Variability in drug metabolism: importance of genetic constitution

Pharmacogenetics affects dosing, efficacy, and toxicity of cytochrome P450-metabolized drugs

Drug-metabolizing enzyme activity is one of many factors affecting patient response to medications. The objective of this review is to highlight the potential for genetic variability in cytochrome P450 enzyme activity that can lead to interperson differences in response to drugs. Awareness and application of this knowledge will improve drug use in clinical practice and provide the physician with further appreciation that standard drug dosing may not be appropriate in all patients.

Rapid screening for polymorphisms in dextromethorphan and mephenytoin metabolism

1. The phenotyping parameters for dextromethorphan and mephenytoin were assessed in 48 normal male volunteers following administration of each metabolic probe drug on separate occasions and together according to a randomized 3-way crossover design. 2. Neither the urinary S-/R-mephenytoin ratio nor the dextromethorphan metabolic ratio were altered significantly by coadministration of the probe drugs. 3. Five-hundred and nineteen subjects were screened for expression of mephenytoin 4-hydroxylase and dextromethorphan O-demethylase activity following the coadministration of mephenytoin and dextromethorphan. The activity was determined in each case by methods not requiring any quantitative measurements. 4. Nineteen (3.7%) of the subjects were identified as poor metabolizers (PMs) of mephenytoin and 35 subjects (6.7%) as PMs of dextromethorphan. 5. All PMs of dextromethorphan were confirmed by more rigorous evaluation of the metabolic ratio.

Metabolism of the contraceptive steroid desogestrel by human liver in vitro

The metabolism of the progestogen oral contraceptive desogestrel (Dg) has been studied in vitro using human liver microsomes. Metabolites have been separated using radiometric high performance liquid chromatography and identified by co-chromatography with authentic standards and by mass spectrometry. All the livers examined (n = 6) were able to form 3-keto desogestrel as the main identifiable metabolite and also the presumed intermediates 3 alpha-hydroxydesogestrel (3 alpha-OHDg) and 3 beta-hydroxydesogestrel (3 beta-OHDg). In addition, a large polar heterogenous peak was evident on the radiochromatograms which did not co-chromatograph with any known metabolites of desogestrel. Inter-individual variability in metabolite formation was seen. A number of drugs were examined for their propensity to inhibit desogestrel metabolism. Primaquine was the most potent tested having an IC50 value (inhibitory concentration reducing overall metabolite production by 50%) of 30 microM. Cimetidine, trilostane and levonorgestrel failed to inhibit at 250 microM. With 3 alpha-OHDg as substrate, 3 alpha-hydroxysteroid dehydrogenase (3 alpha-HSDH) activity was 1.0 +/- 0.3 nmol min-1 mg-1 protein which was five times greater than the activity of the 3 beta-HSDH towards 3 beta-OHDg. Miconazole was the most potent inhibitor tested having IC50 values of 14 and 95 microM for 3 alpha- and 3 beta-HSDH respectively. Surprisingly, trilostane was without inhibitory effect on either enzyme, which contrasts with other data involving 3 beta-HSDH in steroidogenic tissue. Our observations with trilostane may reflect tissue differences in the enzyme and/or differences in endogenous vs exogenous steroids (i.e. in the conversion of 3 beta-OHDg to 3-ketodesogestrel there is no requirement for isomerization). Kinetic parameters of 3 alpha-HSDH were also determined.