Drug receptor/effector polymorphisms and pharmacogenetics: current status and challenges

Expanding role of pharmacogenomics in the management of cardiovascular disorders

Cardiovascular disease is a leading cause of death worldwide. Many pharmacologic therapies are available that aim to reduce the risk of cardiovascular disease but there is significant inter-individual variation in drug response, including both efficacy and toxicity. Pharmacogenetics aims to personalize medication choice and dosage to ensure that maximum clinical benefit is achieved whilst side effects are minimized. Over the past decade, our knowledge of pharmacogenetics in cardiovascular therapies has increased significantly. The anticoagulant warfarin represents the most advanced application of pharmacogenetics in cardiovascular medicine. Prospective randomized clinical trials are currently underway utilizing dosing algorithms that incorporate genetic polymorphisms in cytochrome P450 (CYP)2C9 and vitamin k epoxide reductase (VKORC1) to determine warfarin dosages. Polymorphisms in CYP2C9 and VKORC1 account for approximately 40 % of the variance in warfarin dose. There is currently significant controversy with regards to pharmacogenetic testing in anti-platelet therapy. Inhibition of platelet aggregation by aspirin in vitro has been associated with polymorphisms in the cyclo-oxygenase (COX)-1 gene. However, COX-1 polymorphisms did not affect clinical outcomes in patients prescribed aspirin therapy. Similarly, CYP2C19 polymorphisms have been associated with clopidogrel resistance in vitro, and have shown an association with stent thrombosis, but not with other cardiovascular outcomes in a consistent manner. Response to statins has been associated with polymorphisms in the cholesterol ester transfer protein (CETP), apolipoprotein E (APOE), 3-hydroxy-3-methylglutaryl coenzyme A (HMG-CoA) reductase, calmin (CLMN) and apolipoprotein-CI (APOC1) genes. Although these genes contribute to the variation in lipid levels during statin therapy, their effects on cardiovascular outcomes requires further investigation. Polymorphisms in the solute carrier organic anion transporter 1B1 (SLCO1B1) gene is associated with increased statin exposure and simvastatin-induced myopathy. Angiotensin-converting enzyme (ACE) inhibitors and β-adrenoceptor antagonists (β-blockers) are medications that are important in the management of hypertension and heart failure. Insertion and deletion polymorphisms in the ACE gene are associated with elevated and reduced serum levels of ACE, respectively. No significant association was reported between the polymorphism and blood pressure reduction in patients treated with perindopril. However, a pharmacogenetic score incorporating single nucleotide polymorphisms (SNPs) in the bradykinin type 1 receptor gene and angiotensin-II type I receptor gene predicted those most likely to benefit and suffer harm from perindopril therapy. Pharmacogenetic studies into β-blocker therapy have focused on variations in the β1-adrenoceptor gene and CYP2D6, but results have been inconsistent. Pharmacogenetic testing for ACE inhibitor and β-blocker therapy is not currently used in clinical practice. Despite extensive research, no pharmacogenetic tests are currently in clinical practice for cardiovascular medicines. Much of the research remains in the discovery phase, with researchers struggling to demonstrate clinical utility and validity. This is a problem seen in many areas of therapeutics and is because of many factors, including poor study design, inadequate sample sizes, lack of replication, and heterogeneity amongst patient populations and phenotypes. In order to progress pharmacogenetics in cardiovascular therapies, researchers need to utilize next-generation sequencing technologies, develop clear phenotype definitions and engage in multi-center collaborations, not only to obtain larger sample sizes but to replicate associations and confirm results across different ethnic groups.

Genome-wide identification of structural variants in genes encoding drug targets: possible implications for individualized drug therapy

OBJECTIVE

The objective of the present study was to identify structural variants of drug target-encoding genes on a genome-wide scale. We also aimed at identifying drugs that are potentially amenable for individualization of treatments based on knowledge about structural variation in the genes encoding their targets.

METHODS

Information about human drug targets of all therapeutic drugs and nutraceuticals approved by the Food and Drug Administration and with an Anatomical Therapeutic Chemical (ATC) code, namely, 876, was obtained from the DrugBank and applied to interrogate the Database of Genomic Variants.

RESULTS

We identified 1721 structural variants, which affected 495 of 1005 different genes encoding drug targets. About 70% of the Food and Drug Administration-approved drugs had targets subjected to structural variation, in particular copy number variation. The distribution of drugs with targets encoded by copy number variable genes differed between ATC groups with pronounced over-representation in ATC group N, that is, nervous system drugs (P=3.75e-5). Several narrow therapeutic index drugs with targets subjected to genomic structural variation were identified. Information about the frequencies of the structural variants and drug consumption allowed us to identify potential candidates for implementation in pharmacogenetic testing and individualized drug treatments.

CONCLUSION

Structural variants in pharmacodynamic genes may play a larger role in determining individual variation in drug responses than currently believed. Inclusion of such genes in pharmacogenetic testing holds promising prospects as they may have large effect sizes.

Pharmacokinetic-pharmacodynamic modeling of mood and withdrawal symptoms in relation to plasma concentrations of methadone in patients undergoing methadone maintenance treatment

The aims of the present study were to characterize the relationship between plasma racemic methadone and its enantiomers' concentrations with respect to their pharmacodynamic effects and to investigate the influence of potential covariates on the pharmacodynamic parameters in patients on methadone maintenance treatment (MMT). Eighty-eight regular subjects at the Sheffield Care Trust Substance Misuse Services were studied. Samples of blood and urine were collected before the daily dose of methadone. Blood samples were taken up to 5 hours after dose. Total plasma concentrations of (RS)-methadone and total and unbound plasma concentrations of both enantiomers were measured by liquid chromatography-mass spectrometry. The Total Mood Disturbance Score (TMDS), the Objective Opioid Withdrawal Scale (OOWS), and the Subjective Opioid Withdrawal Scale (SOWS) were used as measures of mood and withdrawal. Population pharmacokinetic/pharmacodynamic analysis and subsequent multiple regression analysis were used to determine the factors influencing the pharmacodynamic effects of methadone. Significant decreases (P ≤ 0.04) were observed in the scores for the TMDS, SOWS, and OOWS for 5 hours after methadone dosage. The TMDS had returned to baseline by 10 hours after dose (P = 0.98), at which time the SOWS remained significantly below baseline (P = 0.001). Multiple regression analysis revealed that 33% of the overall variation in unbound (R)-methadone EC50 was explained by 3 variables, namely CYP3A activity (9%), age (16%), and sex (8%). Age also accounted for 8% and 9% of the variation in total (rac)- and (R)-methadone EC50. The present study has confirmed that the duration of mood change in the present study was shorter than the effect of methadone in stabilizing withdrawal symptoms. Thus, it is likely that a once-daily dose of methadone, albeit effective for preventing withdrawal, may not be sufficient to improve mood in some patients. Finally, it was established that CYP3A activity, years of dependent use, sex, and age are major determinants of methadone EC50 with respect to TMDS.

Personalized medicine in cardiovascular diseases

Personalized medicine is a novel medical model with all decisions and practices being tailored to individual patients in whatever ways possible. In the era of genomics, personalized medicine combines the genetic information for additional benefit in preventive and therapeutic strategies. Personalized medicine may allow the physician to provide a better therapy for patients in terms of efficiency, safety and treatment length to reduce the associated costs. There was a remarkable growth in scientific publication on personalized medicine within the past few years in the cardiovascular field. However, so far, only very few cardiologists in the USA are incorporating personalized medicine into clinical treatment. We review the concepts, strengths, limitations and challenges of personalized medicine with a particular focus on cardiovascular diseases (CVDs). There are many challenges from both scientific and policy perspectives to personalized medicine, which can overcome them by comprehensive concept and understanding, clinical application, and evidence based practices. Individualized medicine serves a pivotal role in the evolution of national and global healthcare reform, especially, in the CVDs fields. Ultimately, personalized medicine will affect the entire landscape of health care system in the near future.

Adipose tissue deletion of Gpr116 impairs insulin sensitivity through modulation of adipose function

G protein-coupled receptor 116 (GPR116) is a novel member of the G protein-coupled receptors and its function is largely unknown. To investigate the physiological function of GPR116 in vivo, we generated adipose tissue specific conditional Gpr116 knockout mice (CKO) and fed them on standard chow or high fat diets. Selective deletion of Gpr116 in adipose tissue caused a pronounced glucose intolerance and insulin resistance in mice, especially when challenged with a high fat diet. Biochemical analysis revealed a more severe hepatosteatosis in CKO mice. Additionally, we found that CKO mice showed a lowered concentration of circulating adiponectin and an increased level of serum resistin. Our study suggests that GPR116 may play a critical role in controlling adipocyte biology and systemic energy homeostasis.

Pharmacogenomics of the heptahelical receptor regulators G-protein-coupled receptor kinases and arrestins: the known and the unknown

Heptahelical G-protein-coupled receptors are the most diverse and therapeutically important family of receptors, playing major roles in the physiology of various organs and tissues. They couple their ligand binding to G-protein activation, which then transmits intracellular signals. G-protein signaling is terminated by phosphorylation of the receptor by the family of G-protein-coupled receptor kinases (GRKs), followed by arrestin (Arr) binding, which uncouples the phosphorylated receptor from the G-protein and subsequently targets the receptor for internalization. Moreover, Arrs can transmit signals in their own right during receptor internalization. Genetic polymorphisms in receptors, as well as in GRK and Arr family members per se, which affect regulation of receptor signaling and function, have just started being identified and characterized. The present review will discuss what is known so far in this evolving field of GRK/Arr pharmacogenomics, as well as highlight important areas likely to produce invaluable information in the future.

Lack of effect of the alpha2C-adrenoceptor Del322-325 polymorphism on inhibition of cyclic AMP production in HEK293 cells

BACKGROUND AND PURPOSE

The alpha(2C)-adrenoceptor has multiple functions, including inhibiting release of noradrenaline from presynaptic nerve terminals. A human alpha(2C) polymorphism, Del322-325, a potential risk factor for heart failure, has been reported to exhibit reduced signalling in CHO cells. To further understand the role of the Del322-325 polymorphism on receptor signalling, we attempted to replicate and further study the reduced signalling in HEK293 cells.

EXPERIMENTAL APPROACH

Human alpha(2C) wild-type (WT) and Del322-325 adrenoceptors were stably transfected into HEK293 cells. Radioligand binding was performed to determine affinities for both receptors. In intact cells, inhibition of forskolin-stimulated cyclic AMP production by WT and Del322-325 clones with a range of receptor densities (200-2320 fmol.mg(-1) protein) was measured following agonist treatment.

KEY RESULTS

Noradrenaline, brimonidine and clonidine exhibited similar binding affinities for WT and Del322-325. Brimonidine and clonidine also had similar efficacies and potencies for both receptors for the inhibition of cyclic AMP production at all receptor densities tested. A linear regression analysis comparing efficacy and potency with receptor expression levels showed no differences in slopes between WT and Del322-325.

CONCLUSIONS AND IMPLICATIONS

The alpha(2C) WT and Del322-325 adrenoceptors exhibited similar binding properties. Additionally, inhibition of cyclic AMP production by Del322-325 was similar to that of WT over a range of receptor densities. Therefore, in intact HEK293 cells, the alpha(2C)-Del322-325 polymorphism does not exhibit reduced signalling to adenylyl cyclase and may not represent a clinically important phenotype.

GPCR signaling: understanding the pathway to successful drug discovery

Modulators of G protein-coupled receptors (GPCRs) form a key area for the pharmaceutical industry, representing approximately 27% of all Food and Drug Administration (FDA)-approved drugs. Consequently, there are a wide variety of in vitro plate-based screening technologies that enable the measurement of compound affinity, potency, and efficacy for almost every type of GPCR. However, to maximize success it is prudent to ensure that (i) the most suitable assay formats are identified, (ii) they are configured optimally to detect the desired compound activity, and (iii) that they form a basis for predicting clinical effects. To achieve this, an understanding of the pathways and mechanisms of receptor activation relevant to the disease mechanism, as well as the benefits and/or limitations of the specific techniques, is key.

Interaction between beta2 adrenergic receptor polymorphisms determines the extent of isoproterenol-induced vasodilatation ex vivo

OBJECTIVES

Single nucleotide polymorphisms at nucleotides 46, 79 and 491 of the beta2 adrenergic receptor (beta2AR) gene modify its pharmacological properties and may alter the response to agonists. The purpose of this study was to evaluate the role played by beta2AR polymorphisms on isoproterenol-induced relaxation of internal mammary arteries ex vivo.

METHODS

Internal mammary leftover segments were collected from 96 patients undergoing coronary artery bypass operation. Vascular rings were allowed to reach equilibrium with physiological Krebs solution before precontraction with U46619. Using the organ bath technique, cumulative dose-response curve of isoproterenol was constructed and average EC50 calculated. beta2AR genotyping was performed using a PCR-RFLP analysis.

RESULTS

Arterial segments obtained from Gly16 homozygotes displayed reduced sensitivity to isoproterenol compared with carriers of Arg16 allele(s) [Mean (-log) EC50+/-SD, 6.42+/-0.24, 95% confidence interval (CI) 6.32-6.53 vs. 6.67+/-0.25, 95% CI 6.62-6.73, P<0.001]. Among Gly16 homozygotes, the presence of two Glu27 alleles restored vascular response to the level noted among Arg16 carriers (6.58+/-0.17, 95% CI 6.41-6.76). The least response to isoproterenol was noted in a single patient carrying the Gly16Gly-Gln27Glu-Thr164Ile combined genotype requiring almost six-fold higher isoproterenol concentration than carriers of the wild-type genotype to achieve half the maximal arterial dilatation (17.78 x 10(-7) vs. 3.01 x 10(-7) +/- 2.62 x 10(-7) mol/l).

CONCLUSIONS

Vascular dilatation by isoproterenol is determined by a complex interaction between polymorphisms at nucleotides 46, 79 and 491 of the beta2AR gene. Further studies are warranted to evaluate the effect of additional polymorphisms in the coding and noncoding regions on vascular reactivity.

Quantitative systems-level determinants of human genes targeted by successful drugs

What makes a successful drug target? A target molecule with an appropriate (druggable) tertiary structure is a necessary but not the sufficient condition for success. Here we analyzed specific properties of human genes and proteins targeted by 919 FDA-approved drugs and identified several quantitative measures that distinguish them from other genes and proteins at a highly significant level. Compared to an average gene and its encoded protein(s), successful drug targets are more highly connected (but far from being the most highly connected), have higher betweenness values, lower entropies of tissue expression, and lower ratios of nonsynonymous to synonymous single-nucleotide polymorphisms. Furthermore, we have identified human tissues that are significantly over- or undertargeted relative to the full spectrum of genes that are active in each tissue. Our study provides quantitative guidelines that could aid in the computational screening of new drug targets in human cells.

Association analyses of adrenergic receptor polymorphisms with obesity and metabolic alterations

Genes involved in the regulation of catecholamine function may be important in obesity because of the role catecholamines play in energy expenditure and lipolysis. To determine if common single nucleotide polymorphisms (SNPs) in beta(1)-adrenergic receptor (ADRB1), beta(2)-adrenergic receptor (ADRB2), beta(3)-adrenergic receptor (ADRB3), and alpha(2)-adrenergic receptor (ADRA2A) genes associate with obesity and metabolic alterations, we recruited 74 healthy African American and 161 white men and women (age, 18-49 years) to participate in this case-control genetic association study. Genotypes were determined by polymerase chain reaction and restriction fragment length polymorphism. Associations between genotype and body mass index (BMI), percentage of body fat (by measuring skinfold thickness in 7 different sites), fasting (12-hour) plasma glucose, insulin, potassium concentrations, glycated hemoglobin, and insulin resistance (homeostasis model assessment [HOMA(IR)] score) were performed. Among whites, the ADRB1 Arg389-->Gly variant associated with insulin concentrations and HOMA(IR): mean +/- SD values for insulin and HOMA(IR) in Arg389 homozygotes and carriers of the Gly were 10 +/- 7.0 and 12 +/- 9.4 micro IU/mL (P = .02) and 2.1 +/- 1.7 and 2.6 +/- 2.2 (P = .057), respectively. Systolic blood pressure was higher in whites for carriers of the ADBR1 Ser49 compared to Gly49 homozygotes (124 +/- 12.6 vs 119 +/- 11.3 mm Hg, respectively; P = .02). Subsequent analysis revealed that these associations were attributable to a higher BMI among obese participants. The ADRA2A G1780A SNP associated with BMI and percentage of body fat in African Americans (P = .05). Interactions were detected between ADRA2A C-1291G and ADRB2 Gln27-->Glu variants for obesity in African Americans and between ADRA2A C-1291G SNP and ADBR1 haplotype for obesity in whites. We conclude that common SNPs in adrenergic receptor genes may be important susceptibility loci for obesity and related alterations. Because of the limited size of our populations, our results should be interpreted with caution and should be replicated in larger populations.

Impact of GPCRs in clinical medicine: monogenic diseases, genetic variants and drug targets

By virtue of their large number, widespread distribution and important roles in cell physiology and biochemistry, G-protein-coupled receptors (GPCR) play multiple important roles in clinical medicine. Here, we focus on 3 areas that subsume much of the recent work in this aspect of GPCR biology: (1) monogenic diseases of GPCR; (2) genetic variants of GPCR; and (3) clinically useful pharmacological agonists and antagonists of GPCR. Diseases involving mutations of GPCR are rare, occurring in <1/1000 people, but disorders in which antibodies are directed against GPCR are more common. Genetic variants, especially single nucleotide polymorphisms (SNPs), show substantial heterogeneity in frequency among different GPCRs but have not been evaluated for some GPCR. Many therapeutic agonists and antagonists target GPCR and show inter-subject variability in terms of efficacy and toxicity. For most of those agents, it remains an open question whether genetic variation in primary sequence of the GPCR is an important contributor to such inter-subject variability, although this is an active area of investigation.

Can pharmacogenetics help rescue drugs withdrawn from the market?

Observations over the later half of the last century have suggested that genetic factors may be the prime determinant of drug response, at least for some drugs. Retrospectively gathered data have provided further support to the notion that genotype-based prescribing will improve the overall efficacy rates and minimize adverse drug reactions (ADRs), making personalized medicine a reality. During the last 16 years, 38 drugs have been withdrawn from major markets due to safety concerns. Inevitably, a question arises as to whether it might be possible to 'rescue' some of these drugs by promoting genotype-based prescribing. However, ironically pharmacogenetics has not perceptibly improved the risk/benefit of a large number of genetically susceptible drugs that are already in wide clinical use and are associated with serious ADRs. Drug-induced hepatotoxicity and QT interval prolongation (with or without torsade de pointes) account for 24 (63%) of these 38 drug withdrawals. In terms of the number of drugs implicated, both these toxicities are on the increase. Many others have had to be withdrawn due to their inappropriate use. This paper discusses the criteria that a drug would need to fulfill, and summarizes the likely regulatory requirements, before its pharmacogenetic rescue can be considered to be realistic. One drug that fulfils these criteria is perhexiline (withdrawn worldwide in 1988) and is discussed in some detail. For the majority of these 38 drugs there are, at present, no candidates for genetic traits to which the toxicity that led to their withdrawal may be linked. For a few other drugs where a potential candidate for a genetic trait might explain the toxicity of concern, the majority of patients who experienced the index toxicity had easily managed nongenetic risk factors. It may be possible to rescue these drugs simply by careful attention to their dose, interaction potential and prescribing patterns, but without the need for any pharmacogenetic test. In addition, the pharmacogenetic rescue of drugs might not be as effective as anticipated as hardly any pharmacogenetic test is known to have the required test efficiency to promote individualized therapy. Multiple pathways of drug elimination, contribution to toxicity by metabolites as well as the parent drug, gene-gene interactions, multiple mechanisms of toxicity and inadequate characterization of phenotype account for this lack of highly predictive tests. The clinical use of tests that lack the required efficiency carries the risks of over- or under-dosing some patients, denying the drug to others and decreasing physician vigilance of patients. Above all, at present, prescribing physicians lack an adequate understanding of pharmacogenetics and its limitations. It is also questionable whether their prescribing will comply with the requirements for pretreatment pharmacogenetic tests to make pharmacogenetic rescue a realistic goal.

Mechanisms of methamphetamine-induced dopaminergic neurotoxicity

Methamphetamine (METH) is a powerful stimulant of abuse with potent addictive and neurotoxic properties. More than 2.5 decades ago, METH-induced damage to dopaminergic neurons was described. Since then, numerous advancements have been made in the search for the underlying mechanisms whereby METH causes these persistent dopaminergic deficits. Although our understanding of these mechanisms remains incomplete, combinations of various complex processes have been described around a central theme involving reactive species, such as reactive oxygen and/or nitrogen species (ROS and RNS, respectively). For example, METH-induced hyperthermia, aberrant dopamine(DA), or glutamate transmission; or mitochondrial disruption leads to the generation of reactive species with neurotoxic consequences. This review will describe the current understanding of how high-dose METH administration leads to the production of these toxic reactive species and consequent permanent dopaminergic deficits.

Pharmacogenomics and individualized drug therapy

Pharmacogenetics deals with inherited differences in the response to drugs. The best-recognized examples are genetic polymorphisms of drug-metabolizing enzymes, which affect about 30% of all drugs. Loss of function of thiopurine S-methyltransferase (TPMT) results in severe and life-threatening hematopoietic toxicity if patients receive standard doses of mercaptopurine and azathioprine. Gene duplication of cytochrome P4502D6 (CYP2D6), which metabolizes many antidepressants, has been identified as a mechanism of poor response in the treatment of depression. There is also a growing list of genetic polymorphisms in drug targets that have been shown to influence drug response. A major limitation that has heretofore moderated the use of pharmacogenetic testing in the clinical setting is the lack of prospective clinical trials demonstrating that such testing can improve the benefit/risk ratio of drug therapy.

Discordance between availability of pharmacogenetics studies and pharmacogenetics-based prescribing information for the top 200 drugs

BACKGROUND

Despite growing numbers of pharmacogenetics studies, little pharmacogenetics-based prescribing information is available to practitioners. It is possible that the lack of prescribing data for commonly used drugs is due to a paucity of evidence-based pharmacogenetics literature for these agents.

OBJECTIVE

To investigate the relationship between pharmacogenetics prescribing data in drug package inserts (PIs) and pharmacogenetics research literature for agents represented in the top 200 prescribed drugs for 2003.

METHODS

A PubMed search (to August 7, 2004) was performed to identify pharmacogenetics studies relevant to the top 200 drugs. These data were compared with PIs for drugs in the top 200 list that contained pharmacogenetics prescribing information.

RESULTS

Pharmacogenetics data in the literature were available for 71.3% of the top 200 drugs. The gene involved coded for a drug-metabolizing enzyme in 34.5% of the literature sampled. The remaining 65.5% of the pharmacogenetics studies contained information largely related to genetic variability in target proteins and drug transporters. Three drugs with PIs containing pharmacogenetics prescribing information deemed to be useful to guide therapy were in the top 200 list (celecoxib, fluoxetine, pantoprazole). There was no consensus on the strength of association between genetic variability and drug response for these agents.

CONCLUSIONS

The lack of specific pharmacogenetics-based prescribing information in PIs for commonly used drugs does not seem to be related to a paucity of pharmacogenetics data in the research literature. Rather, other factors including, but not limited to, the uncertain clinical relevance of genetic associations may make practical prescribing recommendations difficult.

Patients' and physicians' perspectives on pharmacogenetic testing

INTRODUCTION

The integration of pharmacogenetic testing into routine care will, in part, depend upon the patients' and physicians' acceptance of these tests. Empirical data regarding patients' and physicians' views on pharmacogenetic testing are lacking.

OBJECTIVES

To explore patients' and physicians' perspectives on the potential implications of pharmacogenetic testing, particularly focusing on asthma, and to analyze the possible determinants of their expectations, hopes and fears.

METHODS

We conducted telephone interviews with patients with asthma or chronic obstructive pulmonary disease taking part in a larger pharmacogenetic study, in addition to general practitioners (GPs) from a different region in Germany. A total of 328 patients and 378 GPs were invited to participate. Determinants of their attitudes toward pharmacogenetic testing were assessed using logistic regression analysis.

RESULTS

Informed consent to participate in this study was given by 196 patients (60%) and 106 GPs (28%). Most patients (96%) and physicians (52%) appreciated the availability of pharmacogenetic tests for a disease such as asthma. Approximately a third of the patients worried about potential unfavorable test results (35%) and violation of privacy (36%). Female patients were more likely to have a fearful attitude (odds ratio [OR]=2.85; 95% confidence interval [CI]=1.58-5.12). Younger patients were generally more likely to be hopeful about the usefulness of pharmacogenetic testing (OR=2.12; CI=1.01-4.46). The GPs' concerns were mainly related to the possibility that patients might either be put under pressure to be tested (72%) or be disadvantaged at private health insurance agencies (61%). The nature of the responsible institution, the clarity of the research aim and explicit informed consent from patients influenced a physicians' decision regarding whether to support a pharmacogenetic study.

CONCLUSION

The concerns of patients and GPs differ somewhat with respect to negative psychosocial consequences, discrimination or violation of privacy. Development of information for physicians and patients would be helpful in preventing unrealistic fears or hopes.

Polymorphisms of human nuclear receptors that control expression of drug-metabolizing enzymes

Phenotypic variation in human drug metabolism frequently can be attributed to polymorphisms in genes that encode drug-metabolizing enzymes (DMEs). However, levels of Phase I and Phase II DMEs also vary because many of these enzymes are induced by a myriad of xenobiotic chemicals. Individual differences in the capacity for induction contribute to variation in drug metabolism in human populations. Induction is mediated by intracellular receptors that act as ligand-dependent transcription factors, including several members of the nuclear receptor (NR) superfamily and the aryl hydrocarbon receptor (AHR). Genetic variations (SNPs and others) exist in genes that encode these human receptors but few of the known polymorphisms have any significant effect on enzyme induction. We suggest that the current scarcity of SNPs that are able to alter function in the DME-regulating NRs reflects considerable evolutionary selective pressures that conserve the key functional domains in these receptors.

Pharmacogenomics in depression and antidepressants

Genetic factors are believe y a major role in the variation of treatment response and the incidence of adverse effects to medication. The aim of pharmacogenetics is to elucidate this variability according to hereditary differences. Considering current hypotheses for the mechanisms of action of antidepressants, most investigations to date have concentrated on mutations in genes coding either for the pathways in the serotonergic and noradrenergic systems or for drug-metabolizing enzymes. Recent studies shifted the emphasis on the mains mechanism of drug action from changes in neurotransmitter concentration or receptor function toward long-lasting adaptive processes within the neurons. Although the results are controversial, many studies support the hypothesis that psychopharmacogenetics will help predict an individual's drug response, while minimizing the side effects. The inclusion of functional genomics, investigate the complex gene and/or protein expression in response to a given drug, may lead to the development of novel and safer drugs.

Pharmacogénétique et médicaments antiplaquettaires

PURPOSE

The observation of inherited drug response variability gave rise to the field of pharmacogenetics. Pharmacogenetic research on drug targets, particularly platelet enzymes and receptors, is more recent and is becoming an emerging field.

CURRENT KNOWLEDGE AND KEY POINTS

In the Framingham study, the heritability of platelet aggregation response ranges from 44 to 62%, depending on the agonists used. The gene coding for GPIIIa, a sub-unit of the fibrinogen receptor GPIIbIIIa, is one of the most extensively studied gene in relation with aggregation tests and antiplatelet drugs. The GPIIIa PLA1/PLA2 polymorphism has been associated with clopidogrel and orbofiban platelet response. However, data are more controversial concerning the association with aspirin response. Recently, Cox-1 and GPIa (part of the GPIaIIa collagen receptor) genetic variations have also been pointed out as possible candidates to explain part of the variability of the response to antiplatelet agents. Finally, the H1/H2 polymorphism of the platelet ADP receptor P2Y12 gene has been associated with ADP-induced platelet aggregation response and peripheral arterial disease. This polymorphism may modulate the effect of P2Y12 antagonists like clopidogrel and its clinical implication is currently under study.

FUTURE PROSPECTS AND PROJECTS

Gene-expression profiling and proteomics may allow the identification of new candidate genes whose variations may be associated with the heritability of platelet aggregation response. In the next future, phenotypic or genotypic studies could be available to tailor the prescription of antiplatelet drugs.

Multi-tasking RGS proteins in the heart: the next therapeutic target?

Regulator of G-protein-signaling (RGS) proteins play a key role in the regulation of G-protein-coupled receptor (GPCR) signaling. The characteristic hallmark of RGS proteins is a conserved approximately 120-aa RGS region that confers on these proteins the ability to serve as GTPase-activating proteins (GAPs) for G(alpha) proteins. Most RGS proteins can serve as GAPs for multiple isoforms of G(alpha) and therefore have the potential to influence many cellular signaling pathways. However, RGS proteins can be highly regulated and can demonstrate extreme specificity for a particular signaling pathway. RGS proteins can be regulated by altering their GAP activity or subcellular localization; such regulation is achieved by phosphorylation, palmitoylation, and interaction with protein and lipid-binding partners. Many RGS proteins have GAP-independent functions that influence GPCR and non-GPCR-mediated signaling, such as effector regulation or action as an effector. Hence, RGS proteins should be considered multifunctional signaling regulators. GPCR-mediated signaling is critical for normal function in the cardiovascular system and is currently the primary target for the pharmacological treatment of disease. Alterations in RGS protein levels, in particular RGS2 and RGS4, produce cardiovascular phenotypes. Thus, because of the importance of GPCR-signaling pathways and the profound influence of RGS proteins on these pathways, RGS proteins are regulators of cardiovascular physiology and potentially novel drug targets as well.

Pharmacogenomics and the drug discovery pipeline: when should it be implemented?

One of the key factors in developing improved medicines lies in understanding the molecular basis of the complex diseases we treat. Investigation of genetic associations with disease utilizing advances in linkage disequilibrium-based whole genome association strategies will provide novel targets for therapy and define relevant pathways contributing to disease pathogenesis. Genetic studies in conjunction with gene expression, proteomic, and metabonomic analyses provide a powerful tool to identify molecular subtypes of disease. Using these molecular data, pharmacogenomics has the potential to impact on the drug discovery and development process at many stages of the pipeline, contributing to both target identification and increased confidence in the therapeutic rationale. This is exemplified by the identified association of 5-lipoxygenase-activating protein (ALOX5AP/FLAP) with increased risk of myocardial infarction, and of the chemokine receptor 5 (CCR5) with HIV infection and therapy. Pharmacogenomics has already been used in oncology to demonstrate that molecular data facilitates assessment of disease heterogeneity, and thus identification of molecular markers of response to drugs such as imatinib mesylate (Gleevec) and trastuzumab (Herceptin). Knowledge of genetic variation in a target allows early assessment of the clinical significance of polymorphism through the appropriate design of preclinical studies and use of relevant animal models. A focussed pharmacogenomic strategy at the preclinical phase of drug development will produce data to inform the pharmacogenomic plan for exploratory and full development of compounds. Opportunities post-approval show the value of large well-characterized data sets for a systematic assessment of the contribution of genetic determinants to adverse drug reactions and efficacy. The availability of genomic samples in large phase IV trials also provides a valuable resource for further understanding the molecular basis of disease heterogeneity, providing data that feeds back into the drug discovery process in target identification and validation for the next generation of improved medicines.

Cardiovascular pharmacogenomics

There is large interpatient variability in the response to drugs, including cardiovascular drugs. Thus, while some patients achieve the desired therapeutic response from their drug therapy, others do not. There is also a subset of patients who will experience adverse effects, which can range from bothersome to life threatening. Research in recent years has provided compelling evidence that in many cases, genetics contributes importantly to this variable drug response. Thus, pharmacogenomics is a field focused on unravelling the genetic determinants of variable drug response. Examples from the literature of genetic associations with drug efficacy and toxicity are described to provide insight into the field, including the roles of genetic variability in drug-metabolizing enzymes and drug targets. There is also a detailed discussion of the experimental approaches used in cardiovascular pharmacogenomics. Current research is largely focused on a limited candidate gene approach, which allows for description of significant genetic associations with variable response, but often does not explain the genetic basis of variable drug response enough to be useful clinically. As such, there is a move towards genome-wide approaches, and the various technologies available to obtain genomic data are discussed. Cardiovascular pharmacogenomics has the potential for leading to improvements in the use of cardiovascular drug therapy, through selection of the most appropriate drug therapy in an individual based on their genetic information. It will probably be a decade or more before genetic information is widely used in drug therapy decisions, but it seems clear that important findings in the area will continue to expand and the experimental approaches will continue to evolve.

The Epidemiologic Approach to Pharmacogenomics

The epidemiologic approach enables the systematic evaluation of potential improvements in the safety and efficacy of drug treatment which might result from targeting treatment on the basis of genomic information. The main epidemiologic designs are the randomized control trial, the cohort study, and the case-control study, and derivatives of these proposed for investigating gene-environment interactions. However, no one design is ideal for every situation, and methodological issues, notably selection bias, information bias, confounding and chance, all play a part in determining which study design is best for a given situation. There is also a need to employ a range of different designs to establish a portfolio of evidence about specific gene-drug interactions. In view of the complexity of gene-drug interactions, pooling of data across studies is likely to be needed in order to have adequate statistical power to test hypotheses. We suggest that there may be opportunities (i) to exploit samples from trials already completed to investigate possible gene-drug interactions; (ii) to consider the use of the case-only design nested within randomized controlled trials as a possible means of reducing genotyping costs when dichotomous outcomes are being investigated; and (iii) to make use of population-based disease registries that can be linked with tissue samples, treatment information and death records, to investigate gene-treatment interactions in survival.

Dose and schedule as determinants of outcomes in chemotherapy for breast cancer

Many cytotoxic agents for the adjuvant treatment of breast cancer are available, but they have produced only modest results, even when the tumor burden is low. This relative lack of efficacy may be attributed, in part, to the nonspecificity of the current regimens. Additionally, there is evidence that the chemotherapy doses used in clinical practice are not optimal, which potentially compromises the outcomes when the thresholds of dose intensity are not reached. Variations in treatment underscore the need to return to the basics of chemotherapy administration: dose, schedule, concentration threshold, and therapeutic index. In patients with metastatic breast cancer a clear dose-response curve has been shown with some agents, including anthracyclines. The E-max model, which in its simplest form assumes a direct relation between the dose of a drug and its effect, may be used to improve dosing in the adjuvant treatment of breast cancer. Consistent with this model, threshold effects have been observed in treatment with both anthracyclines and paclitaxel for breast cancer. There is also evidence that using dose-dense schedules may produce better outcomes with some regimens. Maintaining chemotherapy agents at full dose on schedule is crucial to treatment success, especially in adjuvant therapy. Consequently, treatment practices should use both dose intensity and dose compression to increase the likelihood of positive outcomes in patients with breast cancer.

What is the impact of the ACE gene insertion/deletion (I/D) polymorphism on the clinical effectiveness and adverse events of ACE inhibitors?--Protocol of a systematic review

Background

The Angiotensin Converting Enzyme (ACE) insertion/deletion (I/D) polymorphism has received much attention in pharmacogenetic research because observed variations in response to ACE inhibitors might be associated with this polymorphism. Pharmacogenetic testing raises the hope to individualise ACE inhibitor therapy in order to optimise its effectiveness and to reduce adverse effects for genetically different subgroups. However, the extent of its effect modification in patients treated with ACE inhibitors remains inconclusive. Therefore our objective is to quantify the effect modification of the insertion/deletion polymorphism of the angiotensin converting enzyme gene on any surrogate and clinically relevant parameters in patients with cardiovascular diseases, diabetes, renal transplantation and/or renal failure.

Methods

Systematic Review. We will perform literature searches in six electronic databases to identify randomised controlled trials comparing the effectiveness and occurrence of adverse events of ACE inhibitor therapy against placebo or any active treatment stratified by the I/D gene polymorphism. In addition, authors of trials, experts in pharmacogenetics and pharmaceutical companies will be contacted for further published or unpublished data. Hand searching will be accomplished by reviewing the reference lists of all included studies. The methodological quality of included papers will be assessed. Data analyses will be performed in clinically and methodologically cogent subgroups. The results of the quantitative assessment will be pooled statistically where appropriate to produce an estimate of the differences in the effect of ACE inhibitors observed between the three ACE genotypes.

Discussion

This protocol describes a strategy to quantify the effect modification of the ACE polymorphism on ACE inhibitors in relevant clinical domains using meta-epidemiological research methods. The results may provide evidence for the usefulness of pharmacogenetic testing for individualised ACE inhibitor therapy.

Frequency of compound genotypes associated with β-blocker efficacy in congestive heart failure

An important practical problem in pharmacogenetics is the integration of compound genotypes into individualized therapy. Polymorphisms in the genes encoding the angiotensin-converting enzyme, and β1- and β2-adrenoceptors have been identified as predictors of ‘good response’ to β-adrenergic antagonists among heart failure patients. These variants were used as the basis for exploring the concept of compound genotype assessment. The frequency of compound variants in these genes was determined using PCR and pyrosequencing to genotype population samples of 95 African–Americans and 95 European–Americans. Both groups could be divided into four subgroups according to the number of favorable genotypes present. Each subgroup accounted for a significant proportion of subjects (the smallest was 7% of total). This study provides the first look into the population frequency of these compound genotypes, and it provides the necessary first step for future evaluation of polygenic strategies to individualize therapy for heart failure.

Genetic Practice, Education, and Research

PURPOSE/OBJECTIVES

The purpose of this article is to describe how the new genomic era will affect advanced practice registered nurses (APRNs) patient care, education, and research.

BACKGROUND/RATIONALE

Given the exponential growth of genetic information and that 9 of the top 10 leading causes of mortality have genetic components (www.cdc.gov), it is imperative to educate advanced practice nurses about this salient topic.

DESCRIPTION OF THE PROCESS

Because few APRNs in practice or academia have had formal education on genetics, the first step of nursings' own gene discovery is recognizing that there is an ongoing need to understand state of the science genetic information to gain clinical and educational utility.

OUTCOMES

By recognizing APRNs need to know genetics, APRNs will clamor within their workplace for continuing education about this dynamic information. It is critical knowledge for APRNs to classify risk based on family history, target individualized patient prevention and education, modify pharmacologic interventions, and refer when genetic testing is necessary.

INTERPRETATION/CONCLUSION

This article stresses the timely relevance of applying genetics and genomics to practice, teaching, and research.

IMPLICATIONS FOR NURSING PRACTICE

APRNs need to maintain a place at the genetic table with all healthcare providers by developing strategies to expand this nursing knowledge to their practice, teaching, and research. Nurses need to be cognizant of the keen genetic value of family histories, how risk classification will individualize prevention recommendations, and the exciting role of pharmacogenetics, given many APRNs' prescriptive authority. Our core professional belief that each human is highly unique has probably never been more accurate than with the future in genetic and genomic nursing.

Pharmacogenomics and ???Individualized Drug Therapy???

Since 1965 there have been more than 800 pharmacogenetics/genomics reviews - most suggesting that we are on the verge of offering individualized drug therapy to everyone. However, there are numerous reasons why this approach will be extremely difficult to achieve in the foreseeable future. Drug treatment outcome represents a complex phenotype, encoded by dozens, if not hundreds, of genes, and affected by many environmental factors; therefore, we will almost always see a gradient of response. Phenotyping assays of blood enzyme activities (if feasible) are generally more successful than DNA genotyping for predicting unequivocal outcomes of drug therapy in each and every patient. Phenotyping with probe drugs has generally not succeeded, because of the overlapping substrate specificities not only of drug-metabolizing enzymes but also transporters, receptors, ion channels, transcription factors, and other drug targets; drug-drug interactions, enzyme induction and inhibition, and multiple (enzyme, transporter, second-messenger, signal transduction) pathways also present enormous problems. Genotyping to predict drug disposition, efficacy, toxicity, and clinical outcome has been proposed, but the success of genotyping in individualized drug therapy currently appears unlikely because of the many shortcomings (frequency of DNA variant sites, ethnic differences, admixture) and complexities (plasticity of the genome, multiple mechanisms for determining sizes and locations of haplotype blocks) of this approach. Genomics is an important tool in basic research; yet, it is unrealistic to include genotyping within the realm of tests available to the practicing clinician in the foreseeable future. The same can be said for transcriptomics and proteomics, which also rely on available sources (tumors, biopsies, excreta). The newly emerging fields of metabonomics and phenomics might offer solutions to anticipating and decreasing individual risk for adverse drug reactions in each individual patient; however, tests based on these approaches are not expected to become available to the practicing clinician for at least the next 5-10 years.