{"Thioguanine can be affected by a patient's TPMT and NUDT15 phenotype. This patient is predicted to be a TPMT intermediate metabolizer and NUDT15 poor metabolizer. This patient is at high risk for life threatening myelosuppression with normal doses of thioguanine and should receive greatly reduced doses. Reduce doses to 25% of normal dose and adjust doses of thioguanine based on degree of myelosuppression and disease-specific guidelines. Allow 4-6 weeks to reach steady-state after each dose adjustment. In setting of myelosuppression, emphasis should be on reducing thioguanine over other agents. For non-malignant conditions, consider alternative non-thiopurine immunosuppressant therapy. Please consult a clinical pharmacist for more information."}