Abstract
Background
The thiopurine S-methyltransferase (TPMT)/azathioprine (AZA) gene-drug pair is one of the most well-known pharmacogenetic markers. Despite this, few studies investigated the implementation of TPMT testing and the combined evaluation of genotype and phenotype in multidisciplinary clinical settings where patients are undergoing chronic therapy with AZA.
Methods
A total of 356 AZA-treated patients for chronic autoimmune diseases were enrolled. DNA was isolated from whole blood and the samples were analyzed for the c.460G>A and c.719A>G variants by the restriction fragment length polymorphism (RFLP) technique and sequenced for the c.238G>C variant. The TPMT enzyme activity was determined in erythrocytes by a high-performance liquid chromatography (HPLC) assay.
Results
All the patients enrolled were genotyped while the TPMT enzyme activity was assessed in 41 patients. Clinical information was available on 181 patients. We found no significant difference in the odds of having adverse drug reactions (ADRs) in wild-type patients and variant allele carriers, but the latter had an extra risk of experiencing hematologically adverse events. The enzyme activity was significantly associated to genotype.
Conclusions
TPMT variant allele carriers have an extra risk of experiencing hematologically adverse events compared to wild-type patients. Interestingly, only two out of 30 (6.6%) patients had discordant results between genotype, phenotype and onset of ADRs.
Acknowledgments
This paper is dedicated to the memory of Dr. Silvana Penco.
Author contributions: All the authors have accepted responsibility for the entire content of this submitted manuscript and approved submission.
Research funding: None declared.
Employment or leadership: None declared.
Honorarium: None declared.
Competing interests: The funding organization(s) played no role in the study design; in the collection, analysis, and interpretation of data; in the writing of the report; or in the decision to submit the report for publication.
References
[1] Maltzman JS, Koretzky GA. Azathioprine: old drug, new actions. J Clin Invest 2003;111:1122–4.10.1172/JCI200318384Search in Google Scholar
[2] Liu H, Ding L, Zhang F, Zhang Y, Gao X, Hu P, et al. The impact of glutathione S-transferase genotype and phenotype on the adverse drug reactions to azathioprine in patients with inflammatory bowel diseases. J Pharmacol Sci 2015;129:95–100.10.1016/j.jphs.2015.02.013Search in Google Scholar PubMed
[3] McLeod HL, Siva C. The thiopurine S-methyltransferase gene locus – implications for clinical pharmacogenomics. Pharmacogenomics 2002;3:89–98.10.1517/14622416.3.1.89Search in Google Scholar PubMed
[4] Xin HW, Xiong H, Wu XC, Li Q, Xiong L, Yu AR. Relationships between thiopurines S-methyltransferase polymorphism and azathioprine-related ADR in Chinese renal transplant recipients. Eur J Clin Pharmacol 2009; 65:249–55.10.1007/s00228-008-0589-0Search in Google Scholar PubMed
[5] Szumlanski C, Otterness D, Her C, Lee D, Brandriff B, Kelsell D, et al. Thiopurine methyltransferase pharmacogenetics: human gene cloning and characterization of a common polymorphism. DNA Cell Biol 1996;15:17–30.10.1089/dna.1996.15.17Search in Google Scholar PubMed
[6] Seki T, Tanaka T, Nakamura Y. Genomic structure and multiple single-nucleotide polymorphisms (SNPs) of the thiopurine S-methyltransferase (TPMT) gene. J Hum Genet 2000;45:299–302.10.1007/s100380070020Search in Google Scholar PubMed
[7] TPMT Nomenclature Committee (2017) TPMT alleles. Available at http://www.imh.liu.se/tpmtalleles. Accessed: 8 Nov 2018Search in Google Scholar
[8] Weinshilboum RM, Sladek SL. Mercaptopurine pharmacogenetics: monogenic inheritance of erythrocyte thiopurine methyltransferase activity. Am J Hum Genet 1980;32:651–62Search in Google Scholar
[9] Appell ML, Berg J, Duley J, Evans WE, Kennedy MA, Lennard L, et al. Nomenclature for alleles of the thiopurine methyltransferase gene. Pharmacogen Genomics 2013;23:242–8.10.1097/FPC.0b013e32835f1cc0Search in Google Scholar PubMed PubMed Central
[10] Yates CR, Krynetski EY, Loennechen T, Fessing MY, Tai HL, Pui CH, et al. Molecular diagnosis of thiopurine S-methyltransferase deficiency: genetic basis for azathioprine and mercaptopurine intolerance. Ann Intern Med 1997;126:608–14.10.7326/0003-4819-126-8-199704150-00003Search in Google Scholar PubMed
[11] Zhou S. Clinical pharmacogenomics of thiopurine S-methyltransferase. Curr Clin Pharmacol 2006;1:119–2810.2174/157488406784111627Search in Google Scholar PubMed
[12] Wang L, Pelleymounter L, Weinshilboum R, Johnson JA, Hebert JM, Altman RB, et al. Very important pharmacogene summary: thiopurine S-methyltransferase. Pharmacogenet Genomics 2010;20:401–5.10.1097/FPC.0b013e3283352860Search in Google Scholar PubMed PubMed Central
[13] Relling MV, Gardner EE, Sandborn WJ, Schmiegelow K, Pui C-H, Yee SW, et al. Clinical pharmacogenetics implementation consortium guidelines for thiopurine methyltransferase genotype and thiopurine dosing. Clin Pharmacol Ther 2011;89:387–91.10.1038/clpt.2010.320Search in Google Scholar
[14] Katara P. Single nucleotide polymorphism and its dynamics for pharmacogenomics. Interdiscip Sci Comput Life Sci 2014;6:85–92.10.1007/s12539-013-0007-xSearch in Google Scholar
[15] Kumar A, Purohit R. Computational screening and molecular dynamics simulation of disease associated nsSNPs in CENP-E. Mutat Res 2012;738–739:28–37.10.1016/j.mrfmmm.2012.08.005Search in Google Scholar
[16] Demlova R, Mrkvicova M, Sterba J, Bernatikova H, Stary J, Sukova M, et al. Augmenting clinical interpretability of thiopurine methyltransferase laboratory evaluation. Oncology. 2014;86:152–8.10.1159/000357407Search in Google Scholar
[17] Oselin K, Anier K, Tamm R, Kallassalu K, Mäeorg U. Determination of thiopurines S-methyltransferase (TPMT) activity by comparing various normalization factors: reference values for Estonian population using HPLC-UV assay. J Chromatogr B 2006;834:77–83.10.1016/j.jchromb.2006.02.031Search in Google Scholar
[18] Khalil MN, Erb N, Khalil PN, Escherich G, Janka-Schaub. Interference free and simplyfied liquid chromatography-based determination of thiopurines S-methyltransferase activity in erythrocytes. J Chromatogr B 2005;821:105–11.10.1016/j.jchromb.2005.04.028Search in Google Scholar
[19] Dybkaer R. Unit “katal” for catalytic activity (IUPAC Technical Report). Pure Appl Chem 2001;73:927–31.10.1351/pac200173060927Search in Google Scholar
[20] Szumlanski C, Weinshilboum RM. Sulphasalazine inhibition of thiopurine methyltransferase: possible mechanism for interaction with 6-mercaptopurine and azathioprine. Br J clin Pharmacol 1995;39:456–9.10.1111/j.1365-2125.1995.tb04478.xSearch in Google Scholar
[21] Lewis LD, Benin A, Szumlanski CL, Otterness DM, Lennard L, Weinshilboum RM, et al. Olsalazine and 6-mercaptopurine-related bone marrow suppression: a possible drug-drug interaction. Clin Pharmacol Ther 1997;62:464–75.10.1016/S0009-9236(97)90125-9Search in Google Scholar
[22] Lysaa RA, Giverhaug T, Wold HL, Aarbakke J. Inhibition of human thiopurine methyltransferase by furosemide, bendroflumethiazide and trichlormethiazide. Eur J Clin Pharmacol 1996;49:393–6.10.1007/BF00203784Search in Google Scholar
[23] Blaker PA, Arenas-Hernandez M, Smith MA, Shobowale-Bakre EA, Fairbanks L, Irving PM, et al. Mechanism of allopurinol induced TPMT inhibition. Biochem Pharmacol 2013;86:539–47.10.1016/j.bcp.2013.06.002Search in Google Scholar
[24] Gossmann J, Kachel HG, Schoeppe W, Scheuermann EH. Anemia in renal transplant recipients caused by concomitant therapy with azathioprine and angiotensin-converting enzyme inhibitors. Transplantation 1993;56:585–9.10.1097/00007890-199309000-00018Search in Google Scholar
[25] Case DB, Whitman HH, Laragh JH, Spiera H, Kirchertz EJ, Gröne HJ, et al. Successful low dose captopril rechallenge following drug-induced leucopenia. Lancet 1981;1:1362–3.10.1016/S0140-6736(81)92535-6Search in Google Scholar
[26] Van der Schaft J, van Schaik RH, van den Broek MP, Bruijnzeel-Koomen CA, de Bruin-Weller MS. Increased liver enzyme levels during azathioprine treatment: beware of concomitant use of proton pump inhibitors. Br J Dermatol 2015;173:1338–9.10.1111/bjd.14006Search in Google Scholar PubMed
[27] Stocco G, Martelossi S, Barabino A, Fontana M, Lionetti P, Decorti G, et al. TPMT genotype and the use of thiopurines in paediatric inflammatory bowel disease. Dig Liver Dis 2005;37:940–5.10.1016/j.dld.2005.08.003Search in Google Scholar PubMed
[28] Rossi AM, Bianchi M, Guarnieri C, Barale R, Pacifici GM. Genotype-phenotype correlation for thiopurine S-methyltransferase in healthy Italian subjects. Eur J Clin Pharmacol 2001;57:51–410.1007/s002280000246Search in Google Scholar PubMed
[29] Di Salvo A, Fabiano C, Mannara V, Dimarco M, Orlando A, Affronti M, et al. Frequency of thiopurine methyltransferase mutation in patients of Mediterranean area with inflammatory bowel disease and autoimmune disorders. Dig Liver Dis 2016;48:1506–9.10.1016/j.dld.2016.08.125Search in Google Scholar PubMed
[30] Serpe L, Calvo PL, Muntoni E, D’Antico S, Giaccone M, Avagnina A, et al. Thiopurine S-methyltransferase pharmacogenetics in a large-scale healthy Italian-Caucasian population: differences in enzyme activity. Pharmacogenomics 2009;10:1753–65.10.2217/pgs.09.103Search in Google Scholar PubMed
[31] Bielinski SJ, Olson JE, Pathak J, Weinshilboum RM, Wang L, Lyke KJ, et al. Preemptive genotyping for personalized medicine: design of the right drug, right dose, right time-using genomic data to individualize treatment protocol. Mayo Clin Proc 2002;89:25–33.10.1016/j.mayocp.2013.10.021Search in Google Scholar PubMed PubMed Central
[32] Teng K, DiPiero J, Meese T, Doerr M, Leonard M, Daly T, et al. Cleveland Clinic’s Center for personalized healthcare: setting the stage for value-based care. Pharmacogenomics 2014;15:587–91.10.2217/pgs.14.31Search in Google Scholar PubMed
[33] Van der Wouden CH, Cambon-Thomsen A, Cecchin E, Cheung KC, Dávila-Fajardo CL, Deneer VH, et al. Implementing pharmacogenomics in Europe: design and implementation strategy of the ubiquitous pharmacogenomics consortium. Clin Pharmacol Ther 2017;101:341–58.10.1002/cpt.602Search in Google Scholar PubMed
[34] Liu YP, Wu HY, Yang X, Xu HQ, Li YC, Shi DC, et al. Association between thiopurine S-methyltransferase polymorphisms and thiopurine-induced adverse drug reactions in patients with inflammatory bowel disease: a meta-analysis. PLoS One. 2015;10:e0121745.10.1371/journal.pone.0121745Search in Google Scholar PubMed PubMed Central
[35] Dong XW, Zheng Q, Zhu MM, Tong JL, Ran ZH. Thiopurine S-methyltransferase polymorphisms and thiopurine toxicity in treatment of inflammatory bowel disease. World J Gastroenterol 2010;7:3187–95.10.3748/wjg.v16.i25.3187Search in Google Scholar PubMed PubMed Central
[36] Booth RA, Ansari MT, Loit E, Tricco AC, Weeks L, Doucette S, et al. Assessment of thiopurine s-methyltransferase activity in patients prescribed thiopurines: a systematic review. Ann Intern Med 2011;154:814–23.10.7326/0003-4819-154-12-201106210-00009Search in Google Scholar PubMed
[37] Tamm R, Oselin K, Kallassalu K, Magi R, Anier K, Remm M, et al. Thiopurine S-methyltransferase (TPMT) pharmacogenetics: three new mutations and haplotype analysis in the Estonian population. Clin Chem Lab Med 2008;46:974–9.10.1515/CCLM.2008.187Search in Google Scholar PubMed
[38] Schaeffeler E, Fischer C, Brockmeier D, Wernet D, Moerike K, Eichelbaum M, et al. Comprehensive analysis of thiopurine S-methyltransferase phenotype-genotype correlation in a large population of German-Caucasians and identification of novel TPMT variants. Pharmacogenetics 2004;14:407–17.10.1097/01.fpc.0000114745.08559.dbSearch in Google Scholar PubMed
[39] Salavaggione OE, Wang L, Wiepert M, Yee VC, Weinshilboum RM. Thiopurine S-methyltransferase pharmacogenetics: variant allele functional and comparative genomics. Pharmacogenet Genomics 2005;15:801–15.10.1097/01.fpc.0000174788.69991.6bSearch in Google Scholar PubMed
[40] Liu C, Yang W, Pei D, Cheng C, Smith C, Landier W, et al. Genomewide approach validates thiopurine methyltransferase activity is a monogenic pharmacogenomic trait. Clin Pharmacol Ther 2017;101:373–81.10.1002/cpt.463Search in Google Scholar PubMed PubMed Central
[41] Tamm R, Mägi R, Tremmel R, Winter S, Mihailov E, Smid A, et al. Polymorphic variation in TPMT is the principal determinant of TPMT phenotype: a meta-analysis of three genome-wide association studies. Clin Pharmacol Ther 2017;101:684–95.10.1002/cpt.540Search in Google Scholar PubMed PubMed Central
[42] Coelho T, Andreoletti G, Ashton JJ, Batra A, Afzal NA, Gao Y, et al. Genes implicated in thiopurine-induced toxicity: comparing TPMT enzyme activity with clinical phenotype and exome data in a paediatric IBD cohort. Sci Rep 2016;6:34658.10.1038/srep34658Search in Google Scholar PubMed PubMed Central
[43] Ansari A, Arenas M, Greenfield SM, Morris D, Lindsay J, Gilshenan K, et al. Prospective evaluation of the pharmacogenetics of azathioprine in the treatment of inflammatory bowel disease. Aliment Pharmacol Ther 2008;28:973–83.10.1111/j.1365-2036.2008.03788.xSearch in Google Scholar PubMed
[44] Shah SA, Paradkar MU, Desai DC, Ashavaid TF. Preemptive NUDT15 genotyping: redefining the management of patients with thiopurine-induced toxicity. Drug Metab Pers Ther 2018;33:57–60.10.1515/dmpt-2017-0038Search in Google Scholar PubMed
[45] Dewit O, Vanheuverzwyn R, Desager JP, Horsmans Y. Interaction between azathioprine and aminosalicylates: an in vivo study in patients with Crohn’s disease. Aliment Pharmacol Ther 2002;16:79–85.10.1046/j.1365-2036.2002.01156.xSearch in Google Scholar PubMed
[46] Sanderson J, Ansari A, Marinaki T, Duley J. Thiopurine methyltransferase: should it be measured before commencing thiopurine drug therapy? Ann Clin Biochem 2004;41:294–302.10.1258/0004563041201455Search in Google Scholar PubMed
[47] Ford LT, Berg JD. Thiopurine S-methyltransferase (TPMT) assessment prior to starting thiopurine drug treatment; a pharmacogenomic test whose time has come. J Clin Pathol 2010;63:288–95.10.1136/jcp.2009.069252Search in Google Scholar PubMed
[48] Siegel CA, Sands BE. Review article: practical management of inflammatory bowel disease patients taking immunomodulators. Aliment Pharmacol Ther 2005; 22:1–16.10.1111/j.1365-2036.2005.02520.xSearch in Google Scholar PubMed
[49] DiPiero J, Teng K, Hicks JK. Should thiopurine methyltransferase (TPMT) activity be determined before prescribing azathioprine, mercaptopurine, or thioguanine? Cleve Clin J Med 2015;82:409–13.10.3949/ccjm.82a.14106Search in Google Scholar PubMed
[50] Roy LM, Zur RM, Uleryk E, Carew C, Ito S, Ungar WJ. Thiopurine S-methyltransferase testing for averting drug toxicity in patients receiving thiopurines: a systematic review. Pharmacogenomics 2016;17:633–56.10.2217/pgs.16.12Search in Google Scholar PubMed PubMed Central
©2019 Walter de Gruyter GmbH, Berlin/Boston
