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Kreijne JE, de Vries AC, de Veer RC, Bouma G, Dijkstra G, Voskuil MD, West R, van Moorsel SAW, de Jong DJ, de Boer NK, van der Woude CJ. Limited added value of laboratory monitoring in thiopurine maintenance monotherapy in inflammatory bowel disease patients. Aliment Pharmacol Ther 2020; 51:1353-1364. [PMID: 32342997 DOI: 10.1111/apt.15734] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/08/2019] [Revised: 08/13/2019] [Accepted: 03/25/2020] [Indexed: 12/11/2022]
Abstract
BACKGROUND To timely detect myelotoxicity and hepatotoxicity, laboratory monitoring at 3-month intervals is advised throughout thiopurine maintenance treatment for IBD. However, reported incidence rates of myelotoxicity and hepatotoxicity in maintenance treatment are low. AIM To assess incidence rates and clinical consequences of myelotoxicity and hepatotoxicity in thiopurine maintenance therapy after at least 1 year of thiopurine treatment. METHODS Retrospective analysis of therapy adjustment for laboratory toxicity in adult IBD patients after 12 consecutive months of azathioprine (AZA) or mercaptopurine monotherapy (ie baseline) between 2000 and 2016. Incidence rates of laboratory toxicity (ie myelotoxicity [leucocyte count <4.0 × 10e9/L, and/or platelet count <150 × 10e9/L] and/or hepatotoxicity (gamma-glutamyltransferase [GGT], alkaline phosphatase [AP], ALT and/or AST above ULN, excluding isolated increased AST/AP]) and associated diagnostic procedures and complications were assessed. RESULTS In total, 12,391 laboratory assessments were performed on 1132 patients (56% female, AZA 74%) during 3.3 years of median follow-up. Median monitoring frequency was 3.1 assessments/treatment year. Only 83/12,391 (0.7%) assessments resulted in therapy adjustment, dose reduction in 46 patients, cessation in 28 and allopurinol initiation in nine; risk of therapy adjustment was 1.9% per treatment year. Incidence rates of myelotoxicity were 7.1% (5.1% mild/1.8% moderate/0.1% severe) and hepatotoxicity 5.1% (3.8% mild/1.1% moderate/0.2% severe) per treatment year. Treatment-related complications with concurrent laboratory toxicity occurred in 12 patients (1.1%) and would not have been prevented by monitoring. CONCLUSION Severe laboratory toxicity is uncommon after 1 year of thiopurine monotherapy at 4-month monitoring intervals. Therapy adjustments are rare after detection of laboratory toxicity. After 1 year of thiopurine monotherapy, laboratory monitoring may be lowered to less than a 4-month interval.
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Affiliation(s)
- Joany E Kreijne
- Department of Gastroenterology and Hepatology, Erasmus MC University Medical Center, Rotterdam, The Netherlands
| | - Annemarie C de Vries
- Department of Gastroenterology and Hepatology, Erasmus MC University Medical Center, Rotterdam, The Netherlands
| | - Rozanne C de Veer
- Department of Gastroenterology and Hepatology, Erasmus MC University Medical Center, Rotterdam, The Netherlands
| | - Gerd Bouma
- Department of Gastroenterology and Hepatology, Amsterdam UMC, Vrije Universiteit Amsterdam, AG&M Research Institute, Amsterdam, The Netherlands
| | - Gerard Dijkstra
- Department of Gastroenterology and Hepatology, University of Groningen and University Medical Center Groningen, Groningen, The Netherlands
| | - Michiel D Voskuil
- Department of Gastroenterology and Hepatology, University of Groningen and University Medical Center Groningen, Groningen, The Netherlands
| | - Rachel West
- Department of Gastroenterology and Hepatology, Franciscus Gasthuis & Vlietland, Rotterdam, The Netherlands
| | - Sofia A W van Moorsel
- Department of Pharmacology, Zuyderland Medical Center, Heerlen-Sittard-Geleen, The Netherlands
| | - Dirk J de Jong
- Department of Gastroenterology and Hepatology, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Nanne K de Boer
- Department of Gastroenterology and Hepatology, Amsterdam UMC, Vrije Universiteit Amsterdam, AG&M Research Institute, Amsterdam, The Netherlands
| | - C Janneke van der Woude
- Department of Gastroenterology and Hepatology, Erasmus MC University Medical Center, Rotterdam, The Netherlands
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Shin H, Park S, Lee GW, Koh EH, Kim HY. Parvovirus B19 infection presenting with neutropenia and thrombocytopenia: Three case reports. Medicine (Baltimore) 2019; 98:e16993. [PMID: 31464949 PMCID: PMC6736112 DOI: 10.1097/md.0000000000016993] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/03/2022] Open
Abstract
RATIONALE Parvovirus B19 (PV) infection is usually symptomless and can cause benign, short-lived conditions. Anemia associated with PRCA is the most representative hematologic manifestation, but neutropenia and thrombocytopenia have been rarely reported. PATIENT CONCERNS Three patients were admitted to the hospital with neutropenia and thrombocytopenia. The accompanying symptoms were fever, myalgia, rash, or arthralgia, and all patients were previously healthy. DIAGNOSIS Patients were positive for PV PCR and diagnosed with PV infection. Before the diagnosis of PV infection, 2 patients underwent BM study and almost absence of erythroid progenitor cells in BM aspiration were a clue for the PV infection. Other BM findings were hypocellular marrow and a few hemophagocytic histiocytes. INTERVENTIONS Patients received supportive care with follow-up of CBC. OUTCOMES All 3 patients spontaneously recovered from neutropenia and thrombocytopenia within 3 weeks without severe complications. LESSONS The evaluation of PV infection should be considered in situations where there is neutropenia and thrombocytopenia in healthy individuals even without anemia as a differential diagnosis.
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Affiliation(s)
| | - Sungwoo Park
- Division of Hematology-Oncology, Department of Internal Medicine Gyeongsang National University Hospital, Gyeongsang National University School of Medicine
| | - Gyeong-Won Lee
- Division of Hematology-Oncology, Department of Internal Medicine Gyeongsang National University Hospital, Gyeongsang National University School of Medicine
- Institute of Health Science, Gyeongsang National University, Jinju
| | - Eun-Ha Koh
- Department of Laboratory Medicine
- Institute of Health Science, Gyeongsang National University, Jinju
| | - Hyun-Young Kim
- Department of Laboratory Medicine & Genetics, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
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3
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Tavakoli A, Monavari SH, Mollaei H, Bokharaei-Salim F, Esghaei M, Keyvani H, Ghaffari H. Frequency of human Parvovirus B19 among patients with respiratory infection in Iran. Med J Islam Repub Iran 2018; 32:38. [PMID: 30159289 PMCID: PMC6108257 DOI: 10.14196/mjiri.32.38] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2017] [Indexed: 12/11/2022] Open
Abstract
Background: Human parvovirus B19 was known as one of the possible cause of mild respiratory tract diseases in previous studies. However, there are some reports of acute obstructive respiratory disease and severe pneumonia. The purpose of current study was to assess the prevalence and clinical features of parvovirus B19 in respiratory infection. Methods: This study was conducted on 156 patients diagnosed with respiratory infection at the Iran University of Medical Sciencesaffiliated hospitals. After extraction of viral DNA from swab samples, detection of parvovirus B19 was performed by real-time PCR assay. Results: In 156 patient's samples, parvovirus B19 was found in 8 (5.1 %) cases including 5 males (5.9%) and 3 females (4.1%). The most common clinical symptoms were wheezing (100%), tachypnea (100%), fever (75%) and rhinorrhea/pharyngitis (75%). Conclusion: This is the first attempt to assess the prevalence of parvovirus B19 infection in Iranian patients with respiratory infection. The low frequency of parvovirus B19 detected in our study does not support the role of this virus in the development of respiratory infection. However, further studies are needed to better evaluate the etiological role of parvovirus B19 in respiratory infection.
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Affiliation(s)
- Ahmad Tavakoli
- Department of Virology, Faculty of Medicine, Iran University of Medical Sciences, Tehran, Iran
| | | | - Hamidreza Mollaei
- Department of Microbiology and Virology, Faculty of Medicine, Kerman University of Medical Sciences, Kerman, Iran
| | - Farah Bokharaei-Salim
- Department of Virology, Faculty of Medicine, Iran University of Medical Sciences, Tehran, Iran
| | - Maryam Esghaei
- Department of Virology, Faculty of Medicine, Iran University of Medical Sciences, Tehran, Iran
| | - Hossein Keyvani
- Department of Virology, Faculty of Medicine, Iran University of Medical Sciences, Tehran, Iran
| | - Hadi Ghaffari
- Department of Virology, Faculty of Medicine, Iran University of Medical Sciences, Tehran, Iran
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4
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de Boer NKH, Peyrin-Biroulet L, Jharap B, Sanderson JD, Meijer B, Atreya I, Barclay ML, Colombel JF, Lopez A, Beaugerie L, Marinaki AM, van Bodegraven AA, Neurath MF. Thiopurines in Inflammatory Bowel Disease: New Findings and Perspectives. J Crohns Colitis 2018; 12:610-620. [PMID: 29293971 DOI: 10.1093/ecco-jcc/jjx181] [Citation(s) in RCA: 57] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/20/2017] [Accepted: 12/20/2017] [Indexed: 02/08/2023]
Abstract
Thiopurines, available as azathioprine, mercaptopurine, and thioguanine, are immunomodulating agents primarily used to maintain corticosteroid-free remission in patients with inflammatory bowel disease. To provide a state-of-the-art overview of thiopurine treatment in inflammatory bowel disease, this clinical review critically summarises the available literature, as assessed by several experts in the field of thiopurine treatment and research in inflammatory bowel disease.
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Affiliation(s)
- Nanne K H de Boer
- Department of Gastroenterology and Hepatology, VU University Medical Centre, Amsterdam, The Netherlands
| | - Laurent Peyrin-Biroulet
- Department of Gastroenterology and Hepatology and Inserm U954, Nancy University Hospital, Lorraine University, Vandoeuvre-lès-Nancy, France
| | - Bindia Jharap
- Department of Gastroenterology, Meander Medical Centre, Amersfoort, The Netherlands
| | - Jeremy D Sanderson
- Department of Gastroenterology, Guy's and St Thomas' Hospitals, London, UK
| | - Berrie Meijer
- Department of Gastroenterology and Hepatology, VU University Medical Centre, Amsterdam, The Netherlands
| | - Imke Atreya
- Department of Gastroenterology, Pneumology and Endocrinology, Universitätsklinikum Erlangen, University of Erlangen-Nürnberg, Germany
| | - Murray L Barclay
- Department of Gastroenterology, Christchurch Hospital, Christchurch, New Zealand
| | | | - Anthony Lopez
- Department of Gastroenterology and Hepatology and Inserm U954, Nancy University Hospital, Lorraine University, Vandoeuvre-lès-Nancy, France
| | - Laurent Beaugerie
- Department of Gastroenterology, AP-HP, Hôpital Saint-Antoine,UPMC University, Paris, France
| | | | - Adriaan A van Bodegraven
- Department of Gastroenterology and Hepatology, VU University Medical Centre, Amsterdam, The Netherlands.,Department of Gastroenterology, Geriatrics, Internal and Intensive Care Medicine [Co-MIK], Zuyderland Medical Centre, Heerlen-Sittard-Geleen, The Netherlands
| | - Markus F Neurath
- Department of Gastroenterology, Pneumology and Endocrinology, Universitätsklinikum Erlangen, University of Erlangen-Nürnberg, Germany
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5
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Broekman MMTJ, Coenen MJH, Wanten GJ, van Marrewijk CJ, Klungel OH, Verbeek ALM, Hooymans PM, Guchelaar H, Scheffer H, Derijks LJJ, Wong DR, de Jong DJ. Risk factors for thiopurine-induced myelosuppression and infections in inflammatory bowel disease patients with a normal TPMT genotype. Aliment Pharmacol Ther 2017; 46:953-963. [PMID: 28914446 PMCID: PMC5698717 DOI: 10.1111/apt.14323] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/13/2017] [Revised: 07/09/2017] [Accepted: 08/25/2017] [Indexed: 12/21/2022]
Abstract
BACKGROUND Leucopenia is a common side effect in patients treated with thiopurines. Variants in the thiopurine S-methyltransferase (TPMT) gene are the best-known risk factor, but only explain up to 25% of leucopenia cases. AIM To identify the clinical risk factors for thiopurine-induced leucopenia in patients without a common TPMT variant, and explore if these patients are at increased risk for infections. METHODS Post hoc analysis of the Thiopurine response Optimisation by Pharmacogenetic testing in Inflammatory bowel disease Clinics (TOPIC) trial. For this analysis, patients without a variant in TPMT (*2, *3A or*3C) were included. Uni- and multivariate Cox-proportional hazard models were used to identify risk factors for leucopenia and infections. Leucopenia was defined as a white blood cell (WBC) count <3.0 × 109 /L and infections were classified according to the Common Terminology Criteria for Adverse Events. RESULTS Sixty hundred and ninety-five patients (90.6%) included in the TOPIC-trial had no variant in TPMT, of which 45 (6.5%) developed leucopenia. Median time to leucopenia was 56 (29-112) days. Multivariate analysis showed that use of mercaptopurine compared to azathioprine was associated with leucopenia (hazard ratio [HR] 2.61 [95% CIs, 1.39-4.88; P < .01]) and a higher baseline WBC count was protective (HR 0.80 [95% CIs, 0.71-0.89; P < .01]). Risk factors for infections were older age (per 10 year; HR 2.07 [95% CIs, 1.18-3.63; P = .01]) and concomitant use of biologic drugs (HR 2.15 [95% CIs, 1.14-4.07; P = .02]). CONCLUSIONS Low baseline WBC count and mercaptopurine, due to a relatively higher dose, were risk factors for thiopurine-induced leucopenia in patients without a TPMT variant.
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Affiliation(s)
- M. M. T. J. Broekman
- Department of GastroenterologyRadboud Institute for Molecular Life SciencesRadboud University Medical CenterNijmegenThe Netherlands
| | - M. J. H. Coenen
- Department of Human GeneticsRadboud Institute for Health SciencesRadboud University Medical CenterNijmegenThe Netherlands
| | - G. J. Wanten
- Department of GastroenterologyRadboud Institute for Molecular Life SciencesRadboud University Medical CenterNijmegenThe Netherlands
| | - C. J. van Marrewijk
- Department of Human GeneticsRadboud Institute for Health SciencesRadboud University Medical CenterNijmegenThe Netherlands
| | - O. H. Klungel
- Department of Pharmacoepidemiology and PharmacotherapyUtrecht UniversityUtrechtThe Netherlands
| | - A. L. M. Verbeek
- Department for Health EvidenceRadboud University Medical CenterNijmegenThe Netherlands
| | - P. M. Hooymans
- Department of Clinical Pharmacy, Pharmacology and ToxicologyZuyderland Medical CenterSittard‐GeleenThe Netherlands
| | - H.‐J. Guchelaar
- Department of Clinical Pharmacy and ToxicologyLeiden University Medical CenterLeidenThe Netherlands
| | - H. Scheffer
- Department of Human GeneticsRadboud Institute for Health SciencesRadboud University Medical CenterNijmegenThe Netherlands
| | - L. J. J. Derijks
- Department of Clinical PharmacyMáxima Medical CenterVeldhovenThe Netherlands
| | - D. R. Wong
- Department of Clinical Pharmacy, Pharmacology and ToxicologyZuyderland Medical CenterSittard‐GeleenThe Netherlands
| | - D. J. de Jong
- Department of GastroenterologyRadboud Institute for Molecular Life SciencesRadboud University Medical CenterNijmegenThe Netherlands
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6
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Wong DR, Coenen MJH, Vermeulen SH, Derijks LJJ, van Marrewijk CJ, Klungel OH, Scheffer H, Franke B, Guchelaar HJ, de Jong DJ, Engels LGJB, Verbeek ALM, Hooymans PM. Early Assessment of Thiopurine Metabolites Identifies Patients at Risk of Thiopurine-induced Leukopenia in Inflammatory Bowel Disease. J Crohns Colitis 2017; 11:175-184. [PMID: 27402913 DOI: 10.1093/ecco-jcc/jjw130] [Citation(s) in RCA: 42] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/17/2016] [Revised: 06/10/2016] [Accepted: 06/21/2016] [Indexed: 01/28/2023]
Abstract
BACKGROUND AND AIMS Only a quarter of thiopurine-induced myelotoxicity in inflammatory bowel disease [IBD] patients is related to thiopurine S-methyltransferase deficiency. We determined the predictive value of 6-thioguanine nucleotide [6-TGN] and 6-methylmercaptopurine ribonucleotide [6-MMPR] concentrations 1 week after initiation [T1] for development of leukopenia during the first 8 weeks of thiopurine treatment. METHODS The study was performed in IBD patients starting thiopurine therapy as part of the Dutch randomized controlled TOPIC trial [ClinicalTrials.gov NCT00521950]. Blood samples for metabolite measurement were collected at T1. Leukopenia was defined by leukocyte counts of <3.0 × 109/L. For comparison, patients without leukopenia who completed the 8 weeks on the stable dose were selected from the first 272 patients of the TOPIC trial. RESULTS Thirty-two patients with, and 162 patients without leukopenia were analysed. T1 threshold 6-TGN concentrations of 213 pmol/8 × 108 erythrocytes and 3525 pmol/8 × 108 erythrocytes for 6-MMPR were defined: patients exceeding these values were at increased leukopenia risk (odds ratio [OR] 6.2 [95% CI: 2.8-13.8] and 5.9 [95% CI: 2.7-13.3], respectively). Leukopenia rates were higher in patients treated with mercaptopurine, compared with azathioprine (OR 7.3 [95% CI: 3.1-17.0]), and concurrent anti-TNF therapy (OR 5.1 [95% CI: 1.6-16.4]). Logistic regression analysis of thiopurine type, threshold concentrations, and concurrent anti-tumour necrosis factor [TNF] therapy revealed that elevations of both T1 6-TGN and 6-MMPR resulted in the highest risk for leukopenia, followed by exceeding only the T1 6-MMPR or 6-TGN threshold concentration (area under the curve 0.84 [95% CI: 0.76-0.92]). CONCLUSIONS In ~80% of patients, leukopenia could be explained by T1 6-TGN and/or 6-MMPR elevations. Validation of the predictive model is needed before implementing in clinical practice.
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Affiliation(s)
- Dennis R Wong
- Department of Clinical Pharmacy, Pharmacology and Toxicology, Zuyderland Medical Center, Sittard-Geleen, The Netherlands
| | - Marieke J H Coenen
- Department of Human Genetics, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Sita H Vermeulen
- Department of Human Genetics, Radboud University Medical Center, Nijmegen, The Netherlands.,Department for Health Evidence, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Luc J J Derijks
- Department of Clinical Pharmacy, Máxima Medical Centre, Veldhoven, The Netherlands
| | - Corine J van Marrewijk
- Department of Human Genetics, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Olaf H Klungel
- Division of Pharmacoepidemiology and Clinical Pharmacology, Utrecht Institute of Pharmaceutical Sciences, Utrecht University, The Netherlands
| | - Hans Scheffer
- Department of Human Genetics, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Barbara Franke
- Department of Human Genetics, Radboud University Medical Center, Nijmegen, The Netherlands.,Department of Psychiatry, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Henk-Jan Guchelaar
- Department of Clinical Pharmacy and Toxicology, Leiden University Medical Centre, Leiden, The Netherlands
| | - Dirk J de Jong
- Department of Gastroenterology, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Leopold G J B Engels
- Department of Gastroenterology, Zuyderland Medical Center, Sittard-Geleen, The Netherlands
| | - André L M Verbeek
- Department for Health Evidence, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Piet M Hooymans
- Department of Clinical Pharmacy, Pharmacology and Toxicology, Zuyderland Medical Center, Sittard-Geleen, The Netherlands
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7
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Coenen MJH, de Jong DJ, van Marrewijk CJ, Derijks LJJ, Vermeulen SH, Wong DR, Klungel OH, Verbeek ALM, Hooymans PM, Peters WHM, te Morsche RHM, Newman WG, Scheffer H, Guchelaar HJ, Franke B, Pierik M, Mares W, Hameeteman W, Wahab P, Seinen H, Rijk M, Harkema I, de Bièvre M, Oostenbrug L, Bakker C, Aquarius M, van Deursen C, van Nunen A, Goedhard J, Hamacher M, Gisbertz I, Brenninkmeijer B, Tan A, Aparicio-Pagés M, Witteman E, van Tuyl S, Breumelhof R, Stronkhorst A, Gilissen L, Schoon E, Tjhie-Wensing J, Temmerman A, Nicolaï J, van Bergeijk J, Bac D, Witteman B, Mahmmod N, Uil J, Akol H, Ouwendijk R, van Munster I, Pennings M, De Schryver A, van Ditzhuijsen T, Scheffer R, Römkens T, Schipper D, Bus P, Straathof J, Verhulst M, Boekema P, Kamphuis J, van Wijk H, Salemans J, Vermeijden J, van der Werf S, Verburg R, Spoelstra P, de Vree J, van der Linde K, Jebbink H, Jansen M, Holwerda H, van Bentem N, Kolkman J, Russel M, van Olffen G, Kerbert-Dreteler M, Bargeman M, Götz J, Schröder R, Jansen J, Bos L, Engels L, Romberg-Camps M, Keulen E, van Esch A, Drenth J, van Kouwen M, Wanten G, Bisseling T, Römkens T, van Vugt M, van de Meeberg P, van den Hazel S, Stuifbergen W, Grubben M, de Wit U, Dodemont G, Eichhorn R, van den Brande J, Naber AH, van Soest E, Kingma P, Talstra N, Bruin K, Wolfhagen F, Hommes D, van der Veek P, Hardwick J, Stuyt R, Fidder H, Oldenburg B, Tan T. Identification of Patients With Variants in TPMT and Dose Reduction Reduces Hematologic Events During Thiopurine Treatment of Inflammatory Bowel Disease. Gastroenterology 2015; 149:907-17.e7. [PMID: 26072396 DOI: 10.1053/j.gastro.2015.06.002] [Citation(s) in RCA: 149] [Impact Index Per Article: 16.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/06/2015] [Revised: 04/13/2015] [Accepted: 06/03/2015] [Indexed: 01/11/2023]
Abstract
BACKGROUND & AIMS More than 20% of patients with inflammatory bowel disease (IBD) discontinue thiopurine therapy because of severe adverse drug reactions (ADRs); leukopenia is one of the most serious ADRs. Variants in the gene encoding thiopurine S-methyltransferase (TPMT) alter its enzymatic activity, resulting in higher levels of thiopurine metabolites, which can cause leukopenia. We performed a prospective study to determine whether genotype analysis of TPMT before thiopurine treatment, and dose selection based on the results, affects the outcomes of patients with IBD. METHODS In a study performed at 30 Dutch hospitals, patients were assigned randomly to groups that received standard treatment (control) or pretreatment screening (intervention) for 3 common variants of TPMT (TPMT*2, TPMT*3A, and TPMT*3C). Patients in the intervention group found to be heterozygous carriers of a variant received 50% of the standard dose of thiopurine (azathioprine or 6-mercaptopurine), and patients homozygous for a variant received 0%-10% of the standard dose. We compared, in an intention-to-treat analysis, outcomes of the intervention (n = 405) and control groups (n = 378) after 20 weeks of treatment. Primary outcomes were the occurrence of hematologic ADRs (leukocyte count < 3.0*10(9)/L or reduced platelet count < 100*10(9)/L) and disease activity (based on the Harvey-Bradshaw Index for Crohn's disease [n = 356] or the partial Mayo score for ulcerative colitis [n = 253]). RESULTS Similar proportions of patients in the intervention and control groups developed a hematologic ADR (7.4% vs 7.9%; relative risk, 0.93; 95% confidence interval, 0.57-1.52) in the 20 weeks of follow-up evaluation; the groups also had similar mean levels of disease activity (P = .18 for Crohn's disease and P = .14 for ulcerative colitis). However, a significantly smaller proportion of carriers of the TPMT variants in the intervention group (2.6%) developed hematologic ADRs compared with patients in the control group (22.9%) (relative risk, 0.11; 95% confidence interval, 0.01-0.85). CONCLUSIONS Screening for variants in TPMT did not reduce the proportions of patients with hematologic ADRs during thiopurine treatment for IBD. However, there was a 10-fold reduction in hematologic ADRs among variant carriers who were identified and received a dose reduction, compared with variant carriers who did not, without differences in treatment efficacy. ClinicalTrials.gov number: NCT00521950.
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Affiliation(s)
- Marieke J H Coenen
- Department of Human Genetics, Radboud Institute for Health Sciences, Radboud university medical center, Nijmegen, The Netherlands.
| | - Dirk J de Jong
- Department of Gastroenterology, Radboud Institute for Molecular Life Sciences, Radboud university medical center, Nijmegen, The Netherlands
| | - Corine J van Marrewijk
- Department of Human Genetics, Radboud Institute for Health Sciences, Radboud university medical center, Nijmegen, The Netherlands
| | - Luc J J Derijks
- Department of Clinical Pharmacy, Máxima Medical Centre, Veldhoven, The Netherlands
| | - Sita H Vermeulen
- Department of Human Genetics, Radboud Institute for Health Sciences, Radboud university medical center, Nijmegen, The Netherlands; Radboud Institute for Health Sciences, Radboud university medical center, Nijmegen, The Netherlands
| | - Dennis R Wong
- Department of Clinical Pharmacy and Toxicology, Orbis Medical Center, Sittard-Geleen, The Netherlands
| | - Olaf H Klungel
- Department of Pharmacoepidemiology and Pharmacotherapy, Utrecht Institute of Pharmaceutical Sciences, Utrecht University, Utrecht, The Netherlands
| | - Andre L M Verbeek
- Radboud Institute for Health Sciences, Radboud university medical center, Nijmegen, The Netherlands
| | - Piet M Hooymans
- Department of Clinical Pharmacy and Toxicology, Orbis Medical Center, Sittard-Geleen, The Netherlands
| | - Wilbert H M Peters
- Department of Gastroenterology, Radboud Institute for Molecular Life Sciences, Radboud university medical center, Nijmegen, The Netherlands
| | - Rene H M te Morsche
- Department of Gastroenterology, Radboud Institute for Molecular Life Sciences, Radboud university medical center, Nijmegen, The Netherlands
| | - William G Newman
- Centre for Genomic Medicine, St Mary's Hospital, Manchester Academic Health Science Centre, University of Manchester, Manchester, United Kingdom
| | - Hans Scheffer
- Department of Human Genetics, Donders Centre for Neuroscience, Radboud university medical center, Nijmegen, The Netherlands
| | - Henk-Jan Guchelaar
- Department of Clinical Pharmacy and Toxicology, Leiden University Medical Center, Leiden, The Netherlands
| | - Barbara Franke
- Department of Human Genetics, Donders Centre for Neuroscience, Radboud university medical center, Nijmegen, The Netherlands; Department of Psychiatry, Donders Centre for Neuroscience, Radboud university medical center, Nijmegen, The Netherlands
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Brennan DC, Aguado JM, Potena L, Jardine AG, Legendre C, Säemann MD, Mueller NJ, Merville P, Emery V, Nashan B. Effect of maintenance immunosuppressive drugs on virus pathobiology: evidence and potential mechanisms. Rev Med Virol 2012; 23:97-125. [PMID: 23165654 DOI: 10.1002/rmv.1733] [Citation(s) in RCA: 56] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2012] [Revised: 09/07/2012] [Accepted: 09/20/2012] [Indexed: 12/11/2022]
Abstract
Recent evidence suggesting a potential anti-CMV effect of mTORis is of great interest to the transplant community. However, the concept of an immunosuppressant with antiviral properties is not new, with many accounts of the antiviral properties of several agents over the years. Despite these reports, to date, there has been little effort to collate the evidence into a fuller picture. This manuscript was developed to gather the evidence of antiviral activity of the agents that comprise a typical immunosuppressive regimen against viruses that commonly reactivate following transplant (HHV1 and 2, VZV, EBV, CMV and HHV6, 7, and 8, HCV, HBV, BKV, HIV, HPV, and parvovirus). Appropriate immunosuppressive regimens posttransplant that avoid acute rejection while reducing risk of viral reactivation are also reviewed. The existing literature was disparate in nature, although indicating a possible stimulatory effect of tacrolimus on BKV, potentiation of viral reactivation by steroids, and a potential advantage of mammalian target of rapamycin (mTOR) inhibition in several viral infections, including BKV, HPV, and several herpesviruses.
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Deshpande AR, Abreu MT. Optimizing therapy with 6-mercaptopurine and azathioprine: to measure or not to measure? Therap Adv Gastroenterol 2010; 3:275-9. [PMID: 21180608 PMCID: PMC3002589 DOI: 10.1177/1756283x10376121] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023] Open
Affiliation(s)
- Amar R. Deshpande
- Department of Gastroenterology, University of Miami Miller School of Medicine, Miami, FL, USA
| | - María T. Abreu
- Department of Gastroenterology, University of Miami Miller School of Medicine, PO Box 016960 (D-49), Miami, FL 33101, USA
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Moreira T, Lago P, Salgado M, Pimentel R. Epstein-Barr virus and parvovirus B19 coinfection in a Crohn's disease patient under azathioprine. Inflamm Bowel Dis 2010; 16:905-6. [PMID: 19760779 DOI: 10.1002/ibd.21104] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
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11
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Current awareness: Pharmacoepidemiology and drug safety. Pharmacoepidemiol Drug Saf 2009. [DOI: 10.1002/pds.1846] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
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