{"Thioguanine can be affected by a patient's TPMT and NUDT15 phenotype. This patient is predicted to be a TPMT intermediate metabolizer and is at risk for myelosuppression with normal doses of thioguanine. Initiate thioguanine at 30-80% of standard starting dose if standard starting dose is ≥40 mg/m2/day. If starting dose is already below normal recommended starting dose (i.e., <40 mg/m2/day), dose reduction might not be necessary. During therapy, adjust the doses of thioguanine based on the degree of myelosuppression and disease-specific guidelines. It usually takes at least 2-4 weeks of stable dosing to reach steady state after each dose adjustment. If myelosuppression occurs, and the patient is on combination 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. Monitor closely for toxicity. Please consult a clinical pharmacist for more information."}