Usefulness of Measuring Thiopurine Metabolites in Children with Inflammatory Bowel Disease and Autoimmunological Hepatitis, Treated with Azathioprine

Abstract

Introduction. Thiopurines, such as azathioprine (AZA) and 6-mercaptopurine (6-MP), are immunomodulatory agents, used for the maintenance of remission in children with inflammatory bowel disease (IBD)—Crohn’s disease (CD) and ulcerative colitis (UC), as well as with autoimmunological hepatitis (AIH). Measurements of thiopurine metabolites may allow identifying patients at risk for toxicity and nonadherence. It can also provide an explanation for the ineffectiveness of the treatment, observed in some patients. Patients and Methods. A retrospective analysis was carried out of sixty-eight patients (thirty-six patients with CD, eighteen with UC, and fourteen with AIH), treated with AZA. Thiopurine metabolites, 6-thioguanine nucleotide (6-TGN) and 6-methylmercaptopurine (6-MMP), were assayed by high-performance liquid chromatography (HPLC), and the AZA dose was adjusted when 6-TGN concentration was known. Result. Only twenty-five (41%) children had therapeutic 6-TGN concentrations, ten (16%) subjects had suboptimal 6-TGN concentrations, and twenty-six subjects (43%) had 6-TGN concentrations above the recommended therapeutic range. 6-MMP was not above the therapeutic range in any case. Seven subjects revealed undetectable 6-TGN and 6-MMP levels, indicating nonadherence. The mean AZA dose after the 6-TGN concentration-related adjustment did not differ, in comparison to the initial dose, either in IBD or AIH groups. The mean AZA dose was lower in AIH than in IBD. The subjects with an optimal 6-TGN level presented with a higher ratio of remission (88%) than the under- or overdosed patients (60% and 69%), respectively ( Chi − square test = 3.87 , p < 0.05 ). Conclusion. Timely measurements of thiopurine metabolites can be a useful tool to identify nonadherent patients before a decision is taken to switch to another drug. We may also spot the patients who receive either too low or too high doses, compensating dose deviations in an appropriate way. The patients with optimal 6-TGN levels presented a higher percentage of remission than the under- or overdosed patients. In most patients, both initial and adjusted AZA doses, lower than suggested in guidelines, appeared to be sufficient to maintain remission.

The relationship between 6-thioguanine levels and remission outcomes in children with autoimmune hepatitis. Single center experience

“…In an interesting study, Bąk-Drabik et al . [ 9 ] evaluated the usefulness of measuring thiopurine metabolites in children with inflammatory bowel disease and autoimmune hepatitis treated with azathioprine. Bąk-Drabik et al .…”

“…Bąk-Drabik et al . [ 9 ] found that patients with 6-TG concentrations ranging from 230 to 450 pmol/8 × 10 8 RBC exhibited higher remission rates than the under- or overdosed patients. At the same time, the authors also emphasized that an optimal therapeutic 6-TG level for AIH was not determined [ 9 ].…”

“…In an interesting study, Bąk-Drabik et al [9] evaluated the usefulness of measuring thiopurine metabolites in children with inflammatory bowel disease and autoimmune hepatitis treated with azathioprine. Bąk-Drabik et al [9] found that patients with 6-TG concentrations ranging from 230 to 450 pmol/ 8 × 10 8 RBC exhibited higher remission rates than the under-or overdosed patients. At the same time, the authors also emphasized that an optimal therapeutic 6-TG level for AIH was not determined [9].…”