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The third route to immunosuppression involves methyl-thioinosine monophsophate (meTIMP), which inhibits phosphoribosyl pyrophosphate amidotransferase, an enzyme that catalyzes the first step of de novo purine synthesis ( The Role of TPMT Monitoring The American Gastroenterological Association recommends that TPMT activity should be tested prior to the start of thiopurines and the dose adjusted according to TPMT status ( Figure 1 ), TPMT influences the risk of severe and potentially fatal myelosuppression among patients receiving standard doses of azathioprine or 6-mercaptopurine