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Sileshi T, Telele NF, Burkley V, Makonnen E, Aklillu E. Correlation of N-acetyltransferase 2 genotype and acetylation status with plasma isoniazid concentration and its metabolic ratio in ethiopian tuberculosis patients. Sci Rep 2023; 13:11438. [PMID: 37454203 PMCID: PMC10349800 DOI: 10.1038/s41598-023-38716-3] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2023] [Accepted: 07/13/2023] [Indexed: 07/18/2023] Open
Abstract
Unfavorable treatment outcomes for tuberculosis (TB) treatment might result from altered plasma exposure to antitubercular drugs in TB patients. The present study investigated the distribution of the N-Acetyltransferase 2 (NAT2) genotype, isoniazid acetylation status, genotype-phenotype concordance of NAT2, and isoniazid plasma exposure among Ethiopian tuberculosis patients. Blood samples were collected from newly diagnosed TB patients receiving a fixed dose combination of first-line antitubercular drugs daily. Genotyping of NAT2 was done using TaqMan drug metabolism assay. Isoniazid and its metabolite concentration were determined using validated liquid chromatography-tandem mass spectrometry (LC-MS/MS). A total of 120 patients (63 male and 57 female) were enrolled in this study. The mean daily dose of isoniazid was 4.71 mg/kg. The frequency of slow, intermediate, and fast NAT2 acetylators genotypes were 74.2%, 22.4%, and 3.3% respectively. The overall median isoniazid maximum plasma concentration (Cmax) was 4.77 µg/mL and the AUC0-7 h was 11.21 µg.h/mL. The median Cmax in slow, intermediate, and fast acetylators were 5.65, 3.44, and 2.47 μg/mL, respectively. The median AUC0-7 h hour in slow, intermediate, and fast acetylators were 13.1, 6.086, and 3.73 mg•h/L, respectively. The majority (87.5%) of the study participants achieved isoniazid Cmax of above 3 µg/mL, which is considered a lower limit for a favorable treatment outcome. There is 85% concordance between the NAT2 genotype and acetylation phenotypes. NAT2 genotype, female sex, and dose were independent predictors of Cmax and AUC0-7 h (p < 0.001). Our finding revealed that there is a high frequency of slow NAT2 genotypes. The plasma Cmax of isoniazid was higher in the female and slow acetylators genotype group. The overall target plasma isoniazid concentrations in Ethiopian tuberculosis patients were achieved in the majority of the patients. Therefore, it is important to monitor adverse drug reactions and the use of a higher dose of isoniazid should be closely monitored.
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Affiliation(s)
- Tesemma Sileshi
- Department of Pharmacy, Ambo University, Ambo, Ethiopia.
- Department of Pharmacology and Clinical Pharmacy, Addis Ababa University, Addis Ababa, Ethiopia.
| | - Nigus Fikrie Telele
- Department of Laboratory Medicines, Karolinska Institutet, Stockholm, Sweden
| | - Victoria Burkley
- Department of Laboratory Medicines, Karolinska Institutet, Stockholm, Sweden
| | - Eyasu Makonnen
- Department of Pharmacology and Clinical Pharmacy, Addis Ababa University, Addis Ababa, Ethiopia
- Center for Innovative Drug Development and Therapeutic Trials for Africa (CDT-Africa), Addis Ababa University, Addis Ababa, Ethiopia
| | - Eleni Aklillu
- Department of Global Public Health, Karolinska Institutet, Stockholm, Sweden
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Frequency of CYP2B6 Alleles in Major Iranian Ethnicities, Affecting Response to Efavirenz. Genet Res (Camb) 2022; 2022:5754776. [PMID: 36320932 PMCID: PMC9605844 DOI: 10.1155/2022/5754776] [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: 07/20/2022] [Revised: 08/29/2022] [Accepted: 10/03/2022] [Indexed: 11/17/2022] Open
Abstract
Introduction Efavirenz is an antihuman immunodeficiency virus (HIV) drug metabolized by cytochrome P450 2B6 (CYP2B6) enzyme. Cytochrome P450 2B6 is an enzyme that in humans is encoded by the CYP2B6 gene. Polymorphisms of this gene play a crucial role in the metabolism of drugs such as Efavirenz. This study aims to evaluate the frequency of three clinically significant CYP2B6 polymorphisms (CYP2B6∗6 (516G > T), CYP2B6∗4 (785A > G), and CYP2B6∗5 (1459C > T)) in three major Iranian ethnicities. Methods One hundred forty-seven participants from three main Iranian ethnicities were included in this study. After DNA extraction, CYP2B6∗6 (516G > T), CYP2B6∗4 (785A > G), and CYP2B6∗5 (1459C > T) were genotyped using tetra-primer amplification refractory mutation system polymerase chain reaction (ARMS-PCR). Results The frequency of the mutated allele in the Iranian population for CYP2B6∗6 (516G > T) was 41.50 (95% CI: 35.81, 47.36), which was significantly lower than in Kurds (59.62, 95% CI: 45.10, 72.99). Similarly, Kurds had a higher frequency of mutated allele of CYP2B6∗5 (1459C > T) (46.15%, 95% CI: 32.23, 60.53) than in Iranians (24.49%, 95% CI: 19.68, 29.82). The frequency of A and G alleles of CYP2B6∗4 (785A > G) was 62.59% (95% CI: 56.78, 68.13) and 37.41 (95% CI: 31.87, 43.22), respectively. Conclusion Kurds are at higher risk of adverse drug reactions (ADRs) and insufficient anti-HIV response compared to other Iranians.
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Song HY, Xia JS, Chen YG, Chen L. Cytochrome P450 3A5 polymorphism affects the metabolism of sorafenib and its toxicity for hepatocellular carcinoma cells in vitro. Hum Exp Toxicol 2022; 41:9603271221080236. [PMID: 35099304 DOI: 10.1177/09603271221080236] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
OBJECTIVE Cytochrome P450 3A5 (CYP3A5) is a highly polymorphic gene and the encoded protein variants differ in catalytic activity, leading to inter-individual variation in metabolic ability. The aim of the current study was to investigate the effects of seven allelic variants on the ability of CYP3A5 to metabolize sorafenib in vitro and further explore the impacts of CYP3A5 polymorphism on the proliferation and apoptosis of hepatocellular carcinoma cell line (HepG2) induced by sorafenib. METHODS Wild-type and variant CYP3A5 enzymes were expressed in Spodoptera frugiperda insect cells using a baculovirus dual-expression system, and protein expression was checked by western blot. The enzymes were incubated with sorafenib at 37°C for 30 min, and formation of the major metabolite sorafenib N-oxide was assayed using ultra-performance liquid chromatography and tandem mass spectrometry. Intrinsic clearance values (Vmax/Km) were calculated for each enzyme. Additionally, recombinant HepG2 cells transfecting with CYP3A5 variants were used to investigate the effects of sorafenib on the proliferation of HepG2 cells. RESULTS Intrinsic clearance of the six variants CYP3A5*2, CYP3A5*3A, CYP3A5*3C, CYP3A5*4, CYP3A5*5, and CYP3A5*7 was 26.41-71.04% of the wild-type (CYP3A5*1) value. In contrast, the clearance value of the variant CYP3A5*6 was significantly higher (174.74%). Additionally, the decreased ATP levels and cell viability and the increased cell apoptosis in HepG2 cells transfected with CYP3A5*2, CYP3A5*3A, CYP3A5*3C, CYP3A5*4, CYP3A5*5, and CYP3A5*7 were observed, whereas, the increased ATP levels and cell viability and the reduced cell apoptosis in HepG2 cells transfected with CYP3A5*6 were also investigated when compared to CYP3A5*1. CONCLUSION Our results suggest that CYP3A5 polymorphism influences sorafenib metabolism and pharmacotherapeutic effect in hepatic carcinomas. These data may help explain differential response to drug therapy for hepatocellular carcinoma, and they support the need for individualized treatment.
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Affiliation(s)
- Hong-Yan Song
- Department of Pharmacy, 12390Wuhan Third Hospital (Tongren Hospital of Wuhan University), Wuhan, China
| | - Jing-Sheng Xia
- Department of Pharmacy, 12390Wuhan Third Hospital (Tongren Hospital of Wuhan University), Wuhan, China
| | - Yong-Gang Chen
- Department of Pharmacy, 12390Wuhan Third Hospital (Tongren Hospital of Wuhan University), Wuhan, China
| | - Ling Chen
- Department of Pharmacy, 12390Wuhan Third Hospital (Tongren Hospital of Wuhan University), Wuhan, China
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Song HY, Xia JS, Chen YG, Chen L. Cytochrome P450 3A5 polymorphism affects the metabolism of sorafenib and its toxicity for hepatocellular carcinoma cells in vitro. Hum Exp Toxicol 2021; 40:S646-S653. [PMID: 34784831 DOI: 10.1177/09603271211052989] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
OBJECTIVE Cytochrome P450 3A5 (CYP3A5) is a highly polymorphic gene and the encoded protein variants differ in catalytic activity, leading to inter-individual variation in metabolic ability. The aim of the current study was to investigate the effects of seven allelic variants on the ability of CYP3A5 to metabolize sorafenib in vitro and further explore the impacts of CYP3A5 polymorphism on the proliferation and apoptosis of hepatocellular carcinoma cell line (HepG2) induced by sorafenib. METHODS Wild-type and variant CYP3A5 enzymes were expressed in Spodoptera frugiperda insect cells using a baculovirus dual-expression system, and protein expression was checked by western blot. The enzymes were incubated with sorafenib at 37°C for 30 min, and formation of the major metabolite sorafenib N-oxide was assayed using ultra-performance liquid chromatography and tandem mass spectrometry. Intrinsic clearance values (Vmax/Km) were calculated for each enzyme. Additionally, recombinant HepG2 cells transfecting with CYP3A5 variants were used to investigate the effects of sorafenib on the proliferation of HepG2 cells. RESULTS Intrinsic clearance of the six variants CYP3A5*2, CYP3A5*3A, CYP3A5*3C, CYP3A5*4, CYP3A5*5, and CYP3A5*7 was 26.41-71.04% of the wild-type (CYP3A5*1) value. In contrast, the clearance value of the variant CYP3A5*6 was significantly higher (174.74%). Additionally, the decreased ATP levels and cell viability and the increased cell apoptosis in HepG2 cells transfected with CYP3A5*2, CYP3A5*3A, CYP3A5*3C, CYP3A5*4, CYP3A5*5, and CYP3A5*7 were observed, whereas, the increased ATP levels and cell viability and the reduced cell apoptosis in HepG2 cells transfected with CYP3A5*6 were also investigated when compared to CYP3A5*1. CONCLUSION Our results suggest that CYP3A5 polymorphism influences sorafenib metabolism and pharmacotherapeutic effect in hepatic carcinomas. These data may help explain differential response to drug therapy for hepatocellular carcinoma, and they support the need for individualized treatment.
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Affiliation(s)
- Hong-Yan Song
- Department of Pharmacy, 12390Wuhan Third Hospital (Tongren Hospital of Wuhan University), Wuhan, China
| | - Jing-Sheng Xia
- Department of Pharmacy, 12390Wuhan Third Hospital (Tongren Hospital of Wuhan University), Wuhan, China
| | - Yong-Gang Chen
- Department of Pharmacy, 12390Wuhan Third Hospital (Tongren Hospital of Wuhan University), Wuhan, China
| | - Ling Chen
- Department of Pharmacy, 12390Wuhan Third Hospital (Tongren Hospital of Wuhan University), Wuhan, China
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Dhuya M, Pal MM, Hazra A, Chatterjee S, Gogtay N. Cytochrome P 450 2D6 polymorphism in eastern Indian population. Indian J Pharmacol 2020; 52:189-195. [PMID: 32874001 PMCID: PMC7446679 DOI: 10.4103/ijp.ijp_530_17] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/29/2017] [Revised: 12/30/2019] [Accepted: 07/13/2020] [Indexed: 11/15/2022] Open
Abstract
OBJECTIVES: Cytochrome P450 2D6 (CYP2D6) enzyme metabolizes a quarter of prescription drugs. Polymorphisms of CYP2D6 gene and resultant phenotypic variations in metabolic activity have been described in various populations. We assessed the prevalence of CYP2D6 activity phenotypes, employing dextromethorphan (DXM) as probe drug in subjects with at least two parental generations residing in eastern India. MATERIALS AND METHODS: Unrelated healthy subjects took 60 mg DXM after fasting overnight. Blood samples were collected 3 h after dosing and plasma separated. DXM and its primary metabolite dextrorphan (DXT) were measured by liquid chromatography with tandem mass spectrometry. The DXM-to-DXT metabolic ratio (MR) was obtained for each subject. Histogram of MR values suggested bimodal distribution. A polynomial regression equation derived through probit analysis was solved to identify the antimode of the MR values. Subjects with log(MR) < antimode were extensive metabolizers (EMs). Log(MR) ≥ antimode indicated poor metabolizers (PMs). RESULTS: We evaluated the results from 97 participants. The median MR was 0.209 (interquartile range: 0.090–0.609), while the antimode for MR was 3.055. From these, it was inferred that three subjects were PMs, while the rest were EMs. CYP2D6 polymorphism prevalence is low (3.09%; 95% confidence interval: 0.35%–6.54%) in the population of eastern India and matches the prevalence in other zones of the country. CONCLUSIONS: Differences in CYP2D6 activity has treatment implications and may lead to adverse events or therapeutic failure. Phenotyping of subjects receiving CYP2D6 metabolized drugs may help clinicians personalize treatment and avert adverse drug-drug interactions. However, the frequency of the PM phenotype is low in India, and routinely phenotyping for CYP2D6 activity will not be cost-effective. We cannot recommend it at this stage.
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Affiliation(s)
- Monalisa Dhuya
- Department of Pharmacology, Institute of Postgraduate Medical Education and Research, Kolkata, West Bengal, India
| | - Murari Mohan Pal
- Department of Pharmaceutical Technology, Bioequivalence Study Centre, Jadavpur University, Kolkata, West Bengal, India
| | - Avijit Hazra
- Department of Pharmacology, Institute of Postgraduate Medical Education and Research, Kolkata, West Bengal, India
| | - Suparna Chatterjee
- Department of Pharmacology, Institute of Postgraduate Medical Education and Research, Kolkata, West Bengal, India
| | - Nithya Gogtay
- Department of Clinical Pharmacology, Seth GS Medical College and KEM Hospital, Parel, Mumbai, Maharashtra, India
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Chen R, Chen J, Xun J, Hu Z, Huang Q, Zhang R, Steinhart C, Shen Y, Liu L, Lu H. Pharmacogenomics and pharmacokinetics of efavirenz 400 or 600 mg in 184 treatment-naive HIV-infected patients in China. Pharmacogenomics 2020; 21:945-956. [PMID: 32838647 DOI: 10.2217/pgs-2019-0169] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023] Open
Abstract
Background: The pharmacogenomics and pharmacokinetics/pharmacodynamics of 400 mg efavirenz have rarely been reported. Materials & methods: A total of 184 treatment-naive HIV-infected patients were randomly assigned (1:1) to receive a lower dose (tenofovir disoproxil 200 mg, efavirenz 400 mg and lamivudine) or a standard dose regimen. Relationships between pharmacogenomics and efavirenz pharmacokinetics/pharmacodynamics were explored at 48 weeks. Results: There was no relationship between pharmacogenomics and adverse reactions of the central nervous system and antiretoviral efficacy. CYP2B6 516G>T, 785A>G, 18492C>T and ABCB1 3435C>T T/C were associated with higher efavirenz plasma levels in the standard but not the lower dose group. No relationship was found between pharmacogenomics and antiretoviral efficacy. Patients who were <60 kg had higher efavirenz concentration compared with those with weight ≥60 kg when using 600 mg efavirenz, this was not observed with 400 mg efavirenz. Conclusion: The effect of pharmacogenomics and body weight on the efavirenz concentration was significant in the 600 mg group but not in the 400 mg group.
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Affiliation(s)
- Rong Chen
- Department of Infection & Immunology, Shanghai Public Health Clinical Center, Fudan University. Shanghai, 201508, China.,Department of Pharmacy, Zhongshan Hospital, Fudan University, Shanghai, 200032, China
| | - Jun Chen
- Department of Infection & Immunology, Shanghai Public Health Clinical Center, Fudan University. Shanghai, 201508, China
| | - Jingna Xun
- Department of Infection & Immunology, Shanghai Public Health Clinical Center, Fudan University. Shanghai, 201508, China
| | - Zhiliang Hu
- Department of Infectious Disease, The Second Hospital of Nanjing, Nanjing University of Chinese Medicine, Nanjing, 210003, China
| | - Qiong Huang
- Yunnan AIDS Care Center (YNACC), Yunnan Provincial Infectious Disease Hospital, Kunming, 650500, China
| | - Renfang Zhang
- Department of Infection & Immunology, Shanghai Public Health Clinical Center, Fudan University. Shanghai, 201508, China
| | - Corky Steinhart
- CAN Community Health, FL 34232, USA.,Department of Internal Medicine, The University of Central Florida, College of Medicine, FL 32827, USA
| | - Yinzhong Shen
- Department of Infection & Immunology, Shanghai Public Health Clinical Center, Fudan University. Shanghai, 201508, China
| | - Li Liu
- Department of Infection & Immunology, Shanghai Public Health Clinical Center, Fudan University. Shanghai, 201508, China
| | - Hongzhou Lu
- Department of Infection & Immunology, Shanghai Public Health Clinical Center, Fudan University. Shanghai, 201508, China
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Nguefeu Nkenfou C, Atogho Tiedeu B, Nguefeu Nkenfou C, Nji AM, Chedjou JP, Tah Fomboh C, Kouanfack C, Mbacham WF. Adverse Drug Reactions Associated with CYP 2B6 Polymorphisms in HIV/AIDS-Treated Patients in Yaoundé, Cameroon. Appl Clin Genet 2019; 12:261-268. [PMID: 31920362 PMCID: PMC6941599 DOI: 10.2147/tacg.s226318] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2019] [Accepted: 11/23/2019] [Indexed: 01/04/2023] Open
Abstract
PURPOSE The metabolism of antiretroviral drugs is subject to individual variations of the CYP 2B6 gene. The objective of this study was to evaluate the prevalence of CYP 2B6 516 G>T and 983 T>C polymorphisms and investigate their association with the development of adverse drug reactions (ADRs) in people living with HIV/AIDS in Cameroon. PATIENTS AND METHODS A total number of 122 patients, attending the Yaoundé Central Hospital HIV Day Clinic, consented to take part in this study. Blood specimens were collected and DNA was extracted using the Chelex method. Polymerase Chain Reaction-Restriction Fragment Length Polymorphism (PCR-RFLP) was performed for the detection of CYP 2B6 Single-Nucleotide Polymorphisms (SNPs). Genotype frequencies were compared between groups with or without ADRs. Logistic regression analysis was performed to assess association between genotype and adverse effects of antiretroviral therapy (ART). RESULTS Three types of metabolizers were identified: extensive, intermediate and slow. For the 516G>T polymorphism, prevalences of 8.2% GG, 65.6% GT and 26.2% TT were obtained. For the 983T>C polymorphism, 89.3% TT, 4.1% CT and 6.6% CC prevalences were obtained. Those homozygous for the wild-type allele (516GG) were less likely to develop ADR with a statistically significant difference (OR=0.885, P=0.029). For the CYP2B6 T983C SNP, homozygous mutants (CC) may present a higher risk (threefold) of developing adverse reactions (OR=2.677, P=0.164). CONCLUSION These findings demonstrate that ADRs among HIV/AIDS patients under ART may be associated with the genetic variability of the metabolizing enzyme CYP 2B6. Genotyping for this gene may guide the better administration of Efavirenz and Nevirapine to Cameroonian patients.
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Affiliation(s)
- Carine Nguefeu Nkenfou
- Department of Biochemistry, Faculty of Science, University of Yaoundé I, Yaoundé, Cameroon
- The Biotechnology Center, University of Yaoundé I, Yaoundé, Cameroon
| | - Barbara Atogho Tiedeu
- Department of Biochemistry, Faculty of Science, University of Yaoundé I, Yaoundé, Cameroon
- The Biotechnology Center, University of Yaoundé I, Yaoundé, Cameroon
| | - Celine Nguefeu Nkenfou
- Systems Biology, Chantal Biya’ International Reference Centre for Research on HIV and AIDS Prevention and Management (CBIRC), Yaoundé, Cameroon
- Department of Biology, Higher Teachers’ Training College, University of Yaoundé I, Yaoundé, Cameroon
- Molecular Biology Center Yaoundé, Yaoundé, Cameroon
| | - Akindeh M Nji
- Department of Biochemistry, Faculty of Science, University of Yaoundé I, Yaoundé, Cameroon
- The Biotechnology Center, University of Yaoundé I, Yaoundé, Cameroon
| | - Jean Paul Chedjou
- Department of Biochemistry, Faculty of Science, University of Yaoundé I, Yaoundé, Cameroon
- The Biotechnology Center, University of Yaoundé I, Yaoundé, Cameroon
| | - Calvino Tah Fomboh
- The Biotechnology Center, University of Yaoundé I, Yaoundé, Cameroon
- Catholic University of Yaoundé (UCAC), Yaoundé, Cameroon
| | - Charles Kouanfack
- Day Care Unit, Central Hospital Yaoundé, Yaoundé, Cameroon
- Department of Public Health, Faculty of Medicine and Pharmaceutical Sciences, University of Dschang, Dschang, Cameroon
| | - Wilfred F Mbacham
- Department of Biochemistry, Faculty of Science, University of Yaoundé I, Yaoundé, Cameroon
- The Biotechnology Center, University of Yaoundé I, Yaoundé, Cameroon
- Department of Public Health, Faculty of Medicine and Biomedical Sciences, University of Yaoundé I, Yaoundé, Cameroon
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Hananta L, Astuti I, Sadewa AH, Alice J, Hutagalung J, Mustofa. The Prevalence of CYP2B6 Gene Polymorphisms in Malaria-endemic Population of Timor in East Nusa Tenggara Indonesia. Osong Public Health Res Perspect 2018; 9:192-196. [PMID: 30159225 PMCID: PMC6110330 DOI: 10.24171/j.phrp.2018.9.4.08] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023] Open
Abstract
Objectives The CYP2B6 is one of the most polymorphic CYP genes in humans that has the potential to modify the pharmacological and toxicological responses to clinically important drugs such as antimalarial artemisinin and its derivatives. The aim of the study was to determine the frequency of CYP2B6 polymorphisms in Timor malaria endemic area, East Nusa Tenggara, Indonesia where Artemisin-based Combination Therapy (ACT) has been used to treat uncomplicated malaria. Methods A total of 109 healthy subjects were participated in this study. CYP2B6*4, *6 and *9 polymorphisms were analyzed using PCR-RFLP to confirm the SNPs prevalence of 516G>T and 785A>G in exon 4 and 5. Results There were 96 subjects included in the analysis. In the exon 4 of CYP2B6 516G>T, the frequency of the T mutation was 37.5% (39/96), and the wildtype 27.1% (26/96). In the exon 5, CYP2B6 785A>G mutant was detected in 29.2% (28/96) of individuals, and the wildtype allele in 35.4% (34/96). The frequency of CYP2B6*9 (516G>T), CYP2B6*4 (785A>G) and CYP2B6*6 (516G>T and 785A>G) were 40.6%, 29.2% and 22.9%, respectively. The prevalence of these CYP2B6 gene polymorphisms in Timorian ethnic were higher than that in Malay, Han Chinese, Indian, and Egyptian populations. Conclusion The prevalence of these CYP2B6 516G>T and 785A>G polymorphisms in Timorian ethnic is higher than that in other populations. These polymorphisms may affect the metabolism of artemisinin and its derivatives.
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Affiliation(s)
- Linawati Hananta
- Department of Pharmacology and Pharmacy, School of Medicine and Health Sciences, Atma Jaya Catholic University of Indonesia, Jakarta, Indonesia
| | - Indwiani Astuti
- Department of Pharmacology and Therapy, Faculty of Medicine, Public Health and Nursing, Universitas Gadjah Mada, Yogyakarta, Indonesia
| | - Ahmad Hamim Sadewa
- Department of Biochemistry, Faculty of Medicine, Public Health and Nursing, Universitas Gadjah Mada, Yogyakarta, Indonesia
| | - Josephine Alice
- Department of Pharmacology and Pharmacy, School of Medicine and Health Sciences, Atma Jaya Catholic University of Indonesia, Jakarta, Indonesia
| | - Jontari Hutagalung
- The National Institute of Health Research and Development, Biomedical and Basic Health Technology, Ministry of Health, Jakarta, Indonesia
| | - Mustofa
- Department of Pharmacology and Therapy, Faculty of Medicine, Public Health and Nursing, Universitas Gadjah Mada, Yogyakarta, Indonesia
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Aklillu E, Carrillo JA, Makonnen E, Bertilsson L, Djordjevic N. N-Acetyltransferase-2 (NAT2) phenotype is influenced by genotype-environment interaction in Ethiopians. Eur J Clin Pharmacol 2018; 74:903-911. [PMID: 29589062 PMCID: PMC5999125 DOI: 10.1007/s00228-018-2448-y] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2017] [Accepted: 03/14/2018] [Indexed: 12/12/2022]
Abstract
BACKGROUND AND OBJECTIVES N-acetyltransferase 2 (NAT2) metabolize several drugs including isoniazid. We investigated the effect of genotype, geographical difference, and smoking habit on NAT2 phenotype in Ethiopians. METHODS Genotyping for NAT2 191G > A, 341 T > C, 590G > A, and 857G > A was performed in 163 unrelated healthy Ethiopians (85 living in Ethiopia and 78 living in Sweden). The NAT2 phenotype was determined using caffeine as a probe and log AFMU/(AFMU + 1X + 1 U) urinary metabolic ratio (MR) as an index. RESULTS The frequencies of NAT2*4, *5, *6, *7, and *14 haplotypes were 14.1, 48.5, 30.1, 5.5, and 1.8%, respectively. The frequencies of rapid (NAT2*4/*4), intermediate (heterozygous *4), and slow (no *4 allele) acetylator genotypes were 1.8, 24.6, and 73.6%, respectively. The distribution NAT2 MR was bimodal with 70% being phenotypically slow acetylators. NAT2 genotype (p < 0.0001) and country of residence (p = 0.004) independently predicted NAT2 phenotype. Controlling for the effect of genotype, ethnic Ethiopians living in Ethiopia had significantly higher NAT2 MR than those living in Sweden (p = 0.006). NAT2 genotype-phenotype concordance rate was 75%. Distinct country-of-residence-based genotype-phenotype discordance was observed. The proportion of phenotypically determined rapid acetylators was significantly higher and slow acetylators was lower in Ethiopians living in Ethiopia (39% rapid, 61% slow) than in Sweden (20% rapid, 80% slow). Sex and smoking had no significant effect on NAT2 MR. CONCLUSIONS We report a high prevalence of NAT 2 slow acetylators in Ethiopians and a conditional NAT2 genotype-phenotype discordance implicating a partial phenotype conversion and metabolic adaptation. Gene-environment interactions regulate NAT2 phenotype.
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Affiliation(s)
- Eleni Aklillu
- Division of Clinical Pharmacology, Department of Laboratory Medicine, Karolinska Institutet, Karolinska University Hospital, Huddinge C1:68, SE-141 86, Stockholm, Sweden.
| | - Juan Antonio Carrillo
- Division of Clinical Pharmacology, Department of Medical and Surgical Therapeutics, Medical School, University of Extremadura, Badajoz, Spain
| | - Eyasu Makonnen
- Department of Pharmacology, College of Health Sciences, Addis Ababa University, Addis Ababa, Ethiopia
| | - Leif Bertilsson
- Division of Clinical Pharmacology, Department of Laboratory Medicine, Karolinska Institutet, Karolinska University Hospital, Huddinge C1:68, SE-141 86, Stockholm, Sweden
| | - Natasa Djordjevic
- Department of Pharmacology and Toxicology, Faculty of Medical Sciences, University of Kragujevac, Svetozara Markovica 69, Kragujevac, 34 000, Serbia
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Sunilkumar MM, Lockman K. Practical Pharmacology of Methadone: A Long-acting Opioid. Indian J Palliat Care 2018; 24:S10-S14. [PMID: 29497249 PMCID: PMC5806300 DOI: 10.4103/ijpc.ijpc_180_17] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
Abstract
Methadone is a naturally long-acting analgesic with unique pharmacodynamic and pharmacokinetic properties compared to other opioids, available now in India, to treat severe pain. It has the potential to dramatically relieve suffering among patients with serious illness who are living with persistent physical pain. However, clinicians must appreciate its unique pharmacologic properties and its use in clinical practice safely and effectively. The available formulation in India is a racemic mixture of the S- and R-enantiomers, and as such, it will have a propensity for drug-drug and drug-genetic interactions that can increase the risk of Torsades de Point and respiratory depression. Appropriate patient selection, careful dosing and thorough monitoring of methadone will mitigate these risks.
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Affiliation(s)
- M M Sunilkumar
- Department of Pain and Palliative Medicine, Trivandrum Institute of Palliative Sciences, WHO Collaborating Centre for Training and Policy on Access to Pain Relief, Thiruvananthapuram, Kerala, India
| | - Kashelle Lockman
- Department of Pharmacy Practice and Science, University of Iowa, College of Pharmacy, Iowa City, IA 52242, USA
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11
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Sinha S, Gupta K, Tripathy S, Dhooria S, Ranjan S, Pandey RM. Nevirapine- versus Efavirenz-based antiretroviral therapy regimens in antiretroviral-naive patients with HIV and Tuberculosis infections in India: a multi-centre study. BMC Infect Dis 2017; 17:761. [PMID: 29228918 PMCID: PMC5725946 DOI: 10.1186/s12879-017-2864-0] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2017] [Accepted: 11/27/2017] [Indexed: 11/16/2022] Open
Abstract
Background According to World Health Organization (WHO) guidelines, which have also been adopted by the National AIDS Control Organization (NACO), India, Efavirenz-based Anti-Retroviral Therapy (ART) is better in Human-Immunodeficiency-Virus (HIV)-infected patients who are also being treated with Rifampicin-based Anti-Tuberculous Therapy (ATT). However, Efavirenz is much more expensive. We hypothesize that Nevirapine is a cheaper alternative that possesses equal efficacy as Efavirenz in HIV-Tuberculosis (TB) co-infected patients. Methods A parallel open-label randomized clinical trial was conducted at All India Institute of Medical Sciences (AIIMS), New Delhi and National AIDS Research Institute (NARI), Pune. Those who were ART-naïve and co-infected with TB were randomized to receive either Nevirapine (Group 1)- or Efavirenz (Group 2)-based ART along with Rifampicin-based ATT. ATT was begun first in ART-naïve patients according to the NACO guidelines, with a median of 27 days between ATT and ART in both groups. The primary endpoint was a composite unfavourable outcome (death and/or ART failure) at 96 weeks, and the secondary outcome was successful TB treatment at 48 weeks. Results A total of 284 patients (mean age 36.7 ± 8.1 years) were randomized in a 1:1 ratio to receive either Nevirapine (n = 144)- or Efavirenz (n = 140)-based ART after a median ATT-ART gap of 27 days. The median CD4 count was 105 cells/μl, with a median viral load of 820,200 copies/μl and no significant difference between the groups. Composite unfavourable outcomes were reported in 49 patients in the Nevirapine group and 51 patients in the Efavirenz group (35.3% vs. 36.9%; hazard ratio, 0.95, 95% confidence interval (CI), 0.63,1.43, adjusted). There was no difference in successful TB treatment outcome between the groups (71.5% vs. 65.6%, 95% CI -3.8,17.9, adjusted). The results were similar, showing no difference between the groups in the two centres of the study after adjusting for disease stage. Conclusions Composite unfavourable outcome in HIV-TB co-infected patients who were ART-naïve showed no statistically significant difference in the Nevirapine or Efavirenz groups.. Therefore, Nevirapine-based ART is a reasonable alternative to Efavirenz in resource-limited settings. However, multi-centric studies with larger sample sizes are required to confirm these findings. Trial registration NCT01805258 (Retrospectively registered on March 6, 2013) Date of registration: March 2013. Electronic supplementary material The online version of this article (10.1186/s12879-017-2864-0) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Sanjeev Sinha
- Departments of Medicine, All-India Institute of Medical Sciences (AIIMS), Ansari Nagar, New Delhi, 110029, India.
| | - Kartik Gupta
- Departments of Medicine, All-India Institute of Medical Sciences (AIIMS), Ansari Nagar, New Delhi, 110029, India
| | | | - Sahajal Dhooria
- Departments of Medicine, All-India Institute of Medical Sciences (AIIMS), Ansari Nagar, New Delhi, 110029, India
| | - Sanjay Ranjan
- Departments of Medicine, All-India Institute of Medical Sciences (AIIMS), Ansari Nagar, New Delhi, 110029, India
| | - R M Pandey
- Biostatistics, All-India Institute of Medical Sciences, Ansari Nagar, New Delhi, 110029, India
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12
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Gopalan BP, Mehta K, D'souza RR, Rajnala N, A. K. HK, Ramachandran G, Shet A. Sub-therapeutic nevirapine concentration during antiretroviral treatment initiation among children living with HIV: Implications for therapeutic drug monitoring. PLoS One 2017; 12:e0183080. [PMID: 28827836 PMCID: PMC5565187 DOI: 10.1371/journal.pone.0183080] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2017] [Accepted: 07/29/2017] [Indexed: 12/04/2022] Open
Abstract
Nevirapine, a component of antiretroviral therapy (ART) in resource-limited settings, known for auto-induction of metabolism, is initiated at half therapeutic dose until day 14 (‘lead-in period’), and subsequently escalated to full dose. However, studies have shown that this dosing strategy based on adult studies may not be appropriate in children, given that younger children have higher drug clearance rates. In this prospective cohort study, we studied trough plasma nevirapine levels by high performance liquid chromatography (HPLC) at days 7, 14 (lead-in period) and 28 (full dose period) after ART initiation amongst HIV-1 infected children initiating nevirapine-based ART in southern India. Among the 20 children (50% male, median age 9 years) included in the study, sub-therapeutic trough plasma nevirapine concentration (<4μg/ml) was seen in 65% (13/20) of children during the lead-in period within two weeks of ART initiation and among 10% of children at 4 weeks during full-dose nevirapine. Adherence was documented as ≥95% in all children by both caregiver self-report and pill count. Median nevirapine concentrations achieved at week 1 was 4.8 μg/ml, significantly lower than 8 μg/ml, the concentration achieved at week 4 (p = 0.034). Virological failure at one year of ART was observed in six children, and was not associated with median nevirapine concentration achieved during week 1, 2 or 4. We conclude that the dose escalation strategy currently practiced among young children living with HIV-1 resulted in significant subtherapeutic nevirapine concentration (≤4μg/ml) during the lead-in period. We call for a closer look at pediatric-focused dosing strategies for nevirapine initiation in young children. Further studies to establish age-appropriate threshold nevirapine concentration are warranted in young children to corroborate the role of therapeutic drug monitoring in predicting virological outcome.
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Affiliation(s)
- Bindu Parachalil Gopalan
- Division of Infectious Diseases, St. John’s Research Institute, St. John’s National Academy of Health Sciences, Bangalore, Karnataka, India
- The Institute Of Trans-Disciplinary Health Sciences and Technology (TDU), Bangalore, Karnataka, India
| | - Kayur Mehta
- Department of Pediatrics, St. John's Medical College Hospital, Bangalore, Karnataka, India
| | - Reena R. D'souza
- Division of Infectious Diseases, St. John’s Research Institute, St. John’s National Academy of Health Sciences, Bangalore, Karnataka, India
| | - Niharika Rajnala
- Division of Infectious Diseases, St. John’s Research Institute, St. John’s National Academy of Health Sciences, Bangalore, Karnataka, India
| | - Hemanth Kumar A. K.
- National Institute for Research in Tuberculosis (Indian Council of Medical Research), Chennai, Tamil Nadu, India
| | - Geetha Ramachandran
- National Institute for Research in Tuberculosis (Indian Council of Medical Research), Chennai, Tamil Nadu, India
| | - Anita Shet
- Division of Infectious Diseases, St. John’s Research Institute, St. John’s National Academy of Health Sciences, Bangalore, Karnataka, India
- * E-mail:
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13
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Gogtay NJ, Kapileshwar SR, Shah SU, Bendkhale SR, Ramakrishna S, Sridharan K, Thelma BK, Thatte UM, Kshirsagar NA. Evaluation of cytochrome P4502E1 polymorphisms in healthy adult Western Indians and patients with antituberculous drug-induced hepatotoxicity. Indian J Pharmacol 2017; 48:42-6. [PMID: 26997721 PMCID: PMC4778206 DOI: 10.4103/0253-7613.174519] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/28/2022] Open
Abstract
Objectives: Cytochrome P4502E1 (CYP2E1) is involved in the metabolism of isoniazid and the mediation of its hepatotoxicity. It exhibits genetic polymorphism in humans. This study evaluated the polymorphism of CYP2E1 in adult healthy Western Indians and patients on antituberculous drugs by phenotyping and genotyping. Methods: A 500 mg single dose of chlorzoxazone (CZX) was administered to 136 healthy adult Western Indian participants. Venous blood samples 2 h postdose were analyzed for the levels of CZX and 6-hydroxy CZX, and the metabolic ratio (MR) was calculated to determine the extent of rapid and poor metabolizers using probit plot analysis. Patients on antituberculous drugs who had raised the liver enzymes or clinical symptoms of hepatotoxicity were also recruited. Genotyping for CYP2E1 * 5B allele was performed by polymerase chain reaction – rapid fragment length polymorphism technique. Results: A total of 139 healthy participants were enrolled, of which the final analysis consisted of data from 136 participants for genotyping and 137 for phenotyping. Only 1 participant had reported mild drowsiness 2 h postdose, and no other adverse events were observed. The median (range) MR of population was 0.2 (0.1–4.0), and no polymorphisms were detected using phenotype data. A total of 134/136 (98.5%) had c1/c1 genotype and 1/136 each (0.75%) had c1/c2 and c2/c2 genotypes, respectively. Of the 2/136 participants harboring c2 allele, one had MR of 0.1 (c1/c2) and another had 0.5 (c2/c2). A total of 25 cases of antituberculous drug-induced hepatotoxicity and 50 control patients were recruited, of which finally 22 cases and 49 controls were available for evaluation. All the cases had c1/c1 genotype while 42/49 (85.7%) controls had c1/c1, 6/49 (12.2%) had c1/c2, and 1/49 (2.1%) had c2/c2 genotype and the crude odds ratio was 7.9 (0.4, 145.6). Conclusions: A background prevalence of CYP2E1*B polymorphism and their activity in Western Indian population was observed. The study suggests no association between the CYP2E1 genotyping with antituberculous drug-induced hepatotoxicity.
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Affiliation(s)
- Nithya J Gogtay
- Department of Clinical Pharmacology, King Edward Memorial Hospital and Seth Gordhandas Sunderdas Medical College, Mumbai, Maharashtra, India
| | - Swapnali R Kapileshwar
- Department of Clinical Pharmacology, King Edward Memorial Hospital and Seth Gordhandas Sunderdas Medical College, Mumbai, Maharashtra, India
| | - Sanket U Shah
- Department of Clinical Pharmacology, King Edward Memorial Hospital and Seth Gordhandas Sunderdas Medical College, Mumbai, Maharashtra, India
| | - Shital R Bendkhale
- Department of Clinical Pharmacology, King Edward Memorial Hospital and Seth Gordhandas Sunderdas Medical College, Mumbai, Maharashtra, India
| | - Suresh Ramakrishna
- Department of Clinical Pharmacology, King Edward Memorial Hospital and Seth Gordhandas Sunderdas Medical College, Mumbai, Maharashtra, India
| | - Kannan Sridharan
- Department of Health Sciences, College of Medicine, Nursing and Health Sciences, Fiji National University, Suva, Fiji
| | - B K Thelma
- Department of Genetics, University of Delhi, New Delhi, India
| | - Urmila M Thatte
- Department of Clinical Pharmacology, King Edward Memorial Hospital and Seth Gordhandas Sunderdas Medical College, Mumbai, Maharashtra, India
| | - Nilima A Kshirsagar
- Department of Clinical Pharmacology, ESI PGIMSR MGM Hospital, Mumbai, Maharashtra, India
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14
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Swar BD, Bendkhale SR, Rupawala A, Sridharan K, Gogtay NJ, Thatte UM, Kshirsagar NA. Evaluation of cytochrome P450 2C9 activity in normal, healthy, adult Western Indian population by both phenotyping and genotyping. Indian J Pharmacol 2016; 48:248-51. [PMID: 27298492 PMCID: PMC4899995 DOI: 10.4103/0253-7613.182885] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
Objectives: Cytochrome P450 2C9 (CYP2C9) is a member of cytochrome P450 (CYP) family that accounts for nearly 18% of the total CYP protein content in the human liver microsomes and catalyzes almost 15–20% of the drugs. Considering the paucity of data on the polymorphisms of CYP2C9 in Western Indian population, the present study was conducted to evaluate the prevalence of CYP2C9 polymorphisms (*1, *2 and *3) and correlate it with the activity using flurbiprofen (FLB) as a probe drug. Materials and Methods: A 100 mg FLB capsule was administered to 298 healthy adult participants. Venous blood samples were analyzed at 2 h postdose for the estimation of FLB and 4-hydroxy FLB. Metabolic ratio (MR) was calculated to determine the extent of poor metabolizer (PM) and rapid metabolizer status using probit plot. Genotyping of CYP2C9 polymorphism was performed using polymerase chain reaction-restriction fragment length polymorphism technique. Results: Of the total 298 participants, phenotype was assessable in 288 and genotype was performed in 289 participants. The median (range) MR of the study population was 6.6 (1.65–66.05). Five participants were found to be PMs by phenotype. Of the total 289 participants, 209 (72.3%) (66.7, 77.2) had CYP2C9*1/*1, 25 (8.7%) (5.8, 12.7) with CYP2C9*1/*2, 55 (19%) (14.8, 24.1) had CYP2C9*1/*3, 3 (1%) (0.3, 3.3) had CYP2C9*2/*3 genotype. A significant association between phenotype and genotype was observed. Conclusion: To conclude, the present study found significant association of CYP2C9 activity by both phenotype and genotype and these findings have to be corroborated in different kinds of patients.
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Affiliation(s)
- Balkrishna D Swar
- Department of Clinical Pharmacology, Seth GS Medical College and KEM Hospital, Mumbai, Maharashtra, India
| | - Shital R Bendkhale
- Department of Clinical Pharmacology, Seth GS Medical College and KEM Hospital, Mumbai, Maharashtra, India
| | - Abbas Rupawala
- Department of Clinical Pharmacology, Seth GS Medical College and KEM Hospital, Mumbai, Maharashtra, India
| | - Kannan Sridharan
- Department of Health Sciences, Fiji National University, Suva, Fiji
| | - Nithya J Gogtay
- Department of Clinical Pharmacology, Seth GS Medical College and KEM Hospital, Mumbai, Maharashtra, India
| | - Urmila M Thatte
- Department of Clinical Pharmacology, Seth GS Medical College and KEM Hospital, Mumbai, Maharashtra, India
| | - Nilima A Kshirsagar
- Department of Clinical Pharmacology, Seth GS Medical College and KEM Hospital, Mumbai, Maharashtra, India
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15
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Gogtay NJ, Mali NB, Iyer K, Kadam PP, Sridharan K, Shrimal D, Thatte UM. Evaluation of cytochrome P450 2D6 phenotyping in healthy adult Western Indians. Indian J Pharmacol 2015; 46:266-9. [PMID: 24987171 PMCID: PMC4071701 DOI: 10.4103/0253-7613.132154] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/10/2013] [Revised: 01/28/2014] [Accepted: 04/03/2014] [Indexed: 11/30/2022] Open
Abstract
Background: Cytochrome P450 2D6 (CYP2D6) metabolizes around 25% of the drugs used in therapeutics and different polymorphisms have been identified in various populations. This study aimed at finding the prevalence of CYP2D6 polymorphisms using dextromethorphan as a probe drug. Materials and Methods: Healthy participants were administered 60 mg dextromethorphan after an overnight fast and 5 ml of blood was collected 3 h postdose. A validated laboratory method was used to measure both dextromethorphan and its active metabolite, dextrorphan from plasma. Metabolic ratio (MR) of dextromethorphan to dextrorphan was calculated for each of the participants. Probit analysis was done and antimode was defined. Individuals with log MR equal to or higher than the antimode were classified as poor metabolizers (PMs) and those with values less than antimode were categorized as extensive metabolizers (EMs). Results: Data from a total of 149 participants were evaluated and the median (range) of MR was 0.25 (0.03-3.01). The polynomial equation obtained in probit analysis gave an antimode for MR of 1.39. Five (3.36%) participants were PMs and 144 (96.64%) were found to be EMs. One participant had reported mild drowsiness 2 h postdose that subsided spontaneously without any intervention. Conclusion: The prevalence of CYP2D6 polymorphism in Western Indian population is low (3.36%) and is similar to other populations.
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Affiliation(s)
- Nithya J Gogtay
- Department of Clinical Pharmacology, Seth G S Medical College and KEM Hospital, Mumbai, Maharashtra, India
| | - Nitin B Mali
- Department of Clinical Pharmacology, Seth G S Medical College and KEM Hospital, Mumbai, Maharashtra, India
| | - Krishna Iyer
- Department of Pharmaceutical Chemistry, Bombay College of Pharmacy, Mumbai, Maharashtra, India
| | - Prashant P Kadam
- Department of Clinical Pharmacology, Seth G S Medical College and KEM Hospital, Mumbai, Maharashtra, India
| | - Kannan Sridharan
- Department of Clinical Pharmacology, Seth G S Medical College and KEM Hospital, Mumbai, Maharashtra, India
| | - Divya Shrimal
- Department of Clinical Pharmacology, Seth G S Medical College and KEM Hospital, Mumbai, Maharashtra, India
| | - Urmila M Thatte
- Department of Clinical Pharmacology, Seth G S Medical College and KEM Hospital, Mumbai, Maharashtra, India
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