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Khatri D, Felmingham B, Moore C, Lazaraki S, Stenta T, Collier L, Elliott DA, Metz D, Conyers R. Evaluating the evidence for genotype-informed Bayesian dosing of tacrolimus in children undergoing solid organ transplantation: A systematic literature review. Br J Clin Pharmacol 2024. [PMID: 39147586 DOI: 10.1111/bcp.16203] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2023] [Revised: 07/04/2024] [Accepted: 07/18/2024] [Indexed: 08/17/2024] Open
Abstract
Tacrolimus, a calcineurin inhibitor, is a highly effective immunosuppressant used in solid organ transplantation (SOT). However, it is characterized by a narrow therapeutic range and high inter-patient variability in pharmacokinetics. Standard weight-based dosing followed by empiric dose titration is suboptimal in controlling drug concentrations, increasing risk of rejection or toxicity, particularly in the initial months post transplantation. This review explores the potential of combined pre-transplant genotyping and pharmacokinetic (PK) modelling to improve tacrolimus dosing in paediatric SOT recipients. A systematic search of Medline, Embase and Cochrane databases identified studies published between March 2013 and March 2023 that investigated genotype- and PK model-informed tacrolimus dosing in children post-SOT. The Newcastle-Ottawa Scale assessed study quality. Seven studies encompassing paediatric kidney, heart, liver and lung transplants reported using genotype and model-informed dosing. A combination of clinical and genetic factors significantly impacts tacrolimus clearance and thus initial dose recommendation. Body size, transplant organ and co-medications were consistently important, while either time post-transplant or haematocrit emerged in some studies. Several models were identified, however, with limitations evident in some and with absence of evidence for their effectiveness in optimizing initial and subsequent dosing. This review highlights the development of PK models in paediatric SOT that integrate genotype and clinical covariates to personalize early tacrolimus dosing. While promising, prospective studies are needed to validate and confirm their effectiveness in improving time to therapeutic concentrations and reducing under- or overexposure. This approach has the potential to optimize tacrolimus therapy in paediatric SOT, thereby improving outcomes.
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Affiliation(s)
- Dhrita Khatri
- Cancer Therapies, Stem Cell Medicine, Murdoch Children's Research Institute, Parkville, Melbourne, VIC, Australia
| | - Ben Felmingham
- Cancer Therapies, Stem Cell Medicine, Murdoch Children's Research Institute, Parkville, Melbourne, VIC, Australia
| | - Claire Moore
- Cancer Therapies, Stem Cell Medicine, Murdoch Children's Research Institute, Parkville, Melbourne, VIC, Australia
- Department of Paediatrics, The University of Melbourne, Parkville, Melbourne, VIC, Australia
| | - Smaro Lazaraki
- Health Sciences Library, Royal Melbourne Hospital, Melbourne Health, Australia
| | - Tayla Stenta
- Cancer Therapies, Stem Cell Medicine, Murdoch Children's Research Institute, Parkville, Melbourne, VIC, Australia
| | - Lane Collier
- Cancer Therapies, Stem Cell Medicine, Murdoch Children's Research Institute, Parkville, Melbourne, VIC, Australia
| | - David A Elliott
- Cancer Therapies, Stem Cell Medicine, Murdoch Children's Research Institute, Parkville, Melbourne, VIC, Australia
- Department of Paediatrics, The University of Melbourne, Parkville, Melbourne, VIC, Australia
| | - David Metz
- Department of Nephrology, The Royal Children's Hospital, Melbourne, VIC, Australia
- Murdoch Children's Research Institute, Melbourne, VIC, Australia
- Department of Paediatrics, Monash University, Melbourne, VIC, Australia
| | - Rachel Conyers
- Cancer Therapies, Stem Cell Medicine, Murdoch Children's Research Institute, Parkville, Melbourne, VIC, Australia
- Department of Paediatrics, The University of Melbourne, Parkville, Melbourne, VIC, Australia
- Children's Cancer Centre, The Royal Children's Hospital, Melbourne, VIC, Australia
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Rotarescu CA, Maruntelu I, Rotarescu I, Constantinescu AE, Constantinescu I. Single Nucleotide Polymorphisms of CYP3A4 and CYP3A5 in Romanian Kidney Transplant Recipients: Effect on Tacrolimus Pharmacokinetics in a Single-Center Experience. J Clin Med 2024; 13:1968. [PMID: 38610733 PMCID: PMC11012255 DOI: 10.3390/jcm13071968] [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: 02/05/2024] [Revised: 03/24/2024] [Accepted: 03/26/2024] [Indexed: 04/14/2024] Open
Abstract
Background: This study examines the impact of CYP3A4 and CYP 3A5 genotypes on tacrolimus (Tac) pharmacokinetics in Romanian kidney transplanted patients. Methods: We included 112 kidney recipients genotyped for CYP3A5*3, CYP3A4*1.001, and CYP3A4*22. Patients were categorized into poor, intermediate, rapid, and ultra-rapid metabolizers based on the functional defects linked to CYP3A variants. Results: Predominantly male (63.4%) with an average age of 40.58 years, the cohort exhibited a high prevalence of the CYP3A4*1/*1 (86.6%) and CYP3A5*3/*3 (77.7%) genotypes. CYP3A4*1.001 and CYP3A5*1 alleles significantly influenced the Tac concentration-to-dose (C0/D) ratio in various post-transplant periods, while the CYP3A4*22 allele showed no such effect (p = 0.016, p < 0.001). Stepwise regression highlighted the CYP3A4*1.001's impact in early post-transplant phases, with hematocrit and age also influencing Tac variability. Conclusions: The study indicates a complex interaction of CYP3A4 and CYP3A5 genotypes on Tac metabolism, suggesting the necessity for personalized medication approaches based on genetic profiling in kidney transplant recipients.
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Affiliation(s)
- Corina Andreea Rotarescu
- Immunology and Transplant Immunology, Carol Davila University of Medicine and Pharmacy, 258 Fundeni Avenue, 022328 Bucharest, Romania; (C.A.R.); (A.-E.C.); (I.C.)
- Centre of Immunogenetics and Virology, Fundeni Clinical Institute, 258 Fundeni Avenue, 022328 Bucharest, Romania
| | - Ion Maruntelu
- Immunology and Transplant Immunology, Carol Davila University of Medicine and Pharmacy, 258 Fundeni Avenue, 022328 Bucharest, Romania; (C.A.R.); (A.-E.C.); (I.C.)
- Centre of Immunogenetics and Virology, Fundeni Clinical Institute, 258 Fundeni Avenue, 022328 Bucharest, Romania
| | - Ion Rotarescu
- Department of Cardiovascular Surgery, Prof. Dr. C. C. Iliescu Emergency Institute for Cardiovascular Diseases, 258 Fundeni Avenue, 022328 Bucharest, Romania;
| | - Alexandra-Elena Constantinescu
- Immunology and Transplant Immunology, Carol Davila University of Medicine and Pharmacy, 258 Fundeni Avenue, 022328 Bucharest, Romania; (C.A.R.); (A.-E.C.); (I.C.)
| | - Ileana Constantinescu
- Immunology and Transplant Immunology, Carol Davila University of Medicine and Pharmacy, 258 Fundeni Avenue, 022328 Bucharest, Romania; (C.A.R.); (A.-E.C.); (I.C.)
- Centre of Immunogenetics and Virology, Fundeni Clinical Institute, 258 Fundeni Avenue, 022328 Bucharest, Romania
- Academy of Romanian Scientists (AOSR), 3 Ilfov Street, 030167 Bucharest, Romania
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Mohammed Ali Z, Meertens M, Fernández B, Fontova P, Vidal-Alabró A, Rigo-Bonnin R, Melilli E, Cruzado JM, Grinyó JM, Colom H, Lloberas N. CYP3A5*3 and CYP3A4*22 Cluster Polymorphism Effects on LCP-Tac Tacrolimus Exposure: Population Pharmacokinetic Approach. Pharmaceutics 2023; 15:2699. [PMID: 38140040 PMCID: PMC10747255 DOI: 10.3390/pharmaceutics15122699] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2023] [Revised: 11/24/2023] [Accepted: 11/26/2023] [Indexed: 12/24/2023] Open
Abstract
The aim of the study is to develop a population pharmacokinetic (PopPK) model and to investigate the influence of CYP3A5/CYP3A4 and ABCB1 single nucleotide polymorphisms (SNPs) on the Tacrolimus PK parameters after LCP-Tac formulation in stable adult renal transplant patients. The model was developed, using NONMEM v7.5, from full PK profiles from a clinical study (n = 30) and trough concentrations (C0) from patient follow-up (n = 68). The PK profile of the LCP-Tac formulation was best described by a two-compartment model with linear elimination, parameterized in elimination (CL/F) and distributional (CLD/F) clearances and central compartment (Vc/F) and peripheral compartment (Vp/F) distribution volumes. A time-lagged first-order absorption process was characterized using transit compartment models. According to the structural part of the base model, the LCP-Tac showed an absorption profile characterized by two transit compartments and a mean transit time of 3.02 h. Inter-individual variability was associated with CL/F, Vc/F, and Vp/F. Adding inter-occasion variability (IOV) on CL/F caused a statistically significant reduction in the model minimum objective function MOFV (p < 0.001). Genetic polymorphism of CYP3A5 and a cluster of CYP3A4/A5 SNPs statistically significantly influenced Tac CL/F. In conclusion, a PopPK model was successfully developed for LCP-Tac formulation in stable renal transplant patients. CYP3A4/A5 SNPs as a combined cluster including three different phenotypes (high, intermediate, and poor metabolizers) was the most powerful covariate to describe part of the inter-individual variability associated with apparent elimination clearance. Considering this covariate in the initial dose estimation and during the therapeutic drug monitoring (TDM) would probably optimize Tac exposure attainments.
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Affiliation(s)
- Zeyar Mohammed Ali
- Nephrology Department, Hospital Universitari de Bellvitge-IDIBELL, 08908 Barcelona, Spain; (Z.M.A.); (M.M.); (B.F.); (P.F.); (A.V.-A.); (E.M.); (J.M.C.)
- Biopharmaceutics and Pharmacokinetics Unit, Department of Pharmacy and Pharmaceutical Technology and Physical Chemistry, School of Pharmacy, University of Barcelona, 08007 Barcelona, Spain
| | - Marinda Meertens
- Nephrology Department, Hospital Universitari de Bellvitge-IDIBELL, 08908 Barcelona, Spain; (Z.M.A.); (M.M.); (B.F.); (P.F.); (A.V.-A.); (E.M.); (J.M.C.)
- Biopharmaceutics and Pharmacokinetics Unit, Department of Pharmacy and Pharmaceutical Technology and Physical Chemistry, School of Pharmacy, University of Barcelona, 08007 Barcelona, Spain
| | - Beatriz Fernández
- Nephrology Department, Hospital Universitari de Bellvitge-IDIBELL, 08908 Barcelona, Spain; (Z.M.A.); (M.M.); (B.F.); (P.F.); (A.V.-A.); (E.M.); (J.M.C.)
- Biopharmaceutics and Pharmacokinetics Unit, Department of Pharmacy and Pharmaceutical Technology and Physical Chemistry, School of Pharmacy, University of Barcelona, 08007 Barcelona, Spain
| | - Pere Fontova
- Nephrology Department, Hospital Universitari de Bellvitge-IDIBELL, 08908 Barcelona, Spain; (Z.M.A.); (M.M.); (B.F.); (P.F.); (A.V.-A.); (E.M.); (J.M.C.)
| | - Anna Vidal-Alabró
- Nephrology Department, Hospital Universitari de Bellvitge-IDIBELL, 08908 Barcelona, Spain; (Z.M.A.); (M.M.); (B.F.); (P.F.); (A.V.-A.); (E.M.); (J.M.C.)
| | - Raul Rigo-Bonnin
- Biochemistry Department, Hospital Universitari de Bellvitge-IDIBELL, 08908 Barcelona, Spain;
| | - Edoardo Melilli
- Nephrology Department, Hospital Universitari de Bellvitge-IDIBELL, 08908 Barcelona, Spain; (Z.M.A.); (M.M.); (B.F.); (P.F.); (A.V.-A.); (E.M.); (J.M.C.)
| | - Josep M. Cruzado
- Nephrology Department, Hospital Universitari de Bellvitge-IDIBELL, 08908 Barcelona, Spain; (Z.M.A.); (M.M.); (B.F.); (P.F.); (A.V.-A.); (E.M.); (J.M.C.)
| | - Josep M. Grinyó
- Department of Clinical Sciences, Medicine Unit, University of Barcelona, 08007 Barcelona, Spain;
| | - Helena Colom
- Biopharmaceutics and Pharmacokinetics Unit, Department of Pharmacy and Pharmaceutical Technology and Physical Chemistry, School of Pharmacy, University of Barcelona, 08007 Barcelona, Spain
| | - Nuria Lloberas
- Nephrology Department, Hospital Universitari de Bellvitge-IDIBELL, 08908 Barcelona, Spain; (Z.M.A.); (M.M.); (B.F.); (P.F.); (A.V.-A.); (E.M.); (J.M.C.)
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Neishi M, Hamano H, Niimura T, Denda M, Yagi K, Miyata K, Lin TJ, Higashionna T, Goda M, Zamami Y, Ishizawa K, Nawa H. Structural characterization of the optical isomers esomeprazole and omeprazole using the JADER and FAERS databases. Toxicol Appl Pharmacol 2023; 475:116632. [PMID: 37482254 DOI: 10.1016/j.taap.2023.116632] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2023] [Revised: 07/13/2023] [Accepted: 07/20/2023] [Indexed: 07/25/2023]
Abstract
BACKGROUND It is unclear whether the s (-) form of esomeprazole (EPZ) has an improved safety profile when compared with its racemic form omeprazole (OPZ). We assessed the potential complications of these optical isomers when combined with cilostazol, clopidogrel, and prasugrel, which are frequently used concomitant medications. METHODS Using two adverse event spontaneous reporting databases, Japanese Adverse Drug Event Report (JADER) and FDA Adverse Event Reporting System (FAERS), adverse event names for hemorrhage, venous/arterial embolization, and thrombus were obtained from the Medical Dictionary for Regulatory Activities. Reported odds ratios were calculated using a 2 × 2 contingency table, and a signal was considered present if the lower limit of the 95% confidence interval was >1. RESULTS In combination with cilostazol, a hemorrhagic signal for OPZ in JADER and arterial emboli and thrombus signals for EPZ were detected in both databases. In combination with clopidogrel, OPZ showed arterial emboli and thrombus signals in JADER and venous/arterial emboli and thrombus signals in FAERS, while EPZ displayed arterial emboli and thrombus signals in FAERS. In contrast, when in combination with prasugrel, there were no adverse event signals in either database. CONCLUSION This study has confirmed using big data, that EPZ, the optical isomer and racemic form of omeprazole, has the beneficial characteristics of being less sensitive to CYP, as was intended by its design.
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Affiliation(s)
- Mami Neishi
- Faculty of Pharmacy, Department of Pharmacy, Shujitsu University, 1-6-1 Nishikawara, Nakaku, Okayama 703-8516, Japan
| | - Hirofumi Hamano
- Department of Pharmacy, Okayama University Hospital, 2-5-1 Shikata-cho, Kitaku, Okayama 700-8558, Japan.
| | - Takahiro Niimura
- Department of Clinical Pharmacology and Therapeutics, Tokushima University Graduate School of Biomedical Sciences, 2-50-1 Kuramoto-cho, Tokushima 770-8503, Japan
| | - Masaya Denda
- Clinical Research Center for Developmental Therapeutics, Tokushima University Hospital, 2-50-1 Kuramoto-cho, Tokushima 770-8503, Japan
| | - Kenta Yagi
- Clinical Research Center for Developmental Therapeutics, Tokushima University Hospital, 2-50-1 Kuramoto-cho, Tokushima 770-8503, Japan
| | - Koji Miyata
- Department of Clinical Pharmacology and Therapeutics, Tokushima University Graduate School of Biomedical Sciences, 2-50-1 Kuramoto-cho, Tokushima 770-8503, Japan
| | - Tsung-Jen Lin
- Department of Cell and Molecular Biology, Chang Gung University, No. 259, Wenhua 1st Rd, Guishan District, Taoyuan City, Taiwan
| | - Tsukasa Higashionna
- Department of Pharmacy, Okayama University Hospital, 2-5-1 Shikata-cho, Kitaku, Okayama 700-8558, Japan
| | - Mitsuhiro Goda
- Department of Pharmacy, Tokushima University Hospital, 2-50-1 Kuramoto-cho, Tokushima 770-8503, Japan
| | - Yoshito Zamami
- Department of Pharmacy, Okayama University Hospital, 2-5-1 Shikata-cho, Kitaku, Okayama 700-8558, Japan
| | - Keisuke Ishizawa
- Department of Clinical Pharmacology and Therapeutics, Tokushima University Graduate School of Biomedical Sciences, 2-50-1 Kuramoto-cho, Tokushima 770-8503, Japan; Department of Pharmacy, Tokushima University Hospital, 2-50-1 Kuramoto-cho, Tokushima 770-8503, Japan
| | - Hideki Nawa
- Faculty of Pharmacy, Department of Pharmacy, Shujitsu University, 1-6-1 Nishikawara, Nakaku, Okayama 703-8516, Japan
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Abdel-Kahaar E, Keller F. Clinical Pharmacokinetics and Pharmacodynamics of Voclosporin. Clin Pharmacokinet 2023; 62:693-703. [PMID: 37133755 PMCID: PMC10182160 DOI: 10.1007/s40262-023-01246-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/21/2023] [Indexed: 05/04/2023]
Abstract
Voclosporin is an approved option for the long-term treatment of lupus nephritis. We aimed to provide a narrative review of the pharmacokinetics and pharmacodynamics of voclosporin. In addition, we derived values for pharmacokinetic and pharmacodynamic parameters by graphical analysis of published diagrams. Compared with cyclosporin, low-dose voclosporin is associated with a lower nephrotoxicity risk and, compared to tacrolimus, with a lower diabetes risk. After repetitive dosing of 23.7 mg twice daily and at target trough concentrations of 10-20 ng/mL, the dominant or effect-indicative half-life is estimated at 7 hours. Compared with the pharmacodynamics of cyclosporin, the potency of voclosporin is stronger, with a lower concentration CE50 of 50 ng/mL already producing the half-maximum immunosuppressive effect. The Hill coefficient can be predicted to be low at H = 1.3, indicating a concentration-dependent effect on the immune system. The corresponding effect bisection time of 10 hours allows for dosing every 12 hours. Accordingly, the trough concentration will be above the threshold concentration that produces 5% of the maximum effect of 5.2 ng/mL for immunosuppression but below both the predicted threshold of 30 ng/mL for nephrotoxicity and the predicted threshold of 40 ng/mL for new-onset diabetes. The pharmacokinetic and pharmacodynamic properties suggest the use of low-dose voclosporin combined with mycophenolate and low-dose glucocorticoids for immunosuppressive maintenance therapy.
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Affiliation(s)
- Emaad Abdel-Kahaar
- Institute of Experimental and Clinical Pharmacology, Toxicology and Pharmacology of Natural Products, University Hospital Ulm, Helmholtzstrasse 20, 89081, Ulm, Germany
- Department of Pharmacology, Qena Faculty of Medicine, South Valley University, Qena, Egypt
- , Ulm, Germany
| | - Frieder Keller
- Institute of Experimental and Clinical Pharmacology, Toxicology and Pharmacology of Natural Products, University Hospital Ulm, Helmholtzstrasse 20, 89081, Ulm, Germany.
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Nagy I, Baráth BR, Mangó K, Shemirani AH, Monostory K, Nemes B. The Prognostic Role of CYP Enzyme in Kidney Transplantation: A Single Centre Experience. Transplant Proc 2022; 54:2584-2588. [PMID: 36396462 DOI: 10.1016/j.transproceed.2022.10.046] [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: 11/16/2022]
Abstract
BACKGROUND The main goal of immunosuppressive agents is to reach a balance of preserving allograft function while minimizing adverse effects. The purpose of our research is to corroborate the role of CYP3A enzyme in developing individual medication therapy via measuring medicine levels in patients' blood samples. METHODS This retrospective analysis studies 15 kidney transplant recipients. We carried out genotyping (CYP3A5, CYP3A4) after isolating DNA and RNA in patient and donor blood samples; we also determined CYP3A4 messenger RNA expression in case of recipients. Tacrolimus blood levels, dosage, and tacrolimus concentration normalized by dose and the body weight (C0/D ratio) were evaluated. RESULTS In this research, recipients were divided into 2 groups based on their CYP3A5 genotype. Those who carry CYP3A5*1 allele (*1/*1 or *1/*3) are CYP3A5 expressors, whereas those who are homozygous for the nonfunctional CYP3A5*3 allele are CYP3A5 nonexpressors. There were 3 patients with functioning CYP3A5 enzyme (patients with CYP3A5*1/*3 genotype) where increased tacrolimus metabolism was expected. Our data show that C0/D ratio of CYP3A5 nonexpressors was around 3 times higher than of CYP3A5 expressors. Looking at CYP3A4 enzyme, we found 1 patient carried CYP3A4*22/*22 genotype where we expected decreased CYP3A4 expression. It is clear that this patient had adequate therapy medication levels (9.50 μg/L) despite having received very low dosage of tacrolimus (0.03 mg/weight/d). CONCLUSIONS Our results confirmed the importance of determining CYP status of recipients after a transplant because individual differences were observed in tacrolimus treatment that were partly influenced by CYP status of recipients.
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Affiliation(s)
- Ildikó Nagy
- Department of Transplantation, Institute of Surgery, Faculty of Medicine, University of Debrecen, Debrecen, Hungary.
| | - Benjámin Regő Baráth
- Department of Transplantation, Institute of Surgery, Faculty of Medicine, University of Debrecen, Debrecen, Hungary
| | - Katalin Mangó
- Metabolic Drug Interactions Research Group, Institute of Enzymology, Research Centre for Natural Sciences, Budapest, Hungary
| | - Amir-Houshang Shemirani
- Division of Clinical Laboratory Science, Department of Laboratory Medicine, Faculty of Medicine, University of Debrecen, Debrecen, Hungary
| | - Katalin Monostory
- Metabolic Drug Interactions Research Group, Institute of Enzymology, Research Centre for Natural Sciences, Budapest, Hungary
| | - Balázs Nemes
- Department of Transplantation, Institute of Surgery, Faculty of Medicine, University of Debrecen, Debrecen, Hungary
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7
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Sridharan K, Shah S, Jassim A, Hammad M, Ebrahim Al Gadhban J, Al Segai O. Evaluation of Pharmacogenetics of Drug-Metabolizing Enzymes and Drug Efflux Transporter in Renal Transplants Receiving Immunosuppressants. J Pers Med 2022; 12:jpm12050823. [PMID: 35629245 PMCID: PMC9147030 DOI: 10.3390/jpm12050823] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2022] [Revised: 05/12/2022] [Accepted: 05/14/2022] [Indexed: 02/06/2023] Open
Abstract
Cytochrome P450 (CYP) enzymes, such as CYP3A4, and CYP3A5, P450 oxidoreductase (POR), peroxisome proliferator activated receptor alpha (PPAR-alpha), and drug transporter (ABCB1) were observed to influence concentrations of immunosuppressants (cyclosporine, everolimus, sirolimus, and tacrolimus) and outcomes in renal transplants. We carried out the present study to evaluate the prevalence and impact of these single nucleotide polymorphisms (SNPs) in adult renal transplants. SNPs were evaluated using commercial TaqMan® assays. Serum drug concentrations were estimated using immunoassays. One hundred and forty-six patients were recruited. SNPs in CYP3A5*3 were significantly associated with greater dose-adjusted cyclosporine and tacrolimus concentrations. SNPs in POR*28 were observed with significantly lower dose-adjusted concentrations, particularly with cyclosporine and tacrolimus. ABCB1 homozygous polymorphisms were observed with significantly lower time spent in the therapeutic range with cyclosporine and everolimus/sirolimus. Cyclosporine was observed in a significantly greater proportion of patients with elevated GGT, and SNPs in PPAR-alpha were significantly associated with an increased risk of this adverse event. Hypertriglyceridemia with everolimus was significantly associated with POR*28 polymorphisms. There is a need to validate the influence of these SNPs in a prospective study and develop an algorithm predicting the achievement of target concentrations.
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Affiliation(s)
- Kannan Sridharan
- Department of Pharmacology & Therapeutics, College of Medicine & Medical Sciences, Arabian Gulf University, Manama 328, Bahrain
- Correspondence: ; Tel.: +973-33453123
| | - Shamik Shah
- Department of Nephrology, Salmaniya Medical Complex, Manama 328, Bahrain; (S.S.); (J.E.A.G.)
- Department of Internal Medicine, College of Medicine & Medical Sciences, Arabian Gulf University, Manama 328, Bahrain
| | - Anfal Jassim
- Department of Molecular Medicine, College of Medicine and Medical Sciences, Arabian Gulf University, Manama 328, Bahrain;
| | - Mona Hammad
- Salmaniya Medical Complex, Manama 328, Bahrain;
| | | | - Ola Al Segai
- Department of Biochemistry, Salmaniya Medical Complex, Manama 328, Bahrain;
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Radhakrishnan A, Kuppusamy G, Ponnusankar S, Mutalik S. Towards next-generation personalization of tacrolimus treatment: a review on advanced diagnostic and therapeutic approaches. Pharmacogenomics 2021; 22:1151-1175. [PMID: 34719935 DOI: 10.2217/pgs-2021-0008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
The benefit of personalized medicine is that it allows the customization of drug therapy - maximizing efficacy while avoiding side effects. Genetic polymorphisms are one of the major contributors to interindividual variability. Currently, the only gold standard for applying personalized medicine is dose titration. Because of technological advancements, converting genotypic data into an optimum dose has become easier than in earlier years. However, for many medications, determining a personalized dose may be difficult, leading to a trial-and-error method. On the other hand, the technologically oriented pharmaceutical industry has a plethora of smart drug delivery methods that are underutilized in customized medicine. This article elaborates the genetic polymorphisms of tacrolimus as case study, and extensively covers the diagnostic and therapeutic technologies which aid in the delivery of personalized tacrolimus treatment for better clinical outcomes, thereby providing a new strategy for implementing personalized medicine.
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Affiliation(s)
- Arun Radhakrishnan
- Department of Pharmaceutics, JSS College of Pharmacy, JSS Academy of Higher Education & Research, Ooty, Nilgiris, Tamilnadu, India
| | - Gowthamarajan Kuppusamy
- Department of Pharmaceutics, JSS College of Pharmacy, JSS Academy of Higher Education & Research, Ooty, Nilgiris, Tamilnadu, India
| | - Sivasankaran Ponnusankar
- Department of Pharmacy Practice, JSS College of Pharmacy, JSS Academy of Higher Education & Research, Ooty, Nilgiris, Tamilnadu, India
| | - Srinivas Mutalik
- Department of Pharmaceutics, Manipal College of Pharmaceutical Sciences, Manipal Academy of Higher Education, Karnataka, India
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Al-Kofahi M, Oetting WS, Schladt DP, Remmel RP, Guan W, Wu B, Dorr CR, Mannon RB, Matas AJ, Israni AK, Jacobson PA. Precision Dosing for Tacrolimus Using Genotypes and Clinical Factors in Kidney Transplant Recipients of European Ancestry. J Clin Pharmacol 2021; 61:1035-1044. [PMID: 33512723 PMCID: PMC11240873 DOI: 10.1002/jcph.1823] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2020] [Accepted: 01/26/2021] [Indexed: 12/14/2022]
Abstract
Genetic variation in the CYP3A4 and CYP3A5 (CYP3A4/5) genes, which encode the key enzymes in tacrolimus metabolism, is associated with tacrolimus clearance and dose requirements. Tacrolimus has a narrow therapeutic index with high intra- and intersubject variability, in part because of genetic variation. High tacrolimus clearance and low trough concentration are associated with a greater risk for rejection, whereas high troughs are associated with calcineurin-induced toxicity. The objective of this study was to develop a model of tacrolimus clearance with a dosing equation accounting for genotypes and clinical factors in adult kidney transplant recipients of European ancestry that could preemptively guide dosing. Recipients receiving immediate-release tacrolimus for maintenance immunosuppression from 2 multicenter studies were included. Participants in the GEN03 study were used for tacrolimus model development (n = 608 recipients) and was validated by prediction performance in the DeKAF Genomics study (n = 1361 recipients). Nonlinear mixed-effects modeling was used to develop the apparent oral tacrolimus clearance (CL/F) model. CYP3A4/5 genotypes and clinical covariates were tested for their influence on CL/F. The predictive performance of the model was determined by assessing the bias (median prediction error [ME] and median percentage error [MPE]) and the precision (root median squared error [RMSE]) of the model. CYP3A5*3, CYP3A4*22, corticosteroids, calcium channel blocker and antiviral drug use, age, and diabetes significantly contributed to the interindividual variability of oral tacrolimus apparent clearance. The bias (ME, MPE) and precision (RMSE) of the final model was good, 0.49 ng/mL, 6.5%, and 3.09 ng/mL, respectively. Prospective testing of this equation is warranted.
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Affiliation(s)
- Mahmoud Al-Kofahi
- Department of Experimental and Clinical Pharmacology, College of Pharmacy, University of Minnesota, Minneapolis, Minnesota, USA
| | - William S Oetting
- Department of Experimental and Clinical Pharmacology, College of Pharmacy, University of Minnesota, Minneapolis, Minnesota, USA
| | - David P Schladt
- Hennepin Health Research Institute, Minneapolis, Minnesota, USA
| | - Rory P Remmel
- Department of Medicinal Chemistry, University of Minnesota, Minneapolis, Minnesota, USA
| | - Weihua Guan
- Department of Biostatistics, University of Minnesota, Minneapolis, Minnesota, USA
| | - Baolin Wu
- Department of Biostatistics, University of Minnesota, Minneapolis, Minnesota, USA
| | - Casey R Dorr
- Hennepin Health Research Institute, Minneapolis, Minnesota, USA
- Department of Medicine, Hennepin Healthcare, University of Minnesota, Minneapolis, Minnesota, USA
| | - Roslyn B Mannon
- Division of Nephrology, University of Nebraska, Omaha, Nebraska, USA
| | - Arthur J Matas
- Department of Surgery, University of Minnesota, Minneapolis, Minnesota, USA
| | - Ajay K Israni
- Hennepin Health Research Institute, Minneapolis, Minnesota, USA
- Department of Medicine, Hennepin Healthcare, University of Minnesota, Minneapolis, Minnesota, USA
- Department of Epidemiology & Community Health, University of Minnesota, Minneapolis, Minnesota, USA
| | - Pamala A Jacobson
- Department of Experimental and Clinical Pharmacology, College of Pharmacy, University of Minnesota, Minneapolis, Minnesota, USA
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10
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Significance of Ethnic Factors in Immunosuppressive Therapy Management After Organ Transplantation. Ther Drug Monit 2021; 42:369-380. [PMID: 32091469 DOI: 10.1097/ftd.0000000000000748] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Clinical outcomes after organ transplantation have greatly improved in the past 2 decades with the discovery and development of immunosuppressive drugs such as calcineurin inhibitors, antiproliferative agents, and mammalian target of rapamycin inhibitors. However, individualized dosage regimens have not yet been fully established for these drugs except for therapeutic drug monitoring-based dosage modification because of extensive interindividual variations in immunosuppressive drug pharmacokinetics. The variations in immunosuppressive drug pharmacokinetics are attributed to interindividual variations in the functional activity of cytochrome P450 enzymes, UDP-glucuronosyltransferases, and ATP-binding cassette subfamily B member 1 (known as P-glycoprotein or multidrug resistance 1) in the liver and small intestine. Some genetic variations have been found to be involved to at least some degree in pharmacokinetic variations in post-transplant immunosuppressive therapy. It is well known that the frequencies and effect size of minor alleles vary greatly between different races. Thus, ethnic considerations might provide useful information for optimizing individualized immunosuppressive therapy after organ transplantation. Here, we review ethnic factors affecting the pharmacokinetics of immunosuppressive drugs requiring therapeutic drug monitoring, including tacrolimus, cyclosporine, mycophenolate mofetil, sirolimus, and everolimus.
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11
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Mutawi TM, Zedan MM, Yahya RS, Zakria MM, El-Sawi MR, Gaedigk A. Genetic variability of CYP2D6, CYP3A4 and CYP3A5 among the Egyptian population. Pharmacogenomics 2021; 22:323-334. [PMID: 33789449 DOI: 10.2217/pgs-2020-0140] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
Aim: This study investigated major allelic variants of CYP2D6, CYP3A4 and CYP3A5 in Egyptians, an Arabic population for which there is little information regarding these important pharmacogenes. Patients & methods: CYP2D6*2, *4, *5, *10, *41 and gene copy number variation, as well as CYP3A4*22 and CYP3A5*3 were determined with commercially available TaqMan assays in 145 healthy study participants. Results: The CYP2D6 alleles identified suggest that the prevalence of poor metabolizers is low as none were found among the 145 subjects investigated. The frequency for CYP3A5 nonexpressers was 74.5% and the CYP3A4*22 allele frequency was low at 2.0%. Conclusion: These preliminary findings indicate that pharmacogene variation in Egyptians is different from those of other Middle Eastern/Arabic populations and warrants further investigation.
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Affiliation(s)
- Thuraya M Mutawi
- Department of Laboratories, Children Hospital, Faculty of Medicine, Mansoura University, Mansoura, 35516, Egypt
| | - Mohamed M Zedan
- Department of Pediatrics, Faculty of Medicine, Mansoura University, Mansoura, 35516, Egypt
| | - Raida S Yahya
- Department of Laboratories, Children Hospital, Faculty of Medicine, Mansoura University, Mansoura, 35516, Egypt
| | - Mahmoud M Zakria
- The Urology & Nephrology Center, Faculty of Science, Mansoura University, Mansoura, 35516, Egypt
| | - Mamdouh R El-Sawi
- Physiology Division, Zoology Department, Faculty of Science, Mansoura University, Mansoura, 35516, Egypt
| | - Andrea Gaedigk
- Division of Clinical Pharmacology, Toxicology & Therapeutic Innovation, Children's Mercy Kansas City & School of Medicine, University of Missouri-Kansas City, Kansas City, MO 64108, USA
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12
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Yang H, Sun Y, Yu X, Hu X, Wang W, Zhang X, Liu L. Clinical Impact of the Adaptation of Initial Tacrolimus Dosing to the CYP3A5 Genotype After Kidney Transplantation: Systematic Review and Meta-Analysis of Randomized Controlled Trials. Clin Pharmacokinet 2021; 60:877-885. [PMID: 33751414 DOI: 10.1007/s40262-020-00955-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/16/2020] [Indexed: 10/21/2022]
Abstract
OBJECTIVE The aim of this systematic review and meta-analysis was to compare the clinical outcomes between genotype-guided and conventional tacrolimus doses in kidney transplantation patients. MATERIALS AND METHODS We performed a comprehensive literature search of the PubMed, EMBASE, and Cochrane databases from the date of inception to 26 February 2020. References of the retrieved articles were also reviewed and any further relevant studies were included. The search terms included 'tacrolimus', 'cytochrome P-450 CYP3A', 'polymorphism, genetic', 'genomics', 'genome', 'genotype', 'genes', 'alleles', and 'pharmacogenetics'. RESULTS Our study showed that the genotype-guided group included an increased proportion of patients with tacrolimus concentrations in the therapeutic range at steady state (risk ratio [RR] 1.40, 95% confidence interval [CI] 1.14-1.72, p = 0.001; high quality), with a trend for achieving therapeutic concentrations earlier compared with those in the conventional group. However, there was no statistical difference in the incidence of delayed graft function (RR 1.98, 95% CI 0.92-1.76, p = 0.12; moderate quality), incidence of acute rejection (RR 1.00, 95% CI 0.64-1.55, p = 1.00; moderate quality), incidence of graft survival censored for death (RR 1.02, 95% CI 0.98-1.06, p = 0.37; moderate quality), and incidence of adverse effects (AEs). CONCLUSIONS Although the genotype-guided group had a higher proportion of patients within the targeted concentration and less median time to achieve the therapeutic range, the clinical endpoints, including delayed graft function, acute rejection, graft survival censored for death, and AEs were similar in both groups. All in all, evidence suggested there was no utility in pharmacogenetics for tacrolimus based on the cytochrome P450 (CYP) 3A5 genotype. Studies with Chinese and African American populations are needed due to the frequency of genetic polymorphisms of CYP3A5. Furthermore, a dosing algorithm that includes demographic and clinical factors plus multiple genetic variants should be added for consideration, and may optimize early tacrolimus exposure.
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Affiliation(s)
- Hui Yang
- Department of Pharmacy, Beijing Chao-Yang Hospital, Capital Medical University, 8 Gongren Tiyuchang Nanlu, Chaoyang District, Beijing, China
| | - Yiqi Sun
- Department of Pharmacy, Beijing Chao-Yang Hospital, Capital Medical University, 8 Gongren Tiyuchang Nanlu, Chaoyang District, Beijing, China
| | - Xiaojia Yu
- Department of Pharmacy, Beijing Chao-Yang Hospital, Capital Medical University, 8 Gongren Tiyuchang Nanlu, Chaoyang District, Beijing, China
| | - Xiaopeng Hu
- Department of Urology, Beijing Chao-Yang Hospital, Capital Medical University, Beijing, China
| | - Wei Wang
- Department of Urology, Beijing Chao-Yang Hospital, Capital Medical University, Beijing, China
| | - Xiaodong Zhang
- Department of Urology, Beijing Chao-Yang Hospital, Capital Medical University, Beijing, China
| | - Lihong Liu
- Department of Pharmacy, Beijing Chao-Yang Hospital, Capital Medical University, 8 Gongren Tiyuchang Nanlu, Chaoyang District, Beijing, China.
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13
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Csikány N, Kiss Á, Déri M, Fekete F, Minus A, Tóth K, Temesvári M, Sárváry E, Bihari L, Gerlei Z, Kóbori L, Monostory K. Clinical significance of personalized tacrolimus dosing by adjusting to donor CYP3A-status in liver transplant recipients. Br J Clin Pharmacol 2020; 87:1790-1800. [PMID: 32986876 DOI: 10.1111/bcp.14566] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2020] [Revised: 09/02/2020] [Accepted: 09/17/2020] [Indexed: 02/06/2023] Open
Abstract
Donor's CYP3A-status (CYP3A5 genotype and CYP3A4 expression) can provide prognostic information regarding tacrolimus-metabolizing capacity of the liver graft and initial tacrolimus dosing for therapeutic blood concentrations in liver transplants. The present work prospectively investigated whether CYP3A-status guided tacrolimus therapy has any potential clinical benefit for recipients in the early postoperative period. METHODS The contribution of preliminary assaying of donor CYP3A-status to the optimization of initial tacrolimus therapy and to the reduction of adverse events (acute rejection, infection, nephrotoxicity) was investigated in 112 liver transplant recipients (CYPtest group) comparing to 101 control patients on tacrolimus concentration guided therapy. RESULTS The time for achieving therapeutic tacrolimus concentration was significantly reduced, confirming potential benefit of initial tacrolimus therapy adjusted to donor's CYP3A-status over classical clinical practice of tacrolimus concentration guided treatment (4 vs 8 days, P < 0.0001). Acute rejection episodes (3.6 vs 23.8%, P < 0.0001) and tacrolimus induced nephrotoxicity (8 vs 27%, P = 0.0004) were less frequent in CYPtest group than in control patients, whereas occurrence of infectious disease was not influenced by tacrolimus dosing strategy (3.6 vs 5.9% in CYPtest and control groups, P > 0.05). Acute rejection was often accompanied with tacrolimus blood concentrations lower than 10 ng mL-1 (20/24 of control and 2/4 of CYPtest patients), while nephrotoxicity was associated with high tacrolimus concentrations (>20 ng mL-1 ) in the first week after transplantation (13/27 of control and 2/9 of CYPtest patients). CONCLUSION CYP3A-status guided therapy significantly improved the risk of misdosing induced early adverse effects (acute rejection, nephrotoxicity).
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Affiliation(s)
- Nóra Csikány
- Institute of Enzymology, Research Centre for Natural Sciences, Budapest, Hungary.,Department of Transplantation and Surgery, Semmelweis University, Budapest, Hungary
| | - Ádám Kiss
- Institute of Enzymology, Research Centre for Natural Sciences, Budapest, Hungary
| | - Máté Déri
- Institute of Enzymology, Research Centre for Natural Sciences, Budapest, Hungary
| | - Ferenc Fekete
- Institute of Enzymology, Research Centre for Natural Sciences, Budapest, Hungary
| | - Annamária Minus
- Institute of Enzymology, Research Centre for Natural Sciences, Budapest, Hungary
| | - Katalin Tóth
- Institute of Enzymology, Research Centre for Natural Sciences, Budapest, Hungary
| | - Manna Temesvári
- Institute of Enzymology, Research Centre for Natural Sciences, Budapest, Hungary
| | - Enikő Sárváry
- Department of Transplantation and Surgery, Semmelweis University, Budapest, Hungary
| | - László Bihari
- Department of Transplantation and Surgery, Semmelweis University, Budapest, Hungary
| | - Zsuzsa Gerlei
- Department of Transplantation and Surgery, Semmelweis University, Budapest, Hungary
| | - László Kóbori
- Department of Transplantation and Surgery, Semmelweis University, Budapest, Hungary
| | - Katalin Monostory
- Institute of Enzymology, Research Centre for Natural Sciences, Budapest, Hungary
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14
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Genvigir FDV, Campos-Salazar AB, Felipe CR, Tedesco-Silva H, Medina-Pestana JO, Doi SDQ, Cerda A, Hirata MH, Herrero MJ, Aliño SF, Hirata RDC. CYP3A5*3 and CYP2C8*3 variants influence exposure and clinical outcomes of tacrolimus-based therapy. Pharmacogenomics 2020; 21:7-21. [PMID: 31849280 DOI: 10.2217/pgs-2019-0120] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
Aim: The influence of variants in pharmacokinetics-related genes on long-term exposure to tacrolimus (TAC)-based therapy and clinical outcomes was investigated. Patients & methods: Brazilian kidney recipients were treated with TAC combined with everolimus (n = 178) or mycophenolate sodium (n = 97). The variants in CYP2C8, CYP2J2, CYP3A4, CYP3A5, POR, ABCB1, ABCC2, ABCG2, SLCO1B1 and SLCO2B1 were analyzed. Main results: CYP3A5*3/*3 genotype influenced increase in TAC concentration from week 1 to month 6 post-transplantation (p < 0.05). The living donor and CYP2C8*3 variant were associated with reduced risk for delayed graft function (OR = 0.07; 95% CI = 0.03-0.18 and OR = 0.45; 95% CI = 0.20-0.99, respectively, p < 0.05). Conclusion: The CYP3A5*3 variant is associated with increased early exposure to TAC. Living donor and CYP2C8*3 variant seem to be protective factors for delayed graft function in kidney recipients.
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Affiliation(s)
- Fabiana Dalla Vecchia Genvigir
- Department of Clinical & Toxicological Analyses, School of Pharmaceutical Sciences, University of Sao Paulo, Sao Paulo, Brazil
| | - Antony Brayan Campos-Salazar
- Department of Clinical & Toxicological Analyses, School of Pharmaceutical Sciences, University of Sao Paulo, Sao Paulo, Brazil.,Bioinformatics & Pharmacogenetics Laboratory, METOSMOD Research Group, School of Pharmacy & Biochemistry, Universidad Nacional Mayor de San Marcos, Lima, Peru
| | - Claudia Rosso Felipe
- Nephrology Division, Hospital do Rim, Federal University of Sao Paulo, Sao Paulo, Brazil
| | - Helio Tedesco-Silva
- Nephrology Division, Hospital do Rim, Federal University of Sao Paulo, Sao Paulo, Brazil
| | | | - Sonia de Quateli Doi
- Nephrology Research Laboratory, School of Medicine, Uniformed Services University, Bethesda, MD, USA
| | - Alvaro Cerda
- Department of Basic Sciences, Center of Excellence in Translational Medicine, BIOREN, Universidad de La Frontera, Temuco, Chile
| | - Mario Hiroyuki Hirata
- Department of Clinical & Toxicological Analyses, School of Pharmaceutical Sciences, University of Sao Paulo, Sao Paulo, Brazil
| | - María José Herrero
- Department of Pharmacology, University of Valencia. Pharmacogenetics, Instituto Investigación Sanitaria y Hospital La Fe, Valencia, Spain
| | - Salvador Francisco Aliño
- Department of Pharmacology, University of Valencia. Pharmacogenetics, Instituto Investigación Sanitaria y Hospital La Fe, Valencia, Spain
| | - Rosario Dominguez Crespo Hirata
- Department of Clinical & Toxicological Analyses, School of Pharmaceutical Sciences, University of Sao Paulo, Sao Paulo, Brazil
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15
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Zhu J, Pasternak AL, Crona DJ. The future of research into genetics and the precision dosing of tacrolimus: what do we need to know? Pharmacogenomics 2020; 21:1061-1064. [PMID: 32896220 DOI: 10.2217/pgs-2020-0093] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Affiliation(s)
- Jing Zhu
- Division of Pharmacotherapy & Experimental Therapeutics, UNC Eshelman School of Pharmacy, University of North Carolina, Chapel Hill, NC 27599, USA
| | - Amy L Pasternak
- Department of Clinical Pharmacy, College of Pharmacy, University of Michigan, Ann Arbor, MI 48109, USA.,Department of Pharmacy, Michigan Medicine, Ann Arbor, MI 48109, USA
| | - Daniel J Crona
- Division of Pharmacotherapy & Experimental Therapeutics, UNC Eshelman School of Pharmacy, University of North Carolina, Chapel Hill, NC 27599, USA.,UNC Lineberger Comprehensive Cancer Center, Chapel Hill, NC 27599, USA.,Department of Pharmacy, UNC Hospitals & Clinics, Chapel Hill, NC 27514, USA
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16
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Influence of CYP3A polymorphisms on tacrolimus pharmacokinetics in kidney transplant recipients. THE PHARMACOGENOMICS JOURNAL 2020; 21:69-77. [PMID: 32843687 DOI: 10.1038/s41397-020-00179-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/27/2018] [Revised: 05/11/2020] [Accepted: 08/12/2020] [Indexed: 12/19/2022]
Abstract
Tacrolimus is characterized by a highly variable pharmacokinetics (PK) and a small therapeutic window. It is metabolized specifically by the CYP3A isoenzymes. This study aimed to determine, in kidney transplant patients, the influence of different genotypic clusters involving these SNPs CYP3A4*1B, CYP3A4*22, and CYP3A5*3 on Tacrolimus bioavailability during the first (PTP1) and the second (PTP2) posttransplant phase (PT). We included kidney transplant patients who received Tacrolimus and underwent drug monitoring by C0 monitoring. CYP3A4 and CYP3A5 genotyping were performed using PCR-RFLP. We classified the patients into four groups: Slow, Intermediate, rapid, and ultra-rapid metabolizers. We included 80 patients. The Tacrolimus dose-normalized C0 (C0/D ratio) was significantly decreased in intermediate, rapid, and ultra-rapid comparing with slow metabolisers. During PTP1 only CYP3A5*3 and CYP3A4*22 polymorphisms correlate significantly with C0/D ratio. Regardless of the PT phase and during the late one, only the CYP3A4 polymorphisms correlate significantly with the C0/D ratio. We identified that these SNPs are all associated independently with Tacrolimus exposure in different PT phases. Moreover, we are the first to define a genotypic cluster including the three CYP3A SNPs.
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17
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Impacts of High Intra- and Inter-Individual Variability in Tacrolimus Pharmacokinetics and Fast Tacrolimus Metabolism on Outcomes of Solid Organ Transplant Recipients. J Clin Med 2020; 9:jcm9072193. [PMID: 32664531 PMCID: PMC7408675 DOI: 10.3390/jcm9072193] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2020] [Accepted: 07/09/2020] [Indexed: 12/14/2022] Open
Abstract
Tacrolimus is a first-line calcineurin inhibitor (CNI) and an integral part of the immunosuppressive strategy in solid organ transplantation. Being a dose-critical drug, tacrolimus has a narrow therapeutic index that necessitates periodic monitoring to maintain the drug’s efficacy and reduce the consequences of overexposure. Tacrolimus is characterized by substantial intra- and inter-individual pharmacokinetic variability. At steady state, the tacrolimus blood concentration to daily dose ratio (C/D ratio) has been described as a surrogate for the estimation of the individual metabolism rate, where a low C/D ratio reflects a higher rate of metabolism. Fast tacrolimus metabolism (low C/D ratio) is associated with the risk of poor outcomes after transplantation, including reduced allograft function and survival, higher allograft rejection, CNI nephrotoxicity, a faster decline in kidney function, reduced death-censored graft survival (DCGS), post-transplant lymphoproliferative disorders, dyslipidemia, hypertension, and cardiovascular events. In this article, we discuss the potential role of the C/D ratio in a noninvasive monitoring strategy for identifying patients at risk for potential adverse events post-transplant.
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18
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Zhu J, Patel T, Miller JA, Torrice CD, Aggarwal M, Sketch MR, Alexander MD, Armistead PM, Coghill JM, Grgic T, Jamieson KJ, Ptachcinski JR, Riches ML, Serody JS, Schmitz JL, Shaw JR, Shea TC, Suzuki O, Vincent BG, Wood WA, Rao KV, Wiltshire T, Weimer ET, Crona DJ. Influence of Germline Genetics on Tacrolimus Pharmacokinetics and Pharmacodynamics in Allogeneic Hematopoietic Stem Cell Transplant Patients. Int J Mol Sci 2020; 21:E858. [PMID: 32013193 PMCID: PMC7037631 DOI: 10.3390/ijms21030858] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2020] [Revised: 01/24/2020] [Accepted: 01/25/2020] [Indexed: 02/06/2023] Open
Abstract
Tacrolimus exhibits high inter-patient pharmacokinetics (PK) variability, as well as a narrow therapeutic index, and therefore requires therapeutic drug monitoring. Germline mutations in cytochrome P450 isoforms 4 and 5 genes (CYP3A4/5) and the ATP-binding cassette B1 gene (ABCB1) may contribute to interindividual tacrolimus PK variability, which may impact clinical outcomes among allogeneic hematopoietic stem cell transplantation (HSCT) patients. In this study, 252 adult patients who received tacrolimus for acute graft versus host disease (aGVHD) prophylaxis after allogeneic HSCT were genotyped to evaluate if germline genetic variants associated with tacrolimus PK and pharmacodynamic (PD) variability. Significant associations were detected between germline variants in CYP3A4/5 and ABCB1 and PK endpoints (e.g., median steady-state tacrolimus concentrations and time to goal tacrolimus concentration). However, significant associations were not observed between CYP3A4/5 or ABCB1 germline variants and PD endpoints (e.g., aGVHD and treatment-emergent nephrotoxicity). Decreased age and CYP3A5*1/*1 genotype were independently associated with subtherapeutic tacrolimus trough concentrations while CYP3A5*1*3 or CYP3A5*3/*3 genotypes, myeloablative allogeneic HSCT conditioning regimen (MAC) and increased weight were independently associated with supratherapeutic tacrolimus trough concentrations. Future lines of prospective research inquiry are warranted to use both germline genetic and clinical data to develop precision dosing tools that will optimize both tacrolimus dosing and clinical outcomes among adult HSCT patients.
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Affiliation(s)
- Jing Zhu
- The Center for Pharmacogenomics and Individualized Therapy, Division of Pharmacotherapy and Experimental Therapeutics, University of North Carolina Eshelman School of Pharmacy, Chapel Hill, NC 27599, USA; (J.Z.); (T.P.); (C.D.T.); (M.A.); (M.R.S.); (O.S.); (T.W.)
| | - Tejendra Patel
- The Center for Pharmacogenomics and Individualized Therapy, Division of Pharmacotherapy and Experimental Therapeutics, University of North Carolina Eshelman School of Pharmacy, Chapel Hill, NC 27599, USA; (J.Z.); (T.P.); (C.D.T.); (M.A.); (M.R.S.); (O.S.); (T.W.)
| | - Jordan A. Miller
- Department of Pharmacy, University of North Carolina Hospitals and Clinics, Chapel Hill, NC 27599, USA; (J.A.M.); (M.D.A.); (T.G.); (J.R.P.); (J.R.S.); (K.V.R.)
| | - Chad D. Torrice
- The Center for Pharmacogenomics and Individualized Therapy, Division of Pharmacotherapy and Experimental Therapeutics, University of North Carolina Eshelman School of Pharmacy, Chapel Hill, NC 27599, USA; (J.Z.); (T.P.); (C.D.T.); (M.A.); (M.R.S.); (O.S.); (T.W.)
| | - Mehak Aggarwal
- The Center for Pharmacogenomics and Individualized Therapy, Division of Pharmacotherapy and Experimental Therapeutics, University of North Carolina Eshelman School of Pharmacy, Chapel Hill, NC 27599, USA; (J.Z.); (T.P.); (C.D.T.); (M.A.); (M.R.S.); (O.S.); (T.W.)
| | - Margaret R. Sketch
- The Center for Pharmacogenomics and Individualized Therapy, Division of Pharmacotherapy and Experimental Therapeutics, University of North Carolina Eshelman School of Pharmacy, Chapel Hill, NC 27599, USA; (J.Z.); (T.P.); (C.D.T.); (M.A.); (M.R.S.); (O.S.); (T.W.)
| | - Maurice D. Alexander
- Department of Pharmacy, University of North Carolina Hospitals and Clinics, Chapel Hill, NC 27599, USA; (J.A.M.); (M.D.A.); (T.G.); (J.R.P.); (J.R.S.); (K.V.R.)
- Division of Practice Advancement and Clinical Education, University of North Carolina Eshelman School of Pharmacy, Chapel Hill, NC 27599, USA
| | - Paul M. Armistead
- Division of Hematology and Oncology, Department of Medicine, University of North Carolina, Chapel Hill, NC 27599, USA; (P.M.A.); (J.M.C.); (K.J.J.); (M.L.R.); (J.S.S.); (T.C.S.); (B.G.V.); (W.A.W.)
- Lineberger Comprehensive Cancer Center, University of North Carolina, Chapel Hill, NC 27599, USA
| | - James M. Coghill
- Division of Hematology and Oncology, Department of Medicine, University of North Carolina, Chapel Hill, NC 27599, USA; (P.M.A.); (J.M.C.); (K.J.J.); (M.L.R.); (J.S.S.); (T.C.S.); (B.G.V.); (W.A.W.)
- Lineberger Comprehensive Cancer Center, University of North Carolina, Chapel Hill, NC 27599, USA
| | - Tatjana Grgic
- Department of Pharmacy, University of North Carolina Hospitals and Clinics, Chapel Hill, NC 27599, USA; (J.A.M.); (M.D.A.); (T.G.); (J.R.P.); (J.R.S.); (K.V.R.)
| | - Katarzyna J. Jamieson
- Division of Hematology and Oncology, Department of Medicine, University of North Carolina, Chapel Hill, NC 27599, USA; (P.M.A.); (J.M.C.); (K.J.J.); (M.L.R.); (J.S.S.); (T.C.S.); (B.G.V.); (W.A.W.)
- Lineberger Comprehensive Cancer Center, University of North Carolina, Chapel Hill, NC 27599, USA
| | - Jonathan R. Ptachcinski
- Department of Pharmacy, University of North Carolina Hospitals and Clinics, Chapel Hill, NC 27599, USA; (J.A.M.); (M.D.A.); (T.G.); (J.R.P.); (J.R.S.); (K.V.R.)
- Division of Practice Advancement and Clinical Education, University of North Carolina Eshelman School of Pharmacy, Chapel Hill, NC 27599, USA
| | - Marcie L. Riches
- Division of Hematology and Oncology, Department of Medicine, University of North Carolina, Chapel Hill, NC 27599, USA; (P.M.A.); (J.M.C.); (K.J.J.); (M.L.R.); (J.S.S.); (T.C.S.); (B.G.V.); (W.A.W.)
- Lineberger Comprehensive Cancer Center, University of North Carolina, Chapel Hill, NC 27599, USA
| | - Jonathan S. Serody
- Division of Hematology and Oncology, Department of Medicine, University of North Carolina, Chapel Hill, NC 27599, USA; (P.M.A.); (J.M.C.); (K.J.J.); (M.L.R.); (J.S.S.); (T.C.S.); (B.G.V.); (W.A.W.)
- Lineberger Comprehensive Cancer Center, University of North Carolina, Chapel Hill, NC 27599, USA
| | - John L. Schmitz
- Department of Pathology & Laboratory Medicine, University of North Carolina at Chapel Hill School of Medicine, Chapel Hill, NC 27599, USA; (J.L.S.); (E.T.W.)
| | - J. Ryan Shaw
- Department of Pharmacy, University of North Carolina Hospitals and Clinics, Chapel Hill, NC 27599, USA; (J.A.M.); (M.D.A.); (T.G.); (J.R.P.); (J.R.S.); (K.V.R.)
| | - Thomas C. Shea
- Division of Hematology and Oncology, Department of Medicine, University of North Carolina, Chapel Hill, NC 27599, USA; (P.M.A.); (J.M.C.); (K.J.J.); (M.L.R.); (J.S.S.); (T.C.S.); (B.G.V.); (W.A.W.)
- Lineberger Comprehensive Cancer Center, University of North Carolina, Chapel Hill, NC 27599, USA
| | - Oscar Suzuki
- The Center for Pharmacogenomics and Individualized Therapy, Division of Pharmacotherapy and Experimental Therapeutics, University of North Carolina Eshelman School of Pharmacy, Chapel Hill, NC 27599, USA; (J.Z.); (T.P.); (C.D.T.); (M.A.); (M.R.S.); (O.S.); (T.W.)
| | - Benjamin G. Vincent
- Division of Hematology and Oncology, Department of Medicine, University of North Carolina, Chapel Hill, NC 27599, USA; (P.M.A.); (J.M.C.); (K.J.J.); (M.L.R.); (J.S.S.); (T.C.S.); (B.G.V.); (W.A.W.)
- Lineberger Comprehensive Cancer Center, University of North Carolina, Chapel Hill, NC 27599, USA
| | - William A. Wood
- Division of Hematology and Oncology, Department of Medicine, University of North Carolina, Chapel Hill, NC 27599, USA; (P.M.A.); (J.M.C.); (K.J.J.); (M.L.R.); (J.S.S.); (T.C.S.); (B.G.V.); (W.A.W.)
- Lineberger Comprehensive Cancer Center, University of North Carolina, Chapel Hill, NC 27599, USA
| | - Kamakshi V. Rao
- Department of Pharmacy, University of North Carolina Hospitals and Clinics, Chapel Hill, NC 27599, USA; (J.A.M.); (M.D.A.); (T.G.); (J.R.P.); (J.R.S.); (K.V.R.)
- Division of Practice Advancement and Clinical Education, University of North Carolina Eshelman School of Pharmacy, Chapel Hill, NC 27599, USA
| | - Tim Wiltshire
- The Center for Pharmacogenomics and Individualized Therapy, Division of Pharmacotherapy and Experimental Therapeutics, University of North Carolina Eshelman School of Pharmacy, Chapel Hill, NC 27599, USA; (J.Z.); (T.P.); (C.D.T.); (M.A.); (M.R.S.); (O.S.); (T.W.)
- Lineberger Comprehensive Cancer Center, University of North Carolina, Chapel Hill, NC 27599, USA
| | - Eric T. Weimer
- Department of Pathology & Laboratory Medicine, University of North Carolina at Chapel Hill School of Medicine, Chapel Hill, NC 27599, USA; (J.L.S.); (E.T.W.)
| | - Daniel J. Crona
- The Center for Pharmacogenomics and Individualized Therapy, Division of Pharmacotherapy and Experimental Therapeutics, University of North Carolina Eshelman School of Pharmacy, Chapel Hill, NC 27599, USA; (J.Z.); (T.P.); (C.D.T.); (M.A.); (M.R.S.); (O.S.); (T.W.)
- Department of Pharmacy, University of North Carolina Hospitals and Clinics, Chapel Hill, NC 27599, USA; (J.A.M.); (M.D.A.); (T.G.); (J.R.P.); (J.R.S.); (K.V.R.)
- Lineberger Comprehensive Cancer Center, University of North Carolina, Chapel Hill, NC 27599, USA
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