Hypoxanthine guanine phosphoribosyltransferase activity is related to 6-thioguanine nucleotide concentrations and thiopurine-induced leukopenia in the treatment of inflammatory bowel disease
Liang Ding PhD
Institute of Clinical Pharmacology, School of Pharmaceutical Sciences, Sun Yat-sen University, Guangzhou, PR China
Search for more papers by this authorFang-bin Zhang MD
Department of Gastroenterology, First Affiliated Hospital, Sun Yat-sen University, Guangzhou, PR China
Search for more papers by this authorHui Liu MS
Institute of Clinical Pharmacology, School of Pharmaceutical Sciences, Sun Yat-sen University, Guangzhou, PR China
Search for more papers by this authorXiang Gao MD
Department of Gastroenterology, First Affiliated Hospital, Sun Yat-sen University, Guangzhou, PR China
Search for more papers by this authorHui-chang Bi PhD
Institute of Clinical Pharmacology, School of Pharmaceutical Sciences, Sun Yat-sen University, Guangzhou, PR China
Search for more papers by this authorXue-ding Wang PhD
Institute of Clinical Pharmacology, School of Pharmaceutical Sciences, Sun Yat-sen University, Guangzhou, PR China
Search for more papers by this authorBai-li Chen MD
Department of Gastroenterology, First Affiliated Hospital, Sun Yat-sen University, Guangzhou, PR China
Search for more papers by this authorYu Zhang PhD
Institute of Clinical Pharmacology, School of Pharmaceutical Sciences, Sun Yat-sen University, Guangzhou, PR China
Search for more papers by this authorLi-zi Zhao PhD
Institute of Clinical Pharmacology, School of Pharmaceutical Sciences, Sun Yat-sen University, Guangzhou, PR China
Search for more papers by this authorGuo-ping Zhong PhD
Institute of Clinical Pharmacology, School of Pharmaceutical Sciences, Sun Yat-sen University, Guangzhou, PR China
Search for more papers by this authorPin-jin Hu MD
Department of Gastroenterology, First Affiliated Hospital, Sun Yat-sen University, Guangzhou, PR China
Search for more papers by this authorMin-hu Chen MD
Department of Gastroenterology, First Affiliated Hospital, Sun Yat-sen University, Guangzhou, PR China
Search for more papers by this authorCorresponding Author
Ming Huang PhD
Institute of Clinical Pharmacology, School of Pharmaceutical Sciences, Sun Yat-sen University, Guangzhou, PR China
School of Pharmaceutical Sciences, Sun Yat-sen University, 132 East Circle at University City, Guangzhou 510006, P.R. ChinaSearch for more papers by this authorLiang Ding PhD
Institute of Clinical Pharmacology, School of Pharmaceutical Sciences, Sun Yat-sen University, Guangzhou, PR China
Search for more papers by this authorFang-bin Zhang MD
Department of Gastroenterology, First Affiliated Hospital, Sun Yat-sen University, Guangzhou, PR China
Search for more papers by this authorHui Liu MS
Institute of Clinical Pharmacology, School of Pharmaceutical Sciences, Sun Yat-sen University, Guangzhou, PR China
Search for more papers by this authorXiang Gao MD
Department of Gastroenterology, First Affiliated Hospital, Sun Yat-sen University, Guangzhou, PR China
Search for more papers by this authorHui-chang Bi PhD
Institute of Clinical Pharmacology, School of Pharmaceutical Sciences, Sun Yat-sen University, Guangzhou, PR China
Search for more papers by this authorXue-ding Wang PhD
Institute of Clinical Pharmacology, School of Pharmaceutical Sciences, Sun Yat-sen University, Guangzhou, PR China
Search for more papers by this authorBai-li Chen MD
Department of Gastroenterology, First Affiliated Hospital, Sun Yat-sen University, Guangzhou, PR China
Search for more papers by this authorYu Zhang PhD
Institute of Clinical Pharmacology, School of Pharmaceutical Sciences, Sun Yat-sen University, Guangzhou, PR China
Search for more papers by this authorLi-zi Zhao PhD
Institute of Clinical Pharmacology, School of Pharmaceutical Sciences, Sun Yat-sen University, Guangzhou, PR China
Search for more papers by this authorGuo-ping Zhong PhD
Institute of Clinical Pharmacology, School of Pharmaceutical Sciences, Sun Yat-sen University, Guangzhou, PR China
Search for more papers by this authorPin-jin Hu MD
Department of Gastroenterology, First Affiliated Hospital, Sun Yat-sen University, Guangzhou, PR China
Search for more papers by this authorMin-hu Chen MD
Department of Gastroenterology, First Affiliated Hospital, Sun Yat-sen University, Guangzhou, PR China
Search for more papers by this authorCorresponding Author
Ming Huang PhD
Institute of Clinical Pharmacology, School of Pharmaceutical Sciences, Sun Yat-sen University, Guangzhou, PR China
School of Pharmaceutical Sciences, Sun Yat-sen University, 132 East Circle at University City, Guangzhou 510006, P.R. ChinaSearch for more papers by this authorAbstract
Background:
Thiopurine drugs are widely used in the treatment of inflammatory bowel disease (IBD). The polymorphic enzyme thiopurine S-methyltransferase (TPMT) is of importance for thiopurine metabolism and adverse events occurrence. The role of other thiopurine-metabolizing enzymes is less well known. This study investigated the effects of TPMT and hypoxanthine guanine phosphoribosyltransferase (HPRT) activities on 6-thioguanine nucleotides (6-TGNs) concentrations and thiopurine-induced leukopenia in patients with IBD.
Methods:
Clinical data and blood samples were collected from 120 IBD patients who were receiving azathioprine (AZA)/6-mercaptopurine (6-MP) therapy. Erythrocyte TPMT, HPRT activities and 6-TGNs concentrations were determined. HPRT activity and its correlation with TPMT activity, 6-TGNs level, and leukopenia were evaluated.
Results:
The HPRT activity of all patients ranged from 1.63–3.33 (2.31 ± 0.36) μmol/min per g Hb. HPRT activity was significantly higher in patients with leukopenia (27, 22.5%) than without (P < 0.001). A positive correlation between HPRT activity and 6-TGNs concentration was found in patients with leukopenia (r = 0.526, P = 0.005). Patients with HPRT activity > 2.70 μmol/min per g Hb could have an increased risk of developing leukopenia (odds ratio = 7.47, P < 0.001). No correlation was observed between TPMT activity and HPRT activity, 6-TGNs concentration, or leukopenia.
Conclusions:
High levels of HPRT activity could be a predictor of leukopenia and unsafe 6-TGN concentrations in patients undergoing AZA/6-MP therapy. This could partly explain the therapeutic response or toxicity that could not be adequately explained by the polymorphisms of TPMT. (Inflamm Bowel Dis 2011;)
REFERENCES
- 1 Sandborn W, Sutherland L, Pearson D, et al. Azathioprine or 6-mercaptopurine for inducing remission of Crohn's disease. Cochrane Database System Rev (Online). 2000; CD000545.
- 2 Pearson DC, May GR, Fick G, et al. Azathioprine for maintaining remission of Crohn's disease. Cochrane Database System Rev (Online). 2000; CD000067.
- 3 Timmer A, McDonald JW, Macdonald JK. Azathioprine and 6-mercaptopurine for maintenance of remission in ulcerative colitis. Cochrane Database System Rev (Online). 2007; CD000478.
- 4 Adler DJ, Korelitz BI. The therapeutic efficacy of 6-mercaptopurine in refractory ulcerative colitis. Am J Gastroenterol. 1990; 85: 717–722.
- 5 Sandborn WJ. Azathioprine: state of the art in inflammatory bowel disease. Scand J Gastroenterol. 1998; 225: 92–99.
- 6 Jharap B, Seinen ML, de Boer NK, et al. Thiopurine therapy in inflammatory bowel disease patients: analyses of two 8-year intercept cohorts. Inflamm Bowel Dis. 2010; 16: 1541–1549.
- 7 Chalmers AH. Studies on the mechanism of formation of 5-mercapto-1-methyl-4-nitroimidazole, a metabolite of the immunosuppressive drug azathioprine. Biochem Pharmacol. 1974; 23: 1891–1901.
- 8 Krynetskaia NF, Krynetski EY, Evans WE. Human RNase H-mediated RNA cleavage from DNA-RNA duplexes is inhibited by 6-deoxythioguanosine incorporation into DNA. Mol Pharmacol. 1999; 56: 841–848.
- 9 Tiede I, Fritz G, Strand S, et al. CD28-dependent Rac1 activation is the molecular target of azathioprine in primary human CD4+ T lymphocytes. J Clin Investig. 2003; 111: 1133–1145.
- 10 Thomas CW, Myhre GM, Tschumper R, et al. Selective inhibition of inflammatory gene expression in activated T lymphocytes: a mechanism of immune suppression by thiopurines. J Pharmacol Exp Ther. 2005; 312: 537–545.
- 11 Dubinsky MC, Lamothe S, Yang HY, et al. Pharmacogenomics and metabolite measurement for 6-mercaptopurine therapy in inflammatory bowel disease. Gastroenterology. 2000; 118: 705–713.
- 12 Cuffari C, Hunt S, Bayless T. Utilisation of erythrocyte 6-thioguanine metabolite levels to optimise azathioprine therapy in patients with inflammatory bowel disease. Gut. 2001; 48: 642–646.
- 13 Herrlinger KR, Kreisel W, Schwab M, et al. 6-Thioguanine—efficacy and safety in chronic active Crohn's disease. Aliment Pharmacol Ther. 2003; 17: 503–508.
- 14 Gearry RB, Barclay ML. Azathioprine and 6-mercaptopurine pharmacogenetics and metabolite monitoring in inflammatory bowel disease. J Gastroenterol Hepatol. 2005; 20: 1149–1157.
- 15 Sandborn WJ. A review of immune modifier therapy for inflammatory bowel disease: azathioprine, 6-mercaptopurine, cyclosporine, and methotrexate. Am J Gastroenterol. 1996; 91: 423–433.
- 16 Schaeffeler E, Lang T, Zanger UM, et al. High-throughput genotyping of thiopurine S-methyltransferase by denaturing HPLC. Clin Chem. 2001; 47: 548–555.
- 17 Schaeffeler E, Fischer C, Brockmeier D, 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: 407–417.
- 18 Dubinsky MC, Reyes E, Ofman J, et al. A cost-effectiveness analysis of alternative disease management strategies in patients with Crohn's disease treated with azathioprine or 6-mercaptopurine. Am J Gastroenterol. 2005; 100: 2239–2247.
- 19 Sayani FA, Prosser C, Begg EJ, et al. Thiopurine methyltransferase may differ three-fold. Clin Gastroenterol. 2008; 6: 147–151.
- 20 Colombel JF, Ferrari N, Debuysere H, et al. Genotypic analysis of thiopurine S-methyltransferase in patients with Crohn's disease and severe myelosuppression during azathioprine therapy. Gastroenterology. 2000; 118: 1025–1030.
- 21 Gisbert JP, Luna M, Mate J, et al. Choice of azathioprine or 6-mercaptopurine dose based on thiopurine methyltransferase (TPMT) activity to avoid myelosuppression. A prospective study. Hepato-gastroenterology. 2006; 53: 399–404.
- 22 Seegmiller JE, Rosenbloom FM, Kelley WN. Enzyme defect associated with a sex-linked human neurological disorder and excessive purine synthesis. Science. 1967; 155: 1682–1684.
- 23 Kelley WN, Rosenbloom FM, Henderson JF, et al. A specific enzyme defect in gout associated with overproduction of uric acid. Proc Natl Acad Sci U S A. 1967; 57: 1735–1739.
- 24 Lennard-Jones JE. Classification of inflammatory bowel disease. Scand J Gastroenterol. 1989; 170: 2–6; discussion 16–19.
- 25 Silverberg MS, Satsangi J, Ahmad T, et al. Toward an integrated clinical, molecular and serological classification of inflammatory bowel disease: report of a Working Party of the 2005 Montreal World Congress of Gastroenterology. Can J Gastroenterol. 2005; 19( suppl A): 5–36.
- 26 Sakuma R, Nishina T, Kitamura M, et al. Screening for adenine and hypoxanthine phosphoribosyltransferase deficiencies in human erythrocytes by high-performance liquid chromatography. Clin Chim Acta. 1987; 170: 281–289.
- 27 Zhang JP, Guan YY, Wu JH, et al. Phenotyping and genotyping study of thiopurine S-methyltransferase in healthy Chinese children: a comparison of Han and Yao ethnic groups. Br J Clin Pharmacol. 2004; 58: 163–168.
- 28 Dervieux T, Boulieu R. Simultaneous determination of 6-thioguanine and methyl 6-mercaptopurine nucleotides of azathioprine in red blood cells by HPLC. Clin Chem. 1998; 44: 551–555.
- 29 Evans WE. Pharmacogenetics of thiopurine S-methyltransferase and thiopurine therapy. Ther Drug Monitor. 2004; 26: 186–191.
- 30 Nicolas O, Farenc C, Calas M, et al. Quantification of antimalarial bisthiazolium compounds and their neutral bioprecursors in plasma by liquid chromatography-electrospray mass spectrometry. Clin Chem. 2005; 51: 593–602.
- 31 Gardiner SJ, Gearry RB, Begg EJ, et al. Thiopurine dose in intermediate and normal metabolizers of thiopurine methyltransferase may differ three-fold. Clin Gastroenterol Hepatol. 2008; 6: 654–660; quiz 604.
- 32 Krynetski EY, Evans WE. Genetic polymorphism of thiopurine S-methyltransferase: molecular mechanisms and clinical importance. Pharmacology. 2000; 61: 136–146.
- 33 Lennard L. TPMT in the treatment of Crohn's disease with azathioprine. Gut. 2002; 51: 143–146.
- 34 Kubota T, Chiba K. Frequencies of thiopurine S-methyltransferase mutant alleles (TPMT*2, *3A, *3B and *3C) in 151 healthy Japanese subjects and the inheritance of TPMT*3C in the family of a propositus. Br J Clin Pharmacol. 2001; 51: 475–477.
- 35 Collie-Duguid ES, Pritchard SC, Powrie RH, et al. The frequency and distribution of thiopurine methyltransferase alleles in Caucasian and Asian populations. Pharmacogenetics. 1999; 9: 37–42.
- 36 Hindorf U, Peterson C, Almer S. Assessment of thiopurine methyltransferase and metabolite formation during thiopurine therapy: results from a large Swedish patient population. Ther Drug Monit. 2004; 26: 673–678.
- 37 Lennard L, Lilleyman JS. Individualizing therapy with 6-mercaptopurine and 6-thioguanine related to the thiopurine methyltransferase genetic polymorphism. Ther Drug Monit. 1996; 18: 328–334.
- 38 Wong DR, Derijks LJ, den Dulk MO, et al. The role of xanthine oxidase in thiopurine metabolism: a case report. Ther Drug Monit. 2007; 29: 845–848.
- 39 Stocco G, Cheok MH, Crews KR, et al. Genetic polymorphism of inosine triphosphate pyrophosphatase is a determinant of mercaptopurine metabolism and toxicity during treatment for acute lymphoblastic leukemia. Clin Pharmacol Ther. 2009; 85: 164–172.
- 40 Haglund S, Taipalensuu J, Peterson C, et al. IMPDH activity in thiopurine-treated patients with inflammatory bowel disease — relation to TPMT activity and metabolite concentrations. Br J Clin Pharmacol. 2008; 65: 69–77.
- 41 Van Loon JA, Weinshilboum RM. Thiopurine methyltransferase biochemical genetics: human lymphocyte activity. Biochem Genet. 1982; 20: 637–658.
- 42 Szumlanski CL, Honchel R, Scott MC, et al. Human liver thiopurine methyltransferase pharmacogenetics: biochemical properties, liver-erythrocyte correlation and presence of isozymes. Pharmacogenetics. 1992; 2: 148–159.
- 43 Coulthard SA, Howell C, Robson J, et al. The relationship between thiopurine methyltransferase activity and genotype in blasts from patients with acute leukemia. Blood. 1998; 92: 2856–2862.
- 44 McLeod HL, Relling MV, Liu Q, et al. Polymorphic thiopurine methyltransferase in erythrocytes is indicative of activity in leukemic blasts from children with acute lymphoblastic leukemia. Blood. 1995; 85: 1897–1902.
- 45 Wu CH, Lai HM, Yang MC, et al. Identification of a new single-nucleotide mutation on the hypoxanthine-guanine phosphoribosyltransferase gene from 983 cases with gout in Taiwan. J Rheumatol. 2007; 34: 794–797.
- 46 Wilson JM, Young AB, Kelley WN. Hypoxanthine-guanine phosphoribosyltransferase deficiency. The molecular basis of the clinical syndromes. N Engl J Med. 1983; 309: 900–910.
- 47 Peters GJ, Veerkamp JH. Purine and pyrimidine metabolism in peripheral blood lymphocytes. Int J Biochem. 1983; 15: 115–123.
- 48 Lennard L. The clinical pharmacology of 6-mercaptopurine. Eur J Clin Pharmacol. 1992; 43: 329–339.
- 49 van Asseldonk DP, de Boer NK, Smid K, et al. Limited intra-individual variability in hypoxanthine-Guanine phosphoribosyl transferase, thiopurine S-methyl transferase, and xanthine oxidase activity in inflammatory bowel disease patients during 6-thioguanine therapy. Nucleosides Nucleotides Nucleic Acids. 2010; 29: 284–290.
- 50 Palmieri O, Latiano A, Bossa F, et al. Sequential evaluation of thiopurine methyltransferase, inosine triphosphate pyrophosphatase, and HPRT1 genes polymorphisms to explain thiopurines' toxicity and efficacy. Aliment Pharmacol Ther. 2007; 26: 737–745.
- 51 Krynetski E, Evans WE. Drug methylation in cancer therapy: lessons from the TPMT polymorphism. Oncogene. 2003; 22: 7403–7413.
- 52 Gerson SL, Talbot GH, Hurwitz S, et al. Prolonged granulocytopenia: the major risk factor for invasive pulmonary aspergillosis in patients with acute leukemia. Ann Intern Med. 1984; 100: 345–351.
- 53 Derijks LJ, Gilissen LP, Engels LG, et al. Pharmacokinetics of 6-thioguanine in patients with inflammatory bowel disease. Ther Drug Monit. 2006; 28: 45–50.
- 54 Hindorf U, Lyrenas E, Nilsson A, et al. Monitoring of long-term thiopurine therapy among adults with inflammatory bowel disease. Scand J Gastroenterol. 2004; 39: 1105–1112.
- 55 Hindorf U, Lindqvist M, Hildebrand H, et al. Adverse events leading to modification of therapy in a large cohort of patients with inflammatory bowel disease. Aliment Pharmacol Ther. 2006; 24: 331–342.
- 56 Ooi CY, Bohane TD, Lee D, et al. Thiopurine metabolite monitoring in paediatric inflammatory bowel disease. Aliment Pharmacol Ther. 2007; 25: 941–947.
- 57 Wright S, Sanders DS, Lobo AJ, et al. Clinical significance of azathioprine active metabolite concentrations in inflammatory bowel disease. Gut. 2004; 53: 1123–1128.
- 58 Lennard L, Singleton HJ. High-performance liquid chromatographic assay of the methyl and nucleotide metabolites of 6-mercaptopurine: quantitation of red blood cell 6-thioguanine nucleotide, 6-thioinosinic acid and 6-methylmercaptopurine metabolites in a single sample. J Chromatogr. 1992; 583: 83–90.
- 59 Shipkova M, Armstrong VW, Wieland E, et al. Differences in nucleotide hydrolysis contribute to the differences between erythrocyte 6-thioguanine nucleotide concentrations determined by two widely used methods. Clin Chem. 2003; 49: 260–268.
- 60 Lennard L. Commentary on: Differences in nucleotide hydrolysis contribute to the differences between erythrocyte 6-thioguanine nucleotide concentrations determined by two widely used methods. Clin Chem. 2003; 49: 1551; author reply 1551–1552.
- 61 Gearry RB, Barclay ML, Burt MJ, et al. Thiopurine drug adverse effects in a population of New Zealand patients with inflammatory bowel disease. Pharmacoepidemiol Drug Saf. 2004; 13: 563–567.
- 62 Connell WR, Kamm MA, Ritchie JK, et al. Bone marrow toxicity caused by azathioprine in inflammatory bowel disease: 27 years of experience. Gut. 1993; 34: 1081–1085.
- 63 Ansari A, Arenas M, Greenfield SM, et al. Prospective evaluation of the pharmacogenetics of azathioprine in the treatment of inflammatory bowel disease. Aliment Pharmacol Ther. 2008; 28: 973–983.
- 64 Lowry PW, Franklin CL, Weaver AL, et al. Leucopenia resulting from a drug interaction between azathioprine or 6-mercaptopurine and mesalamine, sulphasalazine, or balsalazide. Gut. 2001; 49: 656–664.
- 65 Shah JA, Edwards CM, Probert CS. Should azathioprine and 5-aminosalicylates be coprescribed in inflammatory bowel disease?: an audit of adverse events and outcome. Eur J Gastroenterol Hepatol. 2008; 20: 169–173.
- 66 de Boer NK, Wong DR, Jharap B, et al. Dose-dependent influence of 5-aminosalicylates on thiopurine metabolism. Am J Gastroenterol. 2007; 102: 2747–2753.
- 67 Hande S, Wilson-Rich N, Bousvaros A, et al. 5-Aminosalicylate therapy is associated with higher 6-thioguanine levels in adults and children with inflammatory bowel disease in remission on 6- mercaptopurine or azathioprine. Inflamm Bowel Dis. 2006; 12: 251–257.
- 68 Woodson LC, Ames MM, Selassie CD, et al. Thiopurine methyltransferase. Aromatic thiol substrates and inhibition by benzoic acid derivatives. Mol Pharmacol. 1983; 24: 471–478.
- 69 Szumlanski CL, Weinshilboum RM. Sulphasalazine inhibition of thiopurine methyltransferase: possible mechanism for interaction with 6-mercaptopurine and azathioprine. Br J Clin Pharmacol. 1995; 39: 456–459.
- 70 Lewis LD, Benin A, Szumlanski CL, et al. Olsalazine and 6-mercaptopurine-related bone marrow suppression: a possible drug-drug interaction. Clin Pharmacol Ther. 1997; 62: 464–475.
- 71 Lowry PW, Szumlanski CL, Weinshilboum RM, et al. Balsalazide and azathiprine or 6-mercaptopurine: evidence for a potentially serious drug interaction. Gastroenterology. 1999; 116: 1505–1506.
- 72 Dewit O, Vanheuverzwyn R, Desager JP, et al. Interaction between azathioprine and aminosalicylates: an in vivo study in patients with Crohn's disease. Aliment Pharmacol Ther. 2002; 16: 79–85.
- 73 de Graaf P, de Boer NK, Wong DR, et al. Influence of 5-aminosalicylic acid on 6-thioguanosine phosphate metabolite levels: a prospective study in patients under steady thiopurine therapy. Br J Pharmacol. 2010; 160: 1083–1091.
