Abstract | BACKGROUND:
6-Mercaptopurine (6-MP) is an effective maintenance medication in patients with ulcerative colitis (UC), but toxic effects like myelosuppression limit its clinical benefit. In the blood, 6-thioguanine (6-TGN) is formed from 6-MP and mediates the therapeutic efficacy and most of the toxicities of 6-MP. The level of 6-TGN depends on the activity of thiopurine methyltransferase (TPMT), inherited as 1 of its 3 polymorphic forms with low, moderate, or normal/high activity. Accordingly, the 6-MP dose needs to be pharmacogenetically guided. METHODS: Patients with quiescent UC received 6-MP as maintenance therapy and 6-TGN was assayed as its concentrations in red blood cells (RBCs) done by high-performance liquid chromatography. In a preliminary investigation, 30 mg/day 6-MP (n = 50) was given orally over 12 weeks to determine the time course of blood 6-TGN level. Then 257 patients were given 6-MP at 15-80 mg/day in a stepwise manner based on RBC 6-TGN, white blood cell count, and body weight to monitor 6-MP efficacy and safety profiles. RESULTS: At 30 mg/day 6-MP, RBC 6-TGN peaked over 4-8 weeks. In the main dosing study, the mean RBC 6-TGN level in patients who remained in remission during the 1-year observation time (n = 151) was 322.3 +/- 119.5 pmole/8 x 10(8) RBC versus 204.8 +/- 78.7 pmole/8 x 10(8) RBC in patients (n = 19) who relapsed (P < 0.001). Bone marrow suppression was seen almost exclusively at high 6-TGN concentration ranges. Further, a regression plot showed an inverse relationship between 6-TGN levels in RBC and TPMT enzyme activity. CONCLUSIONS: By regularly measuring RBC 6-TGN in patients with quiescent UC receiving 6-MP as maintenance therapy, we could monitor bone marrow suppression as well as other toxic side effects. Potentially, this strategy should enable physicians to avoid thiopurine-related adverse effects and identify individuals who may benefit most from 6-MP maintenance therapy.
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Authors | Hiroyuki Hanai, Takayuki Iida, Ken Takeuchi, Osamu Arai, Fumitoshi Watanabe, Jinrou Abe, Yasuhiko Maruyama, Akihiko Oohata, Kentarou Ikeya, Masanobu Kageoka, Ichita Miwa, Satou Yoshirou, Yoshisuke Hosoda, Takahiro Kubota |
Journal | Inflammatory bowel diseases
(Inflamm Bowel Dis)
Vol. 16
Issue 8
Pg. 1376-81
(Aug 2010)
ISSN: 1536-4844 [Electronic] England |
PMID | 20049951
(Publication Type: Journal Article, Randomized Controlled Trial)
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Chemical References |
- Immunosuppressive Agents
- Mesalamine
- Prednisolone
- Mercaptopurine
- Methyltransferases
- thiopurine methyltransferase
- Thioguanine
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Topics |
- Adolescent
- Adult
- Aged
- Bone Marrow
(drug effects)
- Bone Marrow Diseases
(chemically induced)
- Colitis, Ulcerative
(drug therapy)
- Drug Monitoring
- Erythrocytes
(chemistry, drug effects)
- Humans
- Immunosuppressive Agents
(administration & dosage, adverse effects, pharmacokinetics)
- Leukapheresis
- Mercaptopurine
(administration & dosage, adverse effects, pharmacokinetics)
- Mesalamine
(therapeutic use)
- Methyltransferases
(analysis, genetics)
- Middle Aged
- Prednisolone
(therapeutic use)
- Thioguanine
(blood)
- Treatment Outcome
- Young Adult
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