Abstract
Pancreatitis occurs in approximately 4% of patients treated with the thiopurines azathioprine or mercaptopurine. Its development is unpredictable and almost always leads to drug withdrawal. We identified patients with inflammatory bowel disease (IBD) who had developed pancreatitis within 3 months of starting these drugs from 168 sites around the world. After detailed case adjudication, we performed a genome-wide association study on 172 cases and 2,035 controls with IBD. We identified strong evidence of association within the class II HLA region, with the most significant association identified at rs2647087 (odds ratio 2.59, 95% confidence interval 2.07–3.26, P = 2 × 10−16). We replicated these findings in an independent set of 78 cases and 472 controls with IBD matched for drug exposure. Fine mapping of the HLA region identified association with the HLA-DQA1*02:01–HLA-DRB1*07:01 haplotype. Patients heterozygous at rs2647087 have a 9% risk of developing pancreatitis after administration of a thiopurine, whereas homozygotes have a 17% risk.
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Acknowledgements
The International Serious Adverse Events Consortium (iSAEC) funded the sample collection and genotyping. The UK National Institute for Health Research (NIHR) provided research nurse support to facilitate recruitment at all UK research sites. We thank Crohn's and Colitis UK for funding support and publicizing this study to its members. A Wellcome Trust Institutional Strategic Support Award (WT097835MF) generously supported the work in this study. Genotyping was undertaken at the Broad Institute, Cambridge, Massachusetts, USA. We thank all the clinicians who assisted with sample collection as part of the IBD Pharmacogenetics Study Group (listed in the Supplementary Note) and the International IBD Genetics Consortium, as well as S. Marriott for her assistance during the trial initiation. We acknowledge The International Serious Adverse Events Scientific Management Committee members (listed in the Supplementary Note), T. Frayling, S. Lin and K. Hunt for kindly providing comments on the draft manuscript, as well as C. Heard and M. Parkinson for their ongoing administrative support to the study. We also thank all the patients for their time and participation.
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G.A.H., K.S., T.K.D., D.A.v.H., P.C.D., A.L.H. and T.A. participated in the conception, design and coordination of the study. C.M.B. was the project manager and coordinated recruitment. G.A.H., M.N.W. and T.A. analyzed the data and participated in writing the paper. K.P. performed DNA preparation. The International Serious Adverse Events Consortium advised on the GWAS, performed genotyping and participated in writing the paper. A.C., T.C., P.C.D., E.G., P.M.I., J.O.L., J. Mawdsley, Z.M., T.R.O., D.R., G.A.H., A.S. and T.A. performed adjudication of the cases. M.C., J.B.S. and M.B. performed the SSP-based HLA genotyping. J.R. and J.P.V. performed the in silico structural analysis. K.S., J.M.A., V.A., P.B., S.B., A.C., S.J.C., T.C., F.R.C., M.D., T.K.D., R.N.F., T.H.F., D.R.G., E.G., J.H., A.H., P.M.I., G.J., A.K., I.C.L., J.C.L., C.L., R.L.-T., J.O.L., J. Mansfield, J. Mawdsley, Z.M., M.P., T.R.O., G.R.-S., R.K.R., D.R., J.S., M.S.S., G.C.S., M.T., E.V.T., A.W., G.W., R.K.W. and S.Z. contributed a substantial number of samples in line with International Committee of Medical Journal Editors criteria. All authors assisted in the writing, reviewing and approval of the manuscript.
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A complete list of all consortia members is provided in the Supplementary Note.
A complete list of all consortia members is provided in the Supplementary Note.
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Supplementary Figure 2 The docking of mercaptopurine (ball-and-stick) to the P1-pocket HLA-DR7 (shown in surface representation)
The in silico docking runs resulted in the placement of mercaptopurine predominantly within the P1 pocket of HLA-DRB1*07:01 with docking scores (ΔG) of -4.6 kcal/mol. Interestingly, mercaptopurine could be docked into the P1 pockets of HLA-DP2 and HLA-DQ8 albeit with considerably different docking angles due to differences in the architectures of the P1 pockets. However, in the cases of both HLA-DRB1*01:01 and HLA-DRB1*04:01, in which the P1 pockets are conserved with that of HLA-DRB1*0701, there resulted identical docking modes and docking scores (ΔG) of -4.6 kcal/mol. The docking of mercaptopurine to the P1 pocket of HLA-DRB1*07:01 would likely affect the residue selection at this primary anchor point for the peptide and is consistent with the mechanism of drug-modified peptide repertoire as detailed previously for the drug abacavir (Illing, P. T. et al. Immune self-reactivity triggered by drug-modified HLA-peptide repertoire. Nature 486, 554–8 (2012)). However, the lack of binding specificity observed across the HLA-DRB1 alleles suggests that there are other factors in the peptide-binding cleft of HLA-DRB1*07:01, beyond the architecture of the P1 pocket alone, that contribute to the hypersensitivity reaction to mercaptopurine.
Supplementary Figure 3 Causality assessment tool
Adapted version of the Liverpool Adverse Drug Reaction Causality Assessment Tool used in the adjudication process. Adapted from Gallagher et al. (Gallagher, R.M. et al. Development and inter-rater reliability of the Liverpool adverse drug reaction causality assessment tool. PLoS One 6, e28096, 2011).
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Supplementary Figures 1–4, Supplementary Note and Supplementary Tables 1–7 (PDF 2711 kb)
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Heap, G., Weedon, M., Bewshea, C. et al. HLA-DQA1–HLA-DRB1 variants confer susceptibility to pancreatitis induced by thiopurine immunosuppressants. Nat Genet 46, 1131–1134 (2014). https://doi.org/10.1038/ng.3093
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DOI: https://doi.org/10.1038/ng.3093
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