Genotypic analysis of thiopurine S-methyltransferase in patients with Crohn's disease and severe myelosuppression during azathioprine therapy

doi:10.1016/S0016-5085(00)70354-4

Gastroenterology

Volume 118, Issue 6, June 2000, Pages 1025-1030

https://doi.org/10.1016/S0016-5085(00)70354-4 Get rights and content

Abstract

Background & Aims: Myelosuppression in patients with Crohn's disease (CD) treated with azathioprine has been attributed to low activity of thiopurine S-methyltransferase (TPMT). Allelic variants of the TPMT gene responsible for changes in the enzyme activity have been characterized. We investigated the distribution of mutant alleles associated with TPMT deficiency in patients with CD and myelosuppression during azathioprine/6-mercaptopurine therapy. Methods: Forty-one patients with CD were included. They developed leukopenia or thrombocytopenia during azathioprine or 6-mercaptopurine treatment. Polymerase chain reaction–based methods were used to search for mutations associated with TPMT deficiency. Results: Four patients (10%) had 2 mutant alleles associated with TPMT deficiency, 7 (17%) had 1 mutant allele, and 30 (73%) had no known TPMT mutation. The delay between administration of the drug and occurrence of bone marrow toxicity was less than 1.5 months in the 4 patients with 2 mutant alleles, and ranged from 1 to 18 months in patients with 1 mutant allele and from 0.5 to 87 months in patients with normal genotype. Conclusions: Twenty-seven percent of patients with CD and myelosuppression during azathioprine therapy had mutant alleles of the TPMT gene associated with enzyme deficiency. Myelosuppression is more often caused by other factors. Continued monitoring of blood cell counts remains mandatory in patients treated with azathioprine.

GASTROENTEROLOGY 2000;118:1025-1030

Section snippets

Patients

Forty-one patients with Crohn's disease (22 women and 19 men; mean age, 44 years; age range, 18–81 years) were included in the study after ethical committee approval and informed consent had been obtained (Table 1). Cytopenia was defined using the criteria used by Connell et al.² All patients had either leukopenia (white blood cell [WBC] count < 3000/mm³; n = 24) or thrombocytopenia (platelets < 100,000/mm³; n = 3), or both (n = 14), leading to discontinuation of treatment (83% of patients) or

Results

Six previously known TPMT alleles were identified. Three of them were functional alleles: TPMT*1, the wild-type allele of the gene; TPMT*1S, which harbors the silent mutation T474C; and TPMT*1A, which harbors the silent mutation C-178T. The 3 other variants were defective alleles associated with the lack of TPMT activity: TPMT*2, which contains the mutation G238C; TPMT*3A, which combines the 2 mutations G460A and A719G; and TPMT*3C, carrying the single mutation A719G. In addition, a novel

Discussion

Bone marrow suppression caused by AZA/6-MP is not uncommon and can sometimes be severe. Individual variations in susceptibility to AZA/6-MP have been attributed to variable intracellular concentrations of the cytotoxic 6-thioguanine nucleotides: TPMT deficiency could induce severe bone marrow suppression by allowing a higher 6-MP conversion to 6-thioguanine nucleotides.5, 6, 7 There is nevertheless increasing evidence that 6-thioguanine nucleotide levels above a certain threshold are associated

Acknowledgements

The authors thank the Clinical Investigation Centre for technical assistance (CHU Lille–INSERM).

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^☆: Address requests for reprints to: Jean-Frédéric Colombel, Clinique des maladies de l'Appareil Digestif et de la Nutrition, Hôpital Huriez, CHRU Lille, 59037, Lille, France. e-mail: [email protected]; fax: (33) 3-2044-4713.

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Alimentary TractGenotypic analysis of thiopurine S-methyltransferase in patients with Crohn's disease and severe myelosuppression during azathioprine therapy☆,☆☆

Abstract

Section snippets

Patients

Results

Discussion

Acknowledgements

Lancet

6-Mercaptopurine in the management of inflammatory bowel disease: short-and long-term toxicity

Ann Intern Med

Bone marrow toxicity caused by azathioprine in inflammatory bowel disease: 27 years of experience

Gut

Methylation of mercaptopurine, thioguanine, and their nucleotide metabolites by heterologously expressed human thiopurine S-methyltransferase

Mol Pharmacol

Mercaptopurine pharmacogenetics: monogenic inheritance of erythrocyte thiopurine methyltransferase activity

Am J Hum Genet

Thiopurine pharmacogenetics in leukemia: correlation of erythrocyte thiopurine methyltransferase activity and 6-thioguanine nucleotide concentrations

Clin Pharmacol Ther

Azathioprine pharmacogenetics: the relationship between 6-thioguanine nucleotides and thiopurine methyltransferase in patients after heart and kidney transplantation

Eur J Clin Chem Clin Biochem

A single point mutation leading to loss of catalytic activity in human thiopurine S-methyltransferase

Proc Natl Acad Sci U S A

Human thiopurine methyltransferase pharmacogenetics: identification of a novel variant allele (abstr)

J Invest Med

Human thiopurine methyltransferase pharmacogenetics: gene sequence polymorphisms

Clin Pharmacol Ther

Human thiopurine methyltransferase pharmacogenetics: kindred with a terminal exon splice junction mutation that results in loss of activity

J Clin Invest

Thiopurine methyltransferase pharmacogenetics: human gene cloning and characterization of a common polymorphism

DNA Cell Biol

Thiopurine S-methyltransferase deficiency: two nucleotide transitions define the most prevalent mutant allele associated with loss of catalytic activity in Caucasians

Am J Hum Genet

Molecular diagnosis of thiopurine S-methyltransferase deficiency: genetic basis for azathioprine and mercaptopurine intolerance

Ann Intern Med

Detection of known and new mutations in the thiopurine S-methyltransferase gene by singlestrand conformation polymorphism analysis

Hum Mutat

Commonly used techniques in molecular cloning

Genotypic and phenotypic analysis of the polymorphic thiopurine S-methyltransferase gene (TPMT) in a European population

Br J Pharmacol

Isolation of a human thiopurine S-methyltransferase (TPMT) complementary DNA with a single nucleotide transition A719G (TPMT*3C) and its association with loss of TPMT protein and catalytic activity in humans

Clin Pharmacol Ther

Alimentary Tract
Genotypic analysis of thiopurine S-methyltransferase in patients with Crohn's disease and severe myelosuppression during azathioprine therapy☆,☆☆