title: Expressing thiopurine S-methyltransferase activity as units per litre of whole-blood overcomes misleading high results in patients with anaemia.
abstract: BACKGROUND
  Thiopurine S-methyltransferase (TPMT) phenotype analysis, expressed as TPMT activity, is established as a routine pharmacogenomic test to screen patients prior to initiating thiopurine drug therapy. Conventionally measured TPMT activity is corrected for red blood cell (RBC) parameters. Here we present evidence that supports the simplification of the TPMT assay: by expressing TPMT activity in mU/L whole blood, without undertaking any haemoglobin (Hb) correction.
  
  
  METHODS
  Hb concentrations were compared in consecutive samples that had been received for TPMT phenotype analysis and which were stratified into samples with high (n = 111) and samples with normal (n = 50) Hb-corrected enzyme activity. TPMT activity was also measured in samples received for full blood count determination, stratified into those with low (n = 50) and normal (n = 50) Hb. A reference interval for TPMT activity in mU/L was derived from a correlation between activity expressed in conventional units and that expressed in mU/L (n = 1563), supported by comparison with associated genotype (n = 201).
  
  
  RESULTS
  In the high TPMT activity group, 83% of specimens had a low Hb concentration compared with 14% of specimens in the normal TPMT group. Samples with a low Hb concentration were found to have significantly higher Hb-corrected TPMT activity than samples with a normal Hb concentration: 83 versus 44 nmol 6-methyl thioguanine /g Hb/h, P < 0.0001. These results strongly suggest that misleading high Hb-corrected TPMT activity is found in anaemic patients. Based on the reference interval for enzyme activity of 70-150 mU/L, phenotype-genotype concordance compared well with the conventional approach (88% versus 89%). Furthermore, distribution of TPMT phenotypes with activity expressed in mU/L was identical: 0.5% deficient, 11% low, 86% normal and 2.5% high, to when it was expressed in conventional units.
  
  
  CONCLUSIONS
  Expressing TPMT activity in mU/L can overcome misleading high Hb-corrected TPMT results occurring in patients with anaemia, which could lead to inappropriate treatment. Removing the need to measure RBC indices further simplifies TPMT phenotyping, leading to a more robust assay, with reduced turn-around time and cost.
authors.affiliation: Clinical Biochemistry Department, City Hospital, Sandwell and West Birmingham Hospitals NHS Trust, Birmingham B187QH, UK.
authors.forename: N L
authors.initials: NL
authors.lastname: Barlow
authors.forename: V
authors.initials: V
authors.lastname: Graham
authors.forename: J D
authors.initials: JD
authors.lastname: Berg
mesh_terms: D000740:Anemia / Q000097:blood* / Q000201:enzymology* / Q000235:genetics; D001774:Blood Chemical Analysis / Q000379:methods* / Q000592:standards; D005189:False Positive Reactions; D005838:Genotype; D006454:Hemoglobins / Q000032:analysis; D006801:Humans; D008780:Methyltransferases / Q000097:blood*; D010641:Phenotype; D012016:Reference Values; D015203:Reproducibility of Results
chemical_list: D006454:Hemoglobins; D008780:Methyltransferases; C022745:thiopurine methyltransferase