1
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Tsermpini EE, Serretti A, Dolžan V. Precision Medicine in Antidepressants Treatment. Handb Exp Pharmacol 2023; 280:131-186. [PMID: 37195310 DOI: 10.1007/164_2023_654] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/18/2023]
Abstract
Precision medicine uses innovative approaches to improve disease prevention and treatment outcomes by taking into account people's genetic backgrounds, environments, and lifestyles. Treatment of depression is particularly challenging, given that 30-50% of patients do not respond adequately to antidepressants, while those who respond may experience unpleasant adverse drug reactions (ADRs) that decrease their quality of life and compliance. This chapter aims to present the available scientific data that focus on the impact of genetic variants on the efficacy and toxicity of antidepressants. We compiled data from candidate gene and genome-wide association studies that investigated associations between pharmacodynamic and pharmacokinetic genes and response to antidepressants regarding symptom improvement and ADRs. We also summarized the existing pharmacogenetic-based treatment guidelines for antidepressants, used to guide the selection of the right antidepressant and its dose based on the patient's genetic profile, aiming to achieve maximum efficacy and minimum toxicity. Finally, we reviewed the clinical implementation of pharmacogenomics studies focusing on patients on antidepressants. The available data demonstrate that precision medicine can increase the efficacy of antidepressants and reduce the occurrence of ADRs and ultimately improve patients' quality of life.
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Affiliation(s)
- Evangelia Eirini Tsermpini
- Pharmacogenetics Laboratory, Institute of Biochemistry and Molecular Genetics, Faculty of Medicine, University of Ljubljana, Ljubljana, Slovenia
| | - Alessandro Serretti
- Department of Biomedical and Neuromotor Sciences, University of Bologna, Bologna, Italy
| | - Vita Dolžan
- Pharmacogenetics Laboratory, Institute of Biochemistry and Molecular Genetics, Faculty of Medicine, University of Ljubljana, Ljubljana, Slovenia.
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2
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Klomp SD, Manson ML, Guchelaar HJ, Swen JJ. Phenoconversion of Cytochrome P450 Metabolism: A Systematic Review. J Clin Med 2020; 9:jcm9092890. [PMID: 32906709 PMCID: PMC7565093 DOI: 10.3390/jcm9092890] [Citation(s) in RCA: 76] [Impact Index Per Article: 19.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2020] [Revised: 09/03/2020] [Accepted: 09/04/2020] [Indexed: 12/15/2022] Open
Abstract
Phenoconversion is the mismatch between the individual’s genotype-based prediction of drug metabolism and the true capacity to metabolize drugs due to nongenetic factors. While the concept of phenoconversion has been described in narrative reviews, no systematic review is available. A systematic review was conducted to investigate factors contributing to phenoconversion and the impact on cytochrome P450 metabolism. Twenty-seven studies met the inclusion criteria and were incorporated in this review, of which 14 demonstrate phenoconversion for a specific genotype group. Phenoconversion into a lower metabolizer phenotype was reported for concomitant use of CYP450-inhibiting drugs, increasing age, cancer, and inflammation. Phenoconversion into a higher metabolizer phenotype was reported for concomitant use of CYP450 inducers and smoking. Moreover, alcohol, pregnancy, and vitamin D exposure are factors where study data suggested phenoconversion. The studies reported genotype–phenotype discrepancies, but the impact of phenoconversion on the effectiveness and toxicity in the clinical setting remains unclear. In conclusion, phenoconversion is caused by both extrinsic factors and patient- and disease-related factors. The mechanism(s) behind and the extent to which CYP450 metabolism is affected remain unexplored. If studied more comprehensively, accounting for phenoconversion may help to improve our ability to predict the individual CYP450 metabolism and personalize drug treatment.
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Affiliation(s)
- Sylvia D. Klomp
- Department of Clinical Pharmacy & Toxicology, Leiden University Medical Center, 2333 ZA Leiden, The Netherlands; (S.D.K.); (H.-J.G.)
- Leiden Network for Personalised Therapeutics, Leiden University Medical Center, 2333 ZA Leiden, The Netherlands;
| | - Martijn L. Manson
- Leiden Network for Personalised Therapeutics, Leiden University Medical Center, 2333 ZA Leiden, The Netherlands;
- Division of BioTherapeutics, Leiden Academic Centre for Drug Research (LACDR), Leiden University, 2333 CC Leiden, The Netherlands
| | - Henk-Jan Guchelaar
- Department of Clinical Pharmacy & Toxicology, Leiden University Medical Center, 2333 ZA Leiden, The Netherlands; (S.D.K.); (H.-J.G.)
- Leiden Network for Personalised Therapeutics, Leiden University Medical Center, 2333 ZA Leiden, The Netherlands;
| | - Jesse J. Swen
- Department of Clinical Pharmacy & Toxicology, Leiden University Medical Center, 2333 ZA Leiden, The Netherlands; (S.D.K.); (H.-J.G.)
- Leiden Network for Personalised Therapeutics, Leiden University Medical Center, 2333 ZA Leiden, The Netherlands;
- Correspondence:
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3
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LLerena A, Peñas-LLedó E, de Andrés F, Mata-Martín C, Sánchez CL, Pijierro A, Cobaleda J. Clinical implementation of pharmacogenetics and personalized drug prescription based on e-health: the MedeA initiative. Drug Metab Pers Ther 2020; 0:/j/dmdi.ahead-of-print/dmdi-2020-0143/dmdi-2020-0143.xml. [PMID: 32877361 DOI: 10.1515/dmdi-2020-0143] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2020] [Accepted: 08/05/2020] [Indexed: 11/15/2022]
Affiliation(s)
- Adrián LLerena
- INUBE Extremadura Biosanitary Research Institute,Badajoz, Spain
- Faculty of Medicine, University of Extremadura,Badajoz, Spain
- CICAB Clinical Research Center, Pharmacogenetics and Personalized Medicine Unit, Badajoz University Hospital, Extremadura Health Service, Badajoz, Spain
| | - Eva Peñas-LLedó
- INUBE Extremadura Biosanitary Research Institute,Badajoz, Spain
- Faculty of Medicine, University of Extremadura,Badajoz, Spain
| | - Fernando de Andrés
- INUBE Extremadura Biosanitary Research Institute,Badajoz, Spain
- CICAB Clinical Research Center, Pharmacogenetics and Personalized Medicine Unit, Badajoz University Hospital, Extremadura Health Service, Badajoz, Spain
| | - Carmen Mata-Martín
- INUBE Extremadura Biosanitary Research Institute,Badajoz, Spain
- CICAB Clinical Research Center, Pharmacogenetics and Personalized Medicine Unit, Badajoz University Hospital, Extremadura Health Service, Badajoz, Spain
| | - Cristina L Sánchez
- INUBE Extremadura Biosanitary Research Institute,Badajoz, Spain
- CICAB Clinical Research Center, Pharmacogenetics and Personalized Medicine Unit, Badajoz University Hospital, Extremadura Health Service, Badajoz, Spain
| | - Agustín Pijierro
- INUBE Extremadura Biosanitary Research Institute,Badajoz, Spain
- Department of Internal Medicine, Badajoz University Hospital, Extremadura Health Service,Badajoz, Spain
| | - Jesús Cobaleda
- INUBE Extremadura Biosanitary Research Institute,Badajoz, Spain
- Faculty of Medicine, University of Extremadura,Badajoz, Spain
- Ciudad Jardín Primary Health Care Center, Extremadura Health Service,Badajoz, Spain
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4
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LLerena A, Peñas-LLedó E, de Andrés F, Mata-Martín C, Sánchez CL, Pijierro A, Cobaleda J. Clinical implementation of pharmacogenetics and personalized drug prescription based on e-health: the MedeA initiative. Drug Metab Pers Ther 2020; 35:dmpt-2020-0143. [PMID: 32975200 DOI: 10.1515/dmpt-2020-0143] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2020] [Accepted: 08/05/2020] [Indexed: 11/15/2022]
Affiliation(s)
- Adrián LLerena
- INUBE Extremadura Biosanitary Research Institute,Badajoz, Spain.,Faculty of Medicine, University of Extremadura,Badajoz, Spain.,CICAB Clinical Research Center, Pharmacogenetics and Personalized Medicine Unit, Badajoz University Hospital, Extremadura Health Service, Badajoz, Spain
| | - Eva Peñas-LLedó
- INUBE Extremadura Biosanitary Research Institute,Badajoz, Spain.,Faculty of Medicine, University of Extremadura,Badajoz, Spain
| | - Fernando de Andrés
- INUBE Extremadura Biosanitary Research Institute,Badajoz, Spain.,CICAB Clinical Research Center, Pharmacogenetics and Personalized Medicine Unit, Badajoz University Hospital, Extremadura Health Service, Badajoz, Spain
| | - Carmen Mata-Martín
- INUBE Extremadura Biosanitary Research Institute,Badajoz, Spain.,CICAB Clinical Research Center, Pharmacogenetics and Personalized Medicine Unit, Badajoz University Hospital, Extremadura Health Service, Badajoz, Spain
| | - Cristina L Sánchez
- INUBE Extremadura Biosanitary Research Institute,Badajoz, Spain.,CICAB Clinical Research Center, Pharmacogenetics and Personalized Medicine Unit, Badajoz University Hospital, Extremadura Health Service, Badajoz, Spain
| | - Agustín Pijierro
- INUBE Extremadura Biosanitary Research Institute,Badajoz, Spain.,Department of Internal Medicine, Badajoz University Hospital, Extremadura Health Service,Badajoz, Spain
| | - Jesús Cobaleda
- INUBE Extremadura Biosanitary Research Institute,Badajoz, Spain.,Faculty of Medicine, University of Extremadura,Badajoz, Spain.,Ciudad Jardín Primary Health Care Center, Extremadura Health Service,Badajoz, Spain
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5
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Storelli F, Desmeules J, Daali Y. Genotype-sensitive reversible and time-dependent CYP2D6 inhibition in human liver microsomes. Basic Clin Pharmacol Toxicol 2018; 124:170-180. [PMID: 30192434 DOI: 10.1111/bcpt.13124] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2018] [Accepted: 08/27/2018] [Indexed: 01/16/2023]
Abstract
Cytochrome P450 (CYP) 2D6 metabolizes a wide range of xenobiotics and is characterized by a huge interindividual variability. A recent clinical study highlighted differential magnitude of CYP inhibition as a function of CYP2D6 genotype. The aim of this study was to investigate the effect of CYP2D6 genotype on the inhibition of dextromethorphan O-demethylation by duloxetine and paroxetine in human liver microsomes (HLMs). The study focused on genotypes defined by the combination of two fully functional alleles (activity score 2, AS 2, n = 6), of one fully functional and one reduced allele (activity score 1.5, AS 1.5, n = 4) and of one fully functional and one non-functional allele (activity score 1, AS 1, n = 6), which all predict extensive metabolizer phenotype. Kinetic experiments showed that maximal reaction velocity was affected by CYP2D6 genotype, with a decrease in 33% of Vmax in AS 1 HLMs compared to AS 2 (P = 0.06). No difference in inhibition parameters Ki , KI and kinact was observed neither with the competitive inhibitor duloxetine nor with the time-dependent inhibitor paroxetine. Among the genotypes tested, we found no difference in absolute CYP2D6 microsomal levels with ELISA immunoquantification. Therefore, our results suggest that genotype-sensitive magnitude of drug-drug interactions recently observed in vivo is likely to be due to differential amounts of functional enzymes at the microsomal level rather than to a difference in inhibition potencies across genotypes, which motivates for further quantitative proteomic investigations of functional and variant CYP2D6 alleles.
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Affiliation(s)
- Flavia Storelli
- Division of Clinical Pharmacology and Toxicology, Geneva University Hospitals, University of Geneva, Geneva, Switzerland.,Geneva-Lausanne School of Pharmacy, University of Geneva, Geneva, Switzerland
| | - Jules Desmeules
- Division of Clinical Pharmacology and Toxicology, Geneva University Hospitals, University of Geneva, Geneva, Switzerland.,Geneva-Lausanne School of Pharmacy, University of Geneva, Geneva, Switzerland.,Faculty of Medicine, University of Geneva, Geneva, Switzerland
| | - Youssef Daali
- Division of Clinical Pharmacology and Toxicology, Geneva University Hospitals, University of Geneva, Geneva, Switzerland.,Geneva-Lausanne School of Pharmacy, University of Geneva, Geneva, Switzerland.,Faculty of Medicine, University of Geneva, Geneva, Switzerland
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6
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Storelli F, Samer C, Reny JL, Desmeules J, Daali Y. Complex Drug-Drug-Gene-Disease Interactions Involving Cytochromes P450: Systematic Review of Published Case Reports and Clinical Perspectives. Clin Pharmacokinet 2018; 57:1267-1293. [PMID: 29667038 DOI: 10.1007/s40262-018-0650-9] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
Drug pharmacokinetics (PK) is influenced by multiple intrinsic and extrinsic factors, among which concomitant medications are responsible for drug-drug interactions (DDIs) that may have a clinical relevance, resulting in adverse drug reactions or reduced efficacy. The addition of intrinsic factors affecting cytochromes P450 (CYPs) activity and/or expression, such as genetic polymorphisms and diseases, may potentiate the impact and clinical relevance of DDIs. In addition, greater variability in drug levels and exposures has been observed when such intrinsic factors are present in addition to concomitant medications perpetrating DDIs. This variability results in poor predictability of DDIs and potentially dramatic clinical consequences. The present review illustrates the issue of complex DDIs using systematically searched published case reports of DDIs involving genetic polymorphisms, renal impairment, cirrhosis, and/or inflammation. Current knowledge on the impact of each of these factors on drug exposure and DDIs is summarized and future perspectives for the management of such complex DDIs in clinical practice are discussed, including the use of advanced Computerized Physician Order Entry (CPOE) systems, the development of model-based dose optimization strategies, and the education of healthcare professionals with respect to personalized medicine.
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Affiliation(s)
- Flavia Storelli
- Division of Clinical Pharmacology and Toxicology, Geneva University Hospitals, University of Geneva, Geneva, Switzerland
- Geneva-Lausanne School of Pharmacy, University of Geneva, Geneva, Switzerland
| | - Caroline Samer
- Division of Clinical Pharmacology and Toxicology, Geneva University Hospitals, University of Geneva, Geneva, Switzerland
- Faculty of Medicine, University of Geneva, Geneva, Switzerland
- Swiss Center for Applied Human Toxicology, Geneva, Switzerland
| | - Jean-Luc Reny
- Faculty of Medicine, University of Geneva, Geneva, Switzerland
- Department of Internal Medicine, Rehabilitation and Geriatrics, Geneva University Hospitals, University of Geneva, Geneva, Switzerland
| | - Jules Desmeules
- Division of Clinical Pharmacology and Toxicology, Geneva University Hospitals, University of Geneva, Geneva, Switzerland
- Geneva-Lausanne School of Pharmacy, University of Geneva, Geneva, Switzerland
- Faculty of Medicine, University of Geneva, Geneva, Switzerland
- Swiss Center for Applied Human Toxicology, Geneva, Switzerland
| | - Youssef Daali
- Division of Clinical Pharmacology and Toxicology, Geneva University Hospitals, University of Geneva, Geneva, Switzerland.
- Geneva-Lausanne School of Pharmacy, University of Geneva, Geneva, Switzerland.
- Faculty of Medicine, University of Geneva, Geneva, Switzerland.
- Swiss Center for Applied Human Toxicology, Geneva, Switzerland.
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7
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Santini SA, Panza F, Lozupone M, Bellomo A, Greco A, Seripa D. Genetics of tailored medicine: Focus on CNS drugs. Microchem J 2018. [DOI: 10.1016/j.microc.2017.02.018] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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8
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Storelli F, Matthey A, Lenglet S, Thomas A, Desmeules J, Daali Y. Impact of CYP2D6 Functional Allelic Variations on Phenoconversion and Drug-Drug Interactions. Clin Pharmacol Ther 2017; 104:148-157. [PMID: 28940476 DOI: 10.1002/cpt.889] [Citation(s) in RCA: 39] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2017] [Revised: 09/11/2017] [Accepted: 09/20/2017] [Indexed: 12/17/2022]
Abstract
We investigated whether CYP2D6 extensive metabolizers carrying a nonfunctional allele are at higher risk of phenoconversion to poor metabolizers in the presence of CYP2D6 inhibitors. Seventeen homozygous carriers of two fully-functional alleles and 17 heterozygous carriers of one fully-functional and one nonfunctional allele participated in this trial. Dextromethorphan 5 mg and tramadol 10 mg were given at each of the three study sessions. CYP2D6 was inhibited by duloxetine 60 mg (session 2) and paroxetine 20 mg (session 3). A higher rate of phenoconversion to intermediate metabolizers with duloxetine (71% vs. 25%, P = 0.009) and to poor metabolizers with paroxetine (94% vs. 56%, P = 0.011) was observed in heterozygous than homozygous extensive metabolizers. The magnitude of drug-drug interaction between dextromethorphan and paroxetine was higher in homozygous than in heterozygous subjects (14.6 vs. 8.5, P < 0.028). Our study suggests that genetic extensive metabolizers may not represent a homogenous population and that available genetic data should be considered when addressing drug-drug interactions in clinical practice.
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Affiliation(s)
- Flavia Storelli
- Division of Clinical Pharmacology and Toxicology, Geneva University Hospitals, Geneva, Switzerland.,Geneva-Lausanne School of Pharmacy, University of Geneva, Geneva, Switzerland
| | - Alain Matthey
- Division of Clinical Pharmacology and Toxicology, Geneva University Hospitals, Geneva, Switzerland
| | | | - Aurélien Thomas
- Unit of Toxicology, CURML, Lausanne-Geneva, Switzerland.,Swiss Center for Applied Human Toxicology, Geneva, Switzerland.,Faculty of Biology and Medicine, Lausanne University Hospital, University of Lausanne, Lausanne, Switzerland
| | - Jules Desmeules
- Division of Clinical Pharmacology and Toxicology, Geneva University Hospitals, Geneva, Switzerland.,Geneva-Lausanne School of Pharmacy, University of Geneva, Geneva, Switzerland.,Swiss Center for Applied Human Toxicology, Geneva, Switzerland.,Faculty of Medicine, University of Geneva, Geneva, Switzerland
| | - Youssef Daali
- Division of Clinical Pharmacology and Toxicology, Geneva University Hospitals, Geneva, Switzerland.,Geneva-Lausanne School of Pharmacy, University of Geneva, Geneva, Switzerland.,Swiss Center for Applied Human Toxicology, Geneva, Switzerland.,Faculty of Medicine, University of Geneva, Geneva, Switzerland
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9
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Lozupone M, Panza F, Stella E, La Montagna M, Bisceglia P, Miscio G, Galizia I, Daniele A, di Mauro L, Bellomo A, Logroscino G, Greco A, Seripa D. Pharmacogenetics of neurological and psychiatric diseases at older age: has the time come? Expert Opin Drug Metab Toxicol 2016; 13:259-277. [DOI: 10.1080/17425255.2017.1246533] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Affiliation(s)
- Madia Lozupone
- Unit of Neurodegenerative Disease, Department of Basic Medicine Sciences, Neuroscience, and Sense Organs, University of Bari ‘Aldo Moro,’, Bari, Italy
| | - Francesco Panza
- Unit of Neurodegenerative Disease, Department of Basic Medicine Sciences, Neuroscience, and Sense Organs, University of Bari ‘Aldo Moro,’, Bari, Italy
- Unit of Neurodegenerative Disease, Department of Clinical Research in Neurology, University of Bari ‘Aldo Moro’ at ‘Pia Fondazione Card. G. Panico,’, Tricase, Lecce, Italy
- Geriatric Unit and Gerontology-Geriatrics Research Laboratory, Department of Medical Sciences, IRCCS Casa Sollievo della Sofferenza, San Giovanni Rotondo, Italy
| | - Eleonora Stella
- Psychiatric Unit, Department of Clinical and Experimental Medicine, University of Foggia, Foggia, Italy
| | - Maddalena La Montagna
- Psychiatric Unit, Department of Clinical and Experimental Medicine, University of Foggia, Foggia, Italy
| | - Paola Bisceglia
- Geriatric Unit and Gerontology-Geriatrics Research Laboratory, Department of Medical Sciences, IRCCS Casa Sollievo della Sofferenza, San Giovanni Rotondo, Italy
| | - Giuseppe Miscio
- Laboratory of Clinical Chemistry, Department of Clinical Pathology, IRCCS Casa Sollievo della Sofferenza, San Giovanni Rotondo, Italy
| | - Ilaria Galizia
- Psychiatric Unit, Department of Clinical and Experimental Medicine, University of Foggia, Foggia, Italy
| | - Antonio Daniele
- Institute of Neurology, Catholic University of Sacred Heart, Rome, Italy
| | - Lazzaro di Mauro
- Laboratory of Clinical Chemistry, Department of Clinical Pathology, IRCCS Casa Sollievo della Sofferenza, San Giovanni Rotondo, Italy
| | - Antonello Bellomo
- Psychiatric Unit, Department of Clinical and Experimental Medicine, University of Foggia, Foggia, Italy
| | - Giancarlo Logroscino
- Unit of Neurodegenerative Disease, Department of Basic Medicine Sciences, Neuroscience, and Sense Organs, University of Bari ‘Aldo Moro,’, Bari, Italy
- Unit of Neurodegenerative Disease, Department of Clinical Research in Neurology, University of Bari ‘Aldo Moro’ at ‘Pia Fondazione Card. G. Panico,’, Tricase, Lecce, Italy
| | - Antonio Greco
- Geriatric Unit and Gerontology-Geriatrics Research Laboratory, Department of Medical Sciences, IRCCS Casa Sollievo della Sofferenza, San Giovanni Rotondo, Italy
| | - Davide Seripa
- Geriatric Unit and Gerontology-Geriatrics Research Laboratory, Department of Medical Sciences, IRCCS Casa Sollievo della Sofferenza, San Giovanni Rotondo, Italy
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10
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Panza F, Lozupone M, Stella E, Miscio G, La Montagna M, Daniele A, di Mauro L, Bellomo A, Logroscino G, Greco A, Seripa D. The pharmacogenetic road to avoid adverse drug reactions and therapeutic failures in revolving door patients with psychiatric illnesses: focus on the CYP2D6 isoenzymes. EXPERT REVIEW OF PRECISION MEDICINE AND DRUG DEVELOPMENT 2016. [DOI: 10.1080/23808993.2016.1232148] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
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11
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Panza F, Lozupone M, Stella E, Lofano L, Gravina C, Urbano M, Daniele A, Bellomo A, Logroscino G, Greco A, Seripa D. Psychiatry meets pharmacogenetics for the treatment of revolving door patients with psychiatric disorders. Expert Rev Neurother 2016; 16:1357-1369. [DOI: 10.1080/14737175.2016.1204913] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Affiliation(s)
- Francesco Panza
- a Geriatric Unit and Geriatric Research Laboratory, Department of Medical Sciences , IRCCS Casa Sollievo della Sofferenza , Foggia , Italy.,b Neurodegenerative Diseases Unit, Department of Basic Medicine, Neuroscience, and Sense Organs , University of Bari "Aldo Moro" , Bari , Italy.,c Neurodegenerative Diseases Unit, Department of Clinical Research in Neurology , University of Bari "Aldo Moro" at "Pia Fondazione Card. G. Panico" , Lecce , Italy
| | - Madia Lozupone
- b Neurodegenerative Diseases Unit, Department of Basic Medicine, Neuroscience, and Sense Organs , University of Bari "Aldo Moro" , Bari , Italy.,d Psychiatric Unit, Department of Clinical and Experimental Medicine , University of Foggia , Foggia , Italy
| | - Eleonora Stella
- d Psychiatric Unit, Department of Clinical and Experimental Medicine , University of Foggia , Foggia , Italy
| | - Lucia Lofano
- e Psychiatric Unit, Department of Basic Medicine Sciences, Neuroscience, and Sense Organs , University of Bari "Aldo Moro" , Bari , Italy
| | - Carolina Gravina
- a Geriatric Unit and Geriatric Research Laboratory, Department of Medical Sciences , IRCCS Casa Sollievo della Sofferenza , Foggia , Italy
| | - Maria Urbano
- a Geriatric Unit and Geriatric Research Laboratory, Department of Medical Sciences , IRCCS Casa Sollievo della Sofferenza , Foggia , Italy
| | - Antonio Daniele
- f Institute of Neurology , Catholic University of Sacred Heart , Rome , Italy
| | - Antonello Bellomo
- d Psychiatric Unit, Department of Clinical and Experimental Medicine , University of Foggia , Foggia , Italy
| | - Giancarlo Logroscino
- b Neurodegenerative Diseases Unit, Department of Basic Medicine, Neuroscience, and Sense Organs , University of Bari "Aldo Moro" , Bari , Italy.,c Neurodegenerative Diseases Unit, Department of Clinical Research in Neurology , University of Bari "Aldo Moro" at "Pia Fondazione Card. G. Panico" , Lecce , Italy
| | - Antonio Greco
- a Geriatric Unit and Geriatric Research Laboratory, Department of Medical Sciences , IRCCS Casa Sollievo della Sofferenza , Foggia , Italy
| | - Davide Seripa
- a Geriatric Unit and Geriatric Research Laboratory, Department of Medical Sciences , IRCCS Casa Sollievo della Sofferenza , Foggia , Italy
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12
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Abstract
Chronic kidney disease (CKD) is a progressive process leading to end stage renal disease and either dialysis or transplantation. Patients with CKD often have numerous comorbid conditions such as diabetes, hypertension, and acid-base and electrolyte disorders that can lead to alterations in homeostasis. Changes in drug disposition including hepatic metabolism via phase 1 (ie, cytochrome P-450 enzymes) and phase 2 (ie, conjugation) pathways have been reported. Biotransformation of drugs and endogenous substances within the kidney itself may also be compromised in the presence of CKD. Reduced hepatic and renal clearance leads to systemic accumulation of the parent drug as well as active and toxic metabolites. Characterization of specific hepatic cytochrome (CYP) enzyme pathways in patients with CKD is an area of current research and will lead to an understanding of phenotypic and genotypic expression patterns of several key drug-metabolizing enzymes. The evolving knowledge of CYP enzymes and the alterations that can occur in CKD should allow clinicians to predict adverse consequences of drug therapy and thus prevent these events from occurring. The pharmacy practitioner can also provide important pharmacotherapy interventions in this special patient population, including dose individualization, therapeutic drug monitoring, and evaluation of therapeutic outcomes.
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Affiliation(s)
- Thomas C. Dowling
- Department of Pharmacy Practice and Science, University of Maryland School of Pharmacy, Baltimore,
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13
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Qiu F, Liu S, Miao P, Zeng J, Zhu L, Zhao T, Ye Y, Jiang J. Effects of the Chinese herbal formula “Zuojin Pill” on the pharmacokinetics of dextromethorphan in healthy Chinese volunteers with CYP2D6*10 genotype. Eur J Clin Pharmacol 2016; 72:689-95. [DOI: 10.1007/s00228-016-2048-7] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2015] [Accepted: 03/16/2016] [Indexed: 11/29/2022]
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14
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Shah RR, Gaedigk A, LLerena A, Eichelbaum M, Stingl J, Smith RL. CYP450 genotype and pharmacogenetic association studies: a critical appraisal. Pharmacogenomics 2016; 17:259-75. [DOI: 10.2217/pgs.15.172] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
Despite strong pharmacological support, association studies using genotype-predicted phenotype as a variable have yielded conflicting or inconclusive evidence to promote personalized pharmacotherapy. Unless the patient is a genotypic poor metabolizer, imputation of patient's metabolic capacity (or metabolic phenotype), a major factor in drug exposure-related clinical response, is a complex and highly challenging task because of limited number of alleles interrogated, population-specific differences in allele frequencies, allele-specific substrate-selectivity and importantly, phenoconversion mediated by co-medications and inflammatory co-morbidities that modulate the functional activity of drug metabolizing enzymes. Furthermore, metabolic phenotype and clinical outcomes are not binary functions; there is large intragenotypic and intraindividual variability. Therefore, the ability of association studies to identify relationships between genotype and clinical outcomes can be greatly enhanced by determining phenotype measures of study participants and/or by therapeutic drug monitoring to correlate drug concentrations with genotype and actual metabolic phenotype. To facilitate improved analysis and reporting of association studies, we propose acronyms with the prefixes ‘g’ (genotype-predicted phenotype) and ‘m’ (measured metabolic phenotype) to better describe this important variable of the study subjects. Inclusion of actually measured metabolic phenotype, and when appropriate therapeutic drug monitoring, promises to reveal relationships that may not be detected by using genotype alone as the variable.
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Affiliation(s)
| | - Andrea Gaedigk
- Clinical Pharmacology, Toxicology &, Therapeutic Innovation, Children's Mercy-Kansas City, 2401 Gillham Rd, Kansas City, MO 64108, USA
- School of Medicine, University of Missouri-Kansas City, MO, USA
| | - Adrián LLerena
- CICAB Clinical Research Centre, Extremadura University Hospital & Medical School, Badajoz, Spain
| | - Michel Eichelbaum
- Dr. Margarete Fischer-Bosch – Institut für Klinische Pharmakologie, 70376 Stuttgart Auerbachstr., 112 Germany
| | - Julia Stingl
- Centre for Translational Medicine, University of Bonn Medical School, Bonn, Germany
| | - Robert L Smith
- Department of Surgery & Cancer, Faculty of Medicine, Imperial College, South Kensington Campus, London, UK
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15
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LLerena A, Peñas-Lledó EM. Metabolic phenotype prediction from genotyping data: a bottleneck for the implementation of pharmacogenetics in drug development and clinical practice. Drug Metab Pers Ther 2015; 30:143-145. [PMID: 26353178 DOI: 10.1515/dmpt-2015-0025] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/05/2023]
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16
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Hicks JK, Bishop JR, Sangkuhl K, Müller DJ, Ji Y, Leckband SG, Leeder JS, Graham RL, Chiulli DL, LLerena A, Skaar TC, Scott SA, Stingl JC, Klein TE, Caudle KE, Gaedigk A. Clinical Pharmacogenetics Implementation Consortium (CPIC) Guideline for CYP2D6 and CYP2C19 Genotypes and Dosing of Selective Serotonin Reuptake Inhibitors. Clin Pharmacol Ther 2015; 98:127-34. [PMID: 25974703 DOI: 10.1002/cpt.147] [Citation(s) in RCA: 638] [Impact Index Per Article: 70.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2015] [Revised: 05/05/2015] [Accepted: 05/08/2015] [Indexed: 11/11/2022]
Abstract
Selective serotonin reuptake inhibitors (SSRIs) are primary treatment options for major depressive and anxiety disorders. CYP2D6 and CYP2C19 polymorphisms can influence the metabolism of SSRIs, thereby affecting drug efficacy and safety. We summarize evidence from the published literature supporting these associations and provide dosing recommendations for fluvoxamine, paroxetine, citalopram, escitalopram, and sertraline based on CYP2D6 and/or CYP2C19 genotype (updates at www.pharmgkb.org).
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Affiliation(s)
- J K Hicks
- Department of Pharmacy, Cleveland Clinic, Cleveland, Ohio, USA; Genomic Medicine Institute, Cleveland Clinic, Cleveland, Ohio, USA; and Department of Medicine, Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland, Ohio, USA
| | - J R Bishop
- University of Minnesota College of Pharmacy, Department of Experimental and Clinical Pharmacology, Minneapolis, Minnesota, USA
| | - K Sangkuhl
- Department of Genetics, Stanford University, Stanford, California, USA
| | - D J Müller
- Campbell Family Mental Health Research Institute, Centre for Addiction and Mental Health, Toronto, Ontario, Canada; Department of Psychiatry, University of Toronto, Toronto, Ontario, Canada
| | - Y Ji
- Department of Laboratory Medicine and Pathology, Division of Laboratory Genetics, Mayo Clinic, Rochester, Minnesota, USA
| | - S G Leckband
- Veterans Affairs San Diego Healthcare System, Mental Health Care Line, University of California, San Diego, Skaggs School of Pharmacy and Pharmaceutical Sciences and Department of Psychiatry, San Diego, California, USA
| | - J S Leeder
- Division of Clinical Pharmacology, Toxicology & Innovative Therapeutics, Children's Mercy Hospital, Kansas City, Missouri and Department of Pediatrics, University of Missouri-Kansas City, Kansas City, Missouri, USA
| | - R L Graham
- Philadelphia Veterans Affairs Medical Center, Philadelphia, Pennsylvania, USA
| | - D L Chiulli
- Veterans Affairs Palo Alto Health Care System, San Jose Division, San Jose, California, USA
| | - A LLerena
- CICAB Clinical Research Center, Extremadura University Hospital and Medical School, Badajoz, Spain
| | - T C Skaar
- Division of Clinical Pharmacology, Department of Medicine, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - S A Scott
- Department of Genetics and Genomic Sciences, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - J C Stingl
- Federal Institute of Drugs and Medical Devices, Bonn, Germany
| | - T E Klein
- Department of Genetics, Stanford University, Stanford, California, USA
| | - K E Caudle
- Department of Pharmaceutical Sciences, St. Jude Children's Research Hospital, Memphis, Tennessee, USA
| | - A Gaedigk
- Division of Clinical Pharmacology, Toxicology & Innovative Therapeutics, Children's Mercy Hospital, Kansas City, Missouri and Department of Pediatrics, University of Missouri-Kansas City, Kansas City, Missouri, USA
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Magalhães P, Alves G, Llerena A, Falcão A. Venlafaxine pharmacokinetics focused on drug metabolism and potential biomarkers. ACTA ACUST UNITED AC 2015; 29:129-41. [PMID: 24607919 DOI: 10.1515/dmdi-2013-0053] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2013] [Accepted: 01/23/2014] [Indexed: 01/16/2023]
Abstract
Venlafaxine (VEN) is one of the safest and most effective drugs used in the treatment of selective serotonin reuptake inhibitors-resistant depression, and thereby it is nowadays one of the most commonly prescribed antidepressants. Nevertheless, patients treated with antidepressant drugs including VEN have exhibited large inter-individual variability in drug outcomes, possibly due to the influence of genetic and nongenetic factors on the drug pharmacokinetics and/or pharmacodynamics. Among them, an increased interest has emerged over the last few years on the genetic and/or phenotypic profile for drug-metabolizing cytochrome P450 isoenzymes and drug transporters such as potential predictive pharmacokinetic-based biomarkers of the variability found in drug biodisposition and antidepressant response. The integration of some of these key therapeutic biomarkers with classic therapeutic drug monitoring constitutes a promising way to individualization of VEN's pharmacotherapy, offering to clinicians the ability to better predict and manage pharmacological treatments to maximize the drug effectiveness. Thus, this review provides an extensive discussion of the pharmacokinetics of VEN focusing in particular on metabolism issues, without forgetting the clinically relevant sources of pharmacokinetics variability (mainly the genetic sources) and aiming on the identification of phenotypic and/or genetic biomarkers for therapy optimization.
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18
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Shah RR, Smith RL. Addressing phenoconversion: the Achilles' heel of personalized medicine. Br J Clin Pharmacol 2015; 79:222-40. [PMID: 24913012 PMCID: PMC4309629 DOI: 10.1111/bcp.12441] [Citation(s) in RCA: 172] [Impact Index Per Article: 19.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2014] [Accepted: 06/04/2014] [Indexed: 02/06/2023] Open
Abstract
Phenoconversion is a phenomenon that converts genotypic extensive metabolizers (EMs) into phenotypic poor metabolizers (PMs) of drugs, thereby modifying their clinical response to that of genotypic PMs. Phenoconversion, usually resulting from nongenetic extrinsic factors, has a significant impact on the analysis and interpretation of genotype-focused clinical outcome association studies and personalizing therapy in routine clinical practice. The high phenotypic variability or genotype-phenotype mismatch, frequently observed due to phenoconversion within the genotypic EM population, means that the real number of phenotypic PM subjects may be greater than predicted from their genotype alone, because many genotypic EMs would be phenotypically PMs. If the phenoconverted population with genotype-phenotype mismatch, most extensively studied for CYP2D6, is as large as the evidence suggests, there is a real risk that genotype-focused association studies, typically correlating only the genotype with clinical outcomes, may miss clinically strong pharmacogenetic associations, thus compromising any potential for advancing the prospects of personalized medicine. This review focuses primarily on co-medication-induced phenoconversion and discusses potential approaches to rectify some of the current shortcomings. It advocates routine phenotyping of subjects in genotype-focused association studies and proposes a new nomenclature to categorize study populations. Even with strong and reliable data associating patients' genotypes with clinical outcome(s), there are problems clinically in applying this knowledge into routine pharmacotherapy because of potential genotype-phenotype mismatch. Drug-induced phenoconversion during routine clinical practice remains a major public health issue. Therefore, the principal challenges facing personalized medicine, which need to be addressed, include identification of the following factors: (i) drugs that are susceptible to phenoconversion; (ii) co-medications that can cause phenoconversion; and (iii) dosage amendments that need to be applied during and following phenoconversion.
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Affiliation(s)
| | - Robert L Smith
- Department of Surgery and Cancer, Faculty of Medicine, Imperial CollegeLondon, UK
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19
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Lazalde-Ramos BP, Martínez-Fierro MDLL, Galaviz-Hernández C, Garza-Veloz I, Naranjo MEG, Sosa-Macías M, Llerena A. CYP2D6 gene polymorphisms and predicted phenotypes in eight indigenous groups from northwestern Mexico. Pharmacogenomics 2014; 15:339-48. [PMID: 24533713 DOI: 10.2217/pgs.13.203] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
AIM Polymorphisms in CYP2D6 impact the interindividual and interethnic variability of drug efficiency; therefore, we determined the CYP2D6 allele distribution in eight Amerindian groups from northwestern Mexico and compared them with the frequencies in Mexican Mestizos. MATERIALS & METHODS A total of 508 Amerindians were studied. Genotyping of CYP2D6*5 and multiplication alleles was performed by long-range PCR, while CYP2D6*2, *3, *4, *6, *10, *17, *29, *35, *41 and copy number were evaluated by real-time PCR. RESULTS The most frequent alleles were CYP2D6*2 (0.05-0.28), CYP2D6*4 (0.003-0.21) and multiplications (0.043-0.107). CYP2D6*5, *6, * 10 and *41 were not observed in the majority of Amerindians, and CYP2D6*3, *17, *35 and *29 were not detected. The poor metabolizer genotype ( *4/*5) was lower (0.2%) in Amerindians than in Mestizos (5%); conversely, the ultrarapid metabolizer genotype was higher (12.6%) in indigenous groups than in Mestizos (7%). CONCLUSION Our data show a lower frequency of CYP2D6 inactive alleles and a higher frequency of duplication/multiplication of CYP2D6 active alleles in indigenous populations that in Mestizos. Original submitted 14 August 2013; Revision submitted 7 October 2013.
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Affiliation(s)
- Blanca Patricia Lazalde-Ramos
- Laboratorio de Medicina Molecular, Unidad Académica de Ciencias Químicas, Universidad Autónoma de Zacatecas, Zacatecas, México
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20
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Peñas-LLedó EM, LLerena A. CYP2D6 variation, behaviour and psychopathology: implications for pharmacogenomics-guided clinical trials. Br J Clin Pharmacol 2014; 77:673-83. [PMID: 24033670 PMCID: PMC3971983 DOI: 10.1111/bcp.12227] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2013] [Accepted: 08/11/2013] [Indexed: 12/16/2022] Open
Abstract
Individual and population differences in polymorphic cytochrome P450 enzyme function have been known for decades. The biological significance of these differences has now been deciphered with regard to drug metabolism, action and toxicity as well as disposition of endogenous substrates, including neuroactive compounds. While the cytochrome P450 enzymes occur abundantly in the liver, they are expressed in most tissues of the body, albeit in varying amounts, including the brain. The latter location of cytochrome P450s is highly pertinent for susceptibility to neuropsychiatric diseases, not to mention local drug metabolism at the site of psychotropic drug action in the brain. In the current era of personality medicine with companion theranostics (i.e. the fusion of therapeutics with diagnostics), this article underscores that such versatile biological roles of cytochrome P450s offer multiple points of entry for personalized medicine and rational therapeutics. We focus our discussion on CYP2D6, one of the most intensively researched drug and endogenous compound metabolism pathways, with a view to relevance for, and optimization of, pharmacogenomic-guided clinical trials. Working on the premise that CYP2D6 is related to human behaviour and certain personality traits such as serotonin and dopamine system function, we further suggest that the motivation of healthy volunteers to participate in clinical trials may in part be influenced by an under- or over-representation of certain CYP2D6 metabolic groups.
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Affiliation(s)
- Eva M Peñas-LLedó
- CICAB Clinical Research Centre, Extremadura University Hospital and Medical SchoolBadajoz
| | - Adrián LLerena
- CICAB Clinical Research Centre, Extremadura University Hospital and Medical SchoolBadajoz
- CIBERSAM, ISCIIIMadrid, Spain
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21
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Peñas-LLedó EM, LLerena A. CYP2D6 genetic polymorphism and psychiatry patients’ hospitalization period. Biomark Med 2013; 7:915-6. [DOI: 10.2217/bmm.13.108] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
A letter in response to: Ruaño G, Szarek BL, Villagra D et al. Length of psychiatric hospitalization is correlated with CYP2D6 functional status in inpatients with major depressive disorder. Biomarkers Med. 7(3), 429–439 (2013).
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Affiliation(s)
| | - Adrián LLerena
- CICAB Clinical Research Center, Extremadura University Hospital & Medical School, Badajoz, Spain
- CIBERSAM, ISCIII, Madrid, Spain
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22
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de Andrés F, Sosa-Macías M, Lazalde-Ramos BP, Naranjo MEG, Tarazona-Santos E, LLerena A. Evaluation of drug-metabolizing enzyme hydroxylation phenotypes in Hispanic populations: the CEIBA cocktail. ACTA ACUST UNITED AC 2013; 28:135-46. [DOI: 10.1515/dmdi-2013-0020] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2013] [Accepted: 05/16/2013] [Indexed: 11/15/2022]
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23
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Dorado P, Peñas-LLedó EM, de la Rubia A, LLerena A. Relevance of CYP2D6-1584C>G polymorphism for thioridazine:mesoridazine plasma concentration ratio in psychiatric patients. Pharmacogenomics 2009; 10:1083-9. [DOI: 10.2217/pgs.09.57] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Aims: The CYP2D6 -1584C>G (rs1080985) polymorphism has been identified as another major factor for CYP2D6 function that is possibly associated with ultrarapid metabolism. The mutant -1584G promoter genotype seems to be consistently related to a higher protein expression than -1584C. However, the impact this SNP in the CYP2D6 promoter region has on plasma levels of patients taking CYP2D6 substrates, such as thioridazine, has not been studied. Previously, we showed the validity of the mesoridazine:thioridazine ratio to assess CYP2D6 activity in clinical settings. Therefore, the aim of this study was to analyze the relationship between the presence of the CYP2D6 -1584C>G polymorphism and the plasma concentrations of thioridazine and its metabolites in a previously studied population of patients in order to evaluate the implications for CYP2D6 hydroxylation capacity. Materials & methods: The CYP2D6 -1584C>G polymorphism was determined by using a PCR-RFLP method in 61 Caucasian psychiatric patients receiving thioridazine monotherapy. Results: Among patients with two active CYP2D6 genes, there were significant differences in the thioridazine:mesoridazine plasma concentrations ratio (p < 0.05) among the three CYP2D6 -1584C>G genotype groups. Moreover, in this group of patients the thioridazine:mesoridazine ratio was lower (p < 0.05) in carriers of CYP2D6 -1584G allele than in patients homozygous for CYP2D6 -1584C allele. However, no differences in thioridazine or its metabolite concentrations between homozygous CYP2D6 -1584C allele carriers and carriers of the -1584G allele were found. Conclusion: According to the present results the concentration ratio of thioridazine to mesoridazine was related to the CYP2D6 -1584C>G polymorphism. It is likely that individuals who carry CYP2D6 -1584G versus homozygotes for the -1584C allele may present an increased CYP2D6 activity.
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Affiliation(s)
- Pedro Dorado
- CICAB Centro de Investigación Clínica, Área de Salud de Badajoz, Servicio Extremeño de Salud, Hospital Universitario Infanta Cristina, 06080 Badajoz, Spain
| | - Eva M Peñas-LLedó
- CICAB Centro de Investigación Clínica, Área de Salud de Badajoz, Servicio Extremeño de Salud, Hospital Universitario Infanta Cristina, 06080 Badajoz, Spain
| | | | - Adrián LLerena
- CICAB Centro de Investigación Clínica, Área de Salud de Badajoz, Servicio Extremeño de Salud, Hospital Universitario Infanta Cristina, 06080 Badajoz, Spain
- Faculdade de Ciencias da Saude, Covilhã, Portugal
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24
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LLerena A, Dorado P, Peñas-Lledó EM. Pharmacogenetics of debrisoquine and its use as a marker for CYP2D6 hydroxylation capacity. Pharmacogenomics 2009; 10:17-28. [DOI: 10.2217/14622416.10.1.17] [Citation(s) in RCA: 51] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Debrisoquine hydroxylation polymorphism is by far the most thoroughly studied genetic polymorphism of the CYP2D6 drug-metabolizing enzyme. Debrisoquine hydroxylation phenotype has been the most used test in humans to evaluate CYP2D6 activity. Two debrisoquine hydroxylation phenotypes have been described: poor and extensive metabolizers. A group with a very low debrisoquine metabolic ratio within the extensive metabolizers, named ultrarapid metabolizers, has also been distinguished. This CYP2D6 variability can be for a large part alternatively determined by genotyping, which appears to be of clinical importance given CYP2D6 involvement in the metabolism of a large number of commonly prescribed drugs. CYP2D6 pharmacogenetics may then become a useful tool to predict drug-related side effects, interactions or therapeutic failures. However, a number of reasons appear to have made research into this field lag behind. The present review focuses on the relevance of genetics and environmental factors for determining debrisoquine hydroxylation phenotype, as well as the relevance of CYP2D6 genetic polymorphism in psychiatric patients treated with antipsychotic drugs.
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Affiliation(s)
- Adrián LLerena
- CICAB, Clinical Research Centre, Extremadura University Hospital and Medical School, Spain
| | - Pedro Dorado
- CICAB, Clinical Research Centre, Extremadura University Hospital and Medical School, Spain
| | - Eva M Peñas-Lledó
- CICAB, Clinical Research Centre, Extremadura University Hospital and Medical School, Spain
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25
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Dorado P, Peñas-Lledó EM, Llerena A. CYP2D6 polymorphism: implications for antipsychotic drug response, schizophrenia and personality traits. Pharmacogenomics 2008; 8:1597-608. [PMID: 18034624 DOI: 10.2217/14622416.8.11.1597] [Citation(s) in RCA: 46] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
The CYP2D6 gene is highly polymorphic, causing absent (poor metabolizers), decreased, normal or increased enzyme activity (extensive and ultrarapid metabolizers). The genetic polymorphism of the CYP2D6 influences plasma concentration of a wide variety of drugs metabolized in the liver by the cytochrome P450 (CYP) 2D6 enzyme, including antipsychotic drugs used for schizophrenia treatment. Additionally, CYP2D6 is involved in the metabolism of endogenous substrates in the brain, and reported to be located in regions such as the cortex, hippocampus and cerebellum, which are impaired in schizophrenia. Moreover, recently we have found that CYP2D6 poor metabolizers are under-represented in a case-control association study of schizophrenia. Furthermore, null CYP2D6 activity in healthy volunteers is associated with personality characteristics of social cognitive anxiety, which may bear some resemblance to milder forms of psychotic-like symptoms. In keeping with this, CYP2D6 may influence, not only variability to drug response, but also vulnerability to disease in schizophrenia patients.
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Affiliation(s)
- Pedro Dorado
- Extremadura University Hospital and Medical School, Clinical Research Center-CICAB, Servicio Extremeño de Salud, Faculty of Medicine, CICAB Hospital Infanta Cristina, Avda. de Elvas s/n. E-06071, Badajoz, Spain.
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26
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Kumar V, Brundage RC, Oetting WS, Leppik IE, Tracy TS. Differential genotype dependent inhibition of CYP2C9 in humans. Drug Metab Dispos 2008; 36:1242-8. [PMID: 18378563 DOI: 10.1124/dmd.108.020396] [Citation(s) in RCA: 40] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023] Open
Abstract
The effects of genetic polymorphisms in drug-metabolizing enzymes (e.g., CYP2C9(*)3) on drug clearance have been well characterized but much less is known about whether these polymorphisms alter susceptibility to drug-drug interactions. Previous in vitro work has demonstrated that genotype-dependent inhibition of CYP2C9 mediated flurbiprofen metabolism, suggesting the possibility of genotype-dependent inhibition interactions in vivo. In the current study, flurbiprofen was used as a probe substrate and fluconazole as a prototypical inhibitor to investigate whether genotype-dependent inhibition of CYP2C9 occurs in vivo. From 189 healthy volunteers who were genotyped for CYP2C9 polymorphisms, 11 control subjects (CYP2C9(*)1/(*)1), 9 heterozygous and 2 homozygous for the CYP2C9(*)3 allele participated in the pharmacokinetic drug interaction study. Subjects received a single 50-mg oral dose of flurbiprofen alone or after administration of either 200 or 400 mg of fluconazole for 7 days using an open, randomized, crossover design. Flurbiprofen and fluconazole plasma concentrations along with flurbiprofen and 4'-hydroxyflurbiprofen urinary excretion were monitored. Flurbiprofen apparent oral clearance differed significantly among the three genotype groups (p < 0.05) at baseline but not after pretreatment with 400 mg of fluconazole for 7 days. Changes in flurbiprofen apparent oral clearance after fluconazole coadministration were gene dose-dependent, with virtually no change occurring in (*)3/(*)3 subjects. Analysis of fractional clearances suggested that the fraction metabolized by CYP2C9, as influenced by genotype, determined the degree of drug interaction observed. In summary, the presence of CYP2C9(*)3 alleles (either one or two alleles) can alter the degree of drug interaction observed upon coadministration of inhibitors.
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Affiliation(s)
- Vikas Kumar
- Department of Experimental and Clinical Pharmacology, College of Pharmacy, University of Minnesota, Minneapolis, MN 55455, USA
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27
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Hellum BH, Nilsen OG. The in vitro Inhibitory Potential of Trade Herbal Products on Human CYP2D6-Mediated Metabolism and the Influence of Ethanol. Basic Clin Pharmacol Toxicol 2007; 101:350-8. [PMID: 17910620 DOI: 10.1111/j.1742-7843.2007.00121.x] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
The six commonly used trade herbal products, St. John's wort, common valerian, common sage, Ginkgo biloba, Echinacea purpurea and horse chestnut, and ethanol, were investigated for their in vitro inhibitory potential of cytochrome P450 2D6 (CYP2D6)-mediated metabolism. Herbal components were extracted from commercially available products in a way that ensured the same composition of constituents in the extract as in the original trade products. c-DNA baculovirus expressed CYP2D6 was used with dextromethorphan as substrate. Quinidine was included as a positive control inhibitor. A validated high performance liquid chromatography methodology was used to quantify the formation of dextrorphan (product of dextromethorphan O-demethylation). Ethanol showed a biphasic effect on CYP2D6 metabolism, increasing initially the CYP2D6 activity with 175% of control up to a concentration of 1.1%, where after ethanol linearly inhibited the CYP2D6 activity. All the investigated herbs inhibited CYP2D6 activity to some extent, but only St. John's wort, common sage and common valerian were considered possible candidates for in vivo clinically significant effects. They showed IC50 values of 0.07 +/- 7 x 10(-3) mg/ml, 0.8 +/- 0.05 mg/ml and 1.6 +/- 0.2 mg/ml, respectively. St. John's wort inhibited CYP2D6-mediated metabolism in an uncompetitive manner, while common valerian and common sage in a non-competitive manner demonstrated interherb differences in inhibition patterns and differences when compared to the more homogenous competitive inhibitor quinidine. Common valerian was the only herb that showed a mechanistic inhibition of CYP2D6 activity and attention should be paid to a possible toxicity of this herb.
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Affiliation(s)
- Bent H Hellum
- Department of Cancer Research and Molecular Medicine, Faculty of Medicine, Norwegian University of Science and Technology, Trondheim, Norway.
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28
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Thanacoody RHK, Daly AK, Reilly JG, Ferrier IN, Thomas SHL. Factors affecting drug concentrations and QT interval during thioridazine therapy. Clin Pharmacol Ther 2007; 82:555-65. [PMID: 17460606 DOI: 10.1038/sj.clpt.6100195] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
The objective of this study was to investigate factors affecting steady-state plasma concentrations of thioridazine. A cross-sectional study of patients receiving chronic thioridazine was employed. Common allelic variants of CYP2D6 and CYP2C19, as well as thioridazine and metabolite concentrations and QTc intervals, were determined. In 97 patients, dose-corrected plasma concentrations (C/Ds) of thioridazine and metabolites were correlated with age but not sex or CYP2C19 genotype. Patients with no functional CYP2D6 alleles (n=9) had significantly higher C/D for thioridazine (P=0.017) and the ring sulfoxide metabolite and a significantly higher thioridazine/mesoridazine ratio compared with those with >/=1 functional CYP2D6 allele (n=82). Smokers had significantly lower C/D for thioridazine, mesoridazine, and sulforidazine and significantly lower thioridazine/ring sulfoxide ratios than non-smokers. QTc interval was not significantly affected by CYP2D6 or CYP2C19 genotypes. Plasma concentrations of thioridazine are influenced by age, smoking, and CYP2D6 genotype, but CYP2D6 genotype does not appear to influence on-treatment QTc interval.
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Affiliation(s)
- R H K Thanacoody
- School of Clinical and Laboratory Sciences, University of Newcastle, Newcastle upon Tyne, UK
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29
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Salih ISM, Thanacoody RHK, McKay GA, Thomas SHL. Comparison of the Effects of Thioridazine and Mesoridazine on the QT Interval in Healthy Adults After Single Oral Doses. Clin Pharmacol Ther 2007; 82:548-54. [PMID: 17410120 DOI: 10.1038/sj.clpt.6100194] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
We compared the effects of single doses of thioridazine and mesoridazine on the heart rate-corrected QT (QTc) interval in healthy adult volunteers. QTc intervals and plasma concentrations of thioridazine, mesoridazine, and metabolites were measured after single oral doses of thioridazine hydrochloride 50 mg, mesoridazine besylate 50 mg, or placebo in a double-blind, crossover study. Mean maximum increases in the QTc interval following thioridazine (37.3+/-4.1 ms, P=0.023) and mesoridazine (46.6+/-7.4 ms, P=0.021) were similar and significantly greater than following placebo (12.9+/-8.1 ms). The area under the effect-time curve over 8 h following drug administration was similar between the two drugs (129.3+/-22.1 vs 148.3+/-43.0 ms h). In conclusion, thioridazine and mesoridazine are associated with similar effects on the QTc interval.
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Affiliation(s)
- I S M Salih
- School of Clinical and Laboratory Sciences, University of Newcastle, Newcastle-upon-Tyne, Newcastle, UK
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30
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Dorado P, Berecz R, Peñas-Lledó EM, de la Rubia A, Llerena A. No effect of the CYP1A2*1F genotype on thioridazine, mesoridazine, sulforidazine plasma concentrations in psychiatric patients. Eur J Clin Pharmacol 2007; 63:527-8. [PMID: 17345072 DOI: 10.1007/s00228-007-0284-6] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2006] [Accepted: 02/17/2007] [Indexed: 10/23/2022]
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31
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Llerena A, Dorado P, Peñas-Lledó EM, Cáceres MC, De la Rubia A. Low frequency of CYP2D6 poor metabolizers among schizophrenia patients. THE PHARMACOGENOMICS JOURNAL 2007; 7:408-10. [PMID: 17325735 DOI: 10.1038/sj.tpj.6500439] [Citation(s) in RCA: 33] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
Abstract
CYP2D6 has been suggested to be functionally similar to the dopamine transporter. The present study was aimed at analysing the frequency of CYP2D6 alleles and genotype among schizophrenic patients compared to healthy volunteers. CYP2D6 *3, *4, *5, *6, *10 and duplicated alleles were analysed in 128 unselected schizophrenia inpatients (SP) and 142 unrelated white European Spanish healthy volunteers (HV). SP and HV with >2, 2, 1 or 0 CYP2D6 active genes were 4.7, 64.8, 28.1 and 2.3%, and 6.3, 52.1, 33.1 and 8.5%, respectively. The frequency of homozygous for CYP2D6 inactive alleles or poor metabolizers (PMs) was lower (P<0.05) in SP than in HV. Furthermore, the frequency of CYP2D6 inactive alleles was also lower in SP than in HV (16.8 vs 25.7; P<0.05), specifically the CYP2D6*6 allele was not found among patients. The present study shows a lower frequency of PMs in schizophrenic patients than in healthy volunteers supporting the hypothesis of a potential role of CYP2D6 in the vulnerability to schizophrenia.
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Affiliation(s)
- A Llerena
- Department of Pharmacology and Psychiatry, School of Medicine, University of Extremadura, Badajoz, Spain.
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Dorado P, Berecz R, Peñas-Lledó EM, Llerena A. Antipsychotic drugs and QTc prolongation: the potential role ofCYP2D6genetic polymorphism. Expert Opin Drug Metab Toxicol 2007; 3:9-19. [PMID: 17269891 DOI: 10.1517/17425255.3.1.9] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Although the most common, and usually serious, side effects of first-generation (or typical) antipsychotic drugs, such as Parkinsonism, dystonias and tardive dyskinesia, were known from early times, their cardiovascular safety was not properly in the focus of treatment management. The growing evidence of these drug-related cardiac changes and the appearance of potentially fatal dysrhythmias have increased the interest on their safety profile. Thus, the introduction of the new second-generation (atypical) antipsychotic drugs put emphasis on the preregistration evaluation of the potential cardiac side effects and electrocardiogram predictors (QT interval lengthening). In spite of this, these drugs do not appear to be exempt from these potential risks. The present review summarizes up-to-date knowledge about the cardiac safety of antipsychotic drugs, and analyses the role of drug metabolic processes (CYP2D6 genetic polymorphism) in the complex pathophysiology of the phenomenon. In addition, some recommendations are formulated.
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Affiliation(s)
- Pedro Dorado
- University of Extremadura, Department of Pharmacology and Psychiatry, Centro de Investigación Clínica CICAB, Servicio Extremeño de Salud, Hospital Universitario Infanta Cristina, Badajoz, Spain
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Gardiner SJ, Begg EJ. Pharmacogenetics, drug-metabolizing enzymes, and clinical practice. Pharmacol Rev 2006; 58:521-90. [PMID: 16968950 DOI: 10.1124/pr.58.3.6] [Citation(s) in RCA: 235] [Impact Index Per Article: 13.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
The application of pharmacogenetics holds great promise for individualized therapy. However, it has little clinical reality at present, despite many claims. The main problem is that the evidence base supporting genetic testing before therapy is weak. The pharmacology of the drugs subject to inherited variability in metabolism is often complex. Few have simple or single pathways of elimination. Some have active metabolites or enantiomers with different activities and pathways of elimination. Drug dosing is likely to be influenced only if the aggregate molar activity of all active moieties at the site of action is predictably affected by genotype or phenotype. Variation in drug concentration must be significant enough to provide "signal" over and above normal variation, and there must be a genuine concentration-effect relationship. The therapeutic index of the drug will also influence test utility. After considering all of these factors, the benefits of prospective testing need to be weighed against the costs and against other endpoints of effect. It is not surprising that few drugs satisfy these requirements. Drugs (and enzymes) for which there is a reasonable evidence base supporting genotyping or phenotyping include suxamethonium/mivacurium (butyrylcholinesterase), and azathioprine/6-mercaptopurine (thiopurine methyltransferase). Drugs for which there is a potential case for prospective testing include warfarin (CYP2C9), perhexiline (CYP2D6), and perhaps the proton pump inhibitors (CYP2C19). No other drugs have an evidence base that is sufficient to justify prospective testing at present, although some warrant further evaluation. In this review we summarize the current evidence base for pharmacogenetics in relation to drug-metabolizing enzymes.
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Affiliation(s)
- Sharon J Gardiner
- Department of Medicine, Christchurch School of Medicine, Private Bag 4345, Christchurch, New Zealand.
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Wójcikowski J, Maurel P, Daniel WA. CHARACTERIZATION OF HUMAN CYTOCHROME P450 ENZYMES INVOLVED IN THE METABOLISM OF THE PIPERIDINE-TYPE PHENOTHIAZINE NEUROLEPTIC THIORIDAZINE. Drug Metab Dispos 2005; 34:471-6. [PMID: 16272405 DOI: 10.1124/dmd.105.006445] [Citation(s) in RCA: 50] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
The aim of the present study was to identify human cytochrome P450 enzymes (P450s) involved in mono-2-, di-2-, and 5-sulfoxidation, and N-demethylation of the piperidine-type phenothiazine neuroleptic thioridazine in the human liver. The experiments were performed in vitro using cDNA-expressed human P450s (Supersomes 1A2, 2A6, 2B6, 2C9, 2C19, 2D6, 2E1, and 3A4), liver microsomes from different donors, and P450-selective inhibitors. The results indicate that CYP1A2 and CYP3A4 are the main enzymes responsible for 5-sulfoxidation and N-demethylation (34-52%), whereas CYP2D6 is the basic enzyme that catalyzes mono-2- and di-2-sulfoxidation of thioridazine in human liver (49 and 64%, respectively). Besides CYP2D6, CYP3A4 contributes to a noticeable degree to thioridazine mono-2-sulfoxidation (22%). Therefore, the sulforidazine/mesoridazine ratio may be an additional and more specific marker than the mesoridazine/thioridazine ratio for assessing the activity of CYP2D6. In contrast to promazine and perazine, CYP2C19 insignificantly contributes to the N-demethylation of thioridazine. Considering serious side-effects of thioridazine and its 5-sulfoxide (cardiotoxicity), as well as strong dopaminergic D2 and noradrenergic alpha1 receptor-blocking properties of mono-2- and di-2-sulfoxides, the obtained results are of pharmacological and clinical importance, in particular, in a combined therapy. Knowledge of the catalysis of thioridazine metabolism helps to choose optimum conditions (a proper coadministered drug and dosage) to avoid undesirable drug interactions.
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Affiliation(s)
- Jacek Wójcikowski
- Polish Academy of Sciences, Institute of Pharmacology, Smetna 12, 31-343 Kraków, Poland.
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Nakagami T, Yasui-Furukori N, Saito M, Mihara K, De Vries R, Kondo T, Kaneko S. Thioridazine inhibits risperidone metabolism: a clinically relevant drug interaction. J Clin Psychopharmacol 2005; 25:89-91. [PMID: 15643105 DOI: 10.1097/01.jcp.0000150234.99619.f3] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Daniel WA, Haduch A, Wójcikowski J. Inhibition of rat liver CYP2D in vitro and after 1-day and long-term exposure to neuroleptics in vivo-possible involvement of different mechanisms. Eur Neuropsychopharmacol 2005; 15:103-10. [PMID: 15572279 DOI: 10.1016/j.euroneuro.2004.05.008] [Citation(s) in RCA: 17] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/26/2003] [Revised: 11/25/2003] [Accepted: 05/25/2004] [Indexed: 11/16/2022]
Abstract
The aim of the present study was to investigate the influence of classic and atypical neuroleptics on the activity of rat CYP2D measured as a rate of ethylmorphine O-deethylation. The reaction was studied in control liver microsomes in the presence of neuroleptics, as well as in microsomes of rats treated intraperitoneally (i.p.) for 1-day or 2-weeks (twice a day) with pharmacological doses of the drugs (promazine, levomepromazine, thioridazine, perazine 10 mg kg(-1); chlorpromazine 3 mg kg(-1); haloperidol 0.3 mg kg(-1); risperidone 0.1 mg kg(-1); sertindole 0.05 mg kg(-1)), in the absence of the neuroleptics in vitro. Neuroleptics added in vitro to control liver microsomes decreased the activity of the rat CYP2D by competitive or mixed inhibition of the enzyme. Thioridazine (Ki=15 microM) was the most potent inhibitor of the rat CYP2D among the drugs studied, whose effect was more pronounced than that of the other neuroleptics tested: phenothiazines (Ki=18-23 microM), haloperidol (Ki=32 microM), sertindole (Ki=51 microM) or risperidone (Ki=165 microM). The investigated neuroleptics-when given to rats in vivo-also seemed to exert an inhibitory effect on CYP2D via other mechanisms. One-day exposure of rats to the classic neuroleptics decreased the activity of CYP2D in rat liver microsomes. After chronic treatment with the investigated neuroleptics, the decreased CYP2D activity produced by the phenothiazines was still maintained, while that caused by haloperidol diminished. Moreover, risperidone decreased the activity of that enzyme. The obtained results indicate drug- and time-dependent interactions between the investigated neuroleptics and the CYP2D subfamily of rat cytochrome P-450, which may proceed via different mechanisms: (1) competitive or mixed inhibition of CYP2D shown in vitro, the inhibitory effects of phenothiazines being stronger than those of haloperidol or atypical neuroleptics, but weaker than the effects of the respective drugs on human CYP2D6; (2) in vivo inhibition of CYP2D, produced by both 1-day and chronic treatment with phenothiazines, which suggests inactivation of enzyme by intermediate metabolites; (3) in vivo inhibition of CYP2D by risperidone, produced only by chronic treatment with the drug, which suggests its influence on the enzyme regulation.
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Affiliation(s)
- W A Daniel
- Polish Academy of Sciences, Institute of Pharmacology, Smetna 12, 31-343 Kraków, Poland.
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Llerena A, Berecz R, Dorado P, de la Rubia A. QTc interval, CYP2D6 and CYP2C9 genotypes and risperidone plasma concentrations. J Psychopharmacol 2004; 18:189-93. [PMID: 15260906 DOI: 10.1177/0269881104042618] [Citation(s) in RCA: 57] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
The role of certain drug metabolizing enzymes in cardiotoxicity, such as CYP2D6 for thioridazine, has been suggested. Risperidone has been shown to inhibit the delayed rectifier leading to lengthening of cardiac repolarization. The heart-rate corrected QT (QTc) interval lengthening has been reported in psychiatric patients receiving risperidone under steady-state conditions. CYP2D6 is involved in the metabolism of risperidone to 9-hydroxy (OH)-risperidone. CYP2C9 enzyme is also involved in the metabolism of several psychotropic drugs, although there are no data about its implication in risperidone metabolism. The present study aimed to evaluate the influence of CYP2D6 and CYP2C9 genotypes, and plasma concentrations of risperidone and 9-OH-risperidone on the QTc interval in patients under steady-state conditions. The relevance of CYP2D6 and CYP2C9 genotypes on risperidone metabolism was also analysed. Thirty-five White European psychiatric patients receiving risperidone monotherapy were studied. QTc interval was longer (p < 0.05) in subjects with one active CYP2D6 gene compared to those with two. The number of CYP2D6 active genes was related to the dose-corrected plasma concentration of risperidone (p < 0.05), the active moiety (risperidone plus 9-OH-risperidone) (p < 0.05) and the risperidone/9-OH-risperidone ratio (p < 0.05). CYP2C9 genotypes were not related to plasma concentrations of risperidone or 9-OH-risperidone, nor QTc interval. The results suggest that CYP2D6, but not CYP2C9, may be related to QTc lengthening during treatment with risperidone. The effect of the CYP2D6 genotype in risperidone metabolism is also shown.
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Affiliation(s)
- Adrián Llerena
- Department of Pharmacology and Psychiatry, Faculty of Medicine, University of Extremadura, Badajoz, and Unit of Research and Clinical Psychopharmacology at Mérida Psychiatric Hospital, Mérida, Spain.
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Berecz R, de la Rubia A, Dorado P, Fernández-Salguero P, Dahl ML, LLerena A. Thioridazine steady-state plasma concentrations are influenced by tobacco smoking and CYP2D6, but not by the CYP2C9 genotype. Eur J Clin Pharmacol 2003; 59:45-50. [PMID: 12682803 DOI: 10.1007/s00228-003-0576-4] [Citation(s) in RCA: 44] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2002] [Accepted: 02/03/2003] [Indexed: 02/07/2023]
Abstract
BACKGROUND Approximately 7% of Caucasians have genetically impaired activity of the cytochrome P450 enzyme CYP2D6 and are classified as poor metabolizers (PM). The disposition of thioridazine has been related to the CYP2D6 phenotype. The present study aimed to evaluate the influence of CYP2D6 and CYP2C9 genotypes, and tobacco smoking on steady-state thioridazine plasma levels. METHODS Seventy-six Caucasian psychiatric patients receiving thioridazine monotherapy were studied. Debrisoquine metabolic ratio (MR) and steady-state plasma levels of thioridazine and its metabolites, mesoridazine and sulforidazine, as well as CYP2D6 (in 74 patients) and CYP2C9 (in 63 patients) genotypes were determined. RESULTS The median dose-corrected, steady-state plasma concentrations (C/D) of thioridazine were related to the number of functional CYP2D6 alleles ( P<0.01), being 15.2, 7.2, 4.0, 4.2 nmol/l per milligram in subjects with no, one, two, and three or more functional CYP2D6 genes, respectively. No significant differences were found in the C/Ds of mesoridazine or sulforidazine. No relationship was found between CYP2C9 genotype and plasma levels of thioridazine or its metabolites. The median C/D of thioridazine was significantly ( P<0.001) lower in smokers (4.0 nmol/l per milligram, range: 1.0-15.5; n=58) than in nonsmokers (7.4 nmol/l per milligram, range: 2.8-23.6; n=18). Also, the C/Ds of mesoridazine and sulforidazine were lower in smokers ( P<0.01). The plasma thioridazine/mesoridazine ratio significantly correlated with the debrisoquine MR ( r(2)=0.30, P<0.001). CONCLUSION The results show that the plasma concentrations of thioridazine and its metabolites are influenced by tobacco smoking and the CYP2D6 genotype, and support the dose-dependent inhibition of CYP2D6 by thioridazine. CYP2C9 does not play an important role in thioridazine metabolism.
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Affiliation(s)
- Roland Berecz
- Department of Pharmacology and Psychiatry, Faculty of Medicine, University of Extremadura, Av. de Elvas s/n, 06071 Badajoz, Spain
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LLerena A, Berecz R, Dorado P, de la Garza CS, Norberto MJ, Cáceres M, Gutiérrez JR. Determination of risperidone and 9-hydroxyrisperidone in human plasma by liquid chromatography: application to the evaluation of CYP2D6 drug interactions. J Chromatogr B Analyt Technol Biomed Life Sci 2003; 783:213-9. [PMID: 12450541 DOI: 10.1016/s1570-0232(02)00661-x] [Citation(s) in RCA: 35] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
A high-pressure liquid chromatography with ultra-violet detection method for the simultaneous determination of risperidone and 9-hydroxyrisperidone in plasma after liquid-liquid extraction has been developed. The limit of quantitation was 5 nmol/L, and the inter-day coefficient of variation was less than 8% for both compounds. The mean recoveries of risperidone and 9-hydroxyrisperidone added to plasma were 96.8 and 99.4%, with an intra-day coefficient of variation of under 5 and 6%, respectively. Studies of analytical interference showed that the most commonly co-administered antidepressants and benzodiazepines did not interfere. The method was used for the determination of the plasma concentrations of a schizophrenic patient treated daily with an oral dose of 4.5 mg risperidone. The patient suffered severe extrapyramidal side-effects after adding risperidone to his previous medication of haloperidol and levomepromazine. The risperidone plasma concentration was well above the average (182 nmol/L), which suggests that a pharmacokinetic interaction occurred, presumably due to inhibition of the enzyme CYP2D6.
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Affiliation(s)
- Adrián LLerena
- Department of Pharmacology, Faculty of Medicine, University of Extremadura, Avda. de Elvas s/n, 06071, Badajoz, Spain.
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LLerena A, Berecz R, de la Rubia A, Dorado P. QTc interval lengthening is related to CYP2D6 hydroxylation capacity and plasma concentration of thioridazine in patients. J Psychopharmacol 2002; 16:361-4. [PMID: 12503836 DOI: 10.1177/026988110201600411] [Citation(s) in RCA: 47] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Thioridazine cardiotoxicity has been associated with a prolonged heart-rate corrected QT (QTc) interval. However, no systematic studies have been performed on patients at therapeutic doses. The present study aimed to evaluate the influence of dose and plasma concentration of thioridazine and CYP2D6 enzyme status on the QTc interval in psychiatric patients. Sixty-five Spanish European psychiatric patients receiving thioridazine antipsychotic monotherapy were studied. The plasma levels of thioridazine and its metabolites were determined by high-performance liquid chromatography. All patients were phenotyped for CYP2D6 activity with debrisoquine during treatment. Thirty-five patients (54%) had a QTc interval over 420 ms. The lengthening of QTc interval was correlated with plasma concentration (p < 0.05) and daily dose (p < 0.05) of thioridazine. CYP2D6 enzyme hydroxylation capacity, evaluated by debrisoquine metabolic ratio (MR) (p < 0.05) and thioridazine/mesoridazine ratio (p < 0.05), was also correlated with QTc intervals. The present study shows the relationship between QTc interval lengthening among psychiatric patients treated at therapeutical doses with the dose and the plasma concentration of thioridazine. Since debrisoquine MR has been shown to be correlated with the QTc intervals, CYP2D6 enzyme hydroxylation capacity might be relevant in determining the risk for QTc interval lengthening. Patients with impaired CYP2D6 enzyme activity due to enzyme inhibition by thioridazine might be more prone to increased risk of sudden death due to torsade de pointes type cardiac dysrhythmia.
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Affiliation(s)
- Adrián LLerena
- Department of Pharmacology and Psychiatry, Faculty of Medicine, University of Extremadura, Badajoz, Spain.
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