Childhood acute lymphoblastic leukemia mercaptopurine intolerance is associated with NUDT15 variants

Pediatr Res. 2021 Jan;89(1):217-222. doi: 10.1038/s41390-020-0868-8. Epub 2020 Mar 27.


Background: Mercaptopurine-induced neutropenia can interrupt chemotherapy and expose patients to infection during childhood acute lymphoblastic leukemia (ALL) treatment. Previously, six candidate gene variants associated with mercaptopurine intolerance were reported. Herein, we investigated the association between the mean tolerable dose of mercaptopurine and these genetic variants in Taiwanese patients.

Methods: In total, 294 children with ALL were treated at the National Taiwan University Hospital from April 1997 to December 2017. Germline variants were analyzed for NUDT15, SUCLA2, TPMT, ITPA, PACSIN2, and MRP4. Mean daily tolerable doses of mercaptopurine in the continuation phase of treatment were correlated with these genetic variants.

Results: Mercaptopurine intolerance was significantly associated with polymorphisms in NUDT15 (P value < 0.0001). Patients with SUCLA2 variants received lower mercaptopurine doses (P value = 0.0119). The mean mercaptopurine doses did not differ among patients with TPMT, ITPA, MRP4, and PACSIN2 polymorphisms (P value = 0.9461, 0.5818, and 0.7951, respectively). After multivariable linear regression analysis, only NUDT15 variants retained their clinically significant correlation with mercaptopurine intolerance (P value < 0.0001).

Conclusion: In this cohort, the major genetic determinant of mercaptopurine intolerance was NUDT15 in Taiwanese patients.

Impact: NUDT15 causes mercaptopurine intolerance in children with ALL. The NUDT15 variant is a stronger predictor of mercaptopurine intolerance than TPMT in a Taiwanese cohort. This finding is similar with studies performed on Asian populations rather than Caucasians. Pre-emptive genotyping of the patients' NUDT15 before administering mercaptopurine may be more helpful than genotyping TPMT in Asians.

Publication types

  • Research Support, Non-U.S. Gov't

MeSH terms

  • Antimetabolites, Antineoplastic / administration & dosage
  • Antimetabolites, Antineoplastic / adverse effects*
  • Humans
  • Mercaptopurine / administration & dosage
  • Mercaptopurine / adverse effects*
  • Methyltransferases / genetics
  • Neutropenia / chemically induced
  • Neutropenia / diagnosis
  • Neutropenia / genetics*
  • Pharmacogenomic Variants*
  • Polymorphism, Single Nucleotide*
  • Precursor Cell Lymphoblastic Leukemia-Lymphoma / diagnosis
  • Precursor Cell Lymphoblastic Leukemia-Lymphoma / drug therapy*
  • Pyrophosphatases / genetics*
  • Retrospective Studies
  • Risk Assessment
  • Risk Factors
  • Taiwan


  • Antimetabolites, Antineoplastic
  • Mercaptopurine
  • Methyltransferases
  • TPMT protein, human
  • NUDT15 protein, human
  • Pyrophosphatases