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Inflammatory Bowel Diseases:
doi: 10.1002/ibd.23021
Original Clinical Articles

Safety and Effectiveness of Long-term Allopurinol–Thiopurine Maintenance Treatment in Inflammatory Bowel Disease

Hoentjen, Frank MD, PhD*,†; Seinen, Margien L. MD; Hanauer, Stephen B. MD, PhD*; de Boer, Nanne K.H. MD, PhD; Rubin, David T. MD*; Bouma, Gerd MD, PhD; Harrell, Laura E. MD*; van Bodegraven, Adriaan A. MD, PhD

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Abstract

Background: Thiopurines are the mainstay of conventional maintenance therapy in inflammatory bowel disease (IBD). Unfortunately, up to 50% of patients discontinue immunosuppressive therapy within 2 years due to intolerance or lack of efficacy. Allopurinol with low-dose thiopurine can optimize thiopurine metabolism for IBD patients with preferential shunting toward 6-methyl mercaptopurine (6-MMP) formation. The aim of this study was to assess long-term maintenance effectiveness and tolerability of allopurinol-thiopurine therapy in a larger multicenter cohort of IBD patients.

Methods: Enrolled patients who failed monotherapy with thiopurines due to a skewed metabolism were subsequently treated with a combination therapy of allopurinol and low-dose thiopurine. Adverse events were monitored and therapeutic adherence was assessed. Seventy-seven IBD patients were enrolled with a mean follow-up of 19 months.

Results: The median 6-thioguanine nucleotide concentration increased from 145 during monotherapy to 271 pmol/8 × 108 red blood cell (RBC) after at least 8 weeks of combination therapy while reducing the thiopurine dosage (P < 0.001). In contrast, median 6-MMP concentrations decreased from 10,110 to 265 pmol/8 × 108 RBC (P < 0.001). Leukopenia occurred in 12 patients (16%), requiring dose adaptation. Liver test abnormalities normalized in 81% of patients after the addition of allopurinol. Sixteen (21%) patients had to discontinue combination therapy. The percentage of patients still using combination therapy at 6, 12, 24, and 60 months was 87%, 85%, 76%, and 65%, respectively.

Conclusions: Long-term combination therapy with allopurinol and low-dose thiopurines is an effective and well-tolerated treatment in IBD patients with a skewed thiopurine metabolism.

© Crohn's & Colitis Foundation of America, Inc.

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