Maternal thiopurine metabolism during pregnancy in inflammatory bowel disease and clearance of thiopurine metabolites and outcomes in exposed neonates
Emma Flanagan, Emily K. Wright, Winita Hardikar, Miles Sparrow, William Connell, Michael A. Kamm, Peter De Cruz, Steven J. Brown, Alexander Thompson, Anthea Greenway, Ian S Westley, Murray L. Barclay, Alyson L Ross, Katerina Kiburg, Sally Bell, PICCOLO Study Group
Abstract
Summary Background Azathioprine and mercaptopurine are considered safe during pregnancy. However, the pharmacokinetic effects of pregnancy on thiopurine metabolism are undefined. Aims To characterise thiopurine metabolism in pregnancy and measure infant metabolite levels and outcomes. Methods Women with IBD who were taking a thiopurine and pregnant or trying to conceive were recruited. Maternal thiopurine metabolites were measured pre‐conception, in each trimester, at delivery and post‐partum. Infant metabolite levels, full blood examination and liver function testing were performed at birth, and repeated until levels undetectable and haematological and biochemical abnormalities resolved. Results Forty patients were included with measurements on at least two occasions, and two with only mother‐baby levels at delivery. The median maternal 6‐TGN level dropped in the second trimester compared with post‐partum (179.0 vs 323.5 pmol/8 × 10 8 RBCs, P < 0.001) and the median 6‐MMP level increased in the second trimester compared with post‐partum (1103.0 vs 329.5 pmol/8 × 10 8 RBCs, P < 0.01). At delivery, the median 6‐TGN level was lower in infants (n = 20) than mothers (78.5 vs 217 pmol/8 × 10 8 RBCs) ( P < 0.001). Metabolites were not detected at 6 weeks in any infants. Anaemia was not seen, but thrombocytosis and abnormal liver biochemistry were detected in 80% of infants from 6 weeks, which gradually improved. Conclusions 6‐TGN levels decrease and 6‐MMP levels increase in the second trimester of pregnancy. Infants are exposed to thiopurine metabolites at low levels with clearance by 6 weeks and no anaemia. The cause of infant thrombocytosis and abnormal liver biochemistry in the absence of metabolites is unclear.