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Staben R, Vnencak-Jones CL, Shi Y, Shotwell MS, Absi T, Shah AS, Wanderer JP, Beller M, Kertai MD. Preemptive Pharmacogenetic-Guided Metoprolol Management for Postoperative Atrial Fibrillation in Cardiac Surgery: The Preemptive Pharmacogenetic-Guided Metoprolol Management for Atrial Fibrillation in Cardiac Surgery Pilot Trial. J Cardiothorac Vasc Anesth 2023; 37:1974-1982. [PMID: 37407326 DOI: 10.1053/j.jvca.2023.06.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/16/2023] [Revised: 05/23/2023] [Accepted: 06/09/2023] [Indexed: 07/07/2023]
Abstract
OBJECTIVES To test the hypothesis that implementation of a cytochrome P-450 2D6 (CYP2D6) genotype-guided perioperative metoprolol administration will reduce the risk of postoperative atrial fibrillation (AF), the authors conducted the Preemptive Pharmacogenetic-Guided Metoprolol Management for Atrial Fibrillation in Cardiac Surgery pilot study. DESIGN Clinical pilot trial. SETTING Single academic center. PARTICIPANTS Seventy-three cardiac surgery patients. MEASUREMENTS AND MAIN RESULTS Patients were classified as normal, intermediate, poor, or ultrarapid metabolizers after testing for their CYP2D6 genotype. A clinical decision support tool in the electronic health record advised providers on CYP2D6 genotype-guided metoprolol dosing. Using historical data, the Bayesian method was used to compare the incidence of postoperative AF in patients with altered metabolizer status to the reference incidence. A logistic regression analysis was performed to study the association between the metabolizer status and postoperative AF while controlling for the Multicenter Study of Perioperative Ischemia AF Risk Index. Of the 73 patients, 30% (n = 22) developed postoperative AF; 89% (n = 65) were normal metabolizers; 11% (n = 8) were poor/intermediate metabolizers; and there were no ultrarapid metabolizer patients identified. The estimated rate of postoperative AF in patients with altered metabolizer status was 30% (95% CI 8%-60%), compared with the historical reference incidence (27%). In the risk-adjusted analysis, there was insufficient evidence to conclude that modifying metoprolol dosing based on poor/intermediate metabolizer status was associated significantly with the odds of postoperative AF (odds ratio 0.82, 95% CI 0.15-4.55, p = 0.82). CONCLUSIONS A CYP2D6 genotype-guided metoprolol management was not associated with a reduction of postoperative AF after cardiac surgery.
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Affiliation(s)
- Rae Staben
- Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, TN
| | - Cindy L Vnencak-Jones
- Department of Pathology, Microbiology and Immunology, Vanderbilt University Medical Center, Nashville, TN
| | - Yaping Shi
- Department of Biostatistics, Vanderbilt University Medical Center, Nashville, TN
| | - Matthew S Shotwell
- Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, TN; Department of Biostatistics, Vanderbilt University Medical Center, Nashville, TN
| | - Tarek Absi
- Department of Cardiac Surgery, Vanderbilt University Medical Center, Nashville, TN
| | - Ashish S Shah
- Department of Cardiac Surgery, Vanderbilt University Medical Center, Nashville, TN
| | - Jonathan P Wanderer
- Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, TN; Department of Biomedical Informatics, Vanderbilt University Medical Center, Nashville, TN
| | - Marc Beller
- Center for Precision Medicine, Vanderbilt University Medical Center, Nashville, TN
| | - Miklos D Kertai
- Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, TN.
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Metoprolol and CYP2D6: A Retrospective Cohort Study Evaluating Genotype-Based Outcomes. J Pers Med 2023; 13:jpm13030416. [PMID: 36983598 PMCID: PMC10058912 DOI: 10.3390/jpm13030416] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2023] [Revised: 02/15/2023] [Accepted: 02/23/2023] [Indexed: 03/02/2023] Open
Abstract
Metoprolol is a medication commonly utilized in select patients to achieve a reduction in heart rate, systolic blood pressure, or other indications. A majority of metoprolol metabolism occurs via CYP2D6. Decreased expression of the CYP2D6 enzyme increases the concentration of metoprolol. Current pharmacogenomics guidelines by the Dutch Pharmacogenomics Working Group recommend slower titrations and dose decreases to minimize adverse effects from poor metabolizers or normal metabolizers taking concomitant medications that are strong inhibitors of CYP2D6 (phenoconverters). This study aimed to evaluate adverse effects such as bradycardia, hypotension, and syncope in patients who are expected to have absent CYP2D6 enzyme activity due to drug–drug or drug–gene interactions. The secondary aims of this study were to evaluate heart rate measurements for the included participants. Retrospective data were collected for individuals with CYP2D6 genotyping results obtained for clinical purposes. Three categories (CYP2D6 normal metabolizers, poor metabolizers, and phenoconverters) were assigned. A total of 325 participants were included. There was no statistically significant difference found in the primary composite outcome between the three metabolizer groups (p = 0.054). However, a statistically significant difference was identified in the incidences of bradycardia between the poor metabolizers and the normal metabolizers or phenoconverters (p < 0.0001). The average heart rates were 2.8 beats per minute (bpm) and 2.6 bpm lower for the poor metabolizer and phenoconverter groups, respectively, compared to the normal metabolizers (p < 0.0001 for both comparisons). This study further supports the role of genetic testing in precision medicine to help individualize patient care as CYP2D6 poor metabolizers taking metoprolol were found to have an increase in bradycardia. Additional research is needed to clarify the dose relationship in this drug–gene interaction.
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Panda G, Mishra N, Sharma D, Kutum R, Bhoyar RC, Jain A, Imran M, Senthilvel V, Divakar MK, Mishra A, Garg P, Banerjee P, Sivasubbu S, Scaria V, Ray A. Comprehensive Assessment of Indian Variations in the Druggable Kinome Landscape Highlights Distinct Insights at the Sequence, Structure and Pharmacogenomic Stratum. Front Pharmacol 2022; 13:858345. [PMID: 35865963 PMCID: PMC9294532 DOI: 10.3389/fphar.2022.858345] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2022] [Accepted: 06/07/2022] [Indexed: 11/13/2022] Open
Abstract
India confines more than 17% of the world’s population and has a diverse genetic makeup with several clinically relevant rare mutations belonging to many sub-group which are undervalued in global sequencing datasets like the 1000 Genome data (1KG) containing limited samples for Indian ethnicity. Such databases are critical for the pharmaceutical and drug development industry where diversity plays a crucial role in identifying genetic disposition towards adverse drug reactions. A qualitative and comparative sequence and structural study utilizing variant information present in the recently published, largest curated Indian genome database (IndiGen) and the 1000 Genome data was performed for variants belonging to the kinase coding genes, the second most targeted group of drug targets. The sequence-level analysis identified similarities and differences among different populations based on the nsSNVs and amino acid exchange frequencies whereas a comparative structural analysis of IndiGen variants was performed with pathogenic variants reported in UniProtKB Humsavar data. The influence of these variations on structural features of the protein, such as structural stability, solvent accessibility, hydrophobicity, and the hydrogen-bond network was investigated. In-silico screening of the known drugs to these Indian variation-containing proteins reveals critical differences imparted in the strength of binding due to the variations present in the Indian population. In conclusion, this study constitutes a comprehensive investigation into the understanding of common variations present in the second largest population in the world and investigating its implications in the sequence, structural and pharmacogenomic landscape. The preliminary investigation reported in this paper, supporting the screening and detection of ADRs specific to the Indian population could aid in the development of techniques for pre-clinical and post-market screening of drug-related adverse events in the Indian population.
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Affiliation(s)
- Gayatri Panda
- Department of Computational Biology, Indraprastha Institute of Information Technology, Okhla, India
| | - Neha Mishra
- Department of Computational Biology, Indraprastha Institute of Information Technology, Okhla, India
| | - Disha Sharma
- Academy of Scientific and Innovative Research (AcSIR), Ghaziabad, India
- CSIR-Institute of Genomics and Integrative Biology, Delhi, India
| | - Rintu Kutum
- Academy of Scientific and Innovative Research (AcSIR), Ghaziabad, India
- CSIR-Institute of Genomics and Integrative Biology, Delhi, India
- Ashoka University, Sonipat, India
| | - Rahul C. Bhoyar
- CSIR-Institute of Genomics and Integrative Biology, Delhi, India
| | - Abhinav Jain
- Academy of Scientific and Innovative Research (AcSIR), Ghaziabad, India
- CSIR-Institute of Genomics and Integrative Biology, Delhi, India
| | - Mohamed Imran
- Academy of Scientific and Innovative Research (AcSIR), Ghaziabad, India
- CSIR-Institute of Genomics and Integrative Biology, Delhi, India
| | - Vigneshwar Senthilvel
- Academy of Scientific and Innovative Research (AcSIR), Ghaziabad, India
- CSIR-Institute of Genomics and Integrative Biology, Delhi, India
| | - Mohit Kumar Divakar
- Academy of Scientific and Innovative Research (AcSIR), Ghaziabad, India
- CSIR-Institute of Genomics and Integrative Biology, Delhi, India
| | - Anushree Mishra
- CSIR-Institute of Genomics and Integrative Biology, Delhi, India
| | - Parth Garg
- Department of Computational Biology, Indraprastha Institute of Information Technology, Okhla, India
| | - Priyanka Banerjee
- Institute for Physiology, Charité-University Medicine Berlin, Berlin, Germany
| | - Sridhar Sivasubbu
- Academy of Scientific and Innovative Research (AcSIR), Ghaziabad, India
- CSIR-Institute of Genomics and Integrative Biology, Delhi, India
| | - Vinod Scaria
- Academy of Scientific and Innovative Research (AcSIR), Ghaziabad, India
- CSIR-Institute of Genomics and Integrative Biology, Delhi, India
| | - Arjun Ray
- Department of Computational Biology, Indraprastha Institute of Information Technology, Okhla, India
- *Correspondence: Arjun Ray,
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Arguelles N, Richards J, El-Sherbeni AA, Miksys S, Tyndale RF. Sex, estrous cycle, and hormone regulation of CYP2D in the brain alters oxycodone metabolism and analgesia. Biochem Pharmacol 2022; 198:114949. [PMID: 35143755 PMCID: PMC9215033 DOI: 10.1016/j.bcp.2022.114949] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2022] [Revised: 02/01/2022] [Accepted: 02/03/2022] [Indexed: 11/19/2022]
Abstract
Opioids, and numerous centrally active drugs, are metabolized by cytochrome P450 2D (CYP2D). There are sex and estrous cycle differences in brain oxycodone analgesia. Here we investigated the mechanism examining the selective role of CYP2D in the brain on sex, estrous cycle, and hormonal regulation. Propranolol, CYP2D-specific mechanism-based inhibitor, or vehicle was delivered into cerebral ventricles 24 hours before administering oxycodone (or oxymorphone, negative control) orally to male and female (in estrus and diestrus) rats. Ovariectomized and sham-operated females received no treatment, estradiol, progesterone or vehicle. Analgesia was measured using tail-flick latency, and brain drug and metabolite concentrations were measured by microdialysis. Data were analyzed by two-way or mixed ANOVA. Following propranolol (versus vehicle) inhibition and oral oxycodone, there were greater increases in brain oxycodone concentrations and analgesia, and greater decreases in brain oxymorphone/oxycodone ratios (an in vivo phenotype of CYP2D in brain) in males and females in estrus, compared to females in diestrus; with no impact on plasma drug concentrations. There was no impact of propranolol pre-treatment, sex, or cycle after oral oxymorphone (non-CYP2D substrate) on brain oxymorphone concentrations or analgesia. There was no impact of propranolol pre-treatment following ovariectomy on brain oxycodone concentrations or analgesia, which was restored in ovariectomized females following estradiol, but not progesterone, treatment. Sex, cycle, and estradiol regulation of CYP2D in brain in turn altered brain oxycodone concentration and response, which may contribute to the large inter-individual variation in response to the numerous centrally acting CYP2D substrate drugs, including opioids.
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Affiliation(s)
- Nicole Arguelles
- Department of Pharmacology and Toxicology, University of Toronto, Toronto, Ontario, Canada
| | - Janielle Richards
- Department of Pharmacology and Toxicology, University of Toronto, Toronto, Ontario, Canada
| | - Ahmed A El-Sherbeni
- Department of Clinical Pharmacy, Faculty of Pharmacy, Tanta University, Tanta, Egypt
| | - Sharon Miksys
- Department of Pharmacology and Toxicology, University of Toronto, Toronto, Ontario, Canada; Campbell Family Mental Health Research Institute, Centre for Addiction and Mental Health (CAMH), Canada
| | - Rachel F Tyndale
- Department of Pharmacology and Toxicology, University of Toronto, Toronto, Ontario, Canada; Campbell Family Mental Health Research Institute, Centre for Addiction and Mental Health (CAMH), Canada; Department of Psychiatry, University of Toronto, Toronto, Ontario, Canada.
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5
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Meloche M, Leclair G, Jutras M, Oussaïd E, Gaulin MJ, Mongrain I, Busseuil D, Tardif JC, Dubé MP, de Denus S. Leveraging large observational studies to discover genetic determinants of drug concentrations: A proof-of-concept study. Clin Transl Sci 2022; 15:1063-1073. [PMID: 35122397 PMCID: PMC9010273 DOI: 10.1111/cts.13230] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2021] [Revised: 12/21/2021] [Accepted: 12/21/2021] [Indexed: 12/16/2022] Open
Abstract
Large, observational genetic studies are commonly used to identify genetic factors associated with diseases and disease‐related traits. Such cohorts have not been commonly used to identify genetic predictors of drug dosing or concentrations, perhaps because of the heterogeneity in drug dosing and formulation, and the random timing of blood sampling. We hypothesized that large sample sizes relative to traditional pharmacokinetic studies would compensate for this variability and enable the identification of pharmacogenetic predictors of drug concentrations. We performed a cross‐sectional, proof‐of‐concept association study to replicate the well‐established association between metoprolol concentrations and CYP2D6 genotype‐inferred metabolizer phenotypes in participants from the Montreal Heart Institute Hospital Cohort undergoing metoprolol therapy. Plasma concentrations of metoprolol and α‐hydroxymetoprolol (α‐OH‐metoprolol) were measured in samples collected randomly regarding the previous metoprolol dose. A total of 999 individuals were included. The metoprolol daily dose ranged from 6.25 to 400 mg (mean 84.3 ± 57.1 mg). CYP2D6‐inferred phenotype was significantly associated with both metoprolol and α‐OH‐metoprolol in unadjusted and adjusted models (all p < 10−14). Models for metoprolol daily dose showed consistent results. Our study suggests that randomly drawn blood samples from biobanks can serve as a new approach to discover genetic associations related to drug concentrations and dosing, with potentially broader implications for genomewide association studies on the pharmacogenomics of drug metabolism.
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Affiliation(s)
- Maxime Meloche
- Faculty of Pharmacy, Université de Montréal, Montreal, Quebec, Canada.,Montreal Heart Institute, Montreal, Quebec, Canada.,Université de Montréal Beaulieu-Saucier Pharmacogenomics Center, Montreal, Quebec, Canada
| | - Grégoire Leclair
- Faculty of Pharmacy, Université de Montréal, Montreal, Quebec, Canada
| | - Martin Jutras
- Faculty of Pharmacy, Université de Montréal, Montreal, Quebec, Canada
| | - Essaïd Oussaïd
- Montreal Heart Institute, Montreal, Quebec, Canada.,Université de Montréal Beaulieu-Saucier Pharmacogenomics Center, Montreal, Quebec, Canada
| | - Marie-Josée Gaulin
- Montreal Heart Institute, Montreal, Quebec, Canada.,Université de Montréal Beaulieu-Saucier Pharmacogenomics Center, Montreal, Quebec, Canada
| | - Ian Mongrain
- Montreal Heart Institute, Montreal, Quebec, Canada.,Université de Montréal Beaulieu-Saucier Pharmacogenomics Center, Montreal, Quebec, Canada
| | - David Busseuil
- Montreal Heart Institute, Montreal, Quebec, Canada.,Université de Montréal Beaulieu-Saucier Pharmacogenomics Center, Montreal, Quebec, Canada
| | - Jean-Claude Tardif
- Montreal Heart Institute, Montreal, Quebec, Canada.,Université de Montréal Beaulieu-Saucier Pharmacogenomics Center, Montreal, Quebec, Canada.,Faculty of Medicine, Université de Montréal, Montreal, Quebec, Canada
| | - Marie-Pierre Dubé
- Montreal Heart Institute, Montreal, Quebec, Canada.,Université de Montréal Beaulieu-Saucier Pharmacogenomics Center, Montreal, Quebec, Canada.,Faculty of Medicine, Université de Montréal, Montreal, Quebec, Canada
| | - Simon de Denus
- Faculty of Pharmacy, Université de Montréal, Montreal, Quebec, Canada.,Montreal Heart Institute, Montreal, Quebec, Canada.,Université de Montréal Beaulieu-Saucier Pharmacogenomics Center, Montreal, Quebec, Canada
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6
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Chan SW, Chu TTW, Ho CS, Kong APS, Tomlinson B, Zeng W. Influence of CYP2D6 and CYP3A5 Polymorphisms on the Pharmacokinetics and Pharmacodynamics of Bisoprolol in Hypertensive Chinese Patients. Front Med (Lausanne) 2021; 8:683498. [PMID: 34568359 PMCID: PMC8458697 DOI: 10.3389/fmed.2021.683498] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2021] [Accepted: 08/16/2021] [Indexed: 11/13/2022] Open
Abstract
Purpose: This study was performed to investigate the effects of common polymorphisms in CYP2D6 and CYP3A5 on the plasma concentrations and antihypertensive effects of bisoprolol in hypertensive Chinese patients. Methods: One hundred patients with essential hypertension were treated with open-label bisoprolol 2.5 mg daily for 6 weeks. Clinic blood pressure (BP) and ambulatory BP (ABP) were measured after the placebo run-in and after 6 weeks treatment. Peak plasma concentrations of bisoprolol were measured at 3 h after the first dose and 3 h after the dose after 6 weeks treatment. Trough levels were measured before the dose after 6 weeks treatment. Bisoprolol plasma concentrations were measured with a validated liquid chromatography tandem mass spectrometry method. Six common polymorphisms in CYP2D6 and the CYP3A5 * 3 polymorphism were genotyped by TaqMan® assay. Results: After 6 weeks of treatment, clinic BP and heart rate were significantly reduced by 14.3 ± 10.9/8.4 ± 6.2 mmHg (P < 0.01) and 6.3 ± 7.6 BPM (P < 0.01), respectively. Similar reductions were seen in ABP values. Bisoprolol plasma concentration at 3 h after the first dose and 3 h post-dose after 6 weeks of treatment were significantly associated with baseline body weight (P < 0.001) but there was no significant effect of the CYP2D6 and CYP3A5 polymorphisms on these or the trough plasma concentrations. There was no significant association of the CYP2D6 and CYP3A5 polymorphisms or plasma bisoprolol concentrations with the clinic BP or ABP responses to bisoprolol. Conclusion: Bisoprolol 2.5 mg daily effectively reduced BP and HR. The common polymorphisms in CYP2D6 that were examined and the CYP3A5 * 3 polymorphism appear to have no benefit in predicting the hemodynamic response to bisoprolol in these patients.
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Affiliation(s)
- Sze Wa Chan
- School of Health Sciences, Caritas Institute of Higher Education, Hong Kong, China
| | - Tanya T W Chu
- Department of Medicine and Therapeutics, The Chinese University of Hong Kong, Prince of Wales Hospital, Hong Kong, China
| | - Chung Shun Ho
- Department of Chemical Pathology, The Chinese University of Hong Kong, Prince of Wales Hospital, Hong Kong, China
| | - Alice P S Kong
- Department of Medicine and Therapeutics, The Chinese University of Hong Kong, Prince of Wales Hospital, Hong Kong, China
| | - Brian Tomlinson
- Department of Medicine and Therapeutics, The Chinese University of Hong Kong, Prince of Wales Hospital, Hong Kong, China.,Faculty of Medicine, Macau University of Science and Technology, Macau, China
| | - Weiwei Zeng
- Shenzhen Baoan Women's and Children's Hospital, Jinan University, Shenzhen, China
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7
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Bernard PS, Wooderchak-Donahue W, Wei M, Bray SM, Wood KC, Parikh B, McMillin GA. Potential Utility of Pre-Emptive Germline Pharmacogenetics in Breast Cancer. Cancers (Basel) 2021; 13:cancers13061219. [PMID: 33799547 PMCID: PMC7998388 DOI: 10.3390/cancers13061219] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2021] [Revised: 03/05/2021] [Accepted: 03/06/2021] [Indexed: 12/14/2022] Open
Abstract
Patients with breast cancer often receive many drugs to manage the cancer, side effects associated with cancer treatment, and co-morbidities (i.e., polypharmacy). Drug-drug and drug-gene interactions contribute to the risk of adverse events (AEs), which could lead to non-adherence and reduced efficacy. Here we investigated several well-characterized inherited (germline) pharmacogenetic (PGx) targets in 225 patients with breast cancer. All relevant clinical, pharmaceutical, and PGx diplotype data were aggregated into a single unifying informatics platform to enable an exploratory analysis of the cohort and to evaluate pharmacy ordering patterns. Of the drugs recorded, there were 38 for which high levels of evidence for clinical actionability with PGx was available from the US FDA and/or the Clinical Pharmacogenetics Implementation Consortium (CPIC). These data were associated with 10 pharmacogenes: DPYD, CYP2C9, CYP2C19, CYP2D6, CYP3A5, CYP4F2, G6PD, MT-RNR1, SLCO1B1, and VKORC1. All patients were taking at least one of the 38 drugs and had inherited at least one actionable PGx variant that would have informed prescribing decisions if this information had been available pre-emptively. The non-cancer drugs with PGx implications that were common (prescribed to at least one-third of patients) included anti-depressants, anti-infectives, non-steroidal anti-inflammatory drugs, opioids, and proton pump inhibitors. Based on these results, we conclude that pre-emptive PGx testing may benefit patients with breast cancer by informing drug and dose selection to maximize efficacy and minimize AEs.
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Affiliation(s)
- Philip S. Bernard
- ARUP Institute for Clinical and Experimental Pathology, Salt Lake City, UT 84108, USA; (P.S.B.); (W.W.-D.)
- Department of Pathology, University of Utah, Salt Lake City, UT 84112, USA
- Huntsman Cancer Institute, University of Utah, Salt Lake City, UT 84112, USA;
| | - Whitney Wooderchak-Donahue
- ARUP Institute for Clinical and Experimental Pathology, Salt Lake City, UT 84108, USA; (P.S.B.); (W.W.-D.)
- Department of Pathology, University of Utah, Salt Lake City, UT 84112, USA
| | - Mei Wei
- Huntsman Cancer Institute, University of Utah, Salt Lake City, UT 84112, USA;
- Division of Oncology, Department of Internal Medicine, University of Utah, Salt Lake City, UT 84112, USA
| | - Steven M. Bray
- LifeOmic Inc., Indianapolis, IN 46202, USA; (S.M.B.); (K.C.W.); (B.P.)
| | - Kevin C. Wood
- LifeOmic Inc., Indianapolis, IN 46202, USA; (S.M.B.); (K.C.W.); (B.P.)
| | - Baiju Parikh
- LifeOmic Inc., Indianapolis, IN 46202, USA; (S.M.B.); (K.C.W.); (B.P.)
| | - Gwendolyn A. McMillin
- ARUP Institute for Clinical and Experimental Pathology, Salt Lake City, UT 84108, USA; (P.S.B.); (W.W.-D.)
- Department of Pathology, University of Utah, Salt Lake City, UT 84112, USA
- Correspondence: ; Tel.: +1-801-583-2787 (ext. 2671)
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Physiologically Based Pharmacokinetic Modeling of Metoprolol Enantiomers and α-Hydroxymetoprolol to Describe CYP2D6 Drug-Gene Interactions. Pharmaceutics 2020; 12:pharmaceutics12121200. [PMID: 33322314 PMCID: PMC7763912 DOI: 10.3390/pharmaceutics12121200] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2020] [Revised: 12/02/2020] [Accepted: 12/05/2020] [Indexed: 01/13/2023] Open
Abstract
The beta-blocker metoprolol (the sixth most commonly prescribed drug in the USA in 2017) is subject to considerable drug–gene interaction (DGI) effects caused by genetic variations of the CYP2D6 gene. CYP2D6 poor metabolizers (5.7% of US population) show approximately five-fold higher metoprolol exposure compared to CYP2D6 normal metabolizers. This study aimed to develop a whole-body physiologically based pharmacokinetic (PBPK) model to predict CYP2D6 DGIs with metoprolol. The metoprolol (R)- and (S)-enantiomers as well as the active metabolite α-hydroxymetoprolol were implemented as model compounds, employing data of 48 different clinical studies (dosing range 5–200 mg). To mechanistically describe the effect of CYP2D6 polymorphisms, two separate metabolic CYP2D6 pathways (α-hydroxylation and O-demethylation) were incorporated for both metoprolol enantiomers. The good model performance is demonstrated in predicted plasma concentration–time profiles compared to observed data, goodness-of-fit plots, and low geometric mean fold errors of the predicted AUClast (1.27) and Cmax values (1.23) over all studies. For DGI predictions, 18 out of 18 DGI AUClast ratios and 18 out of 18 DGI Cmax ratios were within two-fold of the observed ratios. The newly developed and carefully validated model was applied to calculate dose recommendations for CYP2D6 polymorphic patients and will be freely available in the Open Systems Pharmacology repository.
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Rollinson V, Turner R, Pirmohamed M. Pharmacogenomics for Primary Care: An Overview. Genes (Basel) 2020; 11:E1337. [PMID: 33198260 PMCID: PMC7696803 DOI: 10.3390/genes11111337] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2020] [Revised: 11/02/2020] [Accepted: 11/04/2020] [Indexed: 12/11/2022] Open
Abstract
Most of the prescribing and dispensing of medicines happens in primary care. Pharmacogenomics (PGx) is the study and clinical application of the role of genetic variation on drug response. Mounting evidence suggests PGx can improve the safety and/or efficacy of several medications commonly prescribed in primary care. However, implementation of PGx has generally been limited to a relatively few academic hospital centres, with little adoption in primary care. Despite this, many primary healthcare providers are optimistic about the role of PGx in their future practice. The increasing prevalence of direct-to-consumer genetic testing and primary care PGx studies herald the plausible gradual introduction of PGx into primary care and highlight the changes needed for optimal translation. In this article, the potential utility of PGx in primary care will be explored and on-going barriers to implementation discussed. The evidence base of several drug-gene pairs relevant to primary care will be outlined with a focus on antidepressants, codeine and tramadol, statins, clopidogrel, warfarin, metoprolol and allopurinol. This review is intended to provide both a general introduction to PGx with a more in-depth overview of elements relevant to primary care.
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10
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Thomas CD, Mosley SA, Kim S, Lingineni K, El Rouby N, Langaee TY, Gong Y, Wang D, Schmidt SO, Binkley PF, Estores DS, Feng K, Kim H, Kinjo M, Li Z, Fang L, Chapman AB, Cooper-DeHoff RM, Gums JG, Hamadeh IS, Zhao L, Schmidt S, Frye RF, Johnson JA, Cavallari LH. Examination of Metoprolol Pharmacokinetics and Pharmacodynamics Across CYP2D6 Genotype-Derived Activity Scores. CPT-PHARMACOMETRICS & SYSTEMS PHARMACOLOGY 2020; 9:678-685. [PMID: 33067866 PMCID: PMC7762806 DOI: 10.1002/psp4.12563] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/05/2020] [Accepted: 09/29/2020] [Indexed: 12/18/2022]
Abstract
Recent CYP2D6 phenotype standardization efforts by CYP2D6 activity score (AS) are based on limited pharmacokinetic (PK) and pharmacodynamic (PD) data. Using data from two independent clinical trials of metoprolol, we compared metoprolol PK and PD across CYP2D6 AS with the goal of determining whether the PK and PD data support the new phenotype classification. S‐metoprolol apparent oral clearance (CLo), adjusted for clinical factors, was correlated with CYP2D6 AS (P < 0.001). The natural log of CLo was lower with an AS of 1 (7.6 ± 0.4 mL/minute) vs. 2–2.25 (8.3 ± 0.6 mL/minute; P = 0.012), similar between an AS of 1 and 1.25–1.5 (7.8 ± 0.5 mL/minute; P = 0.702), and lower with an AS of 1.25–1.5 vs. 2–2.25 (P = 0.03). There was also a greater reduction in heart rate with metoprolol among study participants with AS of 1 (−10.8 ± 5.5) vs. 2–2.25 (−7.1 ± 5.6; P < 0.001) and no significant difference between those with an AS of 1 and 1.25–1.5 (−9.2 ± 4.7; P = 0.095). These data highlight linear trends among CYP2D6 AS and metoprolol PK and PD, but inconsistencies with the phenotypes assigned by AS based on the current standards. Overall, this case study with metoprolol suggests that utilizing CYP2D6 AS, instead of collapsing AS into phenotype categories, may be the most precise approach for utilizing CYP2D6 pharmacogenomics in clinical practice.
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Affiliation(s)
- Cameron D Thomas
- Department of Pharmacotherapy and Translation Research, Center for Pharmacogenomics and Precision Medicine, College of Pharmacy, University of Florida, Gainesville, Florida, USA
| | - Scott A Mosley
- Department of Pharmacotherapy and Translation Research, Center for Pharmacogenomics and Precision Medicine, College of Pharmacy, University of Florida, Gainesville, Florida, USA
| | - Sarah Kim
- Department of Pharmaceutics, Center for Pharmacometrics and Systems Pharmacology, College of Pharmacy, University of Florida, Orlando, Florida, USA
| | - Karthik Lingineni
- Department of Pharmaceutics, Center for Pharmacometrics and Systems Pharmacology, College of Pharmacy, University of Florida, Orlando, Florida, USA
| | - Nihal El Rouby
- Department of Pharmacotherapy and Translation Research, Center for Pharmacogenomics and Precision Medicine, College of Pharmacy, University of Florida, Gainesville, Florida, USA
| | - Taimour Y Langaee
- Department of Pharmacotherapy and Translation Research, Center for Pharmacogenomics and Precision Medicine, College of Pharmacy, University of Florida, Gainesville, Florida, USA
| | - Yan Gong
- Department of Pharmacotherapy and Translation Research, Center for Pharmacogenomics and Precision Medicine, College of Pharmacy, University of Florida, Gainesville, Florida, USA
| | - Danxin Wang
- Department of Pharmacotherapy and Translation Research, Center for Pharmacogenomics and Precision Medicine, College of Pharmacy, University of Florida, Gainesville, Florida, USA
| | - Siegfried O Schmidt
- Department of Community Health and Family Medicine, College of Medicine, University of Florida, Gainesville, Florida, USA
| | - Philip F Binkley
- Department of Cardiovascular Medicine, College of Medicine, The Ohio State University, Columbus, Ohio, USA
| | - David S Estores
- Division of Gastroenterology, Hepatology & Nutrition, College of Medicine, University of Florida, Gainesville, Florida, USA
| | - Kairui Feng
- Office of Research and Standards, Office of Generic Drugs, Center for Drug Evaluation and Research, US Food and Drug Administration, Silver Spring, Maryland, USA
| | - Hyewon Kim
- Office of Research and Standards, Office of Generic Drugs, Center for Drug Evaluation and Research, US Food and Drug Administration, Silver Spring, Maryland, USA
| | - Minori Kinjo
- Office of Research and Standards, Office of Generic Drugs, Center for Drug Evaluation and Research, US Food and Drug Administration, Silver Spring, Maryland, USA
| | - Zhichuan Li
- Office of Research and Standards, Office of Generic Drugs, Center for Drug Evaluation and Research, US Food and Drug Administration, Silver Spring, Maryland, USA
| | - Lanyan Fang
- Office of Research and Standards, Office of Generic Drugs, Center for Drug Evaluation and Research, US Food and Drug Administration, Silver Spring, Maryland, USA
| | - Arlene B Chapman
- Biological Sciences Division, The University of Chicago, Chicago, Illinois, USA
| | - Rhonda M Cooper-DeHoff
- Department of Pharmacotherapy and Translation Research, Center for Pharmacogenomics and Precision Medicine, College of Pharmacy, University of Florida, Gainesville, Florida, USA.,Division of Cardiovascular Medicine, College of Medicine, University of Florida, Gainesville, Florida, USA
| | - John G Gums
- Department of Pharmacotherapy and Translation Research, Center for Pharmacogenomics and Precision Medicine, College of Pharmacy, University of Florida, Gainesville, Florida, USA
| | - Issam S Hamadeh
- Department of Pharmacotherapy and Translation Research, Center for Pharmacogenomics and Precision Medicine, College of Pharmacy, University of Florida, Gainesville, Florida, USA
| | - Liang Zhao
- Office of Research and Standards, Office of Generic Drugs, Center for Drug Evaluation and Research, US Food and Drug Administration, Silver Spring, Maryland, USA
| | - Stephan Schmidt
- Department of Pharmaceutics, Center for Pharmacometrics and Systems Pharmacology, College of Pharmacy, University of Florida, Orlando, Florida, USA
| | - Reginald F Frye
- Department of Pharmacotherapy and Translation Research, Center for Pharmacogenomics and Precision Medicine, College of Pharmacy, University of Florida, Gainesville, Florida, USA
| | - Julie A Johnson
- Department of Pharmacotherapy and Translation Research, Center for Pharmacogenomics and Precision Medicine, College of Pharmacy, University of Florida, Gainesville, Florida, USA
| | - Larisa H Cavallari
- Department of Pharmacotherapy and Translation Research, Center for Pharmacogenomics and Precision Medicine, College of Pharmacy, University of Florida, Gainesville, Florida, USA
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11
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Shin J, Hills NK, Finley PR. Combining Antidepressants with β-Blockers: Evidence of a Clinically Significant CYP2D6 Drug Interaction. Pharmacotherapy 2020; 40:507-516. [PMID: 32342526 DOI: 10.1002/phar.2406] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2020] [Revised: 03/26/2020] [Accepted: 03/30/2020] [Indexed: 11/11/2022]
Abstract
BACKGROUND The β-blockers and antidepressants are two of the most commonly prescribed drug classes in the United States. Several antidepressants are potent inhibitors of cytochrome P450 2D6 liver enzymes (CYP2D6) and can increase the plasma concentrations of certain β-blockers when administered concomitantly, potentially leading to serious medical consequences such as hypotension, bradycardia, and falls. OBJECTIVE The primary objective of this investigation was to determine whether initiating an antidepressant in patients receiving β-blockers increased the risk of hemodynamic adverse events. Our primary outcome was time to hospital admissions or emergency department (ED) visits for an International Classification of Diseases-9 diagnosis suggestive of excessive β-blockade. METHODS We conducted a survival analysis for adults continuously enrolled in the California Medicaid system (Medi-Cal) between 2004 and 2012. Eligible patients were required to be receiving β-blocker medications that are primarily CYP2D6 substrates (e.g., metoprolol, propranolol, or carvedilol). Univariate and multivariable analyses were performed for patients who concurrently received antidepressants with β-blockers. An additional multivariable analysis analyzed the association of this combination upon hospitalizations or ED visits for all causes. RESULTS A total of 21,292 beneficiaries met the inclusion criteria, and 4.3% of patients required hospitalization or ED visits within 30 days of co-medication. In multivariable analysis, patients receiving antidepressants with moderate to strong CYP2D6 inhibitory potential (fluoxetine, paroxetine, duloxetine, or bupropion) had a greater risk for hospitalization or ED visits for hemodynamic events than those initiated on antidepressants with weak CYP2D6 inhibition for 30 days or less when each was compared with patients receiving no antidepressants (hazard ratio [HR] 1.53, 95% confidence interval [CI] 1.03-2.81; p=0.04 vs HR 1.24; 95% CI 0.82-1.88; p=0.30). Other demographic variables associated with increased morbidity included advanced age, male sex, higher β-blocker doses, and African American race or Hispanic ethnicity. CONCLUSIONS Results of this analysis suggest that initiation of certain antidepressants was associated with an increased risk for serious medical sequelae among patients concurrently receiving β-blockers. Greater risk was observed with antidepressants that potently inhibit the CYP2D6 enzyme, implying that increased morbidity may be mediated by a metabolic drug interaction.
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Affiliation(s)
- Jaekyu Shin
- Department of Clinical Pharmacy, University of California, San Francisco, California, USA
| | - Nancy K Hills
- Department of Epidemiology and Biostatistics, University of California, San Francisco, California, USA
| | - Patrick R Finley
- Department of Clinical Pharmacy, University of California, San Francisco, California, USA
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12
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Meloche M, Khazaka M, Kassem I, Barhdadi A, Dubé MP, de Denus S. CYP2D6 polymorphism and its impact on the clinical response to metoprolol: A systematic review and meta-analysis. Br J Clin Pharmacol 2020; 86:1015-1033. [PMID: 32090368 DOI: 10.1111/bcp.14247] [Citation(s) in RCA: 25] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2019] [Revised: 12/12/2019] [Accepted: 02/05/2020] [Indexed: 12/29/2022] Open
Abstract
AIMS CYP2D6 genetic polymorphisms are associated with metoprolol pharmacokinetics. Whether the clinical response to metoprolol is also affected remains uncertain. METHODS We conducted a systematic review on the effects of CYP2D6 polymorphism on the clinical response to metoprolol. Searches were conducted using MEDLINE. Meta-analyses were performed on the impact of CYP2D6-inferred phenotypes on heart rate (HR) reduction, diastolic (DBP) and systolic (SBP) blood pressure reduction, average daily doses, all-type adverse events and bradycardia. RESULTS Our qualitative assessment indicated inconsistent results in individual studies and endpoints, but CYP2D6 poor metabolizers (PM) generally presented a greater reduction in HR. The meta-analysis of 15 studies, including a total of 1146 individuals, found a reduction in HR of 3 beats/min (P = .017), and of SBP and DBP by 3 mmHg (P = .0048) for PM compared to non-PM individuals using similar metoprolol doses. Bradycardia appeared more frequent by 4-fold for PM, although significant heterogeneity was observed regarding bradycardia, which limits the scope of this finding. CONCLUSION Patients without any CYP2D6 metabolic capacities appear to have increased reduction in DBP, HR and SBP during metoprolol treatment and may be at a higher risk of bradycardia compared to patients with active CYP2D6 phenotypes. Further prospective data are required to determine whether CYP2D6 is associated with clinical events in patients treated with metoprolol, as well as to demonstrate the clinical utility of an individualized approach of prescribing metoprolol using CYP2D6-inferred phenotypes.
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Affiliation(s)
- Maxime Meloche
- Faculty of Pharmacy, Université de Montréal, Montreal, Quebec, Canada.,Université de Montréal Beaulieu-Saucier Pharmacogenomics Centre, Montreal, Quebec, Canada.,Montreal Heart Institute, Montreal, Quebec, Canada
| | - Michael Khazaka
- Faculty of Pharmacy, Université de Montréal, Montreal, Quebec, Canada.,Centre hospitalier de l'Université de Montréal (CHUM), Montreal, Quebec, Canada
| | - Imad Kassem
- Faculty of Pharmacy, Université de Montréal, Montreal, Quebec, Canada
| | - Amina Barhdadi
- Faculty of Pharmacy, Université de Montréal, Montreal, Quebec, Canada.,Université de Montréal Beaulieu-Saucier Pharmacogenomics Centre, Montreal, Quebec, Canada
| | - Marie-Pierre Dubé
- Université de Montréal Beaulieu-Saucier Pharmacogenomics Centre, Montreal, Quebec, Canada.,Montreal Heart Institute, Montreal, Quebec, Canada.,Faculty of Medicine, Université de Montréal, Montreal, Quebec, Canada
| | - Simon de Denus
- Faculty of Pharmacy, Université de Montréal, Montreal, Quebec, Canada.,Université de Montréal Beaulieu-Saucier Pharmacogenomics Centre, Montreal, Quebec, Canada.,Montreal Heart Institute, Montreal, Quebec, Canada
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13
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Oliveira-Paula GH, Pereira SC, Tanus-Santos JE, Lacchini R. Pharmacogenomics And Hypertension: Current Insights. PHARMACOGENOMICS & PERSONALIZED MEDICINE 2019; 12:341-359. [PMID: 31819590 PMCID: PMC6878918 DOI: 10.2147/pgpm.s230201] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 09/07/2019] [Accepted: 11/05/2019] [Indexed: 11/23/2022]
Abstract
Hypertension is a multifactorial disease that affects approximately one billion subjects worldwide and is a major risk factor associated with cardiovascular events, including coronary heart disease and cerebrovascular accidents. Therefore, adequate blood pressure control is important to prevent these events, reducing premature mortality and disability. However, only one third of patients have the effective control of blood pressure, despite several classes of antihypertensive drugs available. These disappointing outcomes may be at least in part explained by interpatient variability in drug response due to genetic polymorphisms. To address the effects of genetic polymorphisms on blood pressure responses to the antihypertensive drug classes, studies have applied candidate genes and genome wide approaches. More recently, a third approach that considers gene-gene interactions has also been applied in hypertension pharmacogenomics. In this article, we carried out a comprehensive review of recent findings on the pharmacogenomics of antihypertensive drugs, including diuretics, β-blockers, angiotensin-converting enzyme inhibitors and angiotensin II receptor blockers, and calcium channel blockers. We also discuss the limitations and inconsistences that have been found in hypertension pharmacogenomics and the challenges to implement this valuable approach in clinical practice.
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Affiliation(s)
- Gustavo H Oliveira-Paula
- Department of Medicine, Division of Cardiology, Wilf Family Cardiovascular Research Institute, Albert Einstein College of Medicine, New York, NY, USA.,Department of Pharmacology, Ribeirao Preto Medical School, University of Sao Paulo, Ribeirao Preto, SP, Brazil
| | - Sherliane C Pereira
- Department of Pharmacology, Ribeirao Preto Medical School, University of Sao Paulo, Ribeirao Preto, SP, Brazil
| | - Jose E Tanus-Santos
- Department of Pharmacology, Ribeirao Preto Medical School, University of Sao Paulo, Ribeirao Preto, SP, Brazil
| | - Riccardo Lacchini
- Department of Psychiatric Nursing and Human Sciences, Ribeirao Preto College of Nursing, University of Sao Paulo, Ribeirao Preto, SP, Brazil
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14
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Dunham WC, Weinger MB, Slagle J, Pretorius M, Shah AS, Absi TS, Shotwell MS, Beller M, Thomas E, Vnencak-Jones CL, Freundlich RE, Wanderer JP, Sandberg WS, Kertai MD. CYP2D6 Genotype-guided Metoprolol Therapy in Cardiac Surgery Patients: Rationale and Design of the Pharmacogenetic-guided Metoprolol Management for Postoperative Atrial Fibrillation in Cardiac Surgery (PREEMPTIVE) Pilot Study. J Cardiothorac Vasc Anesth 2019; 34:20-28. [PMID: 31606278 DOI: 10.1053/j.jvca.2019.09.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/29/2019] [Revised: 08/29/2019] [Accepted: 09/04/2019] [Indexed: 12/25/2022]
Abstract
OBJECTIVES The Preemptive Pharmacogenetic-guided Metoprolol Management for Atrial Fibrillation in Cardiac Surgery (PREEMPTIVE) pilot trial aims to use existing institutional resources to develop a process for integrating CYP2D6 pharmacogenetic test results into the patient electronic health record, to develop an evidence-based clinical decision support tool to facilitate CYP2D6 genotype-guided metoprolol administration in the cardiac surgery setting, and to determine the impact of implementing this CYP2D6 genotype-guided integrated approach on the incidence of postoperative atrial fibrillation (AF), provider, and cost outcomes. DESIGN One-arm Bayesian adaptive design clinical trial. SETTING Single center, university hospital. PARTICIPANTS The authors will screen (including CYP2D6 genotype) up to 600 (264 ± 144 expected under the adaptive design) cardiac surgery patients, and enroll up to 200 (88 ± 48 expected) poor, intermediate, and ultrarapid CYP2D6 metabolizers over a period of 2 years at a tertiary academic center. INTERVENTIONS All consented and enrolled patients will receive the intervention of CYP2D6 genotype-guided metoprolol management based on CYP2D6 phenotype classified as a poor, intermediate, extensive (normal), or ultrarapid metabolizer. MEASUREMENTS AND MAIN RESULTS The primary outcome will be the incidence of postoperative AF. Secondary outcomes relating to rates of CYP2D6 genotype-guided prescription changes, costs, lengths of stay, and implementation metrics also will be investigated. CONCLUSIONS The PREEMPTIVE pilot study is the first perioperative pilot trial to provide essential information for the design of a future, large-scale trial comparing CYP2D6 genotype-guided metoprolol management with a nontailored strategy in terms of managing AF. In addition, secondary outcomes regarding implementation, clinical benefit, safety, and cost-effectiveness in patients undergoing cardiac surgery will be examined.
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Affiliation(s)
- Wills C Dunham
- Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Matthew B Weinger
- Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, TN, USA; Center for Research and Innovation in System Safety, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Jason Slagle
- Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, TN, USA; Center for Research and Innovation in System Safety, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Mias Pretorius
- Department of anesthesiology, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Ashish S Shah
- Department of Cardiac Surgery, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Tarek S Absi
- Department of Cardiac Surgery, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Matthew S Shotwell
- Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, TN, USA; Department of Biostatistics, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Marc Beller
- Center for Precision Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Erica Thomas
- Department of Pharmaceutical Services, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Cindy L Vnencak-Jones
- Department of Pathology, Microbiology and Immunology, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Robert E Freundlich
- Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Jonathan P Wanderer
- Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, TN, USA; Department of Biomedical Informatics, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Warren S Sandberg
- Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, TN, USA; Department of Biomedical Informatics, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Miklos D Kertai
- Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, TN, USA.
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15
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Jhun EH, Apfelbaum JL, Dickerson DM, Shahul S, Knoebel R, Danahey K, Ratain MJ, O’Donnell PH. Pharmacogenomic considerations for medications in the perioperative setting. Pharmacogenomics 2019; 20:813-827. [PMID: 31411557 PMCID: PMC6949515 DOI: 10.2217/pgs-2019-0040] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2019] [Accepted: 05/08/2019] [Indexed: 11/21/2022] Open
Abstract
Several high-profile examples of adverse outcomes from medications used in the perioperative setting are well known (e.g., malignant hyperthermia, prolonged apnea, respiratory depression, inadequate analgesia), leading to an increased understanding of genetic susceptibilities underlying these risks. Pharmacogenomic information is increasingly being utilized in certain areas of medicine. Despite this, routine preoperative genetic screening to inform medication risk is not yet standard practice. In this review, we assess the current readiness of pharmacogenomic information for clinical consideration for several common perioperative medications, including description of key pharmacogenes, pharmacokinetic implications and potential clinical outcomes. The goal is to highlight medications for which emerging or considerable pharmacogenomic information exists and identify areas for future potential research.
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Affiliation(s)
- Ellie H Jhun
- Committee on Clinical Pharmacology & Pharmacogenomics, University of Chicago, Chicago, IL, 60637, USA
- Current affiliation: Department of Pharmacogenetics, Base10 Genetics, Chicago, IL 60603, USA
| | - Jeffrey L Apfelbaum
- Department of Anesthesia & Critical Care, University of Chicago, Chicago, IL 60637, USA
| | - David M Dickerson
- Department of Anesthesia & Critical Care, University of Chicago, Chicago, IL 60637, USA
- Current affiliation: Northshore University Health System, Evanston, IL 60201, USA
| | - Sajid Shahul
- Department of Anesthesia & Critical Care, University of Chicago, Chicago, IL 60637, USA
| | - Randall Knoebel
- Department of Pharmacy, University of Chicago Medicine, Chicago, IL 60637, USA
| | - Keith Danahey
- Center for Personalized Therapeutics, University of Chicago, Chicago, IL 60637, USA
- Center for Research Informatics, University of Chicago, Chicago, IL 60637, USA
| | - Mark J Ratain
- Committee on Clinical Pharmacology & Pharmacogenomics, University of Chicago, Chicago, IL, 60637, USA
- Center for Personalized Therapeutics, University of Chicago, Chicago, IL 60637, USA
- Department of Medicine, University of Chicago, Chicago, IL 60637, USA
| | - Peter H O’Donnell
- Committee on Clinical Pharmacology & Pharmacogenomics, University of Chicago, Chicago, IL, 60637, USA
- Center for Personalized Therapeutics, University of Chicago, Chicago, IL 60637, USA
- Department of Medicine, University of Chicago, Chicago, IL 60637, USA
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16
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De T, Park CS, Perera MA. Cardiovascular Pharmacogenomics: Does It Matter If You're Black or White? Annu Rev Pharmacol Toxicol 2018; 59:577-603. [PMID: 30296897 DOI: 10.1146/annurev-pharmtox-010818-021154] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
Race and ancestry have long been associated with differential risk and outcomes to disease as well as responses to medications. These differences in drug response are multifactorial with some portion associated with genomic variation. The field of pharmacogenomics aims to predict drug response in patients prior to medication administration and to uncover the biological underpinnings of drug response. The field of human genetics has long recognized that genetic variation differs in frequency between ancestral populations, with some single nucleotide polymorphisms found solely in one population. Thus far, most pharmacogenomic studies have focused on individuals of European and East Asian ancestry, resulting in a substantial disparity in the clinical utility of genetic prediction for drug response in US minority populations. In this review, we discuss the genetic factors that underlie variability to drug response and known pharmacogenomic associations and how these differ between populations, with an emphasis on the current knowledge in cardiovascular pharmacogenomics.
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Affiliation(s)
- Tanima De
- Department of Pharmacology, Feinberg School of Medicine, Northwestern University, Chicago, Illinois 60611, USA;
| | - C Sehwan Park
- Department of Pharmacology, Feinberg School of Medicine, Northwestern University, Chicago, Illinois 60611, USA;
| | - Minoli A Perera
- Department of Pharmacology, Feinberg School of Medicine, Northwestern University, Chicago, Illinois 60611, USA;
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17
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Dadova K, Slaby K, Radvansky J, Matous M, Varekova J, Hodis J, Steffl M, Tufano JJ. Exercise prescription in cardiac patients treated with metoprolol - should the time of day for stress tests and training coincide? Eur J Prev Cardiol 2018; 25:1026-1027. [PMID: 29676165 DOI: 10.1177/2047487318771776] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Affiliation(s)
- Klara Dadova
- 1 Department of Adapted Physical Education and Sports Medicine, Charles University - Faculty of Physical Education and Sport, Prague, Czech Republic
| | - Krystof Slaby
- 2 Department of Sports Medicine, Charles University - 2nd Faculty of Medicine, Prague, Czech Republic
| | - Jiri Radvansky
- 2 Department of Sports Medicine, Charles University - 2nd Faculty of Medicine, Prague, Czech Republic
| | - Milos Matous
- 3 Department for the Study of Obesity and Diabetes, Charles University - 3rd Faculty of Medicine, Prague, Czech Republic
| | - Jitka Varekova
- 1 Department of Adapted Physical Education and Sports Medicine, Charles University - Faculty of Physical Education and Sport, Prague, Czech Republic
| | - Jiri Hodis
- 4 Department of Pharmacology, Charles University - 1st Faculty of Medicine, Prague, Czech Republic
| | - Michal Steffl
- 5 Department of Physiology, Charles University - Faculty of Physical Education and Sport, Prague, Czech Republic
| | - James J Tufano
- 5 Department of Physiology, Charles University - Faculty of Physical Education and Sport, Prague, Czech Republic
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18
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Tieu A, Velenosi TJ, Kucey AS, Weir MA, Urquhart BL. β-Blocker Dialyzability in Maintenance Hemodialysis Patients: A Randomized Clinical Trial. Clin J Am Soc Nephrol 2018; 13:604-611. [PMID: 29519953 PMCID: PMC5969458 DOI: 10.2215/cjn.07470717] [Citation(s) in RCA: 31] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2017] [Accepted: 01/05/2018] [Indexed: 12/20/2022]
Abstract
BACKGROUND AND OBJECTIVES There is a paucity of data available to describe drug dialyzability. Of the available information, most was obtained before implementation of modern hemodialysis membranes. Our study characterized dialyzability of the most commonly prescribed β-blockers in patients undergoing high-flux hemodialysis. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS Patients on hemodialysis (n=8) were recruited to an open label, pharmacokinetic, four-way crossover trial. Single doses of atenolol, metoprolol, bisoprolol, and carvedilol were administered on separate days in random order to each patient. Plasma and dialysate drug concentrations were measured, and dialyzability was determined by the recovery clearance and arterial venous difference methods. RESULTS Using the recovery clearance method, the dialytic clearance values for atenolol, metoprolol, bisoprolol, and carvedilol were 72, 87, 44, and 0.2 ml/min, respectively (P<0.001). Applying the arterial venous difference method, the dialytic clearance values of atenolol, metoprolol, bisoprolol, and carvedilol were 167, 114, 96, and 24 ml/min, respectively (P<0.001). CONCLUSIONS Atenolol and metoprolol are extensively cleared by hemodialysis compared with the negligible dialytic clearance of carvedilol. Contrary to estimates of dialyzability on the basis of previous literature, our data indicate that bisoprolol is also dialyzable. This finding highlights the importance of conducting dialyzability studies to definitively characterize drug dialytic clearance.
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Affiliation(s)
- Alvin Tieu
- Departments of Physiology and Pharmacology and
| | | | | | - Matthew A. Weir
- Division of Nephrology, and
- Epidemiology and Biostatistics, Department of Medicine, Schulich School of Medicine and Dentistry, The University of Western Ontario, London, Ontario, Canada; and
| | - Bradley L. Urquhart
- Departments of Physiology and Pharmacology and
- Epidemiology and Biostatistics, Department of Medicine, Schulich School of Medicine and Dentistry, The University of Western Ontario, London, Ontario, Canada; and
- Lawson Health Research Institute, London, Ontario, Canada
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19
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Burrello J, Monticone S, Buffolo F, Tetti M, Veglio F, Williams TA, Mulatero P. Is There a Role for Genomics in the Management of Hypertension? Int J Mol Sci 2017; 18:ijms18061131. [PMID: 28587112 PMCID: PMC5485955 DOI: 10.3390/ijms18061131] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2017] [Revised: 05/20/2017] [Accepted: 05/21/2017] [Indexed: 12/13/2022] Open
Abstract
Hypertension (HTN) affects about 1 billion people worldwide and the lack of a single identifiable cause complicates its treatment. Blood pressure (BP) levels are influenced by environmental factors, but there is a strong genetic component. Linkage analysis has identified several genes involved in Mendelian forms of HTN and the associated pathophysiological mechanisms have been unravelled, leading to targeted therapies. The majority of these syndromes are due to gain-of-function or loss-of-functions mutations, resulting in an alteration of mineralocorticoid, glucocorticoid, or sympathetic pathways. The diagnosis of monogenic forms of HTN has limited practical implications on the population and a systematic genetic screening is not justifiable. Genome-wide linkage and association studies (GWAS) have identified single nucleotide polymorphisms (SNPs), which influence BP. Forty-three variants have been described with each SNP affecting systolic and diastolic BP by 1.0 and 0.5 mmHg, respectively. Taken together Mendelian inheritance and all GWAS-identified HTN-associated variants explain 2–3% of BP variance. Epigenetic modifications, such as DNA methylation, histone modification and non-coding RNAs, have become increasingly recognized as important players in BP regulation and may justify a further part of missing heritability. In this review, we will discuss how genetics and genomics may assist clinicians in managing patients with HTN.
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Affiliation(s)
- Jacopo Burrello
- Division of Internal Medicine and Hypertension, Department of Medical Sciences, University of Turin, 10126 Turin, Italy.
| | - Silvia Monticone
- Division of Internal Medicine and Hypertension, Department of Medical Sciences, University of Turin, 10126 Turin, Italy.
| | - Fabrizio Buffolo
- Division of Internal Medicine and Hypertension, Department of Medical Sciences, University of Turin, 10126 Turin, Italy.
| | - Martina Tetti
- Division of Internal Medicine and Hypertension, Department of Medical Sciences, University of Turin, 10126 Turin, Italy.
| | - Franco Veglio
- Division of Internal Medicine and Hypertension, Department of Medical Sciences, University of Turin, 10126 Turin, Italy.
| | - Tracy A Williams
- Division of Internal Medicine and Hypertension, Department of Medical Sciences, University of Turin, 10126 Turin, Italy.
- Medizinische Klinik und Poliklinik IV, Klinikum der Universität München, Ludwig-Maximilians-Universität München, 80336 Munich, Germany.
| | - Paolo Mulatero
- Division of Internal Medicine and Hypertension, Department of Medical Sciences, University of Turin, 10126 Turin, Italy.
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Zhang L, Long H, Song P, Li X, Xu K, Meng M, Yin Y, Xi R. Competitive Chemiluminescent Immunoassay for the Sensitive Point-of-Care Determination of Metoprolol. ANAL LETT 2017. [DOI: 10.1080/00032719.2016.1187625] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Affiliation(s)
- Lisha Zhang
- State Key Laboratory of Medicinal Chemical Biology, College of Pharmacy and Tianjin Key Laboratory of Molecular Drug Research, Nankai University, Tianjin, People’s Republic of China
| | - Hao Long
- State Key Laboratory of Medicinal Chemical Biology, College of Pharmacy and Tianjin Key Laboratory of Molecular Drug Research, Nankai University, Tianjin, People’s Republic of China
| | - Pei Song
- State Key Laboratory of Medicinal Chemical Biology, College of Pharmacy and Tianjin Key Laboratory of Molecular Drug Research, Nankai University, Tianjin, People’s Republic of China
| | - Xiaogang Li
- State Key Laboratory of Medicinal Chemical Biology, College of Pharmacy and Tianjin Key Laboratory of Molecular Drug Research, Nankai University, Tianjin, People’s Republic of China
| | - Kun Xu
- State Key Laboratory of Medicinal Chemical Biology, College of Pharmacy and Tianjin Key Laboratory of Molecular Drug Research, Nankai University, Tianjin, People’s Republic of China
| | - Meng Meng
- State Key Laboratory of Medicinal Chemical Biology, College of Pharmacy and Tianjin Key Laboratory of Molecular Drug Research, Nankai University, Tianjin, People’s Republic of China
| | - Yongmei Yin
- State Key Laboratory of Medicinal Chemical Biology, College of Pharmacy and Tianjin Key Laboratory of Molecular Drug Research, Nankai University, Tianjin, People’s Republic of China
| | - Rimo Xi
- State Key Laboratory of Medicinal Chemical Biology, College of Pharmacy and Tianjin Key Laboratory of Molecular Drug Research, Nankai University, Tianjin, People’s Republic of China
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Luzum JA, Sweet KM, Binkley PF, Schmidlen TJ, Jarvis JP, Christman MF, Sadee W, Kitzmiller JP. CYP2D6 Genetic Variation and Beta-Blocker Maintenance Dose in Patients with Heart Failure. Pharm Res 2017; 34:1615-1625. [PMID: 28181117 DOI: 10.1007/s11095-017-2104-8] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2016] [Accepted: 01/13/2017] [Indexed: 01/06/2023]
Abstract
PURPOSE This study examined whether a CYP2D6 polymorphism (CYP2D6*4) was related to beta-blocker maintenance dose in patients with heart failure. METHODS Logistic regression modeling was utilized in a retrospective chart-review analysis of heart-failure patients (60% Male, 90% of European descent) to assess whether CYP2D6*4 (non-functional CYP2D6 allele present in 1 of 5 individuals of European descent) is associated with maintenance dose of carvedilol (n = 65) or metoprolol (n = 33). RESULTS CYP2D6*4 was associated with lower maintenance dose of metoprolol (OR 0.13 [95% CI 0.02-0.75] p = 0.023), and a trend was observed between CYP2D6*4 and higher maintenance dose of carvedilol (OR 2.94 [95% CI 0.84-10.30] p = 0.093). None of the patients that carried CYP2D6*4 achieved the recommended target dose of metoprolol (200 mg/day). CONCLUSION Consistent with the role of CYP2D6 in the metabolism of metoprolol, the tolerated maintenance dose of metoprolol was lower in CYP2D6*4 carriers compared to non-carriers. Consistent with the role of CYP2D6 in activation of carvedilol, tolerated maintenance dose of carvedilol was higher in CYP2D6*4 carriers compared to non-carriers. Further investigation is warranted to ascertain the potential of CYP2D6 as a potential predictive biomarker of beta-blocker maintenance dose in heart failure patients.
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Affiliation(s)
- Jasmine A Luzum
- Center for Pharmacogenomics, Ohio State University College of Medicine, Columbus, Ohio, USA. .,Department of Clinical Pharmacy, University of Michigan College of Pharmacy, 428 Church St., Ann Arbor, Michigan, 48109, USA.
| | - Kevin M Sweet
- Division of Human Genetics, Department of Internal Medicine, Ohio State University College of Medicine, Columbus, Ohio, USA
| | - Philip F Binkley
- Division of Cardiovascular Medicine and the Dorothy M. Davis Heart and Lung Research Institute, Ohio State University College of Medicine, Columbus, Ohio, USA
| | | | - Joseph P Jarvis
- Coriell Institute for Medical Research, Camden, New Jersey, USA
| | | | - Wolfgang Sadee
- Center for Pharmacogenomics, Ohio State University College of Medicine, Columbus, Ohio, USA
| | - Joseph P Kitzmiller
- Center for Pharmacogenomics, Ohio State University College of Medicine, Columbus, Ohio, USA
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Eadon MT, Chapman AB. A Physiologic Approach to the Pharmacogenomics of Hypertension. Adv Chronic Kidney Dis 2016; 23:91-105. [PMID: 26979148 DOI: 10.1053/j.ackd.2016.02.003] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
Hypertension is a multifactorial condition with diverse physiological systems contributing to its pathogenesis. Individuals exhibit significant variation in their response to antihypertensive agents. Traditional markers, such as age, gender, diet, plasma renin level, and ethnicity, aid in drug selection. However, this review explores the contribution of genetics to facilitate antihypertensive agent selection and predict treatment efficacy. The findings, reproducibility, and limitations of published studies are examined, with emphasis placed on candidate genetic variants affecting drug metabolism, the renin-angiotensin system, adrenergic signalling, and renal sodium reabsorption. Single-nucleotide polymorphisms identified and replicated in unbiased genome-wide association studies of hypertension treatment are reviewed to illustrate the evolving understanding of the disease's complex and polygenic pathophysiology. Implementation efforts at academic centers seek to overcome barriers to the broad adoption of pharmacogenomics in the treatment of hypertension. The level of evidence required to support the implementation of pharmacogenomics in clinical practice is considered.
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Guo M, Guo G, Ji X. Genetic polymorphisms associated with heart failure: A literature review. J Int Med Res 2016; 44:15-29. [PMID: 26769713 PMCID: PMC5536573 DOI: 10.1177/0300060515604755] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2015] [Accepted: 08/03/2015] [Indexed: 12/22/2022] Open
Abstract
Objective To review possible associations reported between genetic variants and the risk, therapeutic response and prognosis of heart failure. Methods Electronic databases (PubMed, Web of Science and CNKI) were systematically searched for relevant papers, published between January 1995 and February 2015. Results Eighty-two articles covering 29 genes and 39 polymorphisms were identified. Conclusion Genetic association studies of heart failure have been highly controversial. There may be interaction or synergism of several genetic variants that together result in the ultimate pathological phenotype for heart failure.
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Affiliation(s)
- Mengqi Guo
- Key Laboratory of Cardiovascular Remodeling and Function Research, Department of Cardiology, Qilu Hospital, Shandong University, Jinan, China
| | - Guanlun Guo
- Hubei Key Laboratory of Advanced Technology of Automotive Components, School of Automotive Engineering, Wuhan University of Technology, Wuhan, China
| | - Xiaoping Ji
- Key Laboratory of Cardiovascular Remodeling and Function Research, Department of Cardiology, Qilu Hospital, Shandong University, Jinan, China
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Mugoša S, Djordjević N, Djukanović N, Protić D, Bukumirić Z, Radosavljević I, Bošković A, Todorović Z. Factors affecting the development of adverse drug reactions to β-blockers in hospitalized cardiac patient population. Patient Prefer Adherence 2016; 10:1461-9. [PMID: 27536078 PMCID: PMC4977081 DOI: 10.2147/ppa.s108579] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/04/2023] Open
Abstract
The aim of the present study was to undertake a study on the prevalence of cytochrome P450 2D6 (CYP2D6) poor metabolizer alleles (*3, *4, *5, and *6) on a Montenegrin population and its impact on developing adverse drug reactions (ADRs) of β-blockers in a hospitalized cardiac patient population. A prospective study was conducted in the Cardiology Center of the Clinical Center of Montenegro and included 138 patients who had received any β-blocker in their therapy. ADRs were collected using a specially designed questionnaire, based on the symptom list and any signs that could point to eventual ADRs. Data from patients' medical charts, laboratory tests, and other available parameters were observed and combined with the data from the questionnaire. ADRs to β-blockers were observed in 15 (10.9%) patients. There was a statistically significant difference in the frequency of ADRs in relation to genetically determined enzymatic activity (P<0.001), with ADRs' occurrence significantly correlating with slower CYP2D6 metabolism. Our study showed that the adverse reactions to β-blockers could be predicted by the length of hospitalization, CYP2D6 poor metabolizer phenotype, and the concomitant use of other CYP2D6-metabolizing drugs. Therefore, in hospitalized patients with polypharmacy CYP2D6 genotyping might be useful in detecting those at risk of ADRs.
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Affiliation(s)
- Snežana Mugoša
- Department of Pharmacotherapy, Faculty of Pharmacy, University of Montenegro
- Clinical Trial Department, Agency for Medicines and Medical Devices of Montenegro, Podgorica, Montenegro
| | - Nataša Djordjević
- Department of Pharmacology and Toxicology, Faculty of Medical Sciences, University of Kragujevac, Kragujevac
| | | | - Dragana Protić
- Department of Pharmacology, Clinical Pharmacology and Toxicology
| | - Zoran Bukumirić
- Institute for Medical Statistics and Informatics, Faculty of Medicine, University of Belgrade, Belgrade
| | - Ivan Radosavljević
- Department of Surgery, Faculty of Medical Sciences, University of Kragujevac, Kragujevac, Serbia
| | - Aneta Bošković
- Clinic for Heart Diseases, Clinical Centre of Montenegro, Podgorica, Montenegro
| | - Zoran Todorović
- Department of Pharmacology, Clinical Pharmacology and Toxicology
- Department of Clinical Immunology and Allergy, Medical Center “Bežanijska kosa”, Belgrade, Serbia
- Correspondence: Zoran Todorović, Department of Pharmacology, Clinical Pharmacology and Toxicology, Faculty of Medicine, University of Belgrade, Dr Subotića Starijeg 1, PO Box 38, 11129 Belgrade, Serbia, Tel +381 11 36 43 389, Fax +381 11 36 43 397, Email
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Hannah-Shmouni F, Seidelmann SB, Sirrs S, Mani A, Jacoby D. The Genetic Challenges and Opportunities in Advanced Heart Failure. Can J Cardiol 2015; 31:1338-50. [PMID: 26518444 DOI: 10.1016/j.cjca.2015.07.735] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2015] [Revised: 07/13/2015] [Accepted: 07/16/2015] [Indexed: 12/17/2022] Open
Abstract
The causes of heart failure are diverse. Inherited causes represent an important clinical entity and can be divided into 2 major categories: familial and metabolic cardiomyopathies. The distinct features that might be present in early disease states can become broadly overlapping with other diseases, such as in the case of inherited cardiomyopathies (ie, familial hypertrophic cardiomyopathy or mitochondrial diseases). In this review article, we focus on genetic issues related to advanced heart failure. Because of the emerging importance of this topic and its breadth, we sought to focus our discussion on the known genetic forms of heart failure syndromes, genetic testing, and newer data on pharmacogenetics and therapeutics in the treatment of heart failure, to primarily encourage clinicians to place a priority on the diagnosis and treatment of these potentially treatable conditions.
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Affiliation(s)
- Fady Hannah-Shmouni
- Advanced Heart Failure and Cardiomyopathy Program, Division of Cardiovascular Medicine, Yale-New Haven Hospital, Yale School of Medicine, New Haven, Connecticut, USA; Department of Internal Medicine, Yale-New Haven Hospital, Yale School of Medicine, New Haven, Connecticut, USA; Cardiovascular Genetics Program, Yale-New Haven Hospital, Yale School of Medicine, New Haven, Connecticut, USA
| | - Sara B Seidelmann
- Advanced Heart Failure and Cardiomyopathy Program, Division of Cardiovascular Medicine, Yale-New Haven Hospital, Yale School of Medicine, New Haven, Connecticut, USA; Department of Internal Medicine, Yale-New Haven Hospital, Yale School of Medicine, New Haven, Connecticut, USA; Cardiovascular Genetics Program, Yale-New Haven Hospital, Yale School of Medicine, New Haven, Connecticut, USA
| | - Sandra Sirrs
- Adult Metabolic Diseases Clinic, Division of Endocrinology, Vancouver General Hospital, University of British Columbia, Vancouver, British Columbia, Canada
| | - Arya Mani
- Department of Internal Medicine, Yale-New Haven Hospital, Yale School of Medicine, New Haven, Connecticut, USA; Cardiovascular Genetics Program, Yale-New Haven Hospital, Yale School of Medicine, New Haven, Connecticut, USA; Department of Genetics, Yale-New Haven Hospital, Yale School of Medicine, New Haven, Connecticut, USA
| | - Daniel Jacoby
- Advanced Heart Failure and Cardiomyopathy Program, Division of Cardiovascular Medicine, Yale-New Haven Hospital, Yale School of Medicine, New Haven, Connecticut, USA; Department of Internal Medicine, Yale-New Haven Hospital, Yale School of Medicine, New Haven, Connecticut, USA.
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Wu D, Li G, Deng M, Song W, Huang X, Guo X, Wu Z, Wu S, Xu J. Associations between ADRB1 and CYP2D6 gene polymorphisms and the response to β-blocker therapy in hypertension. J Int Med Res 2015; 43:424-34. [PMID: 25823457 DOI: 10.1177/0300060514563151] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2014] [Accepted: 11/13/2014] [Indexed: 11/15/2022] Open
Abstract
OBJECTIVE To investigate the associations between β1-adrenergic receptor (ADRB1) and cytochrome P450 2D6 (CYP2D6) gene polymorphisms and β-blocker treatment outcomes in patients with hypertension. METHODS Chinese patients with essential hypertension were treated with the β-blocker metoprolol and followed up for 12 weeks. xTAG® liquid-chip technology was used for CYP2D6 100 C > T and ADRB1 1165G > C genotyping. Associations between gene polymorphisms and antihypertensive therapy outcomes were assessed by generalized linear model fitting. A decrease of ≥ 10 mmHg in systolic blood pressure indicated an effective treatment outcome. RESULTS A total of 93 patients were included in the study. Mutant allele frequencies of 61.29% and 58.60% were obtained for ADRB1 and CYP2D6, respectively. There was no significant interaction between the effects of ADRB1 and CYP2D6 gene polymorphisms on treatment outcome. Patients homozygous for the mutant ADRB1 genotype (CC) had better treatment outcomes than those heterozygous for the mutation (GC). Interestingly, β-blocker treatment duration was an independent factor associated with treatment outcome. CONCLUSIONS The ADRB1 1165G > C gene polymorphism and β-blocker treatment duration are independent factors associated with β-blocker treatment outcome. These findings suggest that the selection of antihypertensive therapy should take into consideration the patient's genotype.
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Affiliation(s)
- Dingchang Wu
- Department of Laboratory Medicine, First Affiliated Hospital of Fujian Medical University, Longyan, China
| | - Ganyang Li
- Department of Cardiovascular Medicine, First Affiliated Hospital of Fujian Medical University, Longyan, China
| | - Maoqing Deng
- Department of Laboratory Medicine, First Affiliated Hospital of Fujian Medical University, Longyan, China
| | - Wei Song
- Department of Cardiovascular Medicine, First Affiliated Hospital of Fujian Medical University, Longyan, China
| | - Xiaohua Huang
- Department of Laboratory Medicine, First Affiliated Hospital of Fujian Medical University, Longyan, China
| | - Xiaoru Guo
- Department of Laboratory Medicine, First Affiliated Hospital of Fujian Medical University, Longyan, China
| | - Zhengzheng Wu
- SurExam Bio-Tech Co. Ltd, Guangzhou Technology Innovation Base, Guangzhou, China
| | - Shiyang Wu
- SurExam Bio-Tech Co. Ltd, Guangzhou Technology Innovation Base, Guangzhou, China
| | - Jiasen Xu
- SurExam Bio-Tech Co. Ltd, Guangzhou Technology Innovation Base, Guangzhou, China
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Serum concentrations of risperidone and aripiprazole in subgroups encoding CYP2D6 intermediate metabolizer phenotype. Ther Drug Monit 2014; 36:80-5. [PMID: 24232129 DOI: 10.1097/ftd.0000000000000018] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
BACKGROUND Cytochrome P450 2D6 intermediate metabolizer phenotype (CYP2D6 IM) comprises various genotype subgroups. The aim of this study was to evaluate serum concentrations of the CYP2D6 substrates risperidone and aripiprazole in psychiatric patients with various CYP2D6 genotypes encoding IM phenotype. METHODS The study was based on therapeutic drug monitoring data from CYP2D6-genotyped patients (mainly of white origin) treated with orally administered risperidone (n = 190) or aripiprazole (n = 266). Patients were divided into 3 genotype subgroups encoding IM phenotype: (1) heterozygous carriers of fully functional and nonfunctional variant alleles (*1/def), (2) homozygous carriers of reduced-function variant alleles (red/red), and (3) heterozygous carriers of reduced-function and nonfunctional variant alleles (def/red). Dose-adjusted serum concentrations of risperidone and aripiprazole were compared between the genotype subgroups using *1/def, the most frequent CYP2D6 genotype among these subgroups, as the reference group. RESULTS Median serum concentrations were 4.5- and 1.6-fold higher in the def/red genotype than the *1/def genotype for risperidone and aripiprazole, respectively (P < 0.01 for both). Correspondingly, the serum concentrations were 3.4- and 1.8-fold higher in the red/red subgroup compared with the reference group (P < 0.05 for both). CONCLUSIONS In conclusion, this study revealed substantial variability in serum concentrations of risperidone and aripiprazole between CYP2D6 genotypes associated with IM phenotype. A considerable phenotypical difference was observed between patients carrying 1 and 2 variant alleles.
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Hamadeh IS, Langaee TY, Dwivedi R, Garcia S, Burkley BM, Chapman AB, Gums JG, Turner ST, Gong Y, Cooper-DeHoff RM, Johnson JA. Impact of CYP2D6 polymorphisms on clinical efficacy and tolerability of metoprolol tartrate. Clin Pharmacol Ther 2014; 96:175-81. [PMID: 24637943 PMCID: PMC4111800 DOI: 10.1038/clpt.2014.62] [Citation(s) in RCA: 66] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2013] [Accepted: 03/07/2014] [Indexed: 01/13/2023]
Abstract
Metoprolol is a selective β-1 adrenergic receptor blocker that undergoes extensive metabolism by the polymorphic enzyme cytochrome P450 2D6 (CYP2D6). Our objective was to investigate the influence of CYP2D6 polymorphisms on the efficacy and tolerability of metoprolol tartrate. Two hundred and eighty-one participants with uncomplicated hypertension received 50 mg of metoprolol twice daily followed by response-guided titration to 100 mg twice daily. Phenotypes were assigned based on results of CYP2D6 genotyping and copy number variation assays. Clinical response to metoprolol and adverse effect rates were analyzed in relation to CYP2D6 phenotypes using appropriate statistical tests. Heart rate response differed significantly by CYP2D6 phenotype (P < 0.0001), with poor and intermediate metabolizers showing greater reduction. However, blood pressure response and adverse effect rates were not significantly different by CYP2D6 phenotype. Other than a significant difference in heart rate response, CYP2D6 polymorphisms were not determinants of variability in metoprolol response or tolerability.
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Affiliation(s)
- Issam S. Hamadeh
- Department of Pharmacotherapy and Translational Research, Center for Pharmacogenomics, University of Florida College of Pharmacy, Gainesville, FL
| | - Taimour Y. Langaee
- Department of Pharmacotherapy and Translational Research, Center for Pharmacogenomics, University of Florida College of Pharmacy, Gainesville, FL
| | - Ruti Dwivedi
- Department of Pharmacotherapy and Translational Research, Center for Pharmacogenomics, University of Florida College of Pharmacy, Gainesville, FL
| | - Sofia Garcia
- Department of Pharmacotherapy and Translational Research, Center for Pharmacogenomics, University of Florida College of Pharmacy, Gainesville, FL
| | - Ben M. Burkley
- Department of Pharmacotherapy and Translational Research, Center for Pharmacogenomics, University of Florida College of Pharmacy, Gainesville, FL
| | - Arlene B. Chapman
- Renal Division, Department of Medicine, Emory University School of Medicine, Atlanta, GA
| | - John G. Gums
- Department of Pharmacotherapy and Translational Research, University of Florida School of Pharmacy, Gainesville, FL
- Department of Community Health and Family Medicine, University of Florida College of Medicine, Gainesville, FL
| | - Stephen T. Turner
- Division of Nephrology and Hypertension, Department of Internal Medicine, Mayo Clinic College of Medicine, Rochester MN
| | - Yan Gong
- Department of Pharmacotherapy and Translational Research, Center for Pharmacogenomics, University of Florida College of Pharmacy, Gainesville, FL
| | - Rhonda M. Cooper-DeHoff
- Department of Pharmacotherapy and Translational Research, Center for Pharmacogenomics, University of Florida College of Pharmacy, Gainesville, FL
- Division of Cardiology, Department of Medicine, University of Medicine, University of Florida College of Medicine, Gainesville, FL
| | - Julie A. Johnson
- Department of Pharmacotherapy and Translational Research, Center for Pharmacogenomics, University of Florida College of Pharmacy, Gainesville, FL
- Division of Cardiology, Department of Medicine, University of Medicine, University of Florida College of Medicine, Gainesville, FL
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Wojtczak A, Wojtczak M, Skrętkowicz J. The relationship between plasma concentration of metoprolol and CYP2D6 genotype in patients with ischemic heart disease. Pharmacol Rep 2014; 66:511-4. [DOI: 10.1016/j.pharep.2013.12.010] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2013] [Revised: 11/29/2013] [Accepted: 12/16/2013] [Indexed: 11/25/2022]
Affiliation(s)
- Anna Wojtczak
- Department of Pharmacogenetics, Medical University of Lodz, Łódź, Poland.
| | - Maciej Wojtczak
- Institute of Chemical Technology of Food, Lodz University of Technology, Łódź, Poland
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Aspromonte N, Monitillo F, Puzzovivo A, Valle R, Caldarola P, Iacoviello M. Modulation of cardiac cytochrome P450 in patients with heart failure. Expert Opin Drug Metab Toxicol 2014; 10:327-39. [DOI: 10.1517/17425255.2014.872240] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
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Preoperative CYP2D6 metabolism-dependent β-blocker use and mortality after coronary artery bypass grafting surgery. J Thorac Cardiovasc Surg 2013; 147:1368-1375.e3. [PMID: 24269121 DOI: 10.1016/j.jtcvs.2013.09.067] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/19/2013] [Revised: 09/14/2013] [Accepted: 09/30/2013] [Indexed: 11/21/2022]
Abstract
OBJECTIVE Recently, the role of β-blockers (BBs) in reducing perioperative mortality has been challenged. The conflicting results might have resulted from the extent of BB metabolism by the cytochrome P-450 (CYP2D6) isoenzyme. The purpose of the present study was to assess the association between the preoperative use of BBs dependent on metabolism of the CYP2D6 isoenzyme with operative mortality after coronary artery bypass grafting surgery. METHODS We performed a retrospective study of 5248 patients who had undergone coronary bypass grafting surgery from January 1, 2001 to November 30, 2009 at Duke University Medical Center. The cohorts were defined by the preoperative use of BBs and BB type (non-CYP2D6_BBs, CYP2D6_BBs, or no BBs). Operative mortality was analyzed using inverse probability-weighted estimators with propensity score adjustment. RESULTS Of the 5248 patients, 14% received non-CYP2D6_BBs, 43%, CYP2D6_BBs, and 43%, no BBs. The incidence of operative mortality was 0.8%, 2.1%, and 3.7% in the non-CYP2D6_BB, CYP2D6_BB, and no BB groups, respectively. Multivariable inverse probability-weighted-adjusted analyses showed that non-CYP2D6_BBs were associated with a lower incidence of operative mortality (odds ratio, 0.33; 95% confidence interval, 0.13-0.83; P = .02) compared with no BB use and a trend toward lower operative mortality (odds ratio, 0.44; 95% confidence interval, 0.16-1.07; P = .06) compared with CYP2D6_BBs. No significant decrease occurred in the risk of operative mortality between the CYP2D6_BB and no BB groups (odds ratio, 0.85; 95% confidence interval, 0.54-1.34; P = .48). CONCLUSIONS Among these patients, preoperative non-CYP2D6_BB use, but not CYP2D6_BB use, was associated with a decreased risk of operative mortality.
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Abstract
Interindividual heterogeneity in drug response is a central feature of all drug therapies. Studies in individual patients, families, and populations over the past several decades have identified variants in genes encoding drug elimination or drug target pathways that in some cases contribute substantially to variable efficacy and toxicity. Important associations of pharmacogenomics in cardiovascular medicine include clopidogrel and risk for in-stent thrombosis, steady-state warfarin dose, myotoxicity with simvastatin, and certain drug-induced arrhythmias. This review describes methods used to accumulate and validate these findings and points to approaches--now being put in place at some centers--to implementing them in clinical care.
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Affiliation(s)
- Peter Weeke
- Division of Clinical Pharmacology, Vanderbilt University School of Medicine, Nashville, Tennessee; ,
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An Investigation of CYP2D6 Genotype and Response to Metoprolol CR/XL During Dose Titration in Patients With Heart Failure: A MERIT-HF Substudy. Clin Pharmacol Ther 2013; 95:321-30. [DOI: 10.1038/clpt.2013.193] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2013] [Accepted: 09/16/2013] [Indexed: 12/18/2022]
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[Personalized therapy in cardiology. Biomarkers, pharmacogenetics and therapy of monogenic diseases]. Internist (Berl) 2013; 54:147-8, 150-2, 154. [PMID: 23371262 DOI: 10.1007/s00108-012-3157-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
Abstract
Improved therapy and prophylaxis of cardiovascular diseases have contributed to an increase in life expectancy like no other field of medicine. However, many cardiological diseases remain untreatable and standard therapies often work only in a minority of patients or cause more harm than benefit. Personalized approaches appear to be a promising solution. Monogenic heart diseases are paradigmatic for this approach and can in rare cases be treated mutation specifically. Overall, however, success remains limited. Next generation sequencing will facilitate the identification of mutations causing diseases. Cell culture models based on induced pluripotent stem cells open the perspective of individualized testing of disease severity and pharmacological or genetic therapy. In contrast to monogenic diseases genetic testing plays no practical role yet in the management of multifactorial cardiovascular diseases. Biomarkers can identify individuals with increased cardiovascular risk. Furthermore, biomarker-guided therapy represents an attractive option with troponin-guided therapy of acute coronary syndromes as a successful example. Individual responses to drugs vary and are partly determined by genes. Simple genetic analyses can improve response prediction and minimize side effects in cases such as warfarin and high doses of simvastatin. Taken together personalized approaches will gain importance in the cardiovascular field but this requires the development of better methods and research that quantifies the true value of the new knowledge.
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de Denus S, Kantor PF. Pharmacogenomics and heart failure in congenital heart disease. Can J Cardiol 2013; 29:779-85. [PMID: 23790550 DOI: 10.1016/j.cjca.2013.04.017] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2013] [Revised: 04/17/2013] [Accepted: 04/17/2013] [Indexed: 01/11/2023] Open
Abstract
Congenital heart disease (CHD) constitutes a lifelong challenge in heart failure management. Current therapy is based mainly on physiologic principles extrapolated from the management of left ventricular failure in adult populations with either ischemic or nonischemic cardiomyopathy. However, there is good evidence of genomic variability in the origin and progression of CHD that suggests the need for a individualized approach to treatment. The developing science of pharmacogenomics presents an opportunity for CHD management broadly, and especially in the context of heart failure. There is growing evidence that individualizing drug therapy for these patients might be beneficial, and that prediction of response to therapy might be possible by incorporating genomic data into the treatment algorithm for individual patients.
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Affiliation(s)
- Simon de Denus
- Faculty of Pharmacy, Université de Montréal, Montreal Heart Institute, Montreal, Québec, Canada
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Cascorbi I, Bruhn O, Werk AN. Challenges in pharmacogenetics. Eur J Clin Pharmacol 2013; 69 Suppl 1:17-23. [DOI: 10.1007/s00228-013-1492-x] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2013] [Accepted: 02/19/2013] [Indexed: 12/20/2022]
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Bentzen BH, Grunnet M, Hyveled-Nielsen L, Sundgreen C, Lassen JB, Hansen HH. Anti-hypertensive treatment preserves appetite suppression while preventing cardiovascular adverse effects of tesofensine in rats. Obesity (Silver Spring) 2013; 21:985-92. [PMID: 23784901 DOI: 10.1002/oby.20122] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/18/2012] [Accepted: 09/10/2012] [Indexed: 12/30/2022]
Abstract
OBJECTIVE Tesofensine is a novel triple monoamine reuptake inhibitor which is in development for the treatment of obesity. Preclinical and clinical data suggest that appetite suppression is an important mechanism by which tesofensine exerts its robust weight reducing effect. Notably, the strong hypophagic response to tesofensine treatment is demonstrated to be linked to central stimulation of noradrenergic and dopaminergic neurotransmission. The sympathomimetic mode of action of tesofensine may also associate with the elevated heart rate and blood pressure observed in clinical settings, and we therefore sought experimentally to address this issue. DESIGN AND METHODS The anorexigenic and cardiovascular effects of tesofensine were studied simultaneously in telemetrized conscious rats in a combined real-time food intake and cardiovascular telemetry monitoring system. RESULTS Acute administration of tesofensine caused a dose-dependent hypophagic effect as well as increased heart rate and blood pressure. Interestingly, combined treatment with metoprolol (b1 adrenoceptor blocker, 10-20 mg/kg, p.o.) fully prevented the cardiovascular sympathetic effects of tesofensine while leaving the robust inhibitory efficacy on food intake unaffected. Similarly, the angiotensin AT1 receptor antagonist telmisartan (1.0-3.0 mg/kg, p.o.) did not interfere with the anti-obesity effects of tesofensine, however, telmisartan only partially reversed the increase in systolic blood pressure and had no effect on the elevated heart rate induced by tesofensine. CONCLUSION These data suggests that tesofensine causes elevations in heart rate and blood pressure by increasing sympathetic activity, and that different adrenoceptor subtypes may be responsible for the anti-obesity and cardiovascular effects of tesofensine.
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Ma JD, Nafziger AN, Bertino JS. Genetic Polymorphisms of Cytochrome P450 Enzymes and the Effect on Interindividual, Pharmacokinetic Variability in Extensive Metabolizers. J Clin Pharmacol 2013; 44:447-56. [PMID: 15102864 DOI: 10.1177/0091270004264642] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
Genetic polymorphisms of cytochrome P450 (CYP) enzymes are one of the factors that contribute to the pharmacokinetic (PK) variability of drugs. PK variability is observed in the bimodal distribution between extensive metabolizers (EMs) and poor metabolizers (PMs). PK variability may also exist between individuals genotyped as homozygous EMs and heterozygous EMs. This may carry implications for drug dosing and drug response (e.g., risk of therapeutic failure or drug toxicity). Studies have reported significant PK differences between homozygous and heterozygous EMs. Some literature suggests that this distinction may be of clinical relevance. Due to study design limitations and data that are either sparse or conflicting, generalizations regarding the potential impact of the CYP genotype, within EMs, are difficult. Optimally designed clinical trials are needed. This review evaluates the potential impact of CYP genetic polymorphisms on interindividual PK variability of drugs within an EM population.
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Affiliation(s)
- Joseph D Ma
- Clinical Pharmacology Research Center, Bassett Healthcare, One Atwell Road, Cooperstown, NY 13326-1394, USA
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Gong IY, Kim RB. Pharmacogenetic Advances in Cardiovascular Medicine: Relevance to Personalized Medicine. CURRENT GENETIC MEDICINE REPORTS 2013. [DOI: 10.1007/s40142-012-0001-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
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Abstract
PURPOSE OF REVIEW To survey genetic variation contributing to variable responsiveness and toxicity to important cardiovascular drugs and highlight recent developments in the field of cardiovascular pharmacogenomics and personalized medicine. RECENT FINDINGS Previously recognized pharmacogenomic associations with drug efficacy have been further validated (e.g. with clopidogrel and warfarin) and shown to influence clinically important outcomes. The clinical significance of variants modulating toxicity (e.g. SLCO1B1 with simvastatin) has also been confirmed. The genetic contribution to variable efficacy and toxicity of other important classes of cardiovascular drugs, such as beta-blockers, is becoming increasingly recognized. Prospective trials testing whether the use of genomic information improves clinical care are underway. Guidance based on the most well-established pharmacogenomic findings has appeared in prescribing labeling and is in the early stages of being implemented into routine clinical care. SUMMARY Clinically validated gene variants that modulate responsiveness to cardiovascular drugs continue to be discovered and validated. Early steps are underway to translate these discoveries into clinical care.
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Clinical Application of Cardiovascular Pharmacogenetics. J Am Coll Cardiol 2012; 60:9-20. [DOI: 10.1016/j.jacc.2012.01.067] [Citation(s) in RCA: 49] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/12/2011] [Revised: 01/05/2012] [Accepted: 01/18/2012] [Indexed: 11/18/2022]
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Chan SW, Hu M, Tomlinson B. The pharmacogenetics of β-adrenergic receptor antagonists in the treatment of hypertension and heart failure. Expert Opin Drug Metab Toxicol 2012; 8:767-90. [DOI: 10.1517/17425255.2012.685157] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
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Abstract
Perioperative myocardial infarction is a common and potentially fatal complication after noncardiac surgery, particular among patients with cardiovascular risk factors. β-blockers have been considered a mainstay in prevention and treatment of perioperative myocardial infarction, yet recent evidence suggests that β-blockers may have an unfavorable risk profile in this setting, and the use has become controversial. What seems conspicuously absent from the current discussion is the appreciation of how much interindividual genetic variation influences the clinical response to β-blocker therapy. Genetic variation in the adrenergic signaling pathway is common, and has a major impact on adrenergic receptor function and β-blocker efficacy in other cardiovascular diseases, such as heart failure and hypertension. Genetic variation in the cytochrome P450 2D6, or CYP2D6, enzyme, which is responsible for the metabolism of most β-blockers, is also important and can lead to poor metabolizing of β-blockers (potential toxicity) or their ultra-rapid degradation (decreased efficacy). Here, we review the molecular, cellular, and physiologic consequences of polymorphisms in the adrenergic signaling pathway and CYP2D6 gene, and show that these are likely relevant factors influencing efficacy, safety, and toxicity of β-blocker therapy in prevention and treatment of perioperative myocardial infarction.
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Affiliation(s)
- Peter Nagele
- Division of Clinical and Translational Research, Department of Anesthesiology, Washington University School of Medicine, St. Louis, Missouri 63110, USA.
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von Homeyer P, Schwinn DA. Pharmacogenomics of β-adrenergic receptor physiology and response to β-blockade. Anesth Analg 2011; 113:1305-18. [PMID: 21965354 DOI: 10.1213/ane.0b013e31822b887e] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
Myocardial β-adrenergic receptors (βARs) are important in altering heart rate, inotropic state, and myocardial relaxation (lusitropy). The β1AR and β2AR stimulation increases cyclic adenosine monophosphate concentration with the net result of myocyte contraction, whereas β3AR stimulation results in decreased inotropy. Downregulation of β1ARs in heart failure, as well as an increased β3AR activity and density, lead to decreased cyclic adenosine monophosphate production and reduced inotropy. The βAR antagonists are commonly used in patients with coronary artery disease and heart failure; however, perioperative use of βAR antagonists is controversial. Individual patient's response to beta-blocker therapy is an area of intensive research, and apart from pharmacokinetics, pharmacodynamics, and ethnic differences, genetic alterations have become more important in the last 20 years. The most common genetic variants in humans are single nucleotide polymorphisms (SNPs). There are 2 clinically relevant SNPs for the β1AR (Ser49Gly, Arg389Gly), 3 for the β2AR (Arg16Gly, Gln27Glu, Thr164Ile), and 1 for the β3AR (Trp64Arg). Although results are somewhat controversial, generally large datasets have the potential to show a relationship between βAR SNPs and outcomes such as development and progression of heart failure, coronary artery disease, vascular reactivity, hypertension, asthma, obesity, and diabetes. Although βAR SNPs may not directly cause disease, they appear to be risk factors for, and modifiers of, disease and the response to stress and drugs. In the perioperative setting, this has specifically been demonstrated for the Arg389Gly β1AR polymorphism with which patients with the Gly variant had a higher incidence of adverse perioperative events. Knowing that genetic variants play an important role, perioperative medicine will likely change from simple therapeutic intervention to a more personalized way of adrenergic receptor modulation.
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Affiliation(s)
- Peter von Homeyer
- Department of Anesthesiology & Pain Medicine, University of Washington, Seattle, WA 98195-6540, USA.
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Yin SJ, Ni YB, Wang SM, Wang X, Lou YQ, Zhang GL. Differences in genotype and allele frequency distributions of polymorphic drug metabolizing enzymes CYP2C19 and CYP2D6 in mainland Chinese Mongolian, Hui and Han populations. J Clin Pharm Ther 2011; 37:364-9. [DOI: 10.1111/j.1365-2710.2011.01298.x] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
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Clarke JA, Cutler M, Gong I, Schwarz UI, Freeman D, Dasgupta M. Cytochrome P450 2D6 Phenotyping in an Elderly Population With Dementia and Response to Galantamine in Dementia: A Pilot Study. ACTA ACUST UNITED AC 2011; 9:224-33. [DOI: 10.1016/j.amjopharm.2011.07.003] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/14/2011] [Indexed: 10/18/2022]
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Verschuren JJW, Trompet S, Wessels JAM, Guchelaar HJ, de Maat MPM, Simoons ML, Jukema JW. A systematic review on pharmacogenetics in cardiovascular disease: is it ready for clinical application? Eur Heart J 2011; 33:165-75. [PMID: 21804109 DOI: 10.1093/eurheartj/ehr239] [Citation(s) in RCA: 58] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023] Open
Abstract
Pharmacogenetics is the search for heritable genetic polymorphisms that influence responses to drug therapy. The most important application of pharmacogenetics is to guide choosing agents with the greatest potential of efficacy and smallest risk of adverse drug reactions. Many studies focusing on drug-gene interactions have been published in recent years, some of which led to adaptation of FDA recommendations, indicating that we are on the verge of the clinical application of genetic information in drug therapy. This systematic review provides a comprehensive overview of the current knowledge on pharmacogenetics of all major drug classes currently used in the treatment of cardiovascular diseases.
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Parker RB, Soberman JE. Effects of Paroxetine on the Pharmacokinetics and Pharmacodynamics of Immediate-Release and Extended-Release Metoprolol. Pharmacotherapy 2011; 31:630-41. [DOI: 10.1592/phco.31.7.630] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
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Ravensbergen NJC, Voute MT, Poldermans D. Safety of perioperative β-blocker use: how do β-blockers compare in terms of side effects? Expert Opin Drug Saf 2011; 10:545-58. [PMID: 21247365 DOI: 10.1517/14740338.2011.552500] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
INTRODUCTION In the perioperative setting, there is still a high incidence of adverse cardiac events due to sudden coronary plaque rupture or oxygen supply-demand imbalance. β-Blockers play an important role in preventing these cardiac events. Discussion, however, remains on the side effects accompanying this therapy. AREAS COVERED The evidence for perioperative use of β-blockers is summarized in this review in terms of risk reduction, perioperative safety and current clinical use. Furthermore, data on pharmacokinetics, pharmacodynamics and pharmacogenetics are presented. EXPERT OPINION In perioperative care, β-blockers are recommended and can be given safely when started early in a low dose, titrated to heart rate. In the future, there could be a place for added perioperative short-acting β-blockers to further optimize heart rate control.
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Cascorbi I. Safe and effective medicines for all: is personalized medicine the answer? Expert Rev Clin Pharmacol 2010; 3:627-37. [PMID: 22111745 DOI: 10.1586/ecp.10.36] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
An improvement in drug treatment and clinical outcome is one of the major challenges in clinical medicine. The development of evidence-based standards of care has led to a significant improvement, but, by definition, strictly standardized cohorts in clinical trials have to ignore individual differences. Personalized medicine is defined as the application of genomic and molecular data to better target the delivery of healthcare, facilitate the discovery and clinical testing of new products, and help determine a person's predisposition to a particular disease or condition. After the deciphering of the human genome, however, the high expectations in individualized medicine were not always fulfilled. However, personalized medicine has become indispensable in the treatment of malignant diseases and there is increasing evidence for its benefit in other areas. This article outlines the impact of pharmacogenetics and pharmacogenomics, especially with regard to personalized medicine, in major medical indications and reflects the obstacles and chances taken in current daily practice.
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Affiliation(s)
- Ingolf Cascorbi
- Institute for Experimental and Clinical Pharmacology, University Hospital Schleswig-Holstein, Arnold-Heller-Str. 3, Bldg 30, D-24105 Kiel, Germany.
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