Les thiopurines sont des médicaments cytotoxiques et immunosuppresseurs largement prescrits, notamment dans les maladies inflammatoires chroniques de l’intestin (MICI). Ils représentent l’un des meilleurs exemples d’application clinique de la pharmacogénétique avec le dépistage du déficit en thiopurine S-méthyltransférase (TPMT), enzyme clé du métabolisme des thiopurines. La variabilité interindividuelle de la réponse à ces médicaments rend nécessaire leur optimisation thérapeutique. Ce travail de thèse a d’une part, analysé les relations entre activité TPMT et concentrations des métabolites thiopuriniques, et d’autre part, recherché des facteurs associés à la résistance aux thiopurines. A l’aide d’une base de données pharmacogénétiques hospitalière et d’une étude « PheWAS » à partir d’un entrepôt de données cliniques, nous avons analysé la distribution et la corrélation génotype-phénotype pour la TPMT, en lien avec les concentrations des métabolites thiopuriniques. Nous avons observé qu’une activité TPMT très élevée (phénotype « ultra-rapide ») était associée à des paramètres clinico-biologiques reflétant une maladie évolutive et un traitement inefficace dans les MICI. De plus, une étude clinique rétrospective dans les MICI pédiatriques a permis d’identifier des facteurs associés à la lymphopénie observée sous thiopurines. Enfin, à partir d’un modèle in vitro fondé sur des lignées cellulaires lymphoblastoïdes (LCL) sélectionnées, nous avons établi une signature transcriptomique, incluant 32 gènes, prédictive de la résistance aux thiopurines. Une analyse fonctionnelle bioinformatique a abouti à l’identification de voies métaboliques liées à la protéine p53 et au cycle cellulaire, ainsi que des mécanismes moléculaires associés à la résistance aux thiopurines. En conclusion, ce travail de thèse, qui a exploré la variabilité de réponse aux thiopurines et tout particulièrement la résistance à ces médicaments, propose des hypothèses pour l’individualisation et l’optimisation thérapeutique des thiopurines. / Thiopurines are cytotoxic and immunosuppressive drugs widely prescribed, mainly in inflammatory bowel disease (IBD). They constitute one of the best success story of pharmacogenetic implementation into clinical practice based on the screening of thiopurine S-methyltransferase (TPMT) deficiency, a key enzyme in thiopurine metabolism. Optimization of thiopurine response is challenging because of its large interindividual variability such as inefficacy and toxicities. This thesis has explored, on one hand, the relationships between TPMT activity and metabolite concentrations, and on the other hand, factors associated with thiopurine inefficacy. Using a primary care pharmacogenetic database, we first analyzed TPMT distribution and genotype-phenotype correlation, in relation with thiopurine metabolites in a large population. Using a PheWAS study based on a clinical data warehouse we then reported that a very high TPMT activity (“ultra-rapid” phenotype) was associated with parameters of active IBD and poor response to thiopurines. Furthermore, a retrospective study in pediatric IBD identified factors predicting the occurrence of lymphopenia during thiopurine therapy. Finally, using a lymphoblastoid cell line (LCL) in vitro model, we established a transcriptomic signature, including 32 genes predicting thiopurine cellular resistance. A bioinformatic functional analysis identified metabolic pathways in relation with p53 and cell cycle, as well as molecular mechanisms associated with thiopurine resistance. To conclude, this research work, focusing on the variability of thiopurine response and mainly therapeutic resistance, provides new hypotheses to individualize and optimize therapeutic response to thiopurines.

Thiopurine S-methyltransferase (TPMT) belongs to the Class I S-adenosylmethionine-dependent methyltransferase (SAM-MT) super family of structurally related proteins. Common to the members of this large protein family is the catalysis of methylation reactions using S-adenosylmethionine (SAM) as a methyl group donor, although SAM-MTs act on a wide range of different substrates and carry out numerous biologically important functions. While the natural function of TPMT is unknown, this enzyme is involved in the metabolism of thiopurines, a class of pharmaceutical substances administered in treatment of immune-related disorders. Specifically, methylation by TPMT inactivates thiopurines and their metabolic intermediates, which reduces the efficacy of clinical treatment and increases the risk of adverse side effects. To further complicate matters, TPMT is a polymorphic enzyme with over 40 naturally occurring variants known to date, most of which exhibit lowered methylation activity towards thiopurines. Consequently, there are individual variations in TPMTmediated thiopurine inactivation, and the administered dose has to be adjusted prior to clinical treatment to avoid harmful side effects. Although the clinical relevance of TPMT is well established, few studies have investigated the molecular causes of the reduced methylation activity of variant proteins. In this thesis, the results of biophysical characterization of two variant proteins, TPMT*6 (Y180F) and TPMT*8 (R215H), are presented. While the properties of TPMT*8 were indistinguishable from those of the wild-type protein, TPMT*6 was found to be somewhat destabilized. Interestingly, the TPMT*6 amino acid substitution did not affect the functionality or folding pattern of the variant protein. Therefore, the decreased in vivo functionality reported for TPMT*6 is probably caused by increased proteolytic degradation in response to the reduced stability of this protein variant, rather than loss of function. Also presented herein are novel methodological approaches for studies of TPMT and its variants. Firstly, the advantages of using 8-anilinonaphthalene-1-sulfonic acid (ANS) to probe TPMT tertiary structure and active site integrity are presented. ANS binds exclusively to the native state of TPMT with high affinity (KD ~ 0.2 μm) and a 1:1 ratio. The stability of TPMT was dramatically increased by binding of ANS, which was shown to co-localize with the structurally similar adenine moiety of the cofactor SAM. Secondly, an enzyme activity assay based on isothermal titration calorimetry (ITC) is presented. Using this approach, the kinetics of 6-MP and 6-TG methylation by TPMT has been characterized.