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Background  Neuromyelitis optica spectrum disorders (NMOSD) are demyelinating autoimmune diseases in the central nervous system (CNS) that are characterized by a high relapse rate and the presence of anti-aquaporin 4 antibodies (AQP4-IgG) in the serum. Azathioprine (AZA) is a first-line immunomodulatory drug that is widely used for the treatment of patients with NMOSD. However, the efficacy and safety of AZA vary in different individuals.    Method  Thirty-two patients with NMOSD who regularly took AZA were enrolled in the study at Beijing Tiantan Hospital, Capital Medical University. The efficacy of AZA was evaluated using the expanded disability status scale (EDSS) and the annual relapse rate (ARR). The erythrocyte concentrations of AZA metabolites were detected using an LC-MS/MS method.    Results  The erythrocyte concentrations of 6-thioguanine nucleotides (6-TGNs) and 6-methylmercaptopurine nucleotides (6-MMPNs) were 202.03 ± 63.35 pmol/8*10 8  RBC and 1618.90 ± 1607.06 pmol/8*10 8  RBC, respectively. After the patients had received AZA therapy for more than one year, the EDSS score decreased from 5.21 ± 0.24 to 2.57 ± 0.33 ( p  < 0.0001), and the ARR decreased from 1.41 ± 0.23 to 0.36 ± 0.09 ( p  < 0.0001). The 6-TGN and 6-MMPN levels were significantly different between the non-relapsed and relapsed groups ( p  < 0.0001,  p  = 0.006, respectively). A higher ARR was significantly correlated with higher erythrocyte concentrations of 6-TGNs ( p  < 0.0001) and 6-MMPNs ( p  = 0.004).    Conclusion  AZA can reduce the EDSS score and ARR in NMOSD patients. Additionally, the efficacy of AZA is significantly related to the erythrocyte concentrations of 6-TGNs and 6-MMPNs. Within the safe upper limits, a higher concentration of 6-TGNs is associated with better efficacy of AZA.    Trial registration number    ISRCTN16551495 , retrospectively registered on May 22, 2017.

Relationship between Azathioprine metabolites and therapeutic efficacy in Chinese patients with neuromyelitis optica spectrum disorders