Thioguanine (Monograph)
Brand name: Thioguanine Tabloid
Drug class: Antineoplastic Agents
VA class: AN300
CAS number: 154-42-7
Introduction
Antineoplastic agent; antimetabolite, synthetic purine antagonist.
Uses for Thioguanine
Acute Myeloid Leukemia (AML)
Remission induction (in combination with other antineoplastic agents) in acute myeloid (myelogenous, nonlymphocytic) leukemia (AML, ANLL).
Has been used with other antineoplastic agents in regimens of consolidation therapy for AML following induction of a complete remission; optimal regimen of such therapy in prolonging remissions remains to be established but is typically administered short-term.
Not recommended for maintenance or long-term continuous therapy. (See Hepatic Effects under Cautions.)
Thioguanine Dosage and Administration
General
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Consult specialized references for procedures for proper handling and disposal of antineoplastic drugs.
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Individualize dosage according to clinical and hematologic response and tolerance of the patient.
Administration
Oral Administration
Calculate total daily dose to the nearest multiple of 20 mg and administer orally once daily.
Dosage
Consult currently published protocols for dosages used in combination regimens and method and sequence of administration.
Dosage reduction may be necessary if used concomitantly with other myelosuppressive agents. (See Specific Drugs under Interactions.)
When initiating thioguanine therapy, patients with inherited deficiency of thiopurine S-methyl transferase (TPMT) activity are at increased risk of life-threatening myelotoxicity; substantial dosage reduction may be required. (See Hematologic Effects under Cautions.)
Pediatric Patients
Acute Myeloid Leukemia
Induction and Consolidation Therapy
OralIf monotherapy is appropriate, initially, approximately 2 mg/kg daily. If there is no clinical improvement and no leukocyte or platelet count depression after 4 weeks on initial dosage, dosage may be cautiously increased to 3 mg/kg daily.
Thioguanine should not be part of maintenance therapy. (See Hepatic Effects under Cautions.)
Adults
Acute Myeloid Leukemia
Induction and Consolidation Therapy
OralIf monotherapy is appropriate, initially, approximately 2 mg/kg daily. If there is no clinical improvement and no leukocyte or platelet count depression after 4 weeks on initial dosage, dosage may be cautiously increased to 3 mg/kg daily.
Thioguanine should not be part of maintenance therapy. (See Hepatic Effects under Cautions.)
Special Populations
Hepatic Impairment
Consider dosage reduction; however, no specific dosage recommendations at this time. (See Hepatic Effects under Cautions.)
Renal Impairment
Consider dosage reduction; however, no specific dosage recommendations at this time.
Geriatric Patients
Select dosage with caution because of age-related decreases in hepatic, renal, and/or cardiac function and concomitant disease and drug therapy.
Cautions for Thioguanine
Contraindications
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If a diagnosis of AML has not been adequately established and there is no responsible clinician knowledgeable in assessing response to chemotherapy.
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Patients whose disease was resistant to prior therapy with the drug. Consider that there is complete cross-resistance between thioguanine and mercaptopurine.
Warnings/Precautions
Warnings
Toxicity
Highly toxic; low therapeutic index; therapeutic response is unlikely without some evidence of toxicity. Administer only under supervision of qualified clinicians experienced in use of cytotoxic therapy.
Hepatic Effects
Risk of hepatotoxicity associated with vascular endothelial damage; usually manifested as hepatic veno-occlusive disease (e.g., hyperbilirubinemia, hepatomegaly, ascites) or portal hypertension (e.g., splenomegaly, thrombocytopenia out of proportion with neutropenia, esophageal varices).
Possible jaundice and increases in serum aminotransferases (AST, ALT), alkaline phosphatase, and γ glutamyl transferase concentrations. Hepatoportal sclerosis, nodular regenerative hyperplasia, peliosis hepatitis, and periportal fibrosis reported.
Discontinue immediately if evidence of hepatotoxicity (e.g., jaundice) occurs; signs and symptoms generally reversible after discontinuance of the drug.
Hepatic function must be carefully monitored. Serum transaminase, alkaline phosphatase, and bilirubin concentrations should be determined weekly during initiation of therapy and monthly thereafter. More frequent testing in patients with preexisting liver disease and in those receiving other hepatotoxic drugs.
Hematologic Effects
Risk of myelosuppression (manifested as anemia, leukopenia, and/or thrombocytopenia); usually dose related. Hematologic status must be carefully monitored.
Discontinue temporarily at the first sign of an abnormally large or rapid decrease in leukocytes, platelets, or hemoglobin concentration or abnormal depression of bone marrow, unless induction of bone marrow hypoplasia is desired. Bone marrow examination (aspiration and/or biopsy) may be helpful in distinguishing between progression of leukemia, resistance to therapy, and marrow hypoplasia induced by therapy.
Perform CBC, including platelet count and leukocyte differential, at least once weekly during therapy; more frequent blood counts may be required, particularly during remission induction therapy and with concomitant therapy with other antineoplastic agents.
When initiating thioguanine therapy, patients with inherited deficiency of thiopurine S-methyl transferase (TPMT) activity are at increased risk for life-threatening myelotoxicity; substantial dosage reduction may be required. Concomitant use with drugs that inhibit TPMT (e.g., olsalazine, mesalamine, sulfasalazine) may exacerbate such toxicity. Consider testing for TPMT deficiency prior to initiating therapy.
Infectious Complications and Hemorrhagic Complications
Life-threatening infections due to granulocytopenia may occur. Anti-infectives or granulocyte transfusions may be needed.
Bleeding due to thrombocytopenia may occur. Platelet transfusions may be needed.
Fetal/Neonatal Morbidity and Mortality
May cause fetal harm; teratogenicity demonstrated in animals.
Avoid pregnancy during therapy. If used during pregnancy or if patient becomes pregnant, apprise of potential fetal hazard.
Major Toxicities
GI Effects
Possible nausea, vomiting, anorexia, and stomatitis.
General Precautions
Hyperuricemia
Hyperuricemia occurs frequently because of extensive purine catabolism accompanying rapid cellular destruction. Hyperuricemia may be minimized or prevented by adequate hydration, alkalinization of urine, and/or administration of allopurinol.
Immunization
Effects of thioguanine on immunocompetence are unknown. Avoid live virus vaccines in immunocompromised patients.
Specific Populations
Pregnancy
Category D. (See Fetal/Neonatal Morbidity and Mortality under Cautions.)
Lactation
Not known whether thioguanine is distributed into milk. Discontinue nursing or the drug.
Geriatric Use
Clinical studies did not include sufficient numbers of patients ≥65 years of age to determine whether geriatric patients respond differently than younger adults; select dosage with caution.
Common Adverse Effects
Myelosuppression, hyperuricemia, hepatotoxicity.
Interactions for Thioguanine
Specific Drugs
Drug |
Interaction |
Comments |
---|---|---|
Allopurinol |
Pharmacokinetic interactions not expected |
Dosage adjustments not required |
Aminosalicylates (e.g., olsalazine, mesalamine, sulfasalazine) |
Potential pharmacokinetic interaction; increased risk of thioguanine myelotoxicity (see Hematologic Effects under Cautions) |
Use concomitantly with caution |
Myelosuppressive agents |
Possible additive myelosuppressive effects |
Reduced thioguanine dosage may be necessary with concomitant therapy |
Thioguanine Pharmacokinetics
Absorption
Bioavailability
Absorption from GI tract is variable and incomplete; approximately 30% of an oral dose may be absorbed.
Distribution
Extent
Incorporated into the DNA and RNA of bone marrow cells.
Does not reach therapeutic concentrations in the CSF.
Thioguanine crosses the placenta; not known whether distributed into milk.
Elimination
Metabolism
Rapidly and extensively metabolized in the liver and other tissues, principally to the less toxic and less active methylated derivative 2-amino-6-methylthiopurine.
Elimination Route
Excreted principally in urine as metabolites.
Half-life
Biphasic; terminal half-life averages 11 hours.
Stability
Storage
Oral
Tablets
15–25°C.
Actions
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Converted intracellularly to ribonucleotides that result in a sequential blockade of the synthesis and utilization of purine and guanine nucleotides.
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Thioguanine ribonucleotides incorporate into DNA and RNA; cytotoxic effects may be related primarily to substitution of ribonucleotides into DNA.
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Usually complete cross-resistance between thioguanine and mercaptopurine.
Advice to Patients
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Advise patients that the major toxicities of the drug are related to myelosuppression, hepatotoxicity, and GI toxicity.
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Importance of taking the drug only under medical supervision.
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Importance of patients informing their clinicians if fever, sore throat, jaundice, nausea, vomiting, signs of local infection, bleeding from any site, or symptoms suggestive of anemia occur.
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Importance of women informing their clinician if they are or plan to become pregnant or plan to breast-feed; necessity for clinicians to advise women to avoid pregnancy during therapy and advise pregnant women of risk to the fetus.
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Importance of informing patients of other important precautionary information. (See Cautions.)
Preparations
Excipients in commercially available drug preparations may have clinically important effects in some individuals; consult specific product labeling for details.
Please refer to the ASHP Drug Shortages Resource Center for information on shortages of one or more of these preparations.
Routes |
Dosage Forms |
Strengths |
Brand Names |
Manufacturer |
---|---|---|---|---|
Oral |
Tablets |
40 mg |
Thioguanine Tabloid (scored) |
GlaxoSmithKline |
AHFS DI Essentials™. © Copyright 2023, Selected Revisions March 1, 2009. American Society of Health-System Pharmacists, Inc., 4500 East-West Highway, Suite 900, Bethesda, Maryland 20814.
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