
- Department of Gastroenterology and Hepatology, Amsterdam University Medical Center, The Netherlands
- Department of Medicine and Surgery, University of Milano-Bicocca, Monza, Italy
- Centre for Autoimmune Liver Diseases & Division of Gastroenterology, Fondazione IRCCS San Gerardo dei Tintori, Monza, Italy
- Liver Unit, Hospital Clínic Barcelona, Fundació de Recerca Clínic Barcelona-Institut d’Investigacions Biomèdiques August Pi i Sunyer (FRCB-IDIBAPS), Universitat de Barcelona, Centro de investigación biomédica en red Enfermedades Hepáticas y Digestivas (CIBEREHD), Barcelona, Spain
- Liver Transplant and Hepatobiliary Unit, Queen Elizabeth Hospital, University Hospital of Birmingham NHS Foundation Trust & Centre for Liver and Gastro Research, NIHR Biomedical Research Centre, Institute of Immunology and Immunotherapy, University of Birmingham, Birmingham, UK
- I. Department of Medicine, University Medical Centre Hamburg-Eppendorf, Hamburg, Germany
| | - the European Reference Network for Rare Liver Diseases (ERN RARE-LIVER)
- Department of Gastroenterology, Hepatology, Infectious Diseases and Endocrinology, Hannover Medical School, Hannover, Germany
- Yale School of Medicine, New Haven, CT USA
- Ajmera Transplant Centre, University Health Network, Toronto, Ontario, Canada
- Else Kroener Fresenius Center for Digital Health, Technical University Dresden, Dresden, Germany
- Department of Medicine III, University Hospital RWTH Aachen, Aachen, Germany
- Department of Gastroenterology and Hepatology, Amsterdam University Medical Center, The Netherlands
- Department of Medicine and Surgery, University of Milano-Bicocca, Monza, Italy
- Centre for Autoimmune Liver Diseases & Division of Gastroenterology, Fondazione IRCCS San Gerardo dei Tintori, Monza, Italy
- Liver Unit, Hospital Clínic Barcelona, Fundació de Recerca Clínic Barcelona-Institut d’Investigacions Biomèdiques August Pi i Sunyer (FRCB-IDIBAPS), Universitat de Barcelona, Centro de investigación biomédica en red Enfermedades Hepáticas y Digestivas (CIBEREHD), Barcelona, Spain
- Liver Transplant and Hepatobiliary Unit, Queen Elizabeth Hospital, University Hospital of Birmingham NHS Foundation Trust & Centre for Liver and Gastro Research, NIHR Biomedical Research Centre, Institute of Immunology and Immunotherapy, University of Birmingham, Birmingham, UK
- I. Department of Medicine, University Medical Centre Hamburg-Eppendorf, Hamburg, Germany
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5
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Lee KR, Gulnaz A, Chae YJ. Drug Interaction-Informed Approaches to Inflammatory Bowel Disease Management. Pharmaceutics 2024; 16:1431. [PMID: 39598554 PMCID: PMC11597736 DOI: 10.3390/pharmaceutics16111431] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2024] [Revised: 11/01/2024] [Accepted: 11/07/2024] [Indexed: 11/29/2024] Open
Abstract
Inflammatory bowel disease (IBD) is a complex and chronic condition that requires the use of various pharmacological agents for its management. Despite advancements in IBD research, the multifaceted mechanisms involved continue to pose significant challenges for strategic prevention. Therefore, it is crucial to prioritize safe and effective treatment strategies using the currently available pharmacological agents. Given that patients with IBD often require multiple medications due to combination therapy or other underlying conditions, a comprehensive understanding of drug interactions is essential for optimizing treatment regimens. In this review, we examined the pharmacological treatment options recommended in the current IBD management guidelines and provided a comprehensive analysis of the known pharmacokinetic interactions associated with these medications. In particular, this review includes recent research results for the impact of anti-drug antibodies (ADAs) on the concentrations of biological agents used in IBD treatment. By leveraging detailed interaction data and employing personalized dosing strategies, healthcare providers can improve therapeutic outcomes and minimize adverse effects, ultimately improving the quality of care for patients with IBD.
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Affiliation(s)
- Kyeong-Ryoon Lee
- Laboratory Animal Resource Center, Korea Research Institute of Bioscience and Biotechnology, Cheongju 28116, Republic of Korea
- Department of Bioscience, University of Science and Technology, Daejeon 34113, Republic of Korea
| | - Aneela Gulnaz
- College of Pharmacy, Woosuk University, Wanju 55338, Republic of Korea
| | - Yoon-Jee Chae
- College of Pharmacy, Woosuk University, Wanju 55338, Republic of Korea
- Research Institute of Pharmaceutical Sciences, Woosuk University, Wanju 55338, Republic of Korea
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6
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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 2024; 30:1492-1499. [PMID: 37658804 PMCID: PMC11369064 DOI: 10.1093/ibd/izad197] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [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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7
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Crouwel F, Simsek M, de Boer MA, van Asseldonk DP, Bhalla A, Weusthuis ALM, Gilissen LPL, Verburg RJ, Mares WGN, Jharap B, Kuijvenhoven JP, Oldenburg B, Buiter HJC, Julsgaard M, de Boer NK. Multicentre study and systematic review: Allopurinol exposure during pregnancy. Aliment Pharmacol Ther 2024; 60:503-518. [PMID: 38984819 DOI: 10.1111/apt.18126] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/11/2024] [Revised: 02/12/2024] [Accepted: 06/08/2024] [Indexed: 07/11/2024]
Abstract
BACKGROUND Data about the safety of allopurinol in pregnant women are sparsely reported. AIMS To investigate the risk of adverse pregnancy outcome and congenital abnormalities after in utero exposure to allopurinol in inflammatory bowel disease (IBD) pregnancies and in general. METHODS We collected safety data of patients with IBD who were treated with allopurinol during pregnancy between January 2013 and March 2022. Additionally, we performed a systematic review about the teratogenic potential of allopurinol. RESULTS We collected data from 42 allopurinol-exposed pregnancies, including one twin pregnancy; in all women, allopurinol was combined with a thiopurine. Six pregnancies (14.3%) resulted in miscarriage and one in stillbirth at 32 weeks. A congenital anomaly was observed in one newborn (coarctation of the aorta discovered postpartum). Three pregnancies, including the twin pregnancy, ended in moderate preterm delivery and one in very preterm delivery. Five neonates (15.2%) were small for gestational age. From our literature search, we identified an additional 102 allopurinol-exposed pregnancies resulting in 129 live births, including 36 infants from our cohort. Ten infants (7.8%) were born with a congenital anomaly. Two (1.6%) had a comparable pattern of multiple anomalies. The systematic review sub-analysis including only infants born to mothers with IBD (n = 76) revealed that 2.6% of infants had congenital anomalies after in utero exposure to a low dose of allopurinol. CONCLUSIONS Overall, the teratogenicity of allopurinol remains inconclusive. Children conceived by mothers treated for IBD with allopurinol/thiopurine co-therapy do not seem to have an increased risk of congenital anomalies.
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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
| | - 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 Gynaecology, Vrije Universiteit Amsterdam, Amsterdam Reproduction & Development Research Institute, Amsterdam, The Netherlands
| | - Dirk P van Asseldonk
- Department of Gastroenterology and Hepatology, Noordwest Ziekenhuisgroep, Alkmaar, The Netherlands
| | - Abha Bhalla
- Department of Gastroenterology and Hepatology, HagaZiekenhuis, Den Haag, The Netherlands
| | - Angelique L M Weusthuis
- Department of Gastroenterology and Hepatology, Deventer Ziekenhuis, Deventer, The Netherlands
| | - Lennard P L Gilissen
- Department of Gastroenterology and Hepatology, Catharina Hospital Eindhoven, Eindhoven, The Netherlands
| | - Robert J Verburg
- Department of Gastroenterology and Hepatology, Haaglanden Medisch Centrum, Den Haag, The Netherlands
| | - Wout G N Mares
- Department of Gastroenterology and Hepatology, Ziekenhuis Gelderse Vallei, Ede, The Netherlands
| | - Bindia Jharap
- Department of Gastroenterology and Hepatology, Meander Medisch Centrum, Amersfoort, The Netherlands
| | - Johan P Kuijvenhoven
- Department of Gastroenterology and Hepatology, Spaarne Gasthuis, Haarlem, The Netherlands
| | - Bas Oldenburg
- Department of Gastroenterology and Hepatology, UMC Utrecht, Utrecht, The Netherlands
| | - Hans J C Buiter
- Department of Radiology and Nuclear Medicine, Amsterdam University Medical Centre, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| | - Mette Julsgaard
- Department of Hepatology and Gastroenterology, Aarhus University Hospital, Aarhus, Denmark
- Institute of Clinical Medicine, Health, Aarhus University, Denmark
| | - 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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8
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Mertz Nielsen A, Theede K, Gluud LL, Kiszka-Kanowitz M. Efficacy of optimised thiopurine therapy in patients with moderate-to-severe ulcerative colitis: retrospective long-term follow-up from two randomised trials. Scand J Gastroenterol 2024; 59:669-673. [PMID: 38444060 DOI: 10.1080/00365521.2024.2323502] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/30/2023] [Revised: 02/19/2024] [Accepted: 02/21/2024] [Indexed: 03/07/2024]
Abstract
OBJECTIVE The long-term outcome of thiopurine therapy in patients with ulcerative colitis (UC) enrolled in prospective trials have not been evaluated. We aimed to assess the effects of optimised thiopurine maintenance therapy for UC. METHODS Long-term data were obtained from patients from our center enrolled in two randomised, prospective, open-label, controlled studies comprising 66 thiopurine-naïve moderate-to-severe patients with UC consisting of a low dose azathioprine (AZA)/allopurinol combination or AZA monotherapy. Following the randomised trials, treatment was adjusted according to adverse effects and metabolites. Patients requiring optimisation initially on AZA monotherapy treatment were switched to low dose AZA in combination with allopurinol, low dose 6-mercaptopurin in combination with allopurinol, or 6-mercaptopurin treatment alone, and those treated with low dose AZA in combination with allopurinol were switched to low dose 6-mercaptopurin in combination with allopurinol or 6-mercaptopurin alone. RESULTS A total of 62 patients were included in the analysis; 31 were initially treated with AZA monotherapy and 31 with low dose AZA in combination with allopurinol. Initial treatment was tolerated by 67% patients (7 AZA monotherapy and 28 low dose AZA in combination with allopurinol), increasing to 94% (58 patients) post-adjustment. After a median 52-month follow-up period, 38 (93%) out of the 41 primary responding patients-maintained clinical remission without steroids, biologics or surgery. The four intolerant patients and the 17 not responding to optimisation were more likely to require colectomy (odds ratio 16.36; 95% confidence interval 3.08-87.03, p < 0.0001). CONCLUSION Optimised thiopurine therapy demonstrated effective long-term treatment for patients with ulcerative colitis.
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Affiliation(s)
| | - Klaus Theede
- Gastro Unit, Copenhagen University Hospital Hvidovre, Hvidovre, Denmark
| | - Lise Lotte Gluud
- Gastro Unit, Copenhagen University Hospital Hvidovre, Hvidovre, Denmark
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9
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van Liere ELSA, de Boer NKH. Editorial: Towards optimal thiopurine therapy for inflammatory bowel disease. Aliment Pharmacol Ther 2024; 59:792-793. [PMID: 38401141 DOI: 10.1111/apt.17876] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/26/2024]
Abstract
LINKED CONTENTThis article is linked to Vasudevan et al papers. To view these articles, visit https://doi.org/10.1111/apt.17831 and https://doi.org/10.1111/apt.17895
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Affiliation(s)
- Elsa L S A van Liere
- Department of Gastroenterology and Hepatology, Amsterdam University Medical Center location Vrije Universiteit Amsterdam, Amsterdam, the Netherlands
- Amsterdam Gastroenterology Endocrinology Metabolism Research Institute, Amsterdam, the Netherlands
| | - Nanne K H de Boer
- Department of Gastroenterology and Hepatology, Amsterdam University Medical Center location Vrije Universiteit Amsterdam, Amsterdam, the Netherlands
- Amsterdam Gastroenterology Endocrinology Metabolism Research Institute, Amsterdam, the Netherlands
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10
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Trinh S, Andrew B, Vasudevan A. 6-Mercaptopurine in ulcerative colitis: the potential of upfront dosing with allopurinol. J Crohns Colitis 2024; 18:492. [PMID: 37642331 DOI: 10.1093/ecco-jcc/jjad150] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/31/2023] [Indexed: 08/31/2023]
Affiliation(s)
- Steven Trinh
- Department of Gastroenterology, Eastern Health, Box Hill, Victoria, Australia
| | - Bridgette Andrew
- Department of Gastroenterology, Eastern Health, Box Hill, Victoria, Australia
| | - Abhinav Vasudevan
- Department of Gastroenterology, Eastern Health, Box Hill, Victoria, Australia
- Eastern Health Clinical School, Monash University, Box Hill, Victoria, Australia
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11
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Bayoumy AB, Mulder CJJ, Ansari AR, Barclay ML, Florin T, Kiszka-Kanowitz M, Derijks L, Sharma V, de Boer NKH. Uphill battle: Innovation of thiopurine therapy in global inflammatory bowel disease care. Indian J Gastroenterol 2024; 43:36-47. [PMID: 38383877 PMCID: PMC10924016 DOI: 10.1007/s12664-024-01529-x] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/03/2023] [Accepted: 01/04/2024] [Indexed: 02/23/2024]
Abstract
Inflammatory bowel disease (IBD) is a chronic inflammatory disorder of the gastrointestinal tract that encompasses two major conditions: Crohn's disease (CD) and ulcerative colitis (UC). Historically, IBD has been primarily reported in western countries, but over the past decades, its prevalence is rapidly increasing, especially in lower and middle-income countries (LMICs) such as India and China and also in Sub-Saharan Africa. The prevalence of IBD in LMICs has been the subject of growing concern due to the impact of access to public healthcare and the burden it places on healthcare resources. The classical thiopurines face significant challenges due to cessation of therapy in approximately half of patients within one year due to side effects or ineffectiveness. In this article, we highlight innovating thiopurine treatment for IBD patients in downregulating side effects and improving efficacy.
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Affiliation(s)
- Ahmed B Bayoumy
- Department of Internal Medicine, Amsterdam University Medical Centers, Amsterdam, The Netherlands
| | - Chris J J Mulder
- Department of Gastroenterology and Hepatology, AGEM Research Institute, Amsterdam University Medical Center, Vrije Universiteit Amsterdam, De Boelelaan 1117, 1081 HV, Amsterdam, The Netherlands.
| | - Azhar R Ansari
- Department of Gastroenterology and Hepatology, London Bridge Hospital, London, UK
| | - Murray L Barclay
- Department of Gastroenterology, Christchurch Hospital, Christchurch, Waitaha - Canterbury, New Zealand
- Department of Clinical Pharmacology, Christchurch Hospital, Christchurch, Waitaha - Canterbury, New Zealand
| | - Tim Florin
- Mater Research, University of Queensland, Translational Research Institute, South Brisbane, Australia
| | - Marianne Kiszka-Kanowitz
- Copenhagen Center for Inflammatory Bowel Disease in Children, Adolescents and Adults, Copenhagen University Hospital - Amager and Hvidovre Hospital, Hvidovre, Denmark
| | - Luc Derijks
- Department of Clinical Pharmacy, Máxima Medical Center, Veldhoven, The Netherlands
- Department of Clinical Pharmacy and Toxicology, Maastricht University Medical Center, Maastricht, The Netherlands
| | - Vishal Sharma
- Department of Gastroenterology, Postgraduate Institute of Medical Education and Research, Chandigarh 160 012, India
| | - Nanne K H de Boer
- Department of Gastroenterology and Hepatology, AGEM Research Institute, Amsterdam University Medical Center, Vrije Universiteit Amsterdam, De Boelelaan 1117, 1081 HV, Amsterdam, The Netherlands
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12
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Vasudevan A, Con D, De Cruz P, Sparrow MP, Friedman AB, Garg M, Kashkooli S, Gibson PR, van Langenberg DR. Clinical trial: Combination allopurinol-thiopurine versus standard thiopurine in patients with IBD escalating to immunomodulators (the DECIDER study). Aliment Pharmacol Ther 2024; 59:504-514. [PMID: 38095246 DOI: 10.1111/apt.17831] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/11/2023] [Revised: 09/29/2023] [Accepted: 11/29/2023] [Indexed: 01/23/2024]
Abstract
BACKGROUND Thiopurines are established treatments for inflammatory bowel disease (IBD), yet concerns remain regarding their safety. AIM To evaluate the use of thiopurine-allopurinol combination therapy compared to standard thiopurine therapy in IBD. METHODS We performed a multicentre, randomised, placebo-controlled trial to compare the efficacy and safety of thiopurine-allopurinol versus thiopurine with placebo for adults commencing a thiopurine for IBD. Patients had active disease at baseline; dosing of therapy was based on a pre-specified regimen and subsequent metabolites. The primary outcome was the proportion of patients achieving a composite of symptomatic disease activity remission (Harvey Bradshaw Index <5 for Crohn's disease, Simple Clinical Colitis Activity Index <4 for ulcerative colitis) and a faecal calprotectin <150 μg/g after 26 weeks of treatment. RESULTS The trial was terminated early due to slow recruitment. We randomised 102 participants (54 thiopurine-allopurinol, 48 thiopurine with placebo) with similar age (median 42 vs 48 years) and sex distribution (46% women per group). A higher proportion achieved the primary outcome in the thiopurine-allopurinol group (50% vs 35%, p = 0.14) and fewer participants stopped their allocated therapy due to adverse events (11% vs 29%, p = 0.02). Also, within the thiopurine-allopurinol group, thiopurine dose adjustments were less frequent (69% vs 92%, p = 0.03), a higher proportion achieved an early therapeutic 6-TGN level at week 6 (71% vs 53%, p = 0.19), and adverse events attributed to therapy were less frequent (15% vs 44%, p = 0.002). CONCLUSION Thiopurine-allopurinol therapy is safe and mitigates thiopurine adverse effects, thus enhancing tolerability without compromising efficacy (ACTRN12613001347752).
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Affiliation(s)
- Abhinav Vasudevan
- Department of Gastroenterology and Hepatology, Eastern Health, Box Hill, Victoria, Australia
- Monash University, Eastern Health Clinical School, Box Hill, Victoria, Australia
| | - Danny Con
- Department of Gastroenterology, The Austin Hospital, Melbourne, Victoria, Australia
| | - Peter De Cruz
- Department of Gastroenterology, The Austin Hospital, Melbourne, Victoria, Australia
- Department of Medicine, Austin Academic Centre, University of Melbourne, Melbourne, Victoria, Australia
| | - Miles P Sparrow
- Department of Gastroenterology, Central Clinical School, Monash University and Alfred Health, Melbourne, Victoria, Australia
| | - Antony B Friedman
- Department of Gastroenterology, Central Clinical School, Monash University and Alfred Health, Melbourne, Victoria, Australia
| | - Mayur Garg
- Department of Gastroenterology, Northern Health, Epping, Victoria, Australia
- Department of Medicine, Melbourne University, Melbourne, Australia
| | - Soleiman Kashkooli
- Department of Gastroenterology, Northern Health, Epping, Victoria, Australia
| | - Peter R Gibson
- Department of Gastroenterology, Central Clinical School, Monash University and Alfred Health, Melbourne, Victoria, Australia
| | - Daniel R van Langenberg
- Department of Gastroenterology and Hepatology, Eastern Health, Box Hill, Victoria, Australia
- Monash University, Eastern Health Clinical School, Box Hill, Victoria, Australia
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13
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Nakafero G, Card T, Grainge MJ, Williams HC, Taal MW, Aithal GP, Fox CP, Mallen CD, van der Windt DA, Stevenson MD, Riley RD, Abhishek A. Risk-stratified monitoring for thiopurine toxicity in immune-mediated inflammatory diseases: prognostic model development, validation, and, health economic evaluation. EClinicalMedicine 2023; 64:102213. [PMID: 37745026 PMCID: PMC10514402 DOI: 10.1016/j.eclinm.2023.102213] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/16/2023] [Revised: 08/25/2023] [Accepted: 08/29/2023] [Indexed: 09/26/2023] Open
Abstract
Background Patients established on thiopurines (e.g., azathioprine) are recommended to undergo three-monthly blood tests for the early detection of blood, liver, or kidney toxicity. These side-effects are uncommon during long-term treatment. We developed a prognostic model that could be used to inform risk-stratified decisions on frequency of monitoring blood-tests during long-term thiopurine treatment, and, performed health-economic evaluation of alternate monitoring intervals. Methods This was a retrospective cohort study set in the UK primary-care. Data from the Clinical Practice Research Datalink Aurum and Gold formed development and validation cohorts, respectively. People age ≥18 years, diagnosed with an immune mediated inflammatory disease, prescribed thiopurine by their general practitioner for at-least six-months between January 1, 2007 and December 31, 2019 were eligible. The outcome was thiopurine discontinuation with abnormal blood-test results. Patients were followed up from six-months after first primary-care thiopurine prescription to up to five-years. Penalised Cox regression developed the risk equation. Multiple imputation handled missing predictor data. Calibration and discrimination assessed model performance. A mathematical model evaluated costs and quality-adjusted life years associated with lengthening the interval between blood-tests. Findings Data from 5982 (405 events over 16,117 person-years) and 3573 (269 events over 9075 person-years) participants were included in the development and validation cohorts, respectively. Fourteen candidate predictors (21 parameters) were included. The optimism adjusted R2 and Royston D statistic in development data were 0.11 and 0.76, respectively. The calibration slope and Royston D statistic (95% Confidence Interval) in the validation data were 1.10 (0.84-1.36) and 0.72 (0.52-0.92), respectively. A 2-year period between monitoring blood-test was most cost-effective in all deciles of predicted risk but the gain between monitoring annually or biennially reduced in higher risk deciles. Interpretation This prognostic model requires information that is readily available during routine clinical care and may be used to risk-stratify blood-test monitoring for thiopurine toxicity. These findings should be considered by specialist societies when recommending blood monitoring during thiopurine prescription to bring about sustainable and equitable change in clinical practice. Funding National Institute for Health and Care Research.
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Affiliation(s)
- Georgina Nakafero
- Academic Rheumatology, School of Medicine, University of Nottingham, Nottingham NG5 1PB, UK
| | - Tim Card
- Lifespan and Population Health, School of Medicine, University of Nottingham, Nottingham NG5 1PB, UK
| | - Matthew J. Grainge
- Lifespan and Population Health, School of Medicine, University of Nottingham, Nottingham NG5 1PB, UK
| | - Hywel C. Williams
- Lifespan and Population Health, School of Medicine, University of Nottingham, Nottingham NG5 1PB, UK
| | - Maarten W. Taal
- Centre for Kidney Research and Innovation, School of Medicine, Translational Medical Sciences, University of Nottingham, Derby DE22 3NE, UK
| | - Guruprasad P. Aithal
- Nottingham Digestive Diseases Centre, Translational Medical Sciences, School of Medicine, University of Nottingham, Nottingham NG7 2UH, UK
| | - Christopher P. Fox
- Translational Medical Sciences, School of Medicine, University of Nottingham, Nottingham, UK
| | - Christian D. Mallen
- Primary Care Centre Versus Arthritis, School of Medicine, Keele University, Keele ST5 5BJ, UK
| | | | - Matthew D. Stevenson
- School of Health and Related Research, University of Sheffield, Sheffield S1 4DA, UK
| | - Richard D. Riley
- Institute of Applied Health Research, College of Medical and Dental Sciences, University of Birmingham, Birmingham B15 2TT, UK
| | - Abhishek Abhishek
- Academic Rheumatology, School of Medicine, University of Nottingham, Nottingham NG5 1PB, UK
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14
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Yan Y, Wang Z, Zhou YL, Gao Z, Ning L, Zhao Y, Xuan B, Ma Y, Tong T, Huang X, Hu M, Fang JY, Cui Z, Chen H, Hong J. Commensal bacteria promote azathioprine therapy failure in inflammatory bowel disease via decreasing 6-mercaptopurine bioavailability. Cell Rep Med 2023; 4:101153. [PMID: 37586320 PMCID: PMC10439275 DOI: 10.1016/j.xcrm.2023.101153] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2022] [Revised: 06/07/2023] [Accepted: 07/18/2023] [Indexed: 08/18/2023]
Abstract
Azathioprine (AZA) therapy failure, though not the primary cause, contributes to disease relapse and progression in inflammatory bowel disease (IBD). However, the role of gut microbiota in AZA therapy failure remains poorly understood. We found a high prevalence of Blautia wexlerae in patients with IBD with AZA therapy failure, associated with shorter disease flare survival time. Colonization of B. wexlerae increased inflammatory macrophages and compromised AZA's therapeutic efficacy in mice with intestinal colitis. B. wexlerae colonization reduced 6-mercaptopurine (6-MP) bioavailability by enhancing selenium-dependent xanthine dehydrogenase (sd-XDH) activity. The enzyme sd-XDH converts 6-MP into its inactive metabolite, 6-thioxanthine (6-TX), thereby impairing its ability to inhibit inflammation in mice. Supplementation with Bacillus (B.) subtilis enriched in hypoxanthine phosphoribosyltransferase (HPRT) effectively mitigated B. wexlerae-induced AZA treatment failure in mice with intestinal colitis. These findings emphasize the need for tailored management strategies based on B. wexlerae levels in patients with IBD.
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Affiliation(s)
- Yuqing Yan
- State Key Laboratory for Oncogenes and Related Genes, NHC Key Laboratory of Digestive Diseases, Division of Gastroenterology and Hepatology, Shanghai Institute of Digestive Disease, Shanghai Cancer Institute, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, 145 Middle Shandong Road, Shanghai 200001, China
| | - Zhenhua Wang
- State Key Laboratory for Oncogenes and Related Genes, NHC Key Laboratory of Digestive Diseases, Division of Gastroenterology and Hepatology, Shanghai Institute of Digestive Disease, Shanghai Cancer Institute, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, 145 Middle Shandong Road, Shanghai 200001, China
| | - Yi-Lu Zhou
- State Key Laboratory for Oncogenes and Related Genes, NHC Key Laboratory of Digestive Diseases, Division of Gastroenterology and Hepatology, Shanghai Institute of Digestive Disease, Shanghai Cancer Institute, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, 145 Middle Shandong Road, Shanghai 200001, China
| | - Ziyun Gao
- State Key Laboratory for Oncogenes and Related Genes, NHC Key Laboratory of Digestive Diseases, Division of Gastroenterology and Hepatology, Shanghai Institute of Digestive Disease, Shanghai Cancer Institute, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, 145 Middle Shandong Road, Shanghai 200001, China
| | - Lijun Ning
- State Key Laboratory for Oncogenes and Related Genes, NHC Key Laboratory of Digestive Diseases, Division of Gastroenterology and Hepatology, Shanghai Institute of Digestive Disease, Shanghai Cancer Institute, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, 145 Middle Shandong Road, Shanghai 200001, China
| | - Ying Zhao
- State Key Laboratory for Oncogenes and Related Genes, NHC Key Laboratory of Digestive Diseases, Division of Gastroenterology and Hepatology, Shanghai Institute of Digestive Disease, Shanghai Cancer Institute, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, 145 Middle Shandong Road, Shanghai 200001, China
| | - Baoqin Xuan
- State Key Laboratory for Oncogenes and Related Genes, NHC Key Laboratory of Digestive Diseases, Division of Gastroenterology and Hepatology, Shanghai Institute of Digestive Disease, Shanghai Cancer Institute, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, 145 Middle Shandong Road, Shanghai 200001, China
| | - Yanru Ma
- State Key Laboratory for Oncogenes and Related Genes, NHC Key Laboratory of Digestive Diseases, Division of Gastroenterology and Hepatology, Shanghai Institute of Digestive Disease, Shanghai Cancer Institute, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, 145 Middle Shandong Road, Shanghai 200001, China
| | - Tianying Tong
- State Key Laboratory for Oncogenes and Related Genes, NHC Key Laboratory of Digestive Diseases, Division of Gastroenterology and Hepatology, Shanghai Institute of Digestive Disease, Shanghai Cancer Institute, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, 145 Middle Shandong Road, Shanghai 200001, China
| | - Xiaowen Huang
- State Key Laboratory for Oncogenes and Related Genes, NHC Key Laboratory of Digestive Diseases, Division of Gastroenterology and Hepatology, Shanghai Institute of Digestive Disease, Shanghai Cancer Institute, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, 145 Middle Shandong Road, Shanghai 200001, China
| | - Muni Hu
- State Key Laboratory for Oncogenes and Related Genes, NHC Key Laboratory of Digestive Diseases, Division of Gastroenterology and Hepatology, Shanghai Institute of Digestive Disease, Shanghai Cancer Institute, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, 145 Middle Shandong Road, Shanghai 200001, China
| | - Jing-Yuan Fang
- State Key Laboratory for Oncogenes and Related Genes, NHC Key Laboratory of Digestive Diseases, Division of Gastroenterology and Hepatology, Shanghai Institute of Digestive Disease, Shanghai Cancer Institute, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, 145 Middle Shandong Road, Shanghai 200001, China
| | - Zhe Cui
- Department of Gastrointestinal Surgery, Renji Hospital, Shanghai Jiao Tong University School of Medicine, 145 Middle Shandong Road, Shanghai 200001, China.
| | - Haoyan Chen
- State Key Laboratory for Oncogenes and Related Genes, NHC Key Laboratory of Digestive Diseases, Division of Gastroenterology and Hepatology, Shanghai Institute of Digestive Disease, Shanghai Cancer Institute, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, 145 Middle Shandong Road, Shanghai 200001, China.
| | - Jie Hong
- State Key Laboratory for Oncogenes and Related Genes, NHC Key Laboratory of Digestive Diseases, Division of Gastroenterology and Hepatology, Shanghai Institute of Digestive Disease, Shanghai Cancer Institute, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, 145 Middle Shandong Road, Shanghai 200001, China.
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15
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Burisch J, Zhao M, Odes S, De Cruz P, Vermeire S, Bernstein CN, Kaplan GG, Duricova D, Greenberg D, Melberg HO, Watanabe M, Ahn HS, Targownik L, Pittet VEH, Annese V, Park KT, Katsanos KH, Høivik ML, Krznaric Z, Chaparro M, Loftus EV, Lakatos PL, Gisbert JP, Bemelman W, Moum B, Gearry RB, Kappelman MD, Hart A, Pierik MJ, Andrews JM, Ng SC, D'Inca R, Munkholm P. The cost of inflammatory bowel disease in high-income settings: a Lancet Gastroenterology & Hepatology Commission. Lancet Gastroenterol Hepatol 2023; 8:458-492. [PMID: 36871566 DOI: 10.1016/s2468-1253(23)00003-1] [Citation(s) in RCA: 85] [Impact Index Per Article: 42.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/13/2022] [Revised: 01/09/2023] [Accepted: 01/10/2023] [Indexed: 03/06/2023]
Abstract
The cost of caring for patients with inflammatory bowel disease (IBD) continues to increase worldwide. The cause is not only a steady increase in the prevalence of Crohn's disease and ulcerative colitis in both developed and newly industrialised countries, but also the chronic nature of the diseases, the need for long-term, often expensive treatments, the use of more intensive disease monitoring strategies, and the effect of the diseases on economic productivity. This Commission draws together a wide range of expertise to discuss the current costs of IBD care, the drivers of increasing costs, and how to deliver affordable care for IBD in the future. The key conclusions are that (1) increases in health-care costs must be evaluated against improved disease management and reductions in indirect costs, and (2) that overarching systems for data interoperability, registries, and big data approaches must be established for continuous assessment of effectiveness, costs, and the cost-effectiveness of care. International collaborations should be sought out to evaluate novel models of care (eg, value-based health care, including integrated health care, and participatory health-care models), as well as to improve the education and training of clinicians, patients, and policy makers.
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Affiliation(s)
- Johan Burisch
- Gastro Unit, Medical Division, Copenhagen University Hospital-Amager and Hvidovre, Hvidovre, Denmark; Copenhagen Center for Inflammatory Bowel Disease in Children, Adolescents and Adults, Copenhagen University Hospital-Amager and Hvidovre, Hvidovre, Denmark.
| | - Mirabella Zhao
- Gastro Unit, Medical Division, Copenhagen University Hospital-Amager and Hvidovre, Hvidovre, Denmark; Copenhagen Center for Inflammatory Bowel Disease in Children, Adolescents and Adults, Copenhagen University Hospital-Amager and Hvidovre, Hvidovre, Denmark
| | - Selwyn Odes
- Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer-Sheva, Israel
| | - Peter De Cruz
- Department of Gastroenterology, Austin Health, Melbourne, VIC, Australia; Department of Medicine, Austin Academic Centre, The University of Melbourne, Melbourne, VIC, Australia
| | - Severine Vermeire
- Department of Gastroenterology and Hepatology, University Hospital Leuven, Leuven, Belgium; Faculty of Medicine, KU Leuven University, Leuven, Belgium
| | - Charles N Bernstein
- IBD Clinical and Research Centre, University of Manitoba, Winnipeg, MB, Canada; Department of Internal Medicine, Max Rady College of Medicine, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, MB, Canada
| | - Gilaad G Kaplan
- Department of Medicine and Community Health Sciences, University of Calgary, Calgary, AB, Canada
| | - Dana Duricova
- IBD Clinical and Research Centre for IBD, ISCARE, Prague, Czech Republic; Department of Pharmacology, Faculty of Medicine, Charles University, Prague, Czech Republic
| | - Dan Greenberg
- Department of Health Policy and Management, School of Public Health, Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer-Sheva, Israel; Guilford Glazer Faculty of Business and Management, Ben-Gurion University of the Negev, Beer-Sheva, Israel
| | - Hans O Melberg
- Department of Community Medicine, University of Tromsø-The Arctic University of Norway, Tromsø, Norway; Department of Gastroenterology, Oslo University Hospital, Oslo, Norway
| | - Mamoru Watanabe
- Advanced Research Institute, Tokyo Medical and Dental University, Tokyo, Japan
| | - Hyeong Sik Ahn
- Department of Preventive Medicine, College of Medicine, Korea University, Seoul, South Korea
| | - Laura Targownik
- Division of Gastroenterology and Hepatology, Department of Medicine, Mount Sinai Hospital, University of Toronto, Toronto, ON, Canada
| | - Valérie E H Pittet
- Department of Epidemiology and Health Systems, Center for Primary Care and Public Health, University of Lausanne, Lausanne, Switzerland
| | - Vito Annese
- Division of Gastroenterology, Department of Internal Medicine, Fakeeh University Hospital, Dubai, United Arab Emirates
| | - K T Park
- Stanford Health Care, Packard Health Alliance, Alameda, CA, USA; Genentech (Roche Group), South San Francisco, CA, USA
| | - Konstantinos H Katsanos
- Division of Gastroenterology, Department of Internal Medicine, Faculty of Medicine, University of Ioannina School of Health Sciences, Ioannina, Greece
| | - Marte L Høivik
- Department of Gastroenterology, Oslo University Hospital, Oslo, Norway; Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | - Zeljko Krznaric
- Department of Gastroenterology, Hepatology and Nutrition, University Hospital Zagreb, Zagreb, Croatia
| | - María Chaparro
- Hospital Universitario de La Princesa, Instituto de Investigación Sanitaria Princesa, Universidad Autónoma de Madrid, Madrid, Spain; Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Madrid, Spain
| | - Edward V Loftus
- Division of Gastroenterology and Hepatology, Mayo Clinic College of Medicine and Science, Rochester, MN, USA
| | - Peter L Lakatos
- Division of Gastroenterology, McGill University Montreal, QC, Canada; Department of Internal Medicine and Oncology, Semmelweis University, Budapest, Hungary
| | - Javier P Gisbert
- Hospital Universitario de La Princesa, Instituto de Investigación Sanitaria Princesa, Universidad Autónoma de Madrid, Madrid, Spain; Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Madrid, Spain
| | - Willem Bemelman
- Department of Surgery, Amsterdam University Medical Centers, Amsterdam, Netherlands
| | - Bjorn Moum
- Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | - Richard B Gearry
- Department of Medicine, University of Otago, Christchurch, New Zealand
| | - Michael D Kappelman
- Division of Pediatric Gastroenterology, Department of Pediatrics and Center for Gastrointestinal Biology and Disease, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Ailsa Hart
- IBD Unit, St Mark's Hospital, Middlesex, UK
| | - Marieke J Pierik
- Department of Internal Medicine, Division of Gastroenterology and Hepatology, Maastricht University Medical Centre, Maastricht, Netherlands
| | - Jane M Andrews
- IBD Service, Department of Gastroenterology and Hepatology, Royal Adelaide Hospital, Adelaide, SA, Australia; Faculty of Health Sciences, University of Adelaide, Adelaide, SA, Australia
| | - Siew C Ng
- Department of Medicine and Therapeutics, Li Ka Shing Institute of Health Sciences, State Key Laboratory of Digestive Disease, Institute of Digestive Disease, The Chinese University of Hong Kong, Hong Kong Special Administrative Region, China
| | - Renata D'Inca
- Department of Surgical, Oncological and Gastroenterological Sciences, University of Padua, Padua, Italy
| | - Pia Munkholm
- Department of Gastroenterology, Copenhagen University Hospital-North Zealand, Hillerød, Denmark
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16
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Mateen B, Patel M, Akobeng A, Gordon M, Hayee B. Systematic review: The effectiveness of 6-thioguanine nucleotide-based dose optimisation of thiopurines in the treatment of inflammatory bowel disease. Wellcome Open Res 2023. [DOI: 10.12688/wellcomeopenres.18846.1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023] Open
Abstract
Introduction: Clinical guidelines highlight the potential utility of metabolite-based thiopurine dose optimisation strategies in inflammatory bowel disease (IBD). The aim of this review was to summarise the evidence of effectiveness and safety of a 6-thioguanine nucleotide (6-TGN) metabolite-based dosing strategy for maintenance of remission using azathioprine or mercaptopurine in Crohn's disease and ulcerative colitis. Methods: We searched the Cochrane central register of controlled trials, EMBASE, clinicaltrials.gov, the WHO international clinical trials registry platform, and relevant grey literature, up to 1 December 2021. Inclusion criteria were: all randomised (active comparator) controlled trials of azathioprine or mercaptopurine used for the purposes of maintenance of remission in Crohn's disease or ulcerative colitis where the dose in the intervention arm was optimised based on 6-TGN metabolite assay results. Studies of any duration were eligible for inclusion, and no age restrictions were applied. Results: No studies met the eligibility criteria for this review. Four randomised controlled studies (two of which are currently underway) were identified that assessed the effectiveness of metabolite-based dose optimisation for thiopurine therapy, but were not eligible either because they did not differentiate between induction and maintenance therapy or because of a lack of an appropriate active comparator. Conclusions: There is no RCT-based evidence for dose optimisation using a 6-TGN metabolite-based dosing strategy for maintenance of remission in Crohn's disease or ulcerative colitis. Where evidence is available from combination induction and maintenance trials, it suggests that such a strategy is no better than weight-based dosing. Cochrane protocol registration: CD014795
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Sharma V, Kedia S, Ahuja V. Personalized medicine to implementation science: Thiopurines set for the leap. JGH Open 2022; 6:651-657. [PMID: 36262539 PMCID: PMC9575323 DOI: 10.1002/jgh3.12829] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2022] [Revised: 09/29/2022] [Accepted: 09/30/2022] [Indexed: 11/07/2022]
Affiliation(s)
- Vishal Sharma
- Department of GastroenterologyPostgraduate Institute of Medical Education and ResearchChandigarhIndia
| | - Saurabh Kedia
- Department of Gastroenterology and Human NutritionAll India Institute of Medical SciencesDelhiIndia
| | - Vineet Ahuja
- Department of Gastroenterology and Human NutritionAll India Institute of Medical SciencesDelhiIndia
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18
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Maintenance therapy for acute lymphoblastic leukemia: basic science and clinical translations. Leukemia 2022; 36:1749-1758. [PMID: 35654820 PMCID: PMC9252897 DOI: 10.1038/s41375-022-01591-4] [Citation(s) in RCA: 57] [Impact Index Per Article: 19.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2022] [Revised: 04/27/2022] [Accepted: 04/28/2022] [Indexed: 01/21/2023]
Abstract
Maintenance therapy (MT) with oral methotrexate (MTX) and 6-mercaptopurine (6-MP) is essential for the cure of acute lymphoblastic leukemia (ALL). MTX and 6-MP interfere with nucleotide synthesis and salvage pathways. The primary cytotoxic mechanism involves the incorporation of thioguanine nucleotides (TGNs) into DNA (as DNA-TG), which may be enhanced by the inhibition of de novo purine synthesis by other MTX/6-MP metabolites. Co-medication during MT is common. Although Pneumocystis jirovecii prophylaxis appears safe, the benefit of glucocorticosteroid/vincristine pulses in improving survival and of allopurinol to moderate 6-MP pharmacokinetics remains uncertain. Numerous genetic polymorphisms influence the pharmacology, efficacy, and toxicity (mainly myelosuppression and hepatotoxicity) of MTX and thiopurines. Thiopurine S-methyltransferase (encoded by TPMT) decreases TGNs but increases methylated 6-MP metabolites (MeMPs); similarly, nudix hydrolase 15 (encoded by NUDT15) also decreases TGNs available for DNA incorporation. Loss-of-function variants in both genes are currently used to guide MT, but do not fully explain the inter-patient variability in thiopurine toxicity. Because of the large inter-individual variations in MTX/6-MP bioavailability and metabolism, dose adjustments are traditionally guided by the degree of myelosuppression, but this does not accurately reflect treatment intensity. DNA-TG is a common downstream metabolite of MTX/6-MP combination chemotherapy, and a higher level of DNA-TG has been associated with a lower relapse hazard, leading to the development of the Thiopurine Enhanced ALL Maintenance (TEAM) strategy-the addition of low-dose (2.5-12.5 mg/m2/day) 6-thioguanine to the 6-MP/MTX backbone-that is currently being tested in a randomized ALLTogether1 trial (EudraCT: 2018-001795-38). Mutations in the thiopurine and MTX metabolism pathways, and in the mismatch repair genes have been identified in early ALL relapses, providing valuable insights to assist the development of strategies to detect imminent relapse, to facilitate relapse salvage therapy, and even to bring about changes in frontline ALL therapy to mitigate this relapse risk.
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Turbayne AK, Sparrow MP. Low-Dose Azathioprine in Combination with Allopurinol: The Past, Present and Future of This Useful Duo. Dig Dis Sci 2022; 67:5382-5391. [PMID: 36242689 PMCID: PMC9652213 DOI: 10.1007/s10620-022-07719-x] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/23/2022] [Accepted: 10/03/2022] [Indexed: 01/05/2023]
Abstract
The inflammatory bowel diseases (IBD) are complex immune-mediated inflammatory diseases that are associated with significant morbidity around the world. As our understanding of IBD, and other immune-mediated inflammatory diseases, advances the number of therapeutic targets has increased which has rapidly driven the development and introduction of new therapies. While these new therapies have shown promise they come with the significant drawback of high costs. For many IBD patients around the world the cost of newer therapies is prohibitive which means treating clinicians often need to turn to optimising simpler, older, and inexpensive medications. The concept of optimising well established cheaper medications is not unique to the management of IBD as health systems all over the world look to reduce costs while simultaneously improving patient outcomes. Despite thiopurines being used in the management IBD for over 60 years, many clinicians are still hesitant to use them due to perceptions around limited efficacy and poor tolerance. One method identified to potentially increase utilisation of thiopurines involves the coadministration of allopurinol. In this review we will explore the history, pharmacology, recent studies and give recommendations for the utilisation of the usual duo of azathioprine combined with allopurinol.
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Affiliation(s)
- Alexander Keith Turbayne
- grid.1623.60000 0004 0432 511XDepartment of Gastroenterology, Alfred Hospital, 55 Commercial Road, Melbourne, VIC 3004 Australia
| | - Miles Patrick Sparrow
- grid.1623.60000 0004 0432 511XDepartment of Gastroenterology, Alfred Hospital, 55 Commercial Road, Melbourne, VIC 3004 Australia ,grid.1002.30000 0004 1936 7857Monash University, Clayton, Melbourne, VIC 3800 Australia
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