Tioguanine Explained

Tioguanine, also known as thioguanine or 6-thioguanine (6-TG) or tabloid is a medication used to treat acute myeloid leukemia (AML), acute lymphocytic leukemia (ALL), and chronic myeloid leukemia (CML).[1] Long-term use is not recommended.[1] It is given by mouth.[1]

Common side effects include bone marrow suppression, liver problems and inflammation of the mouth.[1] It is recommended that liver enzymes be checked weekly when on the medication.[1] People with a genetic deficiency in thiopurine S-methyltransferase are at higher risk of side effects.[2] Avoiding pregnancy when on the medication is recommended.[1] Tioguanine is in the antimetabolite family of medications.[2] It is a purine analogue of guanine and works by disrupting DNA and RNA.[3]

Tioguanine was developed between 1949 and 1951.[4] [5] It is on the World Health Organization's List of Essential Medicines.[6]

Medical uses

Side effects

this manifests as:

Hepatic veno-occlusive disease

The major concern that has inhibited the use of thioguanine has been veno-occlusive disease (VOD) and its histological precursor nodular regenerative hyperplasia (NRH). The incidence of NRH with thioguanine was reported as between 33 and 76%.[9] The risk of ensuing VOD is serious and frequently irreversible so this side effect has been a major concern.However, recent evidence using an animal model for thioguanine-induced NRH/VOD has shown that, contrary to previous assumptions, NRH/VOD is dose dependent and the mechanism for this has been demonstrated.[10] This has been confirmed in human trials, where thioguanine has proven to be safe but efficacious for coeliac disease when used at doses below those commonly prescribed.[11] This has led to a revival of interest in thioguanine because of its higher efficacy and faster action compared to other thiopurines and immunosuppressants such as mycophenylate.[12]

Contraindications

The safety warning against breastfeeding may have been a conservative assessment, but research evidence suggests that thiopurines do not enter breastmilk.[13]

Interactions

Cancers that do not respond to treatment with mercaptopurine do not respond to thioguanine. On the other hand, some cases of IBD that are resistant to mercaptopurine (or its pro-drug azathioprine) may be responsive to thioguanine.

Pharmacogenetics

The enzyme thiopurine S-methyltransferase (TPMT) is responsible for the direct inactivation of thioguanine to its methylthioguanine base – this methylation prevents thioguanine from further conversion into active, cytotoxic thioguanine nucleotide (TGN) metabolites.[14] [15] [16] Certain genetic variations within the TPMT gene can lead to decreased or absent TPMT enzyme activity, and individuals who are homozygous or heterozygous for these types of genetic variations may have increased levels of TGN metabolites and an increased risk of severe bone marrow suppression (myelosuppression) when receiving thioguanine.[14] In many ethnicities, TPMT polymorphisms that result in decreased or absent TPMT activity occur with a frequency of approximately 5%, meaning that about 0.25% of patients are homozygous for these variants.[14] [17] However, an assay of TPMT activity in red blood cells or a TPMT genetic test can identify patients with reduced TPMT activity, allowing for the adjustment of thiopurine dose or avoidance of the drug entirely.[14] [18] The FDA-approved drug label for thioguanine notes that patients who are TPMT-deficient may be prone to developing myelosuppression and that laboratories offer testing for TPMT deficiency.[19] Indeed, testing for TPMT activity is currently one of the few examples of pharmacogenetics being translated into routine clinical care.[20]

Metabolism and pharmacokinetics

A single oral dose of thioguanine has incomplete metabolism, absorption and high interindividual variability. The bioavailability of thioguanine has an average of 30% (range 14-46%). The maximum concentration in plasma after a single oral dose is attained after 8 hours.

Thioguanine, like other thiopurines, is cytotoxic to white cells; as a result it is immunosuppressive at lower doses and anti-leukemic/anti-neoplastic at higher doses. Thioguanine is incorporated into human bone marrow cells, but like other thiopurines, it is not known to cross the blood-brain barrier. Thioguanine cannot be demonstrated in cerebrospinal fluid, similar to the closely related compound 6-mercaptopurine which also cannot penetrate to the brain.

The plasma half-life of thioguanine is short, due to the rapid uptake into liver and blood cells and conversion to 6-TGN. The median plasma half-life of 80-minutes with a range of 25–240 minutes. Thioguanine is excreted primarily through the kidneys in urine, but mainly as a metabolite, 2-amino-6-methylthiopurine. However, the intra-cellular thio-nucleotide metabolites of thioguanine (6-TGN) have longer half-lives and can therefore be measured after thioguanine is eliminated from the plasma.

Thioguanine is catabolized (broken down) via two pathways.[21] One route is through the deamination by the enzyme guanine deaminase to 6-thioxanthine, which has minimal anti-neoplastic activity, then by oxidation by xanthine oxidase of the thioxanthine to thiouric acid. This metabolic pathway is not dependent on the efficacy of xanthine oxidase, so that the inhibitor of xanthine oxidase, the drug allopurinol, does not block the breakdown of thioguanine, in contrast to its inhibition of the breakdown of the related thiopurine 6-mercaptopurine. The second pathway is the methylation of thioguanine to 2-amino-6-methylthiopurine, which is minimally effective as an anti-neoplastic and significantly less toxic than thioguanine. This pathway also is independent of the enzyme activity of xanthine oxidase.

Mechanism of action

6-Thioguanine is a thio analogue of the naturally occurring purine base guanine. 6-thioguanine utilises the enzyme hypoxanthine-guanine phosphoribosyltransferase (HGPRTase) to be converted to 6-thioguanosine monophosphate (TGMP). High concentrations of TGMP may accumulate intracellularly and hamper the synthesis of guanine nucleotides via the enzyme Inosine monophosphate dehydrogenase (IMP dehydrogenase), leading to DNA mutations.[22]

TGMP is converted by phosphorylation to thioguanosine diphosphate (TGDP) and thioguanosine triphosphate (TGTP). Simultaneously deoxyribosyl analogs are formed, via the enzyme ribonucleotide reductase. The TGMP, TGDP and TGTP are collectively named 6-thioguanine nucleotides (6-TGN). 6-TGN are cytotoxic to cells by: (1) incorporation into DNA during the synthesis phase (S-phase) of the cell; and (2) through inhibition of the GTP-binding protein (G protein) Rac1, which regulates the Rac/Vav pathway.[23]

Chemistry

It is a pale yellow, odorless, crystalline powder.

Names

Tioguanine (INN, BAN, AAN), or thioguanine (USAN).

Thioguanine is administered by mouth (as a tablet – 'Lanvis').

Further reading

Notes and References

  1. Book: British National Formulary: BNF 69. 2015. British Medical Association. 978-0-85711-156-2. 69th . 588, 592.
  2. Web site: Tioguanine 40 mg Tablets – Summary of Product Characteristics (SPC) – (eMC). www.medicines.org.uk. 21 December 2016. live. https://web.archive.org/web/20161221233317/https://www.medicines.org.uk/emc/medicine/24687. 21 December 2016.
  3. Book: Baca QJ, Coen DM, Golan DE . Principles of antimicrobial and antineoplastic therapy . Golan DE, Tashjian AH, Armstrong EJ . Principles of Pharmacology: The Pathophysiologic Basis of Drug Therapy. 2011. Lippincott Williams & Wilkins. 978-1-60831-270-2. 686. https://books.google.com/books?id=WM7rvNUcrdsC&pg=PA686. en. live. https://web.archive.org/web/20161221162723/https://books.google.ca/books?id=WM7rvNUcrdsC&pg=PA686. 2016-12-21.
  4. Book: Dubler E . Metal Complexes of Sulfur-Containing Purine Derivatives . Sigel A, Sigel H . Metal Ions in Biological Systems . 32: Interactions of Metal Ions with Nucleotides: Nucleic Acids, and Their Constituents. 1996. CRC Press. 978-0-8247-9549-8. 302. https://books.google.com/books?id=UyGwBFGzQHoC&pg=PA302. en. live. https://web.archive.org/web/20161221162720/https://books.google.ca/books?id=UyGwBFGzQHoC&pg=PA302. 2016-12-21.
  5. Book: Ch. 6. Clinical champions as critical determinants of drug development.. Landau R, Achilladelis B, Scriabine A . Pharmaceutical Innovation: Revolutionizing Human Health. 1999. Chemical Heritage Foundation . 978-0-941901-21-5 . 342. https://books.google.com/books?id=IH4lPs6S1bMC&pg=PA342. en. live. https://web.archive.org/web/20161221232758/https://books.google.ca/books?id=IH4lPs6S1bMC&pg=PA342. 2016-12-21.
  6. Book: ((World Health Organization)) . World Health Organization model list of essential medicines: 21st list 2019 . 2019 . 10665/325771 . World Health Organization . World Health Organization . Geneva . WHO/MVP/EMP/IAU/2019.06. License: CC BY-NC-SA 3.0 IGO . free .
  7. Mason C, Krueger GG . Thioguanine for refractory psoriasis: a 4-year experience . Journal of the American Academy of Dermatology . 44 . 1 . 67–72 . January 2001 . 11148479 . 10.1067/mjd.2001.109296 .
  8. Amodio V, Lamba S, Chilà R, Cattaneo CM, Mussolin B, Corti G, Rospo G, Berrino E, Tripodo C, Pisati F, Bartolini A, Aquilano MC, Marsoni S, Mauri G, Marchiò C, Abrignani S, Di Nicolantonio F, Germano G, Bardelli A . 6 . Genetic and pharmacological modulation of DNA mismatch repair heterogeneous tumors promotes immune surveillance . Cancer Cell . 41 . 1 . 196–209.e5 . January 2023 . 36584674 . 9833846 . 10.1016/j.ccell.2022.12.003 .
  9. Dubinsky MC, Vasiliauskas EA, Singh H, Abreu MT, Papadakis KA, Tran T, Martin P, Vierling JM, Geller SA, Targan SR, Poordad FF . 6 . 6-thioguanine can cause serious liver injury in inflammatory bowel disease patients . Gastroenterology . 125 . 2 . 298–303 . August 2003 . 12891528 . 10.1016/S0016-5085(03)00938-7 .
  10. Oancea I, Png CW, Das I, Lourie R, Winkler IG, Eri R, Subramaniam N, Jinnah HA, McWhinney BC, Levesque JP, McGuckin MA, Duley JA, Florin TH . 6 . A novel mouse model of veno-occlusive disease provides strategies to prevent thioguanine-induced hepatic toxicity . Gut . 62 . 4 . 594–605 . April 2013 . 22773547 . 10.1136/gutjnl-2012-302274 . 29585979 .
  11. Tack GJ, van Asseldonk DP, van Wanrooij RL, van Bodegraven AA, Mulder CJ . Tioguanine in the treatment of refractory coeliac disease--a single centre experience . Alimentary Pharmacology & Therapeutics . 36 . 3 . 274–281 . August 2012 . 22646133 . 10.1111/j.1365-2036.2012.05154.x . 24811114 . free .
  12. Van Asseldonk DP, Oancea I, Jharap B, etal . Is thioguanine-associated sinusoidal obstruction syndrome avoidable? Lessons learned from 6-thioguanine treatment of inflammatory bowel disease and a mouse model. . Journal of the Brazilian Medical Association . 58 . Suppl.1 . S8–13 . March 2012 .
  13. Gardiner SJ, Gearry RB, Roberts RL, Zhang M, Barclay ML, Begg EJ . Exposure to thiopurine drugs through breast milk is low based on metabolite concentrations in mother-infant pairs . British Journal of Clinical Pharmacology . 62 . 4 . 453–456 . October 2006 . 16995866 . 1885151 . 10.1111/j.1365-2125.2006.02639.x .
  14. Relling MV, Gardner EE, Sandborn WJ, Schmiegelow K, Pui CH, Yee SW, Stein CM, Carrillo M, Evans WE, Klein TE . 6 . Clinical Pharmacogenetics Implementation Consortium guidelines for thiopurine methyltransferase genotype and thiopurine dosing . Clinical Pharmacology and Therapeutics . 89 . 3 . 387–391 . March 2011 . 21270794 . 3098761 . 10.1038/clpt.2010.320 .
  15. Zaza G, Cheok M, Krynetskaia N, Thorn C, Stocco G, Hebert JM, McLeod H, Weinshilboum RM, Relling MV, Evans WE, Klein TE, Altman RB . 6 . Thiopurine pathway . Pharmacogenetics and Genomics . 20 . 9 . 573–574 . September 2010 . 19952870 . 3098750 . 10.1097/FPC.0b013e328334338f .
  16. Fujita K, Sasaki Y . Pharmacogenomics in drug-metabolizing enzymes catalyzing anticancer drugs for personalized cancer chemotherapy . Current Drug Metabolism . 8 . 6 . 554–562 . August 2007 . 17691917 . 10.2174/138920007781368890 . live . https://archive.today/20130112103320/http://www.bentham-direct.org/pages/content.php?CDM/2007/00000008/00000006/0002F.SGM . 2013-01-12 .
  17. Book: Mutschler E, Schäfer-Korting M . Arzneimittelwirkungen. 107, 936. de. Stuttgart. Wissenschaftliche Verlagsgesellschaft. 2001. 8th . 978-3-8047-1763-3 .
  18. Payne K, Newman W, Fargher E, Tricker K, Bruce IN, Ollier WE . TPMT testing in rheumatology: any better than routine monitoring? . Rheumatology . 46 . 5 . 727–729 . May 2007 . 17255139 . 10.1093/rheumatology/kel427 . free .
  19. Web site: TABLOID- thioguanine tablet. DailyMed. 17 March 2015.
  20. Wang L, Pelleymounter L, Weinshilboum R, Johnson JA, Hebert JM, Altman RB, Klein TE . Very important pharmacogene summary: thiopurine S-methyltransferase . Pharmacogenetics and Genomics . 20 . 6 . 401–405 . June 2010 . 20154640 . 3086840 . 10.1097/FPC.0b013e3283352860 .
  21. Book: Oncea I, Duley J . Chapter 38. Pharmacogenetics of Thiopurines. . Goodman & Gilman's The Pharmacological Basis of Therapeutics. Brunton LL, Lazo JS, Parker K . McGraw-Hill's Access Medicine (on-line) . 2008 . 11th . Goodman & Gilman's The Pharmacological Basis of Therapeutics .
  22. Evans WE . Pharmacogenetics of thiopurine S-methyltransferase and thiopurine therapy . Therapeutic Drug Monitoring . 26 . 2 . 186–191 . April 2004 . 15228163 . 10.1097/00007691-200404000-00018 . 34015182 .
  23. de Boer NK, van Bodegraven AA, Jharap B, de Graaf P, Mulder CJ . Drug Insight: pharmacology and toxicity of thiopurine therapy in patients with IBD . Nature Clinical Practice. Gastroenterology & Hepatology . 4 . 12 . 686–694 . December 2007 . 18043678 . 10.1038/ncpgasthep1000 . 23686284 .

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