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6-Mercaptopurine hepatotoxicity during acute lymphocytic leukemia maintenance therapy

College of Pharmacy, St. John's University, Jamaica, New York, Oncology Clinical Preceptor, North Shore University Hospital, Manhasset, New York

Amy W. Valley, PharmD, BCPS

South Texas Veterans Health Care System, Audie L. Murphy Memorial Veterans Hospital Division, University of Texas Health Science Center San Antonio, San Antonio, Texas

Valerie Relias, PharmD

New England Medical Center, Department of Pharmacy, Boston, Massachusetts

Ashley K. Morris, PharmD, BCPS

Duke University Medical Center, Department of Pharmacy, Durham, North Carolina

Purpose. To describe a case of 6-mercaptopurine acute fulminate hepatotoxicity.

Case Summary. A 65-year-old male with adult acute lymphocytic leukemia was receiving mainte nance therapy with 6-mercaptopurine and methotrex ate when he presented with jaundice, nausea, diar rhea, dysuria, right upper quadrant pain, and dark urine. He presented with elevated bilirubin, aspartate aminotransferase, and alanine aminotransferase. The work-up was negative for other causes of liver dam age. His hospital course included antibiotic therapy, vitamin K, and filgrastim. He was discharged without long-term morbidity from the event and had a normal ization of liver enzymes as an outpatient. Methotrex ate maintenance therapy was continued successfully as an outpatient for > 1 year.

Conclusion. 6-Mercaptopurine is not commonly considered as an agent causing acute hepatotoxicity, but should not be ruled out as a causative agent in the setting of concurrent methotrexate therapy. An epi sode of acute hepatotoxicity did not preclude the continued, safe use of methotrexate in this case.

Key Words: 6-Mercaptopurine • methotrexate; hepatotoxicity • acute lymphocytic leukemia.

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