{"Thioguanine can be affected by a patient's TPMT and NUDT15 phenotype. This patient is predicted to be TPMT intermediate metabolizer and is at risk for myelosuppression with normal doses of thioguanine. Start with reduced doses (50% to 80% of normal dose) if normal starting dose is ≥ 40-60 mg/m2/day (e.g., 20-48 mg/m2/day) and adjust doses of thioguanine based on degree of myelosuppression and disease-specific guidelines. Allow 2-4 weeks to reach steady-state after each dose adjustment. If myelosuppression occurs, and depending on other therapy, emphasis should be on reducing thioguanine over other agents. Because a NUDT15 genotype does not appear to have been ordered for this patient, it is not known if NUDT15 results would further influence the recommended dose or drug. Please consult a clinical pharmacist for more information."}