1
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Yang R, Wan JL, Pi CQ, Wang TH, Zhu XQ, Zhou SJ. Increased antipsychotic drug concentration in hospitalized patients with mental disorders following COVID-19 infection: a call for attention. Front Psychiatry 2024; 15:1421370. [PMID: 39077630 PMCID: PMC11284031 DOI: 10.3389/fpsyt.2024.1421370] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/22/2024] [Accepted: 07/01/2024] [Indexed: 07/31/2024] Open
Abstract
Purpose Examine the alterations in antipsychotic concentrations following coronavirus disease-2019 (COVID-19) infection among hospitalized patients with mental disorders and conduct an analysis of the factors influencing these changes. Methods Data were collected from inpatients at Beijing Huilongguan Hospital between December 12, 2022, and January 11, 2023, pre- and post-COVID-19. Based on the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, 329 inpatients with mental disorders were included (3 with incomplete data excluded). Primary outcomes assessed changes in antipsychotic concentrations pre- and post-COVID-19, while secondary outcomes examined factors linked to concentration increases and antipsychotic dose adjustments. Results Clozapine (P < 0.001), aripiprazole (P < 0.001), quetiapine (P = 0.005), olanzapine (P < 0.001), risperidone (P < 0.001), and paliperidone (P < 0.001) concentrations increased post-COVID-19 in patients with mental disorders. Notably, clozapine concentration surpassing pre-infection levels was highest. Clozapine users were more likely to adjust their dose (50.4%) compared to olanzapine (17.5%) and other antipsychotics. Moreover, traditional Chinese patent medicines and antibiotics during COVID-19 infection were associated with antipsychotic reduction or withdrawal (OR = 2.06, P = 0.0247; OR = 7.53, P = 0.0024, respectively). Conclusion Antipsychotic concentrations in hospitalized patients with mental disorders increased after COVID-19 infection, that may be related not only to COVID-19, but also to the use of Chinese patent medicines during infection. The pre-infection concentration and types of antipsychotics, patient's gender, and combination of traditional Chinese medicine or antibiotics, were factors found to correlate with increased drug concentrations and necessitate dose adjustments.
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Affiliation(s)
- Rui Yang
- Beijing Anding Hospital, Capital Medical University, Beijing, China
| | - Jin-Ling Wan
- Zhangjiakou Shalingzi Hospital, Zhangjiakou Mental Health Center, Zhangjiakou, Hebei, China
| | - Chen-Qi Pi
- Psychiatry Department, Shunyi Women’s & Children’s Hospital of Beijing Children’s Hospital, Beijing, China
| | - Tian-Hui Wang
- Psychiatry Department, Shunyi Women’s & Children’s Hospital of Beijing Children’s Hospital, Beijing, China
| | - Xue-Quan Zhu
- Beijing Anding Hospital, Capital Medical University, Beijing, China
| | - Shuang-Jiang Zhou
- Beijing HuiLongGuan Hospital, Peking University HuiLongGuan Clinical Medical School, Beijing, China
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2
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Harnisch LO, Brockmöller J, Hapke A, Sindern J, Bruns E, Evertz R, Toischer K, Danner BC, Mielke D, Rohde V, Abboud T. Oral Drug Absorption and Drug Disposition in Critically Ill Cardiac Patients. Pharmaceutics 2023; 15:2598. [PMID: 38004576 PMCID: PMC10674156 DOI: 10.3390/pharmaceutics15112598] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2023] [Revised: 10/26/2023] [Accepted: 11/02/2023] [Indexed: 11/26/2023] Open
Abstract
(1) Background: In critically ill cardiac patients, parenteral and enteral food and drug administration routes may be used. However, it is not well known how drug absorption and metabolism are altered in this group of adult patients. Here, we analyze drug absorption and metabolism in patients after cardiogenic shock using the pharmacokinetics of therapeutically indicated esomeprazole. (2) Methods: The pharmacokinetics of esomeprazole were analyzed in a consecutive series of patients with cardiogenic shock and controls before and after elective cardiac surgery. Esomeprazole was administered orally or with a nasogastric tube and once as an intravenous infusion. (3) Results: The maximum plasma concentration and AUC of esomeprazole were, on average, only half in critically ill patients compared with controls (p < 0.005) and remained lower even seven days later. Interestingly, esomeprazole absorption was also markedly compromised on day 1 after elective surgery. The metabolites of esomeprazole showed a high variability between patients. The esomeprazole sulfone/esomeprazole ratio reflecting CYP3A4 activity was significantly lower in critically ill patients even up to day 7, and this ratio was negatively correlated with CRP values (p = 0.002). The 5'-OH-esomeprazole and 5-O-desmethyl-esomeprazol ratios reflecting CYP2C19 activity did not differ significantly between critically ill and control patients. (4) Conclusions: Gastrointestinal drug absorption can be significantly reduced in critically ill cardiac patients compared with elective patients with stable cardiovascular disease. The decrease in bioavailability indicates that, under these conditions, any vital medication should be administered intravenously to maintain high levels of medications. After shock, hepatic metabolism via the CYP3A4 enzyme may be reduced.
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Affiliation(s)
- Lars-Olav Harnisch
- Department of Anesthesiology, University of Göttingen Medical Center, 37075 Göttingen, Germany
| | - Jürgen Brockmöller
- Department of Clinical Pharmacology, University of Göttingen Medical Center, 37075 Göttingen, Germany; (J.B.); (E.B.)
| | - Anne Hapke
- Department of Neurosurgery, University of Göttingen Medical Center, 37075 Göttingen, Germany; (A.H.); (D.M.); (V.R.); (T.A.)
- Department of Otorhinolaryngology-Head and Neck Surgery, RWTH Aachen University Hospital, 52074 Aachen, Germany
| | - Juliane Sindern
- Department of Neurosurgery, University of Göttingen Medical Center, 37075 Göttingen, Germany; (A.H.); (D.M.); (V.R.); (T.A.)
- Department of Anesthesiology and Critical Care Medicine, Medical Center, University of Freiburg, 79106 Freiburg, Germany
| | - Ellen Bruns
- Department of Clinical Pharmacology, University of Göttingen Medical Center, 37075 Göttingen, Germany; (J.B.); (E.B.)
| | - Ruben Evertz
- Department of Cardiology and Pneumology, University of Göttingen Medical Center, 37075 Göttingen, Germany; (R.E.); (K.T.)
| | - Karl Toischer
- Department of Cardiology and Pneumology, University of Göttingen Medical Center, 37075 Göttingen, Germany; (R.E.); (K.T.)
| | - Bernhard C. Danner
- Department of Cardiac, Thoracic and Vascular Surgery, University of Göttingen Medical Center, 37075 Göttingen, Germany;
| | - Dorothee Mielke
- Department of Neurosurgery, University of Göttingen Medical Center, 37075 Göttingen, Germany; (A.H.); (D.M.); (V.R.); (T.A.)
| | - Veit Rohde
- Department of Neurosurgery, University of Göttingen Medical Center, 37075 Göttingen, Germany; (A.H.); (D.M.); (V.R.); (T.A.)
| | - Tammam Abboud
- Department of Neurosurgery, University of Göttingen Medical Center, 37075 Göttingen, Germany; (A.H.); (D.M.); (V.R.); (T.A.)
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Nandar YM, Duangmano S, Lucksiri A, Sirikul C, Palacajornsuk P, Anukul N. Introduction of new alternative pipeline using multiplexed fast COLD‑PCR together with sequencing approach highlighting pharmacoeconomics by detection of CYP variants. Biomed Rep 2022; 17:99. [PMID: 36606140 PMCID: PMC9808490 DOI: 10.3892/br.2022.1582] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2022] [Accepted: 10/11/2022] [Indexed: 01/07/2023] Open
Abstract
In precision medicine, multiple factors are involved in clinical decision-making because of ethnic and racial genetic diversity, family history and other health factors. Although advanced techniques have evolved, there is still an economic obstacle to pharmacogenetic (PGx) implementation in developing countries. The aim of the present study was to provide an alternative pipeline that roughly estimate patient carrier type and prescreen out wild-type samples before sequencing or genotyping to determine genetic status. Fast co-amplification at lower denaturation temperature (COLD)-PCR was used to differentiate genetic variant non-carriers from carriers. The majority of drugs are hepatically cleared by cytochrome P450 (CYP) enzymes and genes encoding CYP enzymes are highly variable. Of all the CYPs, CYP2 family of CYP2C9, CYP2C19, and CYP2D6 isoforms have clinically significant impact on drugs of PGx testing. Therefore, five variants associated with these CYPs were selected for preliminary testing with this novel pipeline. For fast COLD-PCR, the optimal annealing temperature and critical denaturation temperature were determined and evaluated via Sanger sequencing of 27 randomly collected samples. According to precise Tc, to perform in a single-reaction is difficult. However, in this study, this issue was resolved by combination of precise Tc using 10+10+20 cycles. The results showed 100% sensitivity and specificity, with perfect agreement (κ=1.0) compared with Sanger sequencing. The present study provides a prescreening platform by introducing multiplex fast COLD-PCR as a pharmacoeconomic implementation. Our study just present in five variants which are not enough to describe patient metabolic status. Therefore, other actional genetic variants are still needed to cover the actual patient's genotypes. Nevertheless, the proposed method can well-present its efficiency and reliability for serving as a PGx budget platform in the future.
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Affiliation(s)
- Yu Myat Nandar
- Master's Degree Program in Medical Technology (International Program), Department of Medical Technology, Faculty of Associated Medical Sciences, Chiang Mai University, CMU Presidential Scholarship, Chiang Mai 50200, Thailand
| | - Suwit Duangmano
- Department of Medical Technology, Faculty of Associated Medical Sciences, Chiang Mai University, Chiang Mai 50200, Thailand
| | - Aroonrut Lucksiri
- Department of Pharmaceutical Care, Faculty of Pharmacy, Chiang Mai University, Chiang Mai 50200, Thailand
| | - Chonticha Sirikul
- Department of Medical Technology, Faculty of Associated Medical Sciences, Chiang Mai University, Chiang Mai 50200, Thailand
| | - Poonsub Palacajornsuk
- Department of Medical Technology, Faculty of Associated Medical Sciences, Chiang Mai University, Chiang Mai 50200, Thailand
| | - Nampeung Anukul
- Department of Medical Technology, Faculty of Associated Medical Sciences, Chiang Mai University, Chiang Mai 50200, Thailand,Correspondence to: Dr Nampeung Anukul, Department of Medical Technology, Faculty of Associated Medical Sciences, Chiang Mai University, 110 Intawaroroj Road, Sripoom, Chiang Mai 50200, Thailand
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4
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Sun MZ, Zheng QC. The regioselectivity of the interaction between dextromethorphan and CYP2D6. Phys Chem Chem Phys 2022; 24:2234-2242. [PMID: 35014636 DOI: 10.1039/d1cp03933d] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
CYP2D6 is an important enzyme of the cytochrome P450 superfamily, and catalyzes nearly 25% of the drugs sold in the market. For decades, the interactions and metabolism between CYP2D6 and substrates have been a hot topic. However, the key factors of the catalytic regioselectivity for CYP2D6 still remain controversial. Here, we construct four systems to explore the interaction between dextromethorphan (DM) and CYP2D6. A new binding mode of CYP2D6 is defined, and two key residues (residue Asp301 and residue Glu216) are discovered working simultaneously to stabilize the DM at the reactive site by forming water bridge hydrogen bonds when CYP2D6 binds DM. Our results also indicate that the substrate concentration could mediate the binding mode between the substrate and CYP2D6 by decreasing the volume of the catalytic pocket, which is not conducive to the O-demethylation of DM but benefits the N-demethylation of DM. These results could shed light on the process of CYP2D6 binding to the substrate, and help to better understand the regioselectivity of CYP2D6 catalyzing the substrates.
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Affiliation(s)
- Min-Zhang Sun
- Institute of Theoretical Chemistry, College of Chemistry, Jilin University, 2 Liutiao Road, Changchun 130023, P. R. China.
| | - Qing-Chuan Zheng
- Institute of Theoretical Chemistry, College of Chemistry, Jilin University, 2 Liutiao Road, Changchun 130023, P. R. China. .,Key Laboratory for Molecular Enzymology and Engineering of the Ministry of Education, Jilin University, Changchun 130012, P. R. China
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5
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Ten Years of Experience Support Pharmacogenetic Testing to Guide Individualized Drug Therapy. Pharmaceutics 2022; 14:pharmaceutics14010160. [PMID: 35057056 PMCID: PMC8779486 DOI: 10.3390/pharmaceutics14010160] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2021] [Revised: 12/27/2021] [Accepted: 01/07/2022] [Indexed: 12/10/2022] Open
Abstract
Precision medicine utilizing the genetic information of genes involved in the metabolism and disposition of drugs can not only improve drug efficacy but also prevent or minimize adverse events. Polypharmacy is common among multimorbid patients and is associated with increased adverse events. One of the main objectives in health care is safe and efficacious drug therapy, which is directly correlated to the individual response to treatment. Precision medicine can increase drug safety in many scenarios, including polypharmacy. In this report, we share our experience utilizing precision medicine over the past ten years. Based on our experience using pharmacogenetic (PGx)-informed prescribing, we implemented a five-step precision medicine protocol (5SPM) that includes the assessment of the biological-clinical characteristics of the patient, current and past prescription history, and the patient's PGx test results. To illustrate our approach, we present cases highlighting the clinical relevance of precision medicine with a focus on patients with a complex history and polypharmacy.
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6
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Therapeutic Drug Monitoring of Second- and Third-Generation Antipsychotic Drugs-Influence of Smoking Behavior and Inflammation on Pharmacokinetics. Pharmaceuticals (Basel) 2021; 14:ph14060514. [PMID: 34071813 PMCID: PMC8230242 DOI: 10.3390/ph14060514] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2021] [Revised: 05/21/2021] [Accepted: 05/21/2021] [Indexed: 01/08/2023] Open
Abstract
Both inflammation and smoking can influence a drug’s pharmacokinetic properties, i.e., its liberation, absorption, distribution, metabolism, and elimination. Depending on, e.g., pharmacogenetics, these changes may alter treatment response or cause serious adverse drug reactions and are thus of clinical relevance. Antipsychotic drugs, used in the treatment of psychosis and schizophrenia, should be closely monitored due to multiple factors (e.g., the narrow therapeutic window of certain psychotropic drugs, the chronicity of most mental illnesses, and the common occurrence of polypharmacotherapy in psychiatry). Therapeutic drug monitoring (TDM) aids with drug titration by enabling the quantification of patients’ drug levels. Recommendations on the use of TDM during treatment with psychotropic drugs are presented in the Consensus Guidelines for Therapeutic Drug Monitoring in Neuropsychopharmacology; however, data on antipsychotic drug levels during inflammation or after changes in smoking behavior—both clinically relevant in psychiatry—that can aid clinical decision making are sparse. The following narrative review provides an overview of relevant literature regarding TDM in psychiatry, particularly in the context of second- and third-generation antipsychotic drugs, inflammation, and smoking behavior. It aims to spread awareness regarding TDM (most pronouncedly of clozapine and olanzapine) as a tool to optimize drug safety and provide patient-tailored treatment.
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7
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Therapeutic Drug Monitoring of Second- and Third-Generation Antipsychotic Drugs—Influence of Smoking Behavior and Inflammation on Pharmacokinetics. Pharmaceuticals (Basel) 2021. [DOI: 10.3390/ph14060514
expr 938544256 + 801362328] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/16/2023] Open
Abstract
Both inflammation and smoking can influence a drug’s pharmacokinetic properties, i.e., its liberation, absorption, distribution, metabolism, and elimination. Depending on, e.g., pharmacogenetics, these changes may alter treatment response or cause serious adverse drug reactions and are thus of clinical relevance. Antipsychotic drugs, used in the treatment of psychosis and schizophrenia, should be closely monitored due to multiple factors (e.g., the narrow therapeutic window of certain psychotropic drugs, the chronicity of most mental illnesses, and the common occurrence of polypharmacotherapy in psychiatry). Therapeutic drug monitoring (TDM) aids with drug titration by enabling the quantification of patients’ drug levels. Recommendations on the use of TDM during treatment with psychotropic drugs are presented in the Consensus Guidelines for Therapeutic Drug Monitoring in Neuropsychopharmacology; however, data on antipsychotic drug levels during inflammation or after changes in smoking behavior—both clinically relevant in psychiatry—that can aid clinical decision making are sparse. The following narrative review provides an overview of relevant literature regarding TDM in psychiatry, particularly in the context of second- and third-generation antipsychotic drugs, inflammation, and smoking behavior. It aims to spread awareness regarding TDM (most pronouncedly of clozapine and olanzapine) as a tool to optimize drug safety and provide patient-tailored treatment.
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8
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Moschny N, Hefner G, Grohmann R, Eckermann G, Maier HB, Seifert J, Heck J, Francis F, Bleich S, Toto S, Meissner C. Therapeutic Drug Monitoring of Second- and Third-Generation Antipsychotic Drugs-Influence of Smoking Behavior and Inflammation on Pharmacokinetics. Pharmaceuticals (Basel) 2021; 14:514. [PMID: 34071813 PMCID: PMC8230242 DOI: 10.3390/ph14060514&set/a 947965394+957477086] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/16/2023] Open
Abstract
Both inflammation and smoking can influence a drug's pharmacokinetic properties, i.e., its liberation, absorption, distribution, metabolism, and elimination. Depending on, e.g., pharmacogenetics, these changes may alter treatment response or cause serious adverse drug reactions and are thus of clinical relevance. Antipsychotic drugs, used in the treatment of psychosis and schizophrenia, should be closely monitored due to multiple factors (e.g., the narrow therapeutic window of certain psychotropic drugs, the chronicity of most mental illnesses, and the common occurrence of polypharmacotherapy in psychiatry). Therapeutic drug monitoring (TDM) aids with drug titration by enabling the quantification of patients' drug levels. Recommendations on the use of TDM during treatment with psychotropic drugs are presented in the Consensus Guidelines for Therapeutic Drug Monitoring in Neuropsychopharmacology; however, data on antipsychotic drug levels during inflammation or after changes in smoking behavior-both clinically relevant in psychiatry-that can aid clinical decision making are sparse. The following narrative review provides an overview of relevant literature regarding TDM in psychiatry, particularly in the context of second- and third-generation antipsychotic drugs, inflammation, and smoking behavior. It aims to spread awareness regarding TDM (most pronouncedly of clozapine and olanzapine) as a tool to optimize drug safety and provide patient-tailored treatment.
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Affiliation(s)
- Nicole Moschny
- Department of Psychiatry, Social Psychiatry and Psychotherapy, Hannover Medical School, Carl-Neuberg-Str. 1, 30625 Hannover, Germany; (H.B.M.); (J.S.); (F.F.); (S.B.); (S.T.); (C.M.)
- Correspondence: ; Tel.: +49-511-532-3656
| | - Gudrun Hefner
- Department of Psychiatry and Psychotherapy, Vitos Clinic for Forensic Psychiatry, Kloster-Eberbach-Str. 4, 65346 Eltville, Germany;
| | - Renate Grohmann
- Department of Psychiatry and Psychotherapy, Ludwig Maximilian University of Munich, Nussbaum-Str. 7, 80336 Munich, Germany;
| | - Gabriel Eckermann
- Department of Forensic Psychiatry and Psychotherapy, Hospital Kaufbeuren, Kemnater-Str. 16, 87600 Kaufbeuren, Germany;
| | - Hannah B Maier
- Department of Psychiatry, Social Psychiatry and Psychotherapy, Hannover Medical School, Carl-Neuberg-Str. 1, 30625 Hannover, Germany; (H.B.M.); (J.S.); (F.F.); (S.B.); (S.T.); (C.M.)
| | - Johanna Seifert
- Department of Psychiatry, Social Psychiatry and Psychotherapy, Hannover Medical School, Carl-Neuberg-Str. 1, 30625 Hannover, Germany; (H.B.M.); (J.S.); (F.F.); (S.B.); (S.T.); (C.M.)
| | - Johannes Heck
- Institute for Clinical Pharmacology, Hannover Medical School, Carl-Neuberg-Str. 1, 30625 Hannover, Germany;
| | - Flverly Francis
- Department of Psychiatry, Social Psychiatry and Psychotherapy, Hannover Medical School, Carl-Neuberg-Str. 1, 30625 Hannover, Germany; (H.B.M.); (J.S.); (F.F.); (S.B.); (S.T.); (C.M.)
| | - Stefan Bleich
- Department of Psychiatry, Social Psychiatry and Psychotherapy, Hannover Medical School, Carl-Neuberg-Str. 1, 30625 Hannover, Germany; (H.B.M.); (J.S.); (F.F.); (S.B.); (S.T.); (C.M.)
| | - Sermin Toto
- Department of Psychiatry, Social Psychiatry and Psychotherapy, Hannover Medical School, Carl-Neuberg-Str. 1, 30625 Hannover, Germany; (H.B.M.); (J.S.); (F.F.); (S.B.); (S.T.); (C.M.)
| | - Catharina Meissner
- Department of Psychiatry, Social Psychiatry and Psychotherapy, Hannover Medical School, Carl-Neuberg-Str. 1, 30625 Hannover, Germany; (H.B.M.); (J.S.); (F.F.); (S.B.); (S.T.); (C.M.)
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Matthaei J, Brockmöller J, Steimer W, Pischa K, Leucht S, Kullmann M, Jensen O, Ouethy T, Tzvetkov MV, Rafehi M. Effects of Genetic Polymorphism in CYP2D6, CYP2C19, and the Organic Cation Transporter OCT1 on Amitriptyline Pharmacokinetics in Healthy Volunteers and Depressive Disorder Patients. Front Pharmacol 2021; 12:688950. [PMID: 34093211 PMCID: PMC8175851 DOI: 10.3389/fphar.2021.688950] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2021] [Accepted: 05/04/2021] [Indexed: 12/23/2022] Open
Abstract
The tricyclic antidepressant amitriptyline is frequently prescribed but its use is limited by its narrow therapeutic range and large variation in pharmacokinetics. Apart from interindividual differences in the activity of the metabolising enzymes cytochrome P450 (CYP) 2D6 and 2C19, genetic polymorphism of the hepatic influx transporter organic cation transporter 1 (OCT1) could be contributing to interindividual variation in pharmacokinetics. Here, the impact of OCT1 genetic variation on the pharmacokinetics of amitriptyline and its active metabolite nortriptyline was studied in vitro as well as in healthy volunteers and in depressive disorder patients. Amitriptyline and nortriptyline were found to inhibit OCT1 in recombinant cells with IC50 values of 28.6 and 40.4 µM. Thirty other antidepressant and neuroleptic drugs were also found to be moderate to strong OCT1 inhibitors with IC50 values in the micromolar range. However, in 35 healthy volunteers, preselected for their OCT1 genotypes, who received a single dose of 25 mg amitriptyline, no significant effects on amitriptyline and nortriptyline pharmacokinetics could be attributed to OCT1 genetic polymorphism. In contrast, the strong impact of the CYP2D6 genotype on amitriptyline and nortriptyline pharmacokinetics and of the CYP2C19 genotype on nortriptyline was confirmed. In addition, acylcarnitine derivatives were measured as endogenous biomarkers for OCT1 activity. The mean plasma concentrations of isobutyrylcarnitine and 2-methylbutyrylcarnitine were higher in participants with two active OCT1 alleles compared to those with zero OCT1 activity, further supporting their role as endogenous in vivo biomarkers for OCT1 activity. A moderate reduction in plasma isobutyrylcarnitine concentrations occurred at the time points at which amitriptyline plasma concentrations were the highest. In a second, independent study sample of 50 patients who underwent amitriptyline therapy of 75 mg twice daily, a significant trend of increasing amitriptyline plasma concentrations with decreasing OCT1 activity was observed (p = 0.018), while nortriptyline plasma concentrations were unaffected by the OCT1 genotype. Altogether, this comprehensive study showed that OCT1 activity does not appear to be a major factor determining amitriptyline and nortriptyline pharmacokinetics and that hepatic uptake occurs mainly through other mechanisms.
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Affiliation(s)
- Johannes Matthaei
- Institute of Clinical Pharmacology, University Medical Center Göttingen, Georg-August University, Göttingen, Germany
| | - Jürgen Brockmöller
- Institute of Clinical Pharmacology, University Medical Center Göttingen, Georg-August University, Göttingen, Germany
| | - Werner Steimer
- Institute for Clinical Chemistry and Pathobiochemistry, Klinikum rechts der Isar, Technical University of Munich, Munich, Germany
| | - Konstanze Pischa
- Institute for Clinical Chemistry and Pathobiochemistry, Klinikum rechts der Isar, Technical University of Munich, Munich, Germany
| | - Stefan Leucht
- Section Evidence Based Medicine in Psychiatry and Psychotherapy, Department of Psychiatry and Psychotherapy, Klinikum rechts der Isar, Technical University of Munich, Munich, Germany
| | - Maria Kullmann
- Institute of Clinical Pharmacology, University Medical Center Göttingen, Georg-August University, Göttingen, Germany
| | - Ole Jensen
- Institute of Clinical Pharmacology, University Medical Center Göttingen, Georg-August University, Göttingen, Germany
| | - Typhaine Ouethy
- Institute of Clinical Pharmacology, University Medical Center Göttingen, Georg-August University, Göttingen, Germany
| | - Mladen Vassilev Tzvetkov
- Institute of Clinical Pharmacology, University Medical Center Göttingen, Georg-August University, Göttingen, Germany.,Institute of Pharmacology, Center of Drug Absorption and Transport (C_DAT), University Medicine Greifswald, Greifswald, Germany
| | - Muhammad Rafehi
- Institute of Clinical Pharmacology, University Medical Center Göttingen, Georg-August University, Göttingen, Germany
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10
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Sharp CN, Linder MW, Valdes R. Polypharmacy: a healthcare conundrum with a pharmacogenetic solution. Crit Rev Clin Lab Sci 2019:1-20. [PMID: 31680605 DOI: 10.1080/10408363.2019.1678568] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
The use of multiple medications is growing at an alarming rate with some reports documenting an average of 12-22 prescriptions being used by individuals ≥50 years of age. The indirect consequences of polypharmacy include exacerbation of drug-drug interactions, adverse drug reactions, increased likelihood of prescribing cascades, chronic dependence, and hospitalizations - all of which have significant health and economic burden. While many practical solutions for reducing polypharmacy have been proposed, they have been met with limited efficacy. This highlights the need for a new systematic approach for fine-tuning dispensing of medications. Pharmacogenetic testing provides an empirical and scientifically rigorous approach for guiding appropriate selection of medicines, with the potential to reduce unnecessary polypharmacy while improving clinical outcomes. The goal of this review article is to provide healthcare providers with an understanding of polypharmacy, its adverse effects on the healthcare system and highlight how pharmacogenetic information can be used to avoid polypharmacy in patients.
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Affiliation(s)
- Cierra N Sharp
- Department of Pathology and Laboratory Medicine, University of Louisville School of Medicine, Louisville, KY, USA
| | - Mark W Linder
- Department of Pathology and Laboratory Medicine, University of Louisville School of Medicine, Louisville, KY, USA
| | - Roland Valdes
- Department of Pathology and Laboratory Medicine, University of Louisville School of Medicine, Louisville, KY, USA
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11
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Chan W, Li MS, Sundaram SK, Tomlinson B, Cheung PY, Tzang CH. CYP2D6 allele frequencies, copy number variants, and tandems in the population of Hong Kong. J Clin Lab Anal 2018; 33:e22634. [PMID: 30069923 DOI: 10.1002/jcla.22634] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2018] [Accepted: 07/05/2018] [Indexed: 11/08/2022] Open
Abstract
BACKGROUND CYP2D6 plays a crucial role in drug metabolism of several drugs. It is known to be highly polymorphic with enzymatic activity ranging from poor to ultrarapid metabolic rates. While the frequencies of CYP2D6 alleles are generally known in different Asian populations, data on frequencies of the copy number variations (CNV) and tandems in CYP2D6 in which they occur are less well studied in these populations. METHODS A cohort of 800 consecutive, unrelated individuals were referred to Prenetics Limited (Prenetics) iGenes test by physicians in Hong Kong as part of their care with informed consent. These clinical samples were deidentified prior to further analysis. Genotyping and copy number determination of CYP2D6 were performed using target specific TaqMan® SNP genotyping and copy number assays. The phenotypes of CYP2D6 were predicted based on its genotypes and is dependent on the biallelic expression of alleles. RESULTS Among the Asian group (n = 735, 92%), the observed frequency of CYP2D6*36-*10 tandems was 34.1%. We also identified duplication of CYP2D6 alleles in 86 (11.7%) individuals of the study cohort. The frequency of all CYP2D6 duplicated alleles was 154 (10.5%) while only 28 (1.9%) of the duplications were of functional alleles (ie CYP2D6*1 and CYP2D6*2). CONCLUSION The present study provides a comprehensive analysis on the occurrences of CNV and tandems of the CYP2D6 gene in the Hong Kong population. The results contribute to the overall knowledge of pharmacogenomics and may accelerate the implementation of precision medicine in Asia.
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Affiliation(s)
- Wing Chan
- Prenetics Limited, Hong Kong City, Hong Kong
| | - Man S Li
- Prenetics Limited, Hong Kong City, Hong Kong
| | | | - Brian Tomlinson
- Department of Medicine and Therapeutics, The Chinese University of Hong Kong, Hong Kong City, Hong Kong
| | | | - Chi H Tzang
- Prenetics Limited, Hong Kong City, Hong Kong
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12
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Abubakar A, Bentley O. Precision medicine and pharmacogenomics in community and primary care settings. ACTA ACUST UNITED AC 2018. [DOI: 10.1016/j.ptdy.2018.01.036] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
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13
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Rogers JF, Kidd RS. Assessing Home Health Care Pharmacists' Knowledge of Cytochrome P450 Pharmacogenetics. J Pharm Technol 2016. [DOI: 10.1177/875512250201800504] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Objective: Genetic code governs cytochrome P450 activity as a consequence, it may influence an individual's response to medications metabolized by these enzymes. Pharmacists have a prominent role in providing education concerning adverse drug reactions and variability in drug response. This investigation assessed the knowledge of a group of pharmacists regarding cytochrome P450 pharmacogenetics. Methods: This observational, cross-sectional study presented a Web–based questionnaire available for completion by pharmacists contacted via E-mail. Fifty-two pharmacists involved with a nationwide home-care facility participated in the study on a volunteer basis. The main outcome measure was percentage score on a 10-question examination. Results: Fifty-two of 171 contacted pharmacists participated in the study, yielding a response rate of 30%. The mean percentage questionnaire score ± SD was 17.5 ± 15.1. Scores were slightly higher for pharmacists with 2 or more pharmacokinetic classes in their formal education (p < 0.02). Conclusions: Understanding the principles of pharmacogenetics will allow pharmacists to appreciate that patients respond differently to certain medications as influenced by genetic variations encoding drug-metabolizing enzyme activity. As a consequence, some patients will have a normal therapeutic response, whereas others may experience drug toxicity or therapeutic inefficacy when given the same dose of a drug. This study determined, albeit with many limitations, that there is likely a need for improved availability of pharmacogenetic continuing education programs.
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Affiliation(s)
- Janyce F Rogers
- JANYCE F ROGERS PharmD, Clinical Research Scientist, Central Nervous System, Pfizer Global Research & Development, Eastern Point Rd., MS 8260-2219, Groton CT 06340, FAX 815/461-4568
| | - Robert S Kidd
- ROBERT S KIDD PharmD MS, Assistant Professor, Department of Biopharmaceutical Sciences, Bernard J Dunn School of Pharmacy, Shenandoah University, Winchester, VA
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Abstract
This article introduces fundamental principles of pharmacogenetics as applied to personalized and precision medicine. Pharmacogenetics establishes relationships between pharmacology and genetics by connecting phenotypes and genotypes in predicting the response of therapeutics in individual patients. We describe differences between precision and personalized medicine and relate principles of pharmacokinetics and pharmacodynamics to applications in laboratory medicine. We also review basic principles of pharmacogenetics, including its evolution, how it enables the practice of personalized therapeutics, and the role of the clinical laboratory. These fundamentals are a segue for understanding specific clinical applications of pharmacogenetics described in subsequent articles in this issue.
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Affiliation(s)
- Roland Valdes
- Department of Pathology and Laboratory Medicine, University of Louisville School of Medicine, MDR Building, Room 222, 511 South Floyd Street, Louisville, KY 40202, USA; Department of Biochemistry and Molecular Genetics, University of Louisville School of Medicine, HSC-A Building, Louisville, KY 40202, USA.
| | - DeLu Tyler Yin
- Department of Pathology and Laboratory Medicine, University of Louisville School of Medicine, MDR Building, Room 218, 511 South Floyd Street, Louisville, KY 40202, USA
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Shah RR, Smith RL. Addressing phenoconversion: the Achilles' heel of personalized medicine. Br J Clin Pharmacol 2015; 79:222-40. [PMID: 24913012 PMCID: PMC4309629 DOI: 10.1111/bcp.12441] [Citation(s) in RCA: 176] [Impact Index Per Article: 19.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2014] [Accepted: 06/04/2014] [Indexed: 02/06/2023] Open
Abstract
Phenoconversion is a phenomenon that converts genotypic extensive metabolizers (EMs) into phenotypic poor metabolizers (PMs) of drugs, thereby modifying their clinical response to that of genotypic PMs. Phenoconversion, usually resulting from nongenetic extrinsic factors, has a significant impact on the analysis and interpretation of genotype-focused clinical outcome association studies and personalizing therapy in routine clinical practice. The high phenotypic variability or genotype-phenotype mismatch, frequently observed due to phenoconversion within the genotypic EM population, means that the real number of phenotypic PM subjects may be greater than predicted from their genotype alone, because many genotypic EMs would be phenotypically PMs. If the phenoconverted population with genotype-phenotype mismatch, most extensively studied for CYP2D6, is as large as the evidence suggests, there is a real risk that genotype-focused association studies, typically correlating only the genotype with clinical outcomes, may miss clinically strong pharmacogenetic associations, thus compromising any potential for advancing the prospects of personalized medicine. This review focuses primarily on co-medication-induced phenoconversion and discusses potential approaches to rectify some of the current shortcomings. It advocates routine phenotyping of subjects in genotype-focused association studies and proposes a new nomenclature to categorize study populations. Even with strong and reliable data associating patients' genotypes with clinical outcome(s), there are problems clinically in applying this knowledge into routine pharmacotherapy because of potential genotype-phenotype mismatch. Drug-induced phenoconversion during routine clinical practice remains a major public health issue. Therefore, the principal challenges facing personalized medicine, which need to be addressed, include identification of the following factors: (i) drugs that are susceptible to phenoconversion; (ii) co-medications that can cause phenoconversion; and (iii) dosage amendments that need to be applied during and following phenoconversion.
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Affiliation(s)
| | - Robert L Smith
- Department of Surgery and Cancer, Faculty of Medicine, Imperial CollegeLondon, UK
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Shah RR, Smith RL. Inflammation-induced phenoconversion of polymorphic drug metabolizing enzymes: hypothesis with implications for personalized medicine. Drug Metab Dispos 2014; 43:400-10. [PMID: 25519488 DOI: 10.1124/dmd.114.061093] [Citation(s) in RCA: 132] [Impact Index Per Article: 13.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
Phenoconversion transiently converts genotypic extensive metabolizers (EMs) into phenotypic poor metabolizers (PMs) of drugs, potentially with corresponding changes in clinical response. This phenomenon, typically resulting from coadministration of medications that inhibit certain drug metabolizing enzymes (DMEs), is especially well documented for enzymes of the cytochrome P450 family. Nonclinical evidence gathered over the last two decades also strongly implicates elevated levels of some proinflammatory cytokines, released during inflammation, in down-regulation of drug metabolism, especially by certain DMEs of the P450 family, thereby potentially causing transient phenoconversion. Clinically, phenoconversion of NAT2, CYP2C19, and CYP2D6 has been documented in inflammatory conditions associated with elevated cytokines, such as human immunodeficiency virus infection, cancer, and liver disease. The potential of other inflammatory conditions to cause phenoconversion has not been studied but experimental and anecdotal clinical evidence supports infection-induced down-regulation of CYP1A2, CYP3A4, and CYP2C9 as well. Collectively, the evidence supports a hypothesis that certain inflammatory conditions associated with elevated proinflammatory cytokines may cause phenoconversion of certain DMEs. Since inflammatory conditions associated with elevated levels of proinflammatory cytokines are highly prevalent, phenoconversion of genotypic EM patients into transient phenotypic PMs may be more frequent than appreciated. Since drug pharmacokinetics, and therefore the clinical response, is influenced by DME phenotype rather than genotype per se, phenoconversion (whatever its cause) can have a significant impact on the analysis and interpretation of genotype-focused clinical outcome association studies. There is a risk that focusing on genotype alone may miss important associations between clinical outcomes and DME phenotypes, thus compromising future prospects of personalized medicine.
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Affiliation(s)
- Rashmi R Shah
- Rashmi Shah Consultancy Ltd., 8 Birchdale, Gerrards Cross, Buckinghamshire, United Kingdom (R.R.S.); and Department of Surgery and Cancer, Faculty of Medicine, Imperial College, South Kensington campus, London, United Kingdom (R.L.S.)
| | - Robert L Smith
- Rashmi Shah Consultancy Ltd., 8 Birchdale, Gerrards Cross, Buckinghamshire, United Kingdom (R.R.S.); and Department of Surgery and Cancer, Faculty of Medicine, Imperial College, South Kensington campus, London, United Kingdom (R.L.S.)
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Yang Z, Vakkalagadda B, Shen G, Ahlers CM, Has T, Christopher LJ, Kurland JF, Roongta V, Masson E, Zhang S. Inhibitory effect of ketoconazole on the pharmacokinetics of a multireceptor tyrosine kinase inhibitor BMS-690514 in healthy participants: assessing the mechanism of the interaction with physiologically-based pharmacokinetic simulations. J Clin Pharmacol 2013; 53:217-27. [PMID: 23436267 DOI: 10.1177/0091270012439208] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2011] [Accepted: 01/24/2012] [Indexed: 12/12/2022]
Abstract
BMS-690514, a selective inhibitor of the ErbB and vascular endothelial growth factor receptors, has shown antitumor activity in early clinical development. The compound is metabolized by multiple enzymes, with CYP3A4 responsible for the largest fraction (34%) of metabolism. It is also a substrate of P-glycoprotein (P-gp) in vitro. To assess the effect of ketoconazole on BMS-690514 pharmacokinetics, 17 healthy volunteers received 200 mg BMS-690514 alone followed by 100 mg BMS-690514 with ketoconazole (400 mg once daily for 4 days). The AUC(∞) of 100 mg BMS-690514 concomitantly administered with ketoconazole was similar to that of 200 mg BMS-690514 alone. The dose-normalized C(max) and AUC(∞) of BMS-690514 from the 100-mg BMS-690514/400-mg ketoconazole treatment increased by 55% and 127%, respectively, relative to those from 200 mg BMS-690514 alone. Prediction of the drug-drug interaction (DDI) using a population-based simulator (Simcyp) indicated that, in addition to CYP3A4 inhibition, the inhibition of P-gp by ketoconazole in the intestine, liver, and kidneys must be invoked to fully account for the DDI observed. This finding suggests that the inhibition of P-gp by ketoconazole, along with its effect on CYP3A4, needs to be considered when designing a DDI study of ketoconazole with a victim drug that is a dual substrate.
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Affiliation(s)
- Zheng Yang
- Bristol-Bristol Squibb, Princeton, NJ 08543-4000, USA
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Shah RR, Smith RL. Phenocopy and phenoconversion: do they complicate association studies? Pharmacogenomics 2013; 13:981-4. [PMID: 22838943 DOI: 10.2217/pgs.12.71] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
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Tan-Kam T, Suthisisang C, Pavasuthipaisit C, Limsila P, Puangpetch A, Sukasem C. Importance of pharmacogenetics in the treatment of children with attention deficit hyperactive disorder: a case report. PHARMACOGENOMICS & PERSONALIZED MEDICINE 2013; 6:3-7. [PMID: 23526481 PMCID: PMC3596139 DOI: 10.2147/pgpm.s36782] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
This case report highlights the importance of pharmacogenetic testing in the treatment of attention deficit hyperactive disorder (ADHD). A 6-year-old boy diagnosed with ADHD was prescribed methylphenidate 5 mg twice daily (7 am and noon) and the family was compliant with administration of this medication. On the first day of treatment, the patient had an adverse reaction, becoming disobedient, more mischievous, erratic, resistant to discipline, would not go to sleep until midnight, and had a poor appetite. The All-In-One PGX (All-In-One Pharmacogenetics for Antipsychotics test for CYP2D6, CYP2C19, and CYP2C9) was performed using microarray-based and real-time polymerase chain reaction techniques. The genotype of our patient was identified to be CYP2D6*2/*10, with isoforms of the enzyme consistent with a predicted cytochrome P450 2D6 intermediate metabolizer phenotype. Consequently, the physician adjusted the methylphenidate dose to 2.5 mg once daily in the morning. At this dosage, the patient had a good response without any further adverse reactions. Pharmacogenetic testing should be included in the management plan for ADHD. In this case, cooperation between the medical team and the patients’ relatives was key to successful treatment.
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Affiliation(s)
- Teerarat Tan-Kam
- Yuwaprasart Waithayopathum Child and Adolescent Psychiatric Hospital, Department of Mental Health Services, Ministry of Public Health
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Stingl (formerly Kirchheiner) J, Brockmöller J. Study Designs in Clinical Pharmacogenetic and Pharmacogenomic Research. Pharmacogenomics 2013. [DOI: 10.1016/b978-0-12-391918-2.00009-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023] Open
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Temesvári M, Kóbori L, Paulik J, Sárváry E, Belic A, Monostory K. Estimation of drug-metabolizing capacity by cytochrome P450 genotyping and expression. J Pharmacol Exp Ther 2012; 341:294-305. [PMID: 22262920 DOI: 10.1124/jpet.111.189597] [Citation(s) in RCA: 53] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Many undesired side effects or therapeutic failures of drugs are the result of differences or changes in drug metabolism, primarily depending on the levels and activities of cytochrome P450 (P450) enzymes. To assess whether P450 expression profiles can reflect hepatic drug metabolism, we compared P450 mRNA levels in the liver or peripheral leukocytes with the corresponding hepatic P450 activities. A preliminary P450 genotyping for the most frequent polymorphisms in white populations (CYP2C9*2, CYP2C9*3, CYP2C19*2, CYP2C19*3, CYP2D6*3, CYP2D6*4, CYP2D6*6, and CYP3A5*3) was carried out before P450 phenotyping, excluding the donors with nonfunctional alleles of CYP2C9, CYP2C19, and CYP2D6 and those with a functional CYP3A5*1 allele from a correlation analysis. The hepatic mRNA levels of CYP1A2, CYP2B6, CYP2C9, CYP2C19, CYP2D6, and CYP3A4 displayed a strong association with P450 activities in the liver, whereas the expression of CYP1A2, CYP2C9, CYP2C19, and CYP3A4 in leukocytes was proven to reflect the hepatic activities of these P450 species. The leukocytes were found to be inappropriate cells for the assessment of hepatic CYP2B6 and CYP2D6 activities. Combining the results of P450 genotyping and phenotyping analyses, patients' drug-metabolizing capacities can be estimated by the P450 expression in the liver and in leukocytes with some limitations. Patients' genetic and nongenetic variations in P450 status can guide the appropriate selection of drugs and the optimal dose, minimizing the risk of harmful side effects and ensuring a successful outcome of drug therapy.
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Affiliation(s)
- Manna Temesvári
- Research Center for Natural Sciences, Hungarian Academy of Sciences, Budapest, Hungary
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Schwaiblmair M, Behr W, Foerg W, Berghaus T. Cytochrome P450 polymorphisms and drug-induced interstitial lung disease. Expert Opin Drug Metab Toxicol 2011; 7:1547-60. [DOI: 10.1517/17425255.2011.629185] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
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García-Sabina A, Gulín-Dávila J, Sempere-Serrano P, González-Juanatey C, Martínez-Pacheco R. [Specific considerations on the prescription and therapeutic interchange of statins]. FARMACIA HOSPITALARIA 2011; 36:97-108. [PMID: 21820929 DOI: 10.1016/j.farma.2011.02.010] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2010] [Revised: 02/07/2011] [Accepted: 02/16/2011] [Indexed: 10/17/2022] Open
Abstract
OBJECTIVE The pharmaceutical industry currently offers six different statins in Spain and there is one more soon to be available. Choosing the most appropriate drug and dose is determined by the therapeutic target (reduction in LDL-C levels). Statin doses that decrease LDL-C at the same percentage are considered equivalent. Evaluating the pharmacokinetic characteristics of each statin can be useful when setting selection criteria, helping to determine which statin may be more appropriate for a patient based on their individual characteristics and on the other co-administered drugs. METHODS We reviewed the pharmacokinetics properties of each statin and its possible involvement in drug interactions. RESULTS CYP3A4 was responsible for the metabolism of lovastatin, simvastatin and atorvastatin; fluvastatin depends on CYP2C9; P-glycoprotein is responsible for decreased atorvastatin, pravastatin, simvastatin and lovastatin concentrations. The OATPA1B1 transporter involved in all statins' access to the hepatocyte, except for fluvastatin, is essential for rosuvastatin and pravastatin. These circumstances cause those drugs inhibiting or inducing isoenzymes or transporters' activity not to have the same effect on the different statins. CONCLUSION The pharmacokinetics is important when choosing the best statin and could be a limitation in the use of interchange therapeutic programmes when other drugs are present.
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Affiliation(s)
- A García-Sabina
- Servicio de Farmacia, Hospital Universitario Lucus Augusti, Lugo, España.
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Temesvári M, Paulik J, Kóbori L, Monostory K. High-resolution melting curve analysis to establish CYP2C19∗2 single nucleotide polymorphism: Comparison with hydrolysis SNP analysis. Mol Cell Probes 2011; 25:130-3. [DOI: 10.1016/j.mcp.2011.01.003] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2010] [Revised: 01/07/2011] [Accepted: 01/10/2011] [Indexed: 11/27/2022]
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Tzvetkov MV, Saadatmand AR, Bokelmann K, Meineke I, Kaiser R, Brockmöller J. Effects of OCT1 polymorphisms on the cellular uptake, plasma concentrations and efficacy of the 5-HT(3) antagonists tropisetron and ondansetron. THE PHARMACOGENOMICS JOURNAL 2010; 12:22-9. [PMID: 20921968 DOI: 10.1038/tpj.2010.75] [Citation(s) in RCA: 118] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
After uptake into liver cells, the antiemetic drugs tropisetron and ondansetron undergo metabolic inactivation by cytochrome P450 2D6 (CYP2D6). We investigated whether the hepatic organic cation transporter 1 (OCT1; SLC22A1) mediates cellular uptake and whether common OCT1 loss-of-function polymorphisms affect pharmacokinetics and efficacy of both drugs. Both tropisetron and ondansetron inhibited ASP(+) uptake in OCT1-overexpressing HEK293 cells. Overexpression of wild-type, but not OCT1 loss-of-function variants, significantly increased tropisetron uptake. Correspondingly, patients with two loss-of-function OCT1 alleles had higher tropisetron plasma concentrations (n=59, P<0.04) and higher clinical efficacy (n=91, P=0.009) compared with carriers of fully active OCT1. Overexpression of OCT1 did not increase ondansetron uptake. Nevertheless, OCT1 genotypes correlated with pharmacokinetics (n=45, P<0.05) and clinical efficacy (n=222, P<0.02) of ondansetron, the effect size of OCT1 genotypes on pharmacokinetics and efficacy was greater for tropisetron than for ondansetron. In conclusion, in addition to the known effects of CYP2D6, OCT1 deficiency may increase efficacy of tropisetron and potentially of ondansetron by limiting their hepatic uptake.
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Affiliation(s)
- M V Tzvetkov
- Department of Clinical Pharmacology, University Medical Center, Georg-August-University, Göttingen, Germany.
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Cascorbi I. Safe and effective medicines for all: is personalized medicine the answer? Expert Rev Clin Pharmacol 2010; 3:627-37. [PMID: 22111745 DOI: 10.1586/ecp.10.36] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
An improvement in drug treatment and clinical outcome is one of the major challenges in clinical medicine. The development of evidence-based standards of care has led to a significant improvement, but, by definition, strictly standardized cohorts in clinical trials have to ignore individual differences. Personalized medicine is defined as the application of genomic and molecular data to better target the delivery of healthcare, facilitate the discovery and clinical testing of new products, and help determine a person's predisposition to a particular disease or condition. After the deciphering of the human genome, however, the high expectations in individualized medicine were not always fulfilled. However, personalized medicine has become indispensable in the treatment of malignant diseases and there is increasing evidence for its benefit in other areas. This article outlines the impact of pharmacogenetics and pharmacogenomics, especially with regard to personalized medicine, in major medical indications and reflects the obstacles and chances taken in current daily practice.
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Affiliation(s)
- Ingolf Cascorbi
- Institute for Experimental and Clinical Pharmacology, University Hospital Schleswig-Holstein, Arnold-Heller-Str. 3, Bldg 30, D-24105 Kiel, Germany.
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Ozsvár Z, Solymossi Z, Monostory K. [Methyldopa-induced acute reactive hepatitis in pregnancy, drug-metabolizing capacity of the liver]. Orv Hetil 2010; 151:457-61. [PMID: 20211808 DOI: 10.1556/oh.2010.28736] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Alpha-methyldopa is a regularly used antihypertensive drug during pregnancy. Methyldopa, which decreases the sympathoadrenal system, is the first drug of choice since decades. The reactive hepatitis is not frequent, but known serious side effect of alpha-methyldopa. In non-pregnant women the estimated rate of manifest hepatotoxicity is 2.5-10%. In our case, gestation hypertension developed at the 21st gestation week of a 35 year-old pregnant woman. Oral methyldopa, a central alpha adrenergic blocker therapy was introduced. On the 23rd gestation week acute hepatitis developed. During differential diagnosis of hepatitis, the etiology of methyldopa was taken into account. Viral and autoimmune origin was rolled out. No fetal aberration was found during ultrasound examination. The function of drug metabolizing function from blood was measured by CYP phenotyping (CYP gene expression analysis). CYP3A4 enzyme plays a primary role in the metabolism of nifedipine. Antihypertensive therapy was changed from methyldopa to nifedipine. Nifedipine dosage was based on the value of CYP3A4 gene expression. With the reduced nifedipine therapy (30 mg daily), blood pressure was successfully under control. The diagnosis of alpha-methyldopa induced hepatitis was based on anamnesis, clinical picture and the results of chemical and radiological examination and confirmed by the level of drug-metabolizing capacity. The gestation hepatotoxicity of alpha-methyldopa was reported first in 1969 by Elkington Smith, who suggested the monitoring of serum aminotransferase during alpha-methyldopa therapy in pregnancy in their case report. Our case report confirms that monitoring of serum aminotransferase level is still valuable when treating a pregnant woman with alpha-methyldopa.
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Affiliation(s)
- Zsófia Ozsvár
- Fejér Megyei Szent György Kórház Infektológiai Osztály Székesfehérvár Seregélyesi út 3. 8000.
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Mistry GC, Bergman AJ, Zheng W, Hreniuk D, Zinny MA, Gottesdiener KM, Wagner JA, Herman GA, Ruddy M. Sitagliptin, an dipeptidyl peptidase-4 inhibitor, does not alter the pharmacokinetics of the sulphonylurea, glyburide, in healthy subjects. Br J Clin Pharmacol 2008; 66:36-42. [PMID: 18503607 DOI: 10.1111/j.1365-2125.2008.03148.x] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023] Open
Abstract
AIMS Sitagliptin, a dipeptidyl peptidase-4 inhibitor, is an incretin enhancer that is approved for the treatment of Type 2 diabetes. Sitagliptin is mainly renally eliminated and not an inhibitor of CYP450 enzymes in vitro. Glyburide, a sulphonylurea, is an insulin sensitizer and mainly metabolized by CYP2C9. Since both agents may potentially be co-administered, the purpose of this study was to examine the effects of sitagliptin on glyburide pharmacokinetics. METHODS In this open-label, randomized, two-period crossover study, eight healthy normoglycaemic subjects, 22-44 years old, received single 1.25-mg doses of glyburide alone in one period and co-administered with sitagliptin on day 5 following a multiple-dose regimen for sitagliptin (200-mg q.d. x 6 days) in the other period. RESULTS The geometric mean ratios and 90% confidence intervals [(glyburide + sitagliptin)/glyburide] for AUC(0-infinity) and C(max) were 1.09 (0.96, 1.24) and 1.01 (0.84, 1.23), respectively. CONCLUSION Sitagliptin does not alter the pharmacokinetics of glyburide in healthy subjects.
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Kóbori L, Kõhalmy K, Porrogi P, Sárváry E, Gerlei Z, Fazakas J, Nagy P, Járay J, Monostory K. Drug-induced liver graft toxicity caused by cytochrome P450 poor metabolism. Br J Clin Pharmacol 2008; 65:428-36. [PMID: 18070218 PMCID: PMC2291242 DOI: 10.1111/j.1365-2125.2007.03056.x] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2007] [Accepted: 09/18/2007] [Indexed: 12/15/2022] Open
Abstract
UNLABELLED What is already known about this subject. The activity of drug-metabolizing enzymes, primarily cytochrome P450 enzymes, can determine a patient's response to a drug. Therapeutic failure or drug toxicity in the postoperative period after liver transplantation is influenced by the drug metabolizing capacity of the graft. Dose adjustment or selection of an alternative drug, which is not a substrate for the polymorphic enzyme may prevent the development of side-effects in recipients of poor metabolizer liver grafts. What this study adds. A validated analytical system with metabolomic tools has been developed to estimate the drug-metabolizing capacity of transplanted liver, which allows the prediction of potential poor metabolizer phenotypes of donors and facilitates the improvement of individual recipient therapy. In the test of drug-metabolizing status, one of the liver grafts was found to be a CYP2C9 poor metabolizer, while the other was a CYP2C19 poor metabolizer. Rationalization of the medication resulted in the recovery of both the grafts and the recipients within 1 week. AIMS The drug-metabolizing capacity of transplanted liver highly influences drug efficacy or toxicity, particularly in the early postoperative period. The aim of our study was to predict therapeutic failures or severe adverse drug reactions by phenotyping for cytochrome P450 (P450) polymorphism resulting in reduced or no activity of the key drug-metabolizing enzymes. METHODS A validated analytical system with metabolomic tools has been developed for estimation of the drug-metabolizing capacity of transplanted liver, which allows the prediction of potential poor metabolizer phenotypes of donors and facilitates improvement of the individual recipient therapy. RESULTS Of the 109 liver donors in Hungary, the frequency of poor metabolizers was found to be 0.92%, 5.5% and 8.3% for CYP2C9, CYP2C19 and CYP2D6, respectively. In the present study, two liver grafts transplanted in paediatric recipients were reported to be poor metabolizer phenotypes. The liver grafts presented normal function in the early postoperative days; 2 weeks after transplantation, however, increasing liver enzymes were detected. Histological investigation of a liver biopsy suggested drug toxicity. The test of drug metabolizing status showed one of the liver grafts to be a CYP2C9 poor metabolizer, and the other was found to be a CYP2C19 poor metabolizer. Rationalization of the medication resulted in the recovery of both the grafts and the recipients within 1 week. CONCLUSIONS Prospective investigation of the P450 status may lead to the optimization of drug choice and/or dose for a more effective therapy, avoid serious adverse effects, and decrease medical costs. Phenotyping donor livers and tailored medication can contribute to the improvement of graft and recipient survival.
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Affiliation(s)
- László Kóbori
- Transplantation and Surgical Clinic, Semmelweis UniversityBaross 23-25, H-1082 Budapest, Hungary
| | - Krisztina Kõhalmy
- Chemical Research Center, Hungarian Academy of SciencesPusztaszeri 59-67, H-1025 Budapest, Hungary
| | - Pálma Porrogi
- Chemical Research Center, Hungarian Academy of SciencesPusztaszeri 59-67, H-1025 Budapest, Hungary
| | - Enikõ Sárváry
- Transplantation and Surgical Clinic, Semmelweis UniversityBaross 23-25, H-1082 Budapest, Hungary
| | - Zsuzsa Gerlei
- Transplantation and Surgical Clinic, Semmelweis UniversityBaross 23-25, H-1082 Budapest, Hungary
| | - János Fazakas
- Transplantation and Surgical Clinic, Semmelweis UniversityBaross 23-25, H-1082 Budapest, Hungary
| | - Péter Nagy
- Ist Pathology and Experimental Cancer Research, Semmelweis UniversityÜllõi 26, H-1085 Budapest, Hungary
| | - Jenõ Járay
- Transplantation and Surgical Clinic, Semmelweis UniversityBaross 23-25, H-1082 Budapest, Hungary
| | - Katalin Monostory
- Chemical Research Center, Hungarian Academy of SciencesPusztaszeri 59-67, H-1025 Budapest, Hungary
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32
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Abstract
Genotyping of the polymorphic cytochrome P450 (CYP) 2D6 gene is used increasingly in clinical practice. Several psychiatric hospitals already use CYP2D6 testing before treating a patient with antidepressant or antipsychotic drug therapy. In other fields of drug therapy, such as for breast cancer, CYP2D6 status has been reported to be an independent predictor for the outcome with tamoxifen. Thus, a more favorable tamoxifen treatment seems to be feasible through a priori genetic assessment of CYP2D6.
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33
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Yengi LG, Leung L, Kao J. The Evolving Role of Drug Metabolism in Drug Discovery and Development. Pharm Res 2007; 24:842-58. [PMID: 17333392 DOI: 10.1007/s11095-006-9217-9] [Citation(s) in RCA: 51] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2006] [Accepted: 12/13/2006] [Indexed: 01/16/2023]
Abstract
Drug metabolism in pharmaceutical research has traditionally focused on the well-defined aspects of absorption, distribution, metabolism and excretion, commonly-referred to ADME properties of a compound, particularly in the areas of metabolite identification, identification of drug metabolizing enzymes (DMEs) and associated metabolic pathways, and reaction mechanisms. This traditional emphasis was in part due to the limited scope of understanding and the unavailability of in vitro and in vivo tools with which to evaluate more complex properties and processes. However, advances over the past decade in separate but related fields such as pharmacogenetics, pharmacogenomics and drug transporters, have dramatically shifted the drug metabolism paradigm. For example, knowledge of the genetics and genomics of DMEs allows us to better understand and predict enzyme regulation and its effects on exogenous (pharmacokinetics) and endogenous pathways as well as biochemical processes (pharmacology). Advances in the transporter area have provided unprecedented insights into the role of transporter proteins in absorption, distribution, metabolism and excretion of drugs and their consequences with respect to clinical drug-drug and drug-endogenous substance interactions, toxicity and interindividual variability in pharmacokinetics. It is therefore essential that individuals involved in modern pharmaceutical research embrace a fully integrated approach and understanding of drug metabolism as is currently practiced. The intent of this review is to reexamine drug metabolism with respect to the traditional as well as current practices, with particular emphasis on the critical aspects of integrating chemistry and biology in the interpretation and application of metabolism data in pharmaceutical research.
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Affiliation(s)
- Lilian G Yengi
- Drug Metabolism Division, Drug Safety and Metabolism, Wyeth Research, 500 Arcola Road, Collegeville, Pennsylvania 19426, USA.
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34
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Roots I, Laschinski G, Arjomand-Nahad F, Kirchheiner J, Schwarz D, Brockmöller J, Cascorbi I, Gerloff T. Genotype and phenotype relationship in drug metabolism. ERNST SCHERING RESEARCH FOUNDATION WORKSHOP 2007:81-100. [PMID: 17117716 DOI: 10.1007/978-3-540-49529-1_6] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/12/2023]
Abstract
Pharmacogenetics, one of the fields of clinical pharmacology, studies how genetic factors influence drug response. If hereditary traits are taken into account appropriately before starting drug treatment, the type of drug and its dosage can be tailored to the individual patient's needs. Today, the relationships between dosage requirements and genetic variations in drug-metabolizing enzymes such as cytochrome P450 (CYP) 2D6, CYP2C9, and CYP2C19 or in drug transporters such as p-glycoprotein (ABCB1) and OATP-C (SLC21A6) are substantiated best. A standard dose will bring about more adverse effects than usual if enzymatic activity is lacking or feeble. Sometimes, however, therapeutic response might be better because of higher concentrations: proton pump inhibitors for eradication of Helicobacter pylori are more efficacious in carriers of a deficient CYP2C19 variant. In some cases, genetic tests can help distinguish between responders and nonresponders of a specific drug treatment, and genotype-based dosage is possible.
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Affiliation(s)
- I Roots
- Institut für Klinische Pharmakologie, Charité, Universitätsmedizin Berlin, Germany.
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35
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Kirchheiner J, Seeringer A, Brockmöller J. Stand der Pharmakogenetik in der klinischen Arzneimitteltherapie. Bundesgesundheitsblatt Gesundheitsforschung Gesundheitsschutz 2006; 49:995-1003. [PMID: 17013776 DOI: 10.1007/s00103-006-0045-1] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
Individual differences in the effect and side effect of drugs are partly due to genetic factors (genetic polymorphisms). The responsible polymorphisms lie in genes encoding for drug metabolism and transport but also in direct and indirect drug targets. While genetic variants in pharmacokinetic structures exert effects on drug efficacy via the differences in drug exposure, polymorphisms in drug targets can directly affect clinical efficacy and may lead to a broad variation spectrum between inefficacy and severe side effects. However, at present, our knowledge on genetic variants in drug targets is less detailed than the knowledge on pharmacogenetic variability within drug metabolism. A goal of pharmacogenetic diagnostics implemented in clinical practice is to better predict the individual drug effects on the basis of molecular-genetic profiles. Therapy recommendations can be given as dose adjustments, in particular in the case of polymorphisms of drug metabolizing enzymes which will lead to less variable drug concentrations. At present there are few examples of the application of pharmacogenetic tests in Germany in order to improve and individualize drug therapy. The reasons for this are multifold. On the one hand it is due to the limited awareness of pharmacogenetics; on the other hand it may be due to the lack of fast and economical availability of the appropriate laboratory tests. The most important reason, however, may be that most results of pharmacogenetic research are so far not translated into therapeutically usable conclusions and therapy recommendations. Thus, testing for a genotype without concrete consequences for the drug therapy of an individual patient does not make sense. Pharmacogenetic research, thereby, stands in many cases at the threshold to clinical applicability and in many cases, for instance for the genotyping for thiopurine methyltransferase polymorphisms prior to azathioprine therapy or of dihydropyrimidine dehydrogenase polymorphisms prior to treatment with 5-fluorouracil, as well as for diagnostics of CYP2D6 before therapy with certain tricyclic antidepressants and neuroleptics, one would ask already today whether a such drug therapy is still responsible without pharmacogenetic diagnostics.
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Affiliation(s)
- J Kirchheiner
- Klinische Pharmakologie, Abteilung Naturheilkunde & Klinische Pharmakologie, Universität Ulm, Heimholtzstrasse 20, 89081 Ulm, BRD.
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36
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Kirchheiner J, Roots I, Goldammer M, Rosenkranz B, Brockmöller J. Effect of genetic polymorphisms in cytochrome p450 (CYP) 2C9 and CYP2C8 on the pharmacokinetics of oral antidiabetic drugs: clinical relevance. Clin Pharmacokinet 2006; 44:1209-25. [PMID: 16372821 DOI: 10.2165/00003088-200544120-00002] [Citation(s) in RCA: 136] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Type 2 diabetes mellitus affects up to 8% of the adult population in Western countries. Treatment of this disease with oral antidiabetic drugs is characterised by considerable interindividual variability in pharmacokinetics, clinical efficacy and adverse effects. Genetic factors are known to contribute to individual differences in bioavailability, drug transport, metabolism and drug action. Only scarce data exist on the clinical implications of this genetic variability on adverse drug effects or clinical outcomes in patients taking oral antidiabetics. The polymorphic enzyme cytochrome P450 (CYP) 2C9 is the main enzyme catalysing the biotransformation of sulphonylureas. Total oral clearance of all studied sulphonylureas (tolbutamide, glibenclamide [glyburide], glimepiride, glipizide) was only about 20% in persons with the CYP2C9*3/*3 genotype compared with carriers of the wild-type genotype CYP2C9*1/*1, and clearance in the heterozygous carriers was between 50% and 80% of that of the wild-type genotypes. For reasons not completely known, the resulting differences in drug effects were much less pronounced. Nevertheless, CYP2C9 genotype-based dose adjustments may reduce the incidence of adverse effects. The magnitude of how doses might be adjusted can be derived from pharmacokinetic studies. The meglitinide-class drug nateglinide is metabolised by CYP2C9. According to the pharmacokinetic data, moderate dose adjustments based on CYP2C9 genotypes may help in reducing interindividual variability in the antihyperglycaemic effects of nateglinide. Repaglinide is metabolised by CYP2C8 and, according to clinical studies, CYP2C8*3 carriers had higher clearance than carriers of the wild-type genotypes; however, this was not consistent with in vitro data and therefore further studies are needed. CYP2C8*3 is closely linked with CYP2C9*2. CYP2C8 and CYP3A4 are the main enzymes catalysing biotransformation of the thiazolidinediones troglitazone and pioglitazone, whereas rosiglitazone is metabolised by CYP2C9 and CYP2C8. The biguanide metformin is not significantly metabolised but polymorphisms in the organic cation transporter (OCT) 1 and OCT2 may determine its pharmacokinetic variability. In conclusion, pharmacogenetic variability plays an important role in the pharmacokinetics of oral antidiabetic drugs; however, to date, the impact of this variability on clinical outcomes in patients is mostly unknown and prospective studies on the medical benefit of CYP genotyping are required.
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Affiliation(s)
- Julia Kirchheiner
- Institute of Clinical Pharmacology, University Medical Center Charité, Humboldt University, Berlin, Germany.
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37
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Abstract
Knowledge of postoperative nausea and vomiting (PONV) risk factors allows anesthesiologists to optimize the use of prophylactic regimens. Modern PONV risk research began in the 1990s with publication of studies using logistic regression analysis to simultaneously identify multiple independent PONV predictors and publication of meta-analyses and systematic reviews. This literature shows that female gender post-puberty, nonsmoking status, history of PONV or motion sickness, childhood after infancy and younger adulthood, increasing duration of surgery, and use of volatile anesthetics, nitrous oxide, large-dose neostigmine, or intraoperative or postoperative opioids are well established PONV risk factors. Possible risk factors include history of migraine, history of PONV or motion sickness in a child's parent or sibling, better ASA physical status, intense preoperative anxiety, certain ethnicities or surgery types, decreased perioperative fluids, crystalloid versus colloid administration, increasing duration of anesthesia, general versus regional anesthesia or sedation, balanced versus total IV anesthesia, and use of longer-acting versus shorter-acting opioids. Early-phase menstruation, obesity and lack of supplemental oxygen are disproved risk factors. Current risk scoring systems have approximately 55%-80% accuracy in predicting which patient groups will suffer PONV. Further research examining genetic and under-investigated clinical patient characteristics as potential risk factors, and involving outpatients and children, should improve predictive systems.
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Affiliation(s)
- Tong J Gan
- Department of Anesthesiology, Duke University Medical Center, Durham, NC 27710, USA.
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38
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Turman CM, Hatley JM, Ryder DJ, Ravindranath V, Strobel HW. Alternative splicing within the human cytochrome P450 superfamily with an emphasis on the brain: the convolution continues. Expert Opin Drug Metab Toxicol 2006; 2:399-418. [PMID: 16863442 DOI: 10.1517/17425255.2.3.399] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
The human cytochrome P450 (CYP) superfamily of enzymes regulate hepatic phase 1 drug metabolism and subsequently play a significant role in pharmacokinetics, drug discovery and drug development. Alternative splicing of the cytochrome CYP gene transcripts enhances gene diversity and may play a role in transcriptional regulation of certain CYP proteins. Tissue-specific alternative splicing of CYPs is significant for its potential to add greater dimension to differential drug metabolism in hepatic and extrahepatic tissues, such as the brain, and to our understanding of the CYP family. This review provides an overview of tissue-specific splicing patterns, splicing types, regulation and the functional diversities between liver and splice variant CYP proteins and further explores the relevance of tissue-specific alternative splicing of CYPs in the nervous system.
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Affiliation(s)
- Cheri M Turman
- Department of Biochemistry and Molecular Biology, University of Texas Medical School at Houston, 6431 Fannin, Houston, TX 77030, USA.
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39
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Moutel G, Duchange N, Raffi F, Sharara LI, Théodorou I, Noël V, de Montgolfier S, Callies I, Bricaire F, Hervé C, Leport C. Communication of pharmacogenetic research results to HIV-infected treated patients: standpoints of professionals and patients. Eur J Hum Genet 2005; 13:1055-62. [PMID: 15957002 PMCID: PMC1868604 DOI: 10.1038/sj.ejhg.5201450] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023] Open
Abstract
The aim of pharmacogenetic studies is to adapt therapeutic strategies to individual genetic profiles, thus maximising their efficacy and minimising the likelihood of adverse side effects. Since the advent of personalised medicine, the issue of communicating research results to participants has become increasingly important. We addressed this question in the context of HIV infection, as patients and associations are particularly concerned by research and therapeutic advances. We explored the standpoints of both research professionals and participants involved in a pharmacogenetic study conducted in a cohort of HIV-infected patients. The setting of the research protocol was followed over a 2-year period. Participants' standpoints were collected through a questionnaire and interviews were conducted with research professionals. Of 125 participants, 76% wished to receive individual results and 71% wished to receive collective results; 39% did not know when results might be expected. Communication of global research results is a principle that is generally accepted by professionals. Concerning individual feedback, the professionals felt that it was necessary if it could be of direct benefit to the participant, but they expressed doubts for situations with no recognised benefit. Our results highlight the necessity to consider this issue in greater detail. We suggest the need to anticipate the debates concerning individual feedback, to differentiate between situations and the importance of further investigations on the opportunities and modalities of communication. Finally, our work emphasised the opposite pressures between the pursuit of scientific knowledge and the therapeutic orientation of clinical trials.
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Affiliation(s)
- Grégoire Moutel
- Laboratoire d'Ethique Médicale et Médecine Légale & Institut International de Recherche en Ethique Biomédicale, Faculté de Médecine Paris 5. 45 rue des Saints-Pères, Paris 75006, France.
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40
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Gerloff T, Roots I. [Implications of pharmacogenetics in every-day practice]. Internist (Berl) 2005; 46:1270-7. [PMID: 16170512 DOI: 10.1007/s00108-005-1489-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
Pharmacogenetics as one of the areas of clinical pharmacology addresses hereditary factors involved in individually different responses to drugs. Clinical trials combined with molecular genetics seek for underlying reasons influencing efficacy and toxicity of drugs. The declared goal of pharmacogenetics is to provide physicians with knowledge and tools to allow an individualized patient-directed pharmacotherapy. This concept is best evolved for clinical practice in the field of drug-metabolizing enzymes, especially for the cytochromes P450 (CYP) 2D6, CYP2C19 and thiopurine S-methyltransferase (TPMT). Patients with inherited enzyme deficiencies are at risk to accumulate excessive drug concentrations when treated with standard doses which may lead to adverse drug reactions or even to life-threatening conditions. Genetic factors are also involved in drug-target interactions (e. g. receptors). Prospective controlled clinical trials are needed to evaluate the benefit of pharmacogenetics for therapy outcome and to define its role in clinical practice.
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Affiliation(s)
- T Gerloff
- Institut für Klinische Pharmakologie, Charité Universitätsmedizin Berlin.
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41
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Kirchheiner J, Fuhr U, Brockmöller J. Pharmacogenetics-based therapeutic recommendations--ready for clinical practice? Nat Rev Drug Discov 2005; 4:639-47. [PMID: 16056390 DOI: 10.1038/nrd1801] [Citation(s) in RCA: 127] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Although considerable progress has been made in basic pharmacogenetic research, less has been demonstrated in the application of pharmacogenetics (PGx)-based diagnostics to drug development and in clinical practice. There are drugs that are currently used in the clinic for which individualized therapy could be beneficial based on PGx data. However, specific, actionable recommendations on how to implement individualized therapy--particularly with respect to dosage--still have to be developed. Moreover, to apply PGx efficiently in clinical drug development, and later in drug therapy, study designs and the generation and handling of PGx data need to become more standardized. Here, we argue for the development of concise guidelines for implementation of PGx analyses in drug development and therapy.
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Affiliation(s)
- Julia Kirchheiner
- Department of Pharmacology, University of Cologne, Gleueler Strasse 24, 50931, Köln, Germany.
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42
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Wilke RA, Musana A K, Weber WW. Cytochrome P450 gene-based drug prescribing and factors impacting translation into routine clinical practice. Per Med 2005; 2:213-224. [DOI: 10.2217/17410541.2.3.213] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
Pharmacogenetics represents a rapidly advancing, competitive field of investigation. Due to the potential for clinically recognizable interactions between a set of old polymorphic genes and a relatively new environmental insult (drugs), many human geneticists believe that variability in the drug-metabolizing enzyme systems will soon translate into clinical practice across entire populations. Despite this, the field has not yet received widespread clinical acceptance. This article will review the common cytochrome P450 gene polymorphisms and discuss the factors that may facilitate (or attenuate) their translation into clinical practice.
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Affiliation(s)
- Russell A Wilke
- Center for Human Genetics, Marshfield Clinic Research Foundation, Department of Internal Medicine, Marshfield Clinic, 1000 North Oak Avenue, Marshfield, WI 54449, USA
| | - A Kenneth Musana
- Department of Internal Medicine, Marshfield Clinic, Marshfield, WI, USA
| | - Wendell W Weber
- Department of Pharmacology, University of Michigan, Ann Arbor, MI, USA
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43
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Rochat B. Role of Cytochrome P450 Activity in the Fate of Anticancer Agents and in Drug Resistance. Clin Pharmacokinet 2005; 44:349-66. [PMID: 15828850 DOI: 10.2165/00003088-200544040-00002] [Citation(s) in RCA: 95] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2022]
Abstract
Although activity of cytochrome P450 isoenzymes (CYPs) plays a major role in the fate of anticancer agents in patients, there are relatively few clinical studies that evaluate drug metabolism with therapeutic outcome. Nevertheless, many clinical reports in various non-oncology fields have shown the dramatic importance of CYP activity in therapeutic efficacy, safety and interindividual variability of drug pharmacokinetics. Moreover, variability of drug metabolism in the liver as well as in cancer cells must also be considered as a potential factor mediating cancer resistance. This review underlines the role of drug metabolism mediated by CYPs in pharmacokinetic variability, drug resistance and safety. As examples, biotransformation pathways of tamoxifen, paclitaxel and imatinib are reviewed. This review emphasises the key role of therapeutic drug monitoring as a complementary tool of investigation to in vitro data. For instance, pharmacokinetic data of anticancer agents have not often been published within subpopulations of patients who show ultra-rapid, extensive or poor metabolism (e.g. due to CYP2D6 and CYP2C19 genotypes). Besides kinetic variability in the systemic circulation, induction of CYP activity may participate in creating drug resistance by speeding up the cancer agent degradation specifically in the target cells. For one cancer agent, various mechanisms of resistance are usually identified within different cell clones. This review also tries to emphasise that drug resistance mediated by CYP activity in cancer cells should be taken into consideration to a greater degree. The unequivocal identification of the metabolising enzymes involved in clinical conditions will eventually allow improvement and individualisation of anticancer agent therapy, i.e. drug dosage and selection. In addition, a more complete understanding of the metabolism of anticancer agents will assist in the prediction of drug-drug interactions, as anticancer agent combinations are becoming more prevalent.
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Affiliation(s)
- Bertrand Rochat
- Centre Hospitalier Universitaire Vaudois, Lausanne, Switzerland.
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44
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Wu DJ. A Pharmacogenomics Standard for FDA Drug Approval: Arbitrary and Capricious or Safe and Effective? Biotechnol Law Rep 2004. [DOI: 10.1089/blr.2004.23.733] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
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45
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Goldsmith J. Technology And The Boundaries Of The Hospital: Three Emerging Technologies. Health Aff (Millwood) 2004; 23:149-56. [PMID: 15537593 DOI: 10.1377/hlthaff.23.6.149] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
U.S. hospitals have proved remarkably adept at altering their service offerings to incorporate new technologies. New technologies threatened to undercut hospitals' central role in health care delivery in the 1980s. An array of new technologies promise yet again to alter the boundaries of hospitals' franchise. These technologies will not only continue the shift away from acute, inpatient care that we have seen for the past thirty years but will also challenge hospitals to collaborate more effectively with physicians and technology developers. How hospitals and policymakers respond to these emerging technologies will help determine whether hospitals remain at the center of the U.S. health system.
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Affiliation(s)
- Jeff Goldsmith
- School of Medicine, University of Virginia, Charlottesville, VA, USA.
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46
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Roots I, Gerloff T, Meisel C, Kirchheiner J, Goldammer M, Kaiser R, Laschinski G, Brockmöller J, Cascorbi I, Kleeberg U, Hildebrandt AG. Pharmacogenetics‐Based New Therapeutic Concepts. Drug Metab Rev 2004; 36:617-38. [PMID: 15554239 DOI: 10.1081/dmr-200033458] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
Pharmacogenetics, one of the fields of clinical pharmacology, studies how genetic factors influence drug response. If hereditary traits are taken into account appropriately before starting drug treatment, the type of drug and its dosage can be tailored to the individual patient's needs. Pharmacogenetics adds a considerable amount of stringency to the doctor's therapeutic approach. Today, it is the relationship between dosage requirements and genetic variations in drug metabolizing enzymes like cytochrome P450 (CYP) 2D6 and CYP2C19, or in drug transporters like p-glycoprotein, that is substantiated best. A standard dose will bring about more adverse effects than usual if enzymatic activity is lacking or feeble. Sometimes, however, therapeutic response might be better due to higher concentrations: proton pump inhibitors for eradication of Helicobacter pylori are more efficacious in carriers of a deficient CYP2C19 variant. The drug's interaction with its target (e.g. receptor) also depends on genetic factors. In some cases genetic tests can help distinguish between responders and non-responders of a specific drug treatment. The first pharmacogenetic tests are already on the market.
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Affiliation(s)
- Ivar Roots
- Institut für Klinische Pharmakologie, Charité-Universitätsmedizin Berlin, Campus Charitè Mitte, Humboldt-Universität zu Berlin, Berlin, Germany.
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47
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Bukaveckas BL, Valdes R, Linder MW. Pharmacogenetics as related to the practice of cardiothoracic and vascular anesthesia. J Cardiothorac Vasc Anesth 2004; 18:353-65. [PMID: 15232819 DOI: 10.1053/j.jvca.2004.03.019] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Affiliation(s)
- Bonny L Bukaveckas
- Department of Pathology and Laboratory Medicine, University of Louisville, Louisville, KY, USA
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48
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Wehling M, Peiter A. [Drug therapy of elderly patients from the viewpoint of the clinical pharmacologist]. Internist (Berl) 2004; 44:1003-9. [PMID: 14671815 DOI: 10.1007/s00108-003-0950-4] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Polypragmasy (polypharmacotherapy) is often due to the frequent incidence of multimorbidity among elderly patients. This may evoke unpredictable drug-interactions, which often become a reason for hospitalization. Additional medications might be the consequence. Geriatric patients are often characterized by variant pharmacokinetic parameters. Individualized drug-therapy should take into consideration not only the patients' age, liver and kidney functions but also the individual variability of hepatic metabolization and drug-resorption in the intestine based on genetic polymorphisms. Summing up, it is very important to verify a consisting or a new drug-therapy concerning its risk-benefit ratio and if it is needed, to omit or change some of the medications.
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Affiliation(s)
- M Wehling
- Zentrum für Gerontopharmakologie, Institut für Klinische Pharmakologie, Fakultät für Klinische Medizin Mannheim, Universität Heidelberg.
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49
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Borlak J, Hermann R, Erb K, Thum T. A rapid and simple CYP2D6 genotyping assay--case study with the analgetic tramadol. Metabolism 2003; 52:1439-43. [PMID: 14624403 DOI: 10.1016/s0026-0495(03)00256-7] [Citation(s) in RCA: 19] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
There is substantial evidence for a causal relationship between genetic variability of the CYP2D6 gene and changes in the pharmacokinetics of drugs. Therefore, knowledge of single-nucleotide polymorphisms (SNPs) prior to drug administration is highly desired for assisting in the development of individualized pharmacotherapy. We therefore developed a robust assay that detects common CYP2D6 alleles within 60 minutes of blood withdrawal and links carriers of the variant CYP2D6*3 and *4 alleles to the pharmacokinetics of tramadol. This new genotyping assay employs fluorescence resonance energy transfer (FRET) analysis, which permits parallel identification of the CYP2D6*3 and CYP2D6*4 alleles within 60 minutes of blood withdrawal. We determined the genotypes of 100 healthy unrelated individuals and studied the pharmacokinetics of tramadol in 24 CYP2D6 genotyped healthy subjects. The total allelic frequencies of homozygote carriers were 0.015 and 0.25 for the CYP2D6*3 and *4 alleles, respectively, and the plasma area under the curve (AUC) was 84% above those of extensive metabolizers (homozygous EM group): 3,941.2 ng/mL.h (95% confidence interval [CI], 2,928.9 ng/mL.h to 4,953.5 ng/mL.h) versus 2,142.6 ng/mL.h (95% CI, 1,829.6 ng/mL.h to 2,455.7 ng/mL.h). Likewise, the AUC for the O-desmethyl-tramadol metabolite (M1) was significantly reduced in poor metabolizers (PMs): 300.2 ng/mL.h (95% CI, 260.3 ng/mL.h to 340.0 ng/mL.h) versus 842,6 ng/mL.h (95% CI, 715.1 ng/mL.h to 970.0 ng/mL.h). We observed a statistically significant correlation between plasma tramadol AUC and production of the O-desmethyl metabolite in CYP2D6 genotyped healthy volunteers. Our assay can be used reliably in clinical pharmacology studies and may be used for dose adjustment.
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Affiliation(s)
- Jürgen Borlak
- Fraunhofer Institute of Toxicology and Experimental Mecicine, Center of Drug Research and Medical Biotechnology, Hannover, Germany
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50
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Abstract
Interindividual differences in the pharmacokinetics of a number of drugs are often due to hereditary polymorphisms of drug-metabolizing enzymes. Most important is cytochrome p4502D6 (CYP2D6), also known as debrisoquine/sparteine hydroxylase. It catalyzes hydroxylation or demethylation of more than 20% of drugs metabolized in the human liver, such as neuroleptics, antidepressants, some beta-blockers and many others like codeine. About 7%-10% of Caucasians lack any CYP2D6 activity due to deletions and frame-shift or splice-site mutations of the gene. About 1%-3% of Middle-Europeans, but up to 29% of Ethiopians display gene duplications, leading to elevated so-called ultrarapid metabolization rates. Meanwhile there is now a much better understanding of the genetic background of poor, intermediate, extensive and ultrarapid metabolizers, enabling a more precise DNA genotyping-based prediction of plasma levels. Since there is evidence that deteriorated drug elimination partly accounts for drug side-effects, CYP2D6 genotyping could contribute to an individualized and therefore optimized drug therapy.
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Affiliation(s)
- I Cascorbi
- Institute of Pharmacology, Ernst Moritz Arndt University Greifswald, Germany.
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