Azathioprine Research Articles

P825 The course of inflammatory bowel disease in setting of liver transplantation

Abstract Background Liver transplantation (LT) remains the only therapeutic option for patients with primary sclerosing cholangitis (PSC) who develop biliary tract complications or cirrhosis. Around 50-80% of PSC patients have IBD which represent phenotypically unique disease. Patients are prone to negative effects of complications of liver disease and immunosuppression, unpredictable course of both diseases and development of neoplasia. Patients are treated according to standard guidelines related to overall IBD population. Methods The study evaluates the IBD course and effects of therapy in PSC transplanted patients. In a period of 2005-October 2022 1453 patients had LT performed at University hospital Merkur, Zagreb, Croatia. 70 (4.8%) of them refers to complications of PSC. 46 (66%) of PSC patients were diagnosed with IBD, majority 43 (93.5%) before LT. Results As expected 36 (78.3%) had ulcerative colitis (UC) while 9 (19.6%) Crohns disease. 31 (70%) were males, median age 35 years (IQR 28-47). 35 (76.1%) patients had no IBD activity at LT, whereas 11 (23.9%) had continuously active IBD in follow up. 18 (51.4%) patients with remission at LT developed relapse (median time 536 days, IQR 371-1234) whereas other 17 (48.6%) have stable remission. Nine (19.6%) patients had malignant disease, 3 (6,5%) cholangiocelular carcinoma in explanted liver, 5 (10,9%) colorectal cancer (CRC) and 1 both tumors. Before LT 24 (52.2%) patients had no specific IBD treatment, whereas 8 (33.3%) were treated with aminosalicilates (AsA), 5 (10.9%) azathioprine (AzA), 6 (13.1%) glucocorticoids (GK) and 3 (6.5%) biologics. After LT 23 (50%) are treated with ASA, 12 (26.1%) AzA and 11 (23.9%) biological therapy (36.4% anti-TNF, 27,3% vedolizumab and 36,4% on multiple biologics). AsA as monotherapy is successful in 63.6% of treated patients, AzA in 50% and biologic therapy 27.3%, respectfully. Even though it did not reach statistical significance, more patients with relapse of IBD after LT are treated with AzA than in group of continuously active disease (33.3 vrs 9.1%) while this is opposite for biologic therapy (27.8 vrs 54.5%). 8 (17.4%) patients were treated with total colectomy, 2 before, 3 during and 3 after LT, 6 due to CRC and 2 intractable IBD. Regrading immunosuppression 42 (91.3%) are treated with tacrolimus, 4 (8.7%) with cyclosporine, 24 (52.2%) with mycophenolate mofetil and 11 (23.9%) prolonged GK. Conclusion Management of IBD in the context of PSC and LT setting is a major clinical challenge and specific guidelines are urgently needed. Since the effectiveness of standard therapy is possibly weaker with a high risk of cancer it is necessary to consider an earlier approach to colectomy.

Association of genetic polymorphism of NUDT15, TPMT and ITPA gene in the toxicity and efficacy of azathioprine-based regimen in Egyptian inflammatory bowel disease patients

BackgroundInflammatory Bowel disease (IBD) is a chronic progressive condition that prompts generous physical and mental morbidity. Choosing the best kind of management and medication dosage prevents new episodes of high disease activity during therapy because of adverse drug reactions (ADRs). This can lead to cessation or inefficacy of the treatment, or complete non-responsiveness to specific medications. Pharmacogenetics (PGx) is a well-established aspect in IBD. One of the exemplary instances of PGx is thiopurines, which are frequently utilized as IBD therapy. This study aimed to evaluate specific gene polymorphism involved in the toxicity and efficacy of Azathioprine (AZA) use in the management in Egyptian patients and to find the correlation between the polymorphism of Nudix Hydrolase15 (NUDT15) gene (rs116855232), The Thiopurine methyltransferase (TPMT) gene (rs1800460) and Inosine Triphosphatase (ITPA) gene (rs1127354) which are involved in the metabolism of the medications utilized in IBD management.MethodsThis prospective study was performed in 150 patients with IBD. All patients were treated with 2 mg/kg per day AZA (Imuran, GlaxoSmithKline®) for at least 3 months at therapeutic doses to induce remission. Subsequent treatment of AZA. The minimum follow-up period for those who did not experience ADR was one year. Among the studied patients, one hundred twenty-nine patients were treated with combination regimen of steroids (oral prednisone 1 mg/kg/day).Also, treatment failure was considered among the patients who could not tolerate AZA side effects, or there was no improvement after dose modification.ResultsThe most identifiable adverse effect among the studied population was anemia followed by leukopenia and myelosuppression. SNPs genotype TPMT (rs1800460) and ITPA gene (rs1127354) were significantly related to adverse effects among IBD patients receiving Azathioprine treatment. There was a lack of any variants in the NUDT15 genotype among the Egyptian population.ConclusionFurther research is required in to clarify the relationship between NUDT15 PGx and AZA-ADRs. The effect of NUDT15 PGx on toxicity and ADRs as yet necessitates to be elucidated. Studies with a larger sample size and involving different ethnicities are also necessary.

P751 Crohn’s Disease Exclusion Diet: A single centre real-life experience

Abstract Background According to ECCO-ESPGHAN consensus guidelines, exclusive enteral nutrition (EEN) is the first line therapy for induction of remission in children with active luminal Crohn’s disease (CD). Steroids may be considered in cases when EEN is not an option. However, adherence to EEN is not ideal. According to various sources it ranges from 50-91 %. This poor adherence is mainly due to palatability and monotony. Many attempts have been made to find an alternative to EEN. One of them is Crohn’s Disease Exclusion Diet (CDED) with partial enteral nutrition (PEN), which shows promising results in efficacy, safety, and adherence. This study evaluates the efficacy of CDED with PEN in a single European centre. Methods Retrospective evaluation of prospectively collected dated of children treated with CDED with PEN between 10/19-11/22. Wellbeing, anthropometric data, and laboratory results were evaluated prior to the commencement of CDED with PEN and at the end of both phases 1 and 2. A mean, median and a standard deviation were calculated were applicable. ANOVA was used for evaluation of presence of statistically significant differences and a P-value ≤ 0.05 was regarded as such. Results CDED with PEN was used in 24 patients. The mean age at diagnosis was 14.6±3.7 years. At the time of evaluation, 21/24 patients have completed phase 1 and 20/24 have completed phase 2. Three patients were still in phase 1 and 1 in phase 2. One patient decided to quit CDED with PEN at the end of phase 1 and 2 more at the end of phase 2. All patients, who started phase 1 completed it, and 95.2% completed phase 2. Non-adherence was recorded in two patients: once in diet composition and twice in PEN volume. At commencement of CDED with PEN, dietary intervention was the only treatment in 16/24 patients. Three patients were on Azathioprine (AZA), 2 5-aminosalicylic acid (5-ASA), 1 Methotrexate (MTX) and another Prednisone. At the end of phase 1, 8 patients were on anti-TNF-α, 8 were using AZA, 2 5-ASA and 1 MTX. At the end of the phase 2, anti-TNF-α was used in 12 patients, AZA in 8, MTX in 3 and both anti-IL12/23 and 5-ASA in 1 patient. CRP and ESR showed a statistically significant decrease (P< 0.01) at the end of phases 1 and 2, Faecal calprotectin (FC) showed so at the end of phase 2 (P< 0.01). Other followed parameters failed to show a significant difference at the end of follow-up. Conclusion These data support that CDED with PEN is both well tolerated and has a very high adherence rate. They also confirm that CRP and ESR decrease significantly at the end of both phases and FC at the end of phase 2. CDED with PEN should be considered as an alternative to EEN and steroids in induction of remission of luminal CD in children.

P448 Long term effectiveness of first-line infliximab treatment compared to conventional treatment in paediatric moderate-to-severe Crohn’s disease – an update from the TISKids study

Abstract Background Current guidelines recommend first-line anti-TNF therapy (start at diagnosis) only in children with high risk for a complicated disease course. However, previous results of the TISKids study showed that first-line infliximab (FL-IFX) treatment (5 infusions in total) combined with azathioprine (AZA) was more effective to achieve clinical remission without treatment escalation at week 52 compared to conventional induction treatment (CONV) with AZA in therapy-naïve children with moderate-to-severe CD, irrespective of having high risk for development of complications1. The aim of our study was to investigate the effects at 3-year follow-up of the TISKids cohort. Methods The TISKids study is a multicentre, open-label randomised controlled trial in which untreated patients with a new diagnosis of CD (3–17 years old, weighted paediatric CD activity index score >40) were included. Patients were randomised to FL-IFX (5 infusions of 5 mg/kg infliximab at weeks 0, 2, 6, 14, 22) or CONV (EEN or prednisolone). Both treatment groups were combined with AZA maintenance. The primary outcome was biochemical remission (faecal calprotectin <250 ug/g) without need for additional biological treatment at 3 years. Secondary outcomes were time to additional biological treatment and number of patients with luminal surgery until 3 years. Additional biological treatment in the FL-IFX group included intensification, continuation or restart of IFX. Differences in proportions were tested using the Chi-square or Fisher-exact test, time to additional biological was analysed using Kaplan-Meier method with log-rank test. Results In total, 50 patients received FL-IFX and 47 CONV. One patient from each group was lost to follow-up, data at 3 years was available in 89/97 patients. At 3 years, 5/43 (12%) FL-IFX patients were in biochemical remission without need for additional biological treatment compared to 4/42 (10%) CONV patients (p=1.00). The time to additional biological treatment was significantly longer for the FL-IFX patients (median 63 weeks) compared to CONV patients (median 32 weeks), p=0.019. The number of luminal surgeries (all ileocaecal resections) until 3 years was not significantly different between FL-IFX (n=2/46, 4%) compared to CONV (n=5/43, 12%), p=0.256. Conclusion These results imply that there still is a significant benefit of FL-IFX during 3 years of follow-up (longer time to additional biological treatment compared to CONV), demonstrating durability of providing effective induction treatment. Further research should identify in which patient and when IFX may be stopped and which maintenance treatment would be appropriate in order to sustain and further optimize the benefits of FL-IFX treatment. 1. Jongsma MME et al. Gut. 2020. PMID: 33384335

A comparison of the efficacy of tocilizumab versus azathioprine for neuromyelitis optica spectrum disorder: A study protocol for systematic review and meta-analysis.

Neuromyelitis optica spectrum disorder (NMOSD) is a chronic inflammatory disease of the nervous system, which is frequently accompanied by a pathological humoral immune response against aquaporin-4 water channel. The most common feature of the disorder is recurrent episodes of longitudinally extensive transverse myelitis and optic neuritis. Frequent relapse leads to the gradual accumulation of neurological dysfunction. Azathioprine (AZA) is an empirical attack -preventive immunotherapies drug to prevent the relapse of NMOSD, and tocilizumab (TCZ) has been also reported reduce the activity of NMOSD. Therefore, we designed this systematic review and meta-analysis to evaluate the efficacy between TCZ and AZA in the treatment of NMOSD patients. This study followed the PRISMA guidelines. We searched the English literature between 2000 and 2022 by using relevant medical subject heading and entry terms in PubMed, MEDLINE, Embase and CENTRAL databases. A meta-analysis of drug efficacy was performed using expanded disability status scale score and annualized relapse rate (ARR) as the primary outcome indicators. The literature search found a total of 1546 articles about TCZ and AZA in the treatment of NMOSD, 27 of which were included in this study after a series of screening. 930 and 148 patients with NMOSD were enrolled, who had been treated with AZA and TCZ, respectively. The pooled standardized mean difference (SMD) of expanded disability status scale score before and after AZA treated was -0.40 (95%CI: -0.50, -0.30) (I2 = 65.4%, P < .001), before and after TCZ treated was -0.84 (95%CI: -1.08, -0.60) (I2 = 45.6%, P = .076). The SMD of ARR before and after AZA treated was -1.01 (95%CI: -1.12, -0.90) (I2 = 83.4%, P < .001), before and after TCZ treated was -1.27 (95%CI: -1.52, -1.03) (I2 = 52.7%, P = .039). In addition, TCZ reduce ARR more significantly compared with AZA (P = .031). The results of this study showed that the treatment of NMOSD patients with AZA and TCZ are associated with decreased number of relapses and disability improvement as well. In addition, compared with AZA, TCZ more significantly reduce ARR.

Risk factors for serious infections in ANCA-associated vasculitis

ObjectivesSevere infections contribute to morbidity and mortality in antineutrophil cytoplasm antibody-associated vasculitis (AAV). This study aimed to identify risk factors associated with severe infections in participants of the Rituximab versus...

Human leukocyte antigen association with azathioprine-induced drug hypersensitivity reactions in patients with anti-neutrophil cytoplasmic antibody associated vasculitis

Azathioprine (AZA) drug hypersensitivity reaction (DHR) is an uncommon yet potentially lethal condition that often goes unrecognised in patients with anti-Neutrophil Cytoplasmic Antibody (ANCA) associated vasculitis (AAV). We conducted a retrospective review of AAV patients on AZA maintenance therapy (N = 35). Participants were categorised into those who had experienced AZA-DHR (N = 15) and those who were AZA-tolerant (N = 20). Human leukocyte antigen (HLA) typing was performed in both groups. The primary endpoint was identification of a HLA gene association with AZA-DHR in the context of AAV. HLA-C*06:02, was solely expressed in AZA-DHR patients (33.3 %), whilst no patient who tolerated AZA carried this allele (0.0 %). This yielded a positive predictive value of 100 % for HLA-C*06:02 in predicting AZA-DHR in AAV patients, negative predictive value of 66.7 %, sensitivity of 33.3 % and specificity of 100 %. HLA-C*06:02 may predict the development of AZA-DHR in patients with AAV and inform safer therapeutic choice.

Thiopurines impair the apical plasma membrane expression of CFTR in pancreatic ductal cells via RAC1 inhibition

Background and aimsThiopurine-induced acute pancreatitis (TIP) is one of the most common adverse events among inflammatory bowel disease patients treated with azathioprine (AZA), representing a significant clinical burden. Previous studies focused on immune-mediated processes, however, the exact pathomechanism of TIP is essentially unclear.MethodsTo model TIP in vivo, we triggered cerulein-induced experimental pancreatitis in mice receiving a daily oral dose of 1.5 mg/kg AZA. Also, freshly isolated mouse pancreatic cells were exposed to AZA ex vivo, and acinar cell viability, ductal and acinar Ca2+ signaling, ductal Cl– and HCO3– secretion, as well as cystic fibrosis transmembrane conductance regulator (CFTR) expression were assessed using microscopy techniques. Ras-related C3 botulinum toxin substrate (RAC1) activity was measured with a G-LISA assay. Super-resolution microscopy was used to determine protein colocalization.ResultsWe demonstrated that AZA treatment increases tissue damage in the early phase of cerulein-induced pancreatitis in vivo. Also, both per os and ex vivo AZA exposure impaired pancreatic fluid and ductal HCO3– and Cl– secretion, but did not affect acinar cells. Furthermore, ex vivo AZA exposure also inhibited RAC1 activity in ductal cells leading to decreased co-localization of CFTR and the anchor protein ezrin, resulting in impaired plasma membrane localization of CFTR.ConclusionsAZA impaired the ductal HCO3– and Cl– secretion through the inhibition of RAC1 activity leading to diminished ezrin-CFTR interaction and disturbed apical plasma membrane expression of CFTR. We report a novel direct toxic effect of AZA on pancreatic ductal cells and suggest that the restoration of ductal function might help to prevent TIP in the future.

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

The treatment of autoimmune hepatitis (AIH) is based on steroids and azathioprine (AZA). AZA is a pro-drug which is converted among others into 6-thioguanine (6-TG) and 6-methylmercaptopurine (6-MMP). The aim of the study was to determine the relationship between the AZA active metabolite 6-TG and both the biochemical and histological remission outcomes. The authors conducted a retrospective analysis of a single chart review. The sample size consisted of 44 pediatric patients with AIH. Biochemical remission was defined as an alanine aminotransferase (ALT) level below 40 U/l and histological remission was defined as a situation when the control biopsy revealed inflammation grade G1 (or lower) in the Batts-Ludwig score. Statistical analysis was applied to assess the difference in remission outcomes in patients with different levels of 6-TG. In the benchmark variant of our statistical analysis, we found that the correlation between 6-TG and ALT in the sample was not statistically significant. Moreover, the difference between the mean levels of ALT in the populations in and without remission was not statistically significant (the p-value of the t-test was 0.16). Our results tend to support the claim that there is no statistically significant relationship between 6-TG concentration and remission (both biochemical and histological) in pediatric patients with AIH.

Concomitant 5-aminosalicylic acid treatment does not affect 6-thioguanine nucleotide levels in patients with inflammatory bowel disease on thiopurines.

There are conflicting data as to whether co-treatment with 5-aminosalicylic acid (5-ASA) in patients with inflammatory bowel disease (IBD) under azathioprine (AZA) or 6-mercaptopurine (6-MP) therapy may influence 6-thioguanine nucleotide (6-TGN) concentrations, and whether this combination puts patients at risk of side-effects. The aim of the study was to determine 6-TGN levels in patients treated with AZA/6-MP, either alone or in combination with 5-ASA. Available blood samples from patients treated with AZA or 6-MP were retrieved from the Swiss IBD Cohort Study (SIBDCS). The eligible individuals were divided into 2 groups: those with vs. without 5-ASA co-medication. Levels of 6-TGN and 6-methylmercaptopurine ribonucleotides (6-MMPR) were determined and compared. Potential confounders were compared between the groups, and also evaluated as potential predictors for a multivariate regression model. Of the 110 patients enrolled in this analysis, 40 received concomitant 5-ASA at the time of blood sampling. The median 6-TGN levels in patients with vs. those without 5-ASA co-treatment were 261 and 257 pmol/8×108 erythrocytes, respectively (P=0.97). Likewise, there were no significant differences in 6-MMPR levels (P=0.79). Through multivariate analysis, 6-TGN levels were found to be significantly higher in non-smokers, patients without prior surgery, and those without signs of stress-hyperarousal. Blood concentrations of 6-TGN and 6-MMPR did not differ between patients with vs. those without 5-ASA co-treatment. Our data warrant neither more frequent lab monitoring nor dose adaptation of AZA in patients receiving concomitant 5-ASA treatment.

Influence of the Photodegradation of Azathioprine on DNA and Cells.

Azathioprine (AZA) is a pharmacologic immunosuppressive agent administrated in various conditions such as autoimmune disease or to prevent the rejection of organ transplantation. The mechanism of action is based on its biologically active metabolite 6-mercaptopurine (6-MP), which is converted, among others, into thioguanine nucleotides capable of incorporating into replicating DNA, which may act as a strong UV chromophore and trigger DNA oxidation. The interaction between azathioprine and DNA, before and after exposure to solar simulator radiation, was investigated using UV-vis spectrometry and differential pulse voltammetry at a glassy carbon electrode. The results indicated that the interaction of AZA with UV radiation was pH-dependent and occurred with the formation of several metabolites, which induced oxidative damage in DNA, and the formation of DNA-metabolite adducts. Moreover, the viability assays obtained for the L929 cell culture showed that both azathioprine and degraded azathioprine induced a decrease in cell proliferation.

Autoimmune Hemolytic Anemia in Inflammatory Bowel Disease-Report of a Case and Review of the Literature.

A wide spectrum of extraintestinal manifestations (EIMs) can burden patients with inflammatory bowel disease (IBD). EIMs contribute fairly to morbidity and mortality rates in IBD patients. Moreover, EIMs in IBD patients are so frequent that some suggest that IBD should be approached as a systemic disorder. Anemia is very common in IBD patients. The two most common types of anemia in IBD, iron deficiency anemia and anemia of chronic disease, are extraintestinal complications. Autoimmune hemolytic anemia (AIHA) is a rare extraintestinal manifestation of IBD, more frequent in ulcerative colitis (UC) than in Crohn's disease (CD). In this case-based review of the literature, we present a 36-year-old female patient diagnosed with Crohn's disease (CD) and Coombs positive AIHA, complicated by pulmonary thromboembolism and successfully treated with anti-tumor necrosis factor (anti-TNF) therapy. The underlying pathophysiological mechanism of AIHA in IBD is unclear. Treatment options for AIHA in IBD patients before biologic therapy included corticosteroids alone or in combination with azathioprine (AZA), methotrexate, and surgical treatment (colectomy and/or splenectomy). Currently, biologic therapy is a promising therapeutic option, especially in corticosteroid refractory or corticosteroid-dependent IBD patients with AIHA.

Scoping beyond pulmonary artery involvement; pulmonary involvement in Behcet's disease; a retrospective analysis of 28 patients.

Pulmonary involvement other than pulmonary artery involvement in Behcet's disease still remains an area of investigation. The aim of this study was to evaluate pulmonary involvement associated with Behcet's disease. We retrospectively investigated all Behcet's disease patients in terms of pulmonary involvement. Twenty-eight patients, whose radiologic examinations were consistent with Behcet's disease-related involvement after excluding other possibilities, were included in this study. Data regarding demographic characteristics, other clinical components of Behcet's disease, treatment modalities, and types of pulmonary involvement were analyzed. Pulmonary involvement was seen more common in male (82.1% vs 17.9%). Mean age for Behcet's disease diagnosis was found 32 years (SD 10.9) and mean age for pulmonary involvement was calculated 37 years (SD 11.4). Deep vein thrombosis (DVT) was the most common associated vascular involvement (53.6%). In our study population, alveolar hemorrhage and/or ground glass appearance were seen in 46.4% (13/28) of BD patients with pulmonary involvement. Totally, pulmonary artery aneurysm (PAA), small-sized pulmonary vasculitis (sPV), and pulmonary thrombosis (PT) were seen in 7 (25%), 13 (46.3%), and 18 (64.4%) of patients, respectively. Intracardiac thrombosis (ICT) in the right ventricle was present in 5 patients. Cyclophosphamide (CYC) was the most common preferred agent (78%) followed by azathioprine (AZA) in the first line. Warfarin was used in 18 patients. Overall mortality was seen in 3 patients: 1 due to PAA bleeding and others with unknown causes. Despite the importance of pulmonary artery involvement and pulmonary thrombosis in Behcet's disease, small-sized pulmonary vasculitis in the form of small vessel involvement is generally overlooked. Our study findings have shown that alveolar hemorrhage and/or ground-glass appearance in the absence of pulmonary artery aneurysm and pulmonary thrombosis are seen commonly as well. Key Points • The characteristics of pulmonary small vasculature involvement in Behcet's disease which is still an area of investigation warrant further attention. • The clinician should bear in mind that the spectrum of pulmonary involvement in Behcet's disease may be variable, but an extensive work up is still of great importance especially in atypical cases.

Steroid Resistance/Dependence Might Be an Alarming Feature for Cytomegalovirus Infection Among Ulcerative Colitis Patients With Increased Disease Activity.

Background/Aims This study aimed to determine the prevalence of cytomegalovirus (CMV) infection among patients with moderate to severe active ulcerative colitis (UC) and to determine the risk factors for CMV infection according to the demographic features of these patients. Patients/Methods A total of 183 patients with severe or moderate active UC were enrolled in the study after retrospective analysis. The disease severity of UC was determined according to the Mayo Score. CMV infection was investigated by real-time quantitative polymerase chain reaction (PCR) and the immunohistochemical (IHC) staining method in colonic mucosal biopsies. Results CMV infection was diagnosed in 33.9% of patients with UC. UC patients diagnosed with CMV infection had significantly higher Mayo Score levels (9.68 vs 8.56 and p=0.001). The long-term presence of UC disease, steroid, azathioprine (AZA), and anti-tumor necrosis factor-alpha (anti-TNF-alpha) usage increased the risk of CMV infection (p=0.001 and odds ratio=1.168; p=0.001 and odds ratio=2.967; p=0.004 and odds ratio=2.953; p=0.003 and odds ratio=3.861, respectively). CMV infection increases the risk of developing steroid resistance or dependency (p=0.002 and odds ratio=3.147; p=0.002 and odds ratio=5.085, respectively). Post-treatment clinical remission and mucosal healing rates were higher in CMV-negative patients than in CMV-positive patients (99.2% vs 91.9%, p=0.018 and 86.8% vs 70.9%, p=0.015). A higher rate of need for colectomy had been found in patients with CMV infection (5 patients vs 1 patient; p=0.034 and odds ratio=10.526). Conclusions The presence of CMV infection increases the severity of the diseaseand worsens clinical outcomes, leading to adverse treatment outcomes. CMV infection increases the requirement for colectomy. The presence of steroids, immunosuppressives such as AZA, and anti-TNF-alpha usage increases the occurrence of CMV infection. CMV infection should be suspected in patients with moderate to severe UC activity.

RETRACTED ARTICLE: Impact of gervital against histopathological, ultrastructural, and biochemical alterations caused by methotrexate or azathioprine in albino rat testis

Methotrexate (MTX) and azathioprine (AZA) are chemotherapeutic, immunosuppressive, cytotoxic drugs with reported adverse effects, including oxidative damage to testis. This study aims to evaluate the potential effect of grape seed extract (GSE; gervital) to prevent testicular damage caused by MTX and AZA. Male albino rats were separated into six groups: group I, normal control group; group II, GSE (150 mg/kg/day); group III, MTX (8 mg/kg/week); group IV, AZA (15 mg/kg/day); group V, GSE (150 mg/kg/day) + MTX (8 mg/kg/week); group VI, GSE (150 mg/kg/day) + AZA (15 mg/kg/day). All rats were sacrificed, blood samples were obtained for testosterone analysis, and testis was removed for histological and ultrastructural studies and oxidation measurements. A reduction in relative body and testis weight, along with a significant decrease in testosterone levels, was observed. Histopathological and ultrastructural alterations induced by MTX or AZA included reduced spermatozoa, sloughing, marked reduction of spermatogenic cells, and pyknosis of some nuclei. Significant oxidative stress manifested as reduced glutathione (GSH) levels and catalase (CAT) and superoxide dismutase (SOD) activities, as well as increased malondialdehyde (MDA) levels. GSE administration showed an ameliorative effect on testosterone levels and histopathological and ultrastructural changes. GSE treatment also suppressed the increases in MDA levels and the decreases in GSH levels and CAT and SOD activities. In conclusion, these findings confirm that GSE is an effective antioxidant that protects testis from histopathological and ultrastructural damage induced by MTX and AZA. Therefore, GSE is a promising candidate for future use to minimize and alleviate MTX and AZA risks.Graphical abstract

Improved HPLC Quantification of 6-Mercaptopurine Metabolites in Red Blood Cells: Monitoring Data and Literature Analysis.

Thiopurine drugs azathioprine (AZA) and 6-mercaptopurine (6-MP) are used extensively in pediatric and adult patients with inflammatory and neoplastic diseases. They are metabolized to 6-thioguanine nucleotides (6-TGN) or to 6-methyl-mercaptopurine nucleotides (6-MMPN). The balance between 6-TGN and 6-MMPN is highly variable and monitoring is recommended, but its benefit in outcome gives rise to conflicting results, potentially increased by differences in quantifying 6-MP metabolism. Our aim was to report (1) the HPLC-UV procedure used in our laboratory to quantify red blood cells (RBCs) with 6-TGN and 6-MMPN (as its derivate: 6-MMP(d)) in patients treated with thiopurines and (2) additional tests, sometimes confirmatory, to improve method standardization. The comparison of two methods to count RBCs shows that metabolite concentrations were slightly lower in the washed and resuspended RBCs than in whole blood. Perchloric acid (0.7 M), dithiothreitol (DTT, final 0.013 M sample concentration) and 60 min hydrolysis were selected for acid hydrolysis. (3) Monitoring data from 83 patients receiving AZA or 6-MP showed that at steady state, only 53/183 (29%) had 6-TGN and 6-MMPN in the recommended therapeutic range. Our method is discussed in light of the technical conditions and sample stability data from 17 publications identified since the first analytical report in 1987. Monitoring data demonstrate, if required, that inter-patient variability in 6-TGN and 6-MMPN concentrations is high in samples from treated patients.

S2738 Isolated Celiac Artery Vasculitis Presenting as Ileus in a Patient With Ulcerative Colitis

Introduction: Small case series have reported an association between IBD and large vessel vasculitides, ANCA-associated vasculitis, and cutaneous vasculitis. Gastrointestinal (GI) involvement of vasculitis can be a severe complication, resulting in mesenteric ischemia, ileus, or GI bleeding, and often requires aggressive medical or surgical interventions. We report a case of celiac artery vasculitis presenting as abdominal pain and ileus in a patient with ulcerative colitis (UC). Case Description/Methods: A 69 year old male with an 11 year history of UC in remission on infliximab and azathioprine (AZA) presented to the emergency room with abdominal pain and constipation for five days. He had decreased AZA from 200 mg to 100 mg one month prior. Initial CT abdomen and pelvis showed stranding surrounding the celiac artery, fluid-filled small bowel loops, and segmental areas of distal colon collapse with proximal colon distention. He developed progressive small bowel and colonic distention with cecum diameter of 10 cm. A colonoscopy was performed for decompression. He had no evidence of active UC. EGD demonstrated dusky appearing gastroesophageal junction and inflammation with cratered ulcers in the gastric cardia and body. Biopsies confirmed ischemic necrosis. CTA demonstrated perivascular inflammation of a patent celiac artery without evidence for dissection, suggestive of acute vasculitis. ESR and CRP were 50 mm/hr and 7.8 mg/dL respectively. Myeloperoxidase, serine-proteinase 3, rheumatoid factor, ANA, were negative. He was started on methylprednisolone IV with oral prednisone taper at discharge, and AZA was increased to 200 mg daily. A CT one month later showed minimal residual inflammation. ESR and CRP had normalized. (Figure) Discussion: We present the first case of isolated celiac artery vasculitis in a patient with IBD. A diagnosis of IBD often precedes vasculitis, and patients are typically on immunosuppressive therapy at the time of onset. Anti-TNF agents have been implicated as a potential inciting cause. Although it is unclear whether long-term anti-TNF therapy precipitated vasculitis in our patient, the dose reduction in AZA prior to presentation may have unmasked vasculitis. This was supported by his rapid clinical and radiographic improvement with combination of steroids and increased AZA dose despite continuation of infliximab. This case highlights the importance of maintaining a high degree of suspicion for vasculitis in patients with IBD on immunosuppressive therapy presenting with ischemia or ileus.Figure 1.: A 69 year old male underwent EGD for evaluation of abdominal pain and NG tube placement; he was found to have inflammation with a dusky appearing mucosa at the gastroesophageal junction (GEJ) (A). Non-bleeding gastric ulcers with overlying pigment (Forrest Class IIc) were identified (B). H&E stain image shows the GEJ biopsy with extensive ischemic necrosis and hemorrhage (C). Initial CTA abdomen/pelvis shows fat stranding surrounding the celiac artery (D).

Effectiveness and safety of tripterygium glycosides tablet for lupus nephritis: a systematic review and Meta-analysis.

To investigate the effectiveness and safety of tripterygium glycosides (TG) tablet for the treatment of Lupus nephritis (LN). Several databases were systematically searched including PubMed, Embase, Cochrane, Wiley, China National Knowledge Infrastructure Database, SinoMed and Wanfang Library till June 20, 2020. Revman5.3 was utilized to analyze the data according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Statement. In total, 8 randomized controlled trials involving 583 participants were identified. Meta-analyses showed that, compared with glucocorticoids (GC) alone, the combination with TG tablet provided a statistically significant improvement in total remission (TR) ( = 1.27, 95% : 1.08-1.50, = 0.004), complete remission (CR) ( = 1.61, 95% : 1.05-2.47, = 0.03) and C3 levels ( = 0.27, 95% : 0.14-0.39, < 0.000 1), C4 levels ( = 0.12, 95% : 0.07-0.17, < 0.000 01). No significant differences were seen in TR, CR, proteinuria, serum creatinine, C3 and C4 (TR: = 1.00, 95% : 0.87-1.16, = 0.95; CR: = 1.10, 95% : 0.78-1.56, = 0.58; proteinuria levels: = -0.06, 95% : -0.13 to 0.01, = 0.10; serum creatinine levels: = -0.01, 95%: -7.36 to 7.35, = 1.00; C3 levels: = 0.01, 95%: -0.06 to 0.07, = 0.84; C4 levels: = -0.01, 95%: -0.03 to 0.01, = 0.49) between azathioprine (AZA) / leflomit (LEF) + GC and TG tablet + GC. Adverse events (hepatic dysfunction, nausea, vomitting) showed no statistical differences between the TG tablet + GC group and the GC group. There were more new onset of irregular menstruation in the TG tablet + GC group than those in the AZA + GC ( = 3.57, 95% : 1.40-9.11, = 0.008) /LEF+ GC ( = 6.69, 95% : 2.42-18.46, = 0.000 2) group, but leucopenia lower than those in AZA + GC group ( = 0.38, 95% : 0.17-0.85, = 0.02) and alopecia ( = 0.14, 95% : 0.03-0.77, = 0.02) and rash ( = 0.09, 95% : 0.01-0.69, = 0.02) lower than those in LEF + GC group. This review indicates that TG tablet maybe effective in LN treatment. Nevertheless, adverse events cannot be ignored. Large sample, multi-center, high-quality clinical studies are needed to verify the exact effects and safety of TG tablet in treatment of LN.

S2753 Nodular Regenerative Hyperplasia-Induced Peristomal Variceal Bleeding: A Rare Thiopurine Side Effect

Introduction: Azathioprine (AZA) and 6-Mercaptopurine (6-MP) are agents used to treat Inflammatory Bowel Disease (IBD). One of the rare side-effects described in cases throughout the literature is the development of Nodular Regenerative Hyperplasia (NRH) of the liver. NRH can lead to the development of non-cirrhotic portal hypertension (NCPH) which can then progress to ascites and varices. We present a patient who developed NRH from long-standing 6MP leading to peristomal variceal bleeding. Case Description/Methods: This case involves a 12 y/o male with fistulizing and stricturing Crohn’s disease, who was on 6-MP monotherapy from ages 14-18 and then restarted at age 27. At age 29, he underwent a partial colectomy with colostomy creation. Subsequently, he began to experience blood in his ostomy bag, which was later identified to be due to peristomal varices. Abdominal CT revealed lower esophageal varices and a nodular appearing liver. Liver biopsy then confirmed NRH, which had progressed to NCPH, and ultimately bleeding peristomal varices. The patient underwent a successful TIPS procedure with resolution of the varices and has not had any further bleeding. (Figure) Discussion: While there are a few cases of esophageal and gastric variceal bleeding due to NCPH secondary to thiopurine induced NRH, a case of peristomal variceal bleeding has yet to be described. NRH is a poorly understood condition that is characterized by diffuse transformation of normal liver parenchyma into small regenerative nodules with little to no fibrosis. Increased liver nodularity can cause NCPH and subsequently formation of varices throughout the GI tract. Patients with IBD on thiopurines have a cumulative incidence of NRH of 0.6% and 1.28% at 5 and 10 years, respectively1. NRH has a variable clinical presentation- from asymptomatic to severe complications of NCPH--and patients often do not present until late in the disease course. Several risk factors associated with development of NRH are male sex, stricturing and/or fistulizing disease, and history of a bowel resection. While NRH and its pursuing complications from thiopurines remains a rare entity, clinicians should be cognizant of this potential complication--particularly in those with fistulizing/stricturing disease and/or a surgical resection with an ostomy who present with gastrointestinal bleeding.Figure 1.: A – Digital subtraction angiographic (DSA) image shows catheter-directed venography of a dilated branch of the inferior mesenteric vein (IMV) that supplies a network of peristomal varices (black arrow). B - After successful creation of a transjugular intrahepatic portosystemic shunt (TIPS) with a covered stent (white arrow), a DSA image shows a plug and foam (black arrow) in the dilated IMV branch with decreased blood flow into the peristomal varices. C- Final DSA image of completion IMV venography shows absent blood flow into the dilated IMV branch and peristomal varices.

Long-term results of mycophenolate mofetil vs. azathioprine use in individuals with autoimmune hepatitis

We have shown previously that mycophenolate mofetil (MMF) might be used as first-line treatment instead of azathioprine (AZA) in individuals with autoimmune hepatitis (AIH). Herein, we present our long-term prospective data on response and outcome after first-line therapy with MMF in treatment-naïve individuals with AIH, as similar data are missing. During the 21 years of the study, 292 individuals with AIH were included (females: 213; median age: 59 [17-85] years). Patients received either prednisolone 0.5-1mg/kg/day alone (n= 19) or in combination with AZA 1-2mg/kg/day (n= 64) or MMF (n= 183). The tapering schedule of prednisolone was identical between groups. We assessed the rates of complete biochemical response (CBR) at 6 months, 12 months, and the end of follow-up; non-response (4 weeks of treatment); CBR off prednisolone; adverse effects; CBR off treatment; histological remission; and overall and liver-related mortality between the AZA and MMF groups. The MMF group had lower non-response (p= 0.02) and higher CBR rates at 12 months (86 vs. 71.8%; p <0.05) and the end of follow-up (96 vs. 87.2%; p= 0.03) than the AZA group. Treatment change was more frequent in the AZA group (43.7 vs. 11%; p <0.001), mostly because of intolerance, whereas MMF was proven safe (serious complications 3.8 vs. 18.8%; p= 0.0003). MMF-treated patients were more frequently eligible to stop immunosuppression according to the guidelines (p <0.05). Cirrhosis at diagnosis, age at diagnosis >60 years, and longer disease duration were independent predictors of liver-related mortality. MMF seems an efficient alternative first-line treatment option for AIH, bearing lower non-response at 4 weeks and higher CBR rates at 12 months and the end of follow-up than AZA. In addition, MMF was proven to be safe, leading more frequently to the eligibility for stopping immunosuppression according to the guidelines. For more than 40 years, azathioprine (AZA) has been considered the standard treatment for induction and maintenance of response in autoimmune hepatitis (AIH). However, treatment usually needs to be maintained for life, as relapses are common after AZA cessation. Therefore, alternative treatment options are needed. Herein, we showed that the use of mycophenolate mofetil (MMF) as an alternative first-line immunosuppressant was much more efficient in the long-term than AZA as attested by the lower non-response rates at 4 weeks and higher response rates at 12 months and the end of follow-up. Moreover, AZA-treated patients were more prone to change treatment because of intolerance, whereas MMF-treated patients were more often eligible to achieve treatment withdrawal.