Thiopurines in Inflammatory Bowel Disease. How to Optimize Thiopurines in the Biologic Era?
Thiopurines have been a cornerstone in the treatment of inflammatory bowel disease (IBD). Although they have been used for more than 50 years, there are still some unsolved issues about their efficacy and, also, some safety concerns, mainly the risk of myelosuppression and life-threatening lymphopro...
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| Formato: | Artículo |
| Lenguaje: | English |
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Frontiers Media S.A.
2021-07-01
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| Colección: | Frontiers in Medicine |
| Materias: | |
| Acceso en línea: | https://www.frontiersin.org/articles/10.3389/fmed.2021.681907/full |
| _version_ | 1831531862064889856 |
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| author | Carla J. Gargallo-Puyuelo Viviana Laredo Fernando Gomollón Fernando Gomollón Fernando Gomollón Fernando Gomollón |
| author_facet | Carla J. Gargallo-Puyuelo Viviana Laredo Fernando Gomollón Fernando Gomollón Fernando Gomollón Fernando Gomollón |
| author_sort | Carla J. Gargallo-Puyuelo |
| collection | DOAJ |
| description | Thiopurines have been a cornerstone in the treatment of inflammatory bowel disease (IBD). Although they have been used for more than 50 years, there are still some unsolved issues about their efficacy and, also, some safety concerns, mainly the risk of myelosuppression and life-threatening lymphoproliferative disorders. Furthermore, the development of biological therapy raises the question whether there is still a role for thiopurines in the IBD treatment algorithm. On the other hand, limited cost and wide availability make thiopurines a reasonable option in settings of limited resources and increasing prevalence of IBD. In fact, there is a growing interest in optimizing thiopurine therapy, since pharmacogenomic findings suggest that a personalized approach based on the genotyping of some molecules involved in its metabolism could be useful to prevent side effects. Polymorphisms of thiopurine methyltransferase enzyme (TPMT) that result in low enzymatic activity have been associated with an increased risk of myelotoxicity, especially in Caucasians; however, in Asians it is assumed that the variants of nudix hydrolase 15 (NUDT15) are more relevant in the development of toxicity. Age is also important, since in elderly patients the risk of complications seems to be increased. Moreover, the primo-infection of Epstein Barr virus and cytomegalovirus under thiopurine treatment has been associated with severe lymphoproliferative disorders. In addition to assessing individual characteristics that may influence thiopurines treatment outcomes, this review also discusses other strategies to optimize the therapy. Low-dose thiopurines combined with allopurinol can be used in hypermethylators and in thiopurine-related hepatotoxicity. The measurement of metabolites could be useful to assess compliance, identify patients at risk of adverse events and also facilitating the management of refractory patients. Thioguanine is also a rescue therapy in patients with toxicity related to conventional thiopurine therapy. Finally, the current indications for thiopurines in monotherapy or in combination with biologics, as well as the optimal duration of treatment, are also reviewed. |
| first_indexed | 2024-12-16T20:43:22Z |
| format | Article |
| id | doaj.art-b42a6e764a434c0dba3ee53edcc5c37e |
| institution | Directory Open Access Journal |
| issn | 2296-858X |
| language | English |
| last_indexed | 2024-12-16T20:43:22Z |
| publishDate | 2021-07-01 |
| publisher | Frontiers Media S.A. |
| record_format | Article |
| series | Frontiers in Medicine |
| spelling | doaj.art-b42a6e764a434c0dba3ee53edcc5c37e2022-12-21T22:17:00ZengFrontiers Media S.A.Frontiers in Medicine2296-858X2021-07-01810.3389/fmed.2021.681907681907Thiopurines in Inflammatory Bowel Disease. How to Optimize Thiopurines in the Biologic Era?Carla J. Gargallo-Puyuelo0Viviana Laredo1Fernando Gomollón2Fernando Gomollón3Fernando Gomollón4Fernando Gomollón5Department of Gastroenterology, University Clinic Hospital Lozano Blesa, Zaragoza, SpainDepartment of Gastroenterology, University Clinic Hospital Lozano Blesa, Zaragoza, SpainDepartment of Gastroenterology, University Clinic Hospital Lozano Blesa, Zaragoza, SpainDepartment of Medicine, Psychiatry and Dermatology, University of Zaragoza, Zaragoza, SpainInstitute for Health Research Aragón (IIS Aragón), Zaragoza, SpainCentro de Investigación Biomédica en Red, Enfermedades Hepáticas y Digestivas, Madrid, SpainThiopurines have been a cornerstone in the treatment of inflammatory bowel disease (IBD). Although they have been used for more than 50 years, there are still some unsolved issues about their efficacy and, also, some safety concerns, mainly the risk of myelosuppression and life-threatening lymphoproliferative disorders. Furthermore, the development of biological therapy raises the question whether there is still a role for thiopurines in the IBD treatment algorithm. On the other hand, limited cost and wide availability make thiopurines a reasonable option in settings of limited resources and increasing prevalence of IBD. In fact, there is a growing interest in optimizing thiopurine therapy, since pharmacogenomic findings suggest that a personalized approach based on the genotyping of some molecules involved in its metabolism could be useful to prevent side effects. Polymorphisms of thiopurine methyltransferase enzyme (TPMT) that result in low enzymatic activity have been associated with an increased risk of myelotoxicity, especially in Caucasians; however, in Asians it is assumed that the variants of nudix hydrolase 15 (NUDT15) are more relevant in the development of toxicity. Age is also important, since in elderly patients the risk of complications seems to be increased. Moreover, the primo-infection of Epstein Barr virus and cytomegalovirus under thiopurine treatment has been associated with severe lymphoproliferative disorders. In addition to assessing individual characteristics that may influence thiopurines treatment outcomes, this review also discusses other strategies to optimize the therapy. Low-dose thiopurines combined with allopurinol can be used in hypermethylators and in thiopurine-related hepatotoxicity. The measurement of metabolites could be useful to assess compliance, identify patients at risk of adverse events and also facilitating the management of refractory patients. Thioguanine is also a rescue therapy in patients with toxicity related to conventional thiopurine therapy. Finally, the current indications for thiopurines in monotherapy or in combination with biologics, as well as the optimal duration of treatment, are also reviewed.https://www.frontiersin.org/articles/10.3389/fmed.2021.681907/fullthiopurinesinflammatory bowel diseasepharmacogenomicstoxicityindicationsoptimize |
| spellingShingle | Carla J. Gargallo-Puyuelo Viviana Laredo Fernando Gomollón Fernando Gomollón Fernando Gomollón Fernando Gomollón Thiopurines in Inflammatory Bowel Disease. How to Optimize Thiopurines in the Biologic Era? Frontiers in Medicine thiopurines inflammatory bowel disease pharmacogenomics toxicity indications optimize |
| title | Thiopurines in Inflammatory Bowel Disease. How to Optimize Thiopurines in the Biologic Era? |
| title_full | Thiopurines in Inflammatory Bowel Disease. How to Optimize Thiopurines in the Biologic Era? |
| title_fullStr | Thiopurines in Inflammatory Bowel Disease. How to Optimize Thiopurines in the Biologic Era? |
| title_full_unstemmed | Thiopurines in Inflammatory Bowel Disease. How to Optimize Thiopurines in the Biologic Era? |
| title_short | Thiopurines in Inflammatory Bowel Disease. How to Optimize Thiopurines in the Biologic Era? |
| title_sort | thiopurines in inflammatory bowel disease how to optimize thiopurines in the biologic era |
| topic | thiopurines inflammatory bowel disease pharmacogenomics toxicity indications optimize |
| url | https://www.frontiersin.org/articles/10.3389/fmed.2021.681907/full |
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