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Sommer J, Wozniak J, Schmitt J, Koch J, Stingl JC, Just KS. Assessment of Substrate Status of Drugs Metabolized by Polymorphic Cytochrome P450 (CYP) 2 Enzymes: An Analysis of a Large-Scale Dataset. Biomedicines 2024; 12:161. [PMID: 38255266 PMCID: PMC10813138 DOI: 10.3390/biomedicines12010161] [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: 11/23/2023] [Revised: 01/02/2024] [Accepted: 01/03/2024] [Indexed: 01/24/2024] Open
Abstract
BACKGROUND The analysis of substrates of polymorphic cytochrome P450 (CYP) enzymes is important information to enable drug-drug interactions (DDIs) analysis and the relevance of pharmacogenetics in this context in large datasets. Our aim was to compare different approaches to assess the substrate properties of drugs for certain polymorphic CYP2 enzymes. METHODS A standardized manual method and an automatic method were developed and compared to assess the substrate properties for the metabolism of drugs by CYP2D6, 2C9, and 2C19. The automatic method used a matching approach to three freely available resources. We applied the manual and automatic methods to a large real-world dataset deriving from a prospective multicenter study collecting adverse drug reactions in emergency departments in Germany (ADRED). RESULTS In total, 23,878 medication entries relating to 895 different drugs were analyzed in the real-world dataset. The manual method was able to assess 12.2% (n = 109) of drugs, and the automatic method between 12.1% (n = 109) and 88.9% (n = 796), depending on the resource used. The CYP substrate classifications demonstrated moderate to almost perfect agreements for CYP2D6 and CYP2C19 (Cohen's Kappa (κ) 0.48-0.90) and fair to moderate agreements for CYP2C9 (κ 0.20-0.48). CONCLUSION A closer look at different classifications between methods revealed that both methods are prone to error in different ways. While the automated method excels in time efficiency, completeness, and actuality, the manual method might be better able to identify CYP2 substrates with clinical relevance.
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Affiliation(s)
- Jakob Sommer
- Institute of Clinical Pharmacology, University Hospital of RWTH Aachen, 52074 Aachen, Germany; (J.S.); (J.W.); (J.K.); (J.C.S.)
- Department of Radiology and Biomedical Imaging, Yale University School of Medicine, New Haven, CT 06510, USA
| | - Justyna Wozniak
- Institute of Clinical Pharmacology, University Hospital of RWTH Aachen, 52074 Aachen, Germany; (J.S.); (J.W.); (J.K.); (J.C.S.)
| | - Judith Schmitt
- Institute of Clinical Pharmacology, University Hospital of RWTH Aachen, 52074 Aachen, Germany; (J.S.); (J.W.); (J.K.); (J.C.S.)
| | - Jana Koch
- Institute of Clinical Pharmacology, University Hospital of RWTH Aachen, 52074 Aachen, Germany; (J.S.); (J.W.); (J.K.); (J.C.S.)
| | - Julia C. Stingl
- Institute of Clinical Pharmacology, University Hospital of RWTH Aachen, 52074 Aachen, Germany; (J.S.); (J.W.); (J.K.); (J.C.S.)
| | - Katja S. Just
- Institute of Clinical Pharmacology, University Hospital of RWTH Aachen, 52074 Aachen, Germany; (J.S.); (J.W.); (J.K.); (J.C.S.)
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Extended Pharmacist Assessment of Medication Safety for Nursing Home Residents—A Cross-Sectional and Prospective Study. J Clin Med 2022; 11:jcm11216602. [DOI: 10.3390/jcm11216602] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2022] [Revised: 11/03/2022] [Accepted: 11/04/2022] [Indexed: 11/09/2022] Open
Abstract
In the routine pharmacist’s medication review in ambulatory care and nursing homes in Germany, clinical diagnoses are often insufficiently considered as they are frequently not accessible to pharmacists and their electronic support tools. This may leave a significant proportion of medication-related problems (MRP) undetected and unresolved. Moreover, limited and incomplete data may promote spurious alerts of low clinical relevance. In order to assess the impact of improved data availability, we conducted a study (German Clinical Trials Register DRKS00025346) to evaluate the impact of an extended pharmacist’s medication review, made possible by diagnosis data being routinely available to the pharmacist. At six nursing homes in the Nuremberg metropolitan area, 338 patients treated by 32 physicians were enrolled. A pharmacist’s medication review, considering only the medication data, identified 114 potential MRPs, and additional consideration of diagnoses further identified 69 potential MRPs. The physicians adapted the therapy in response to 69.9% of alerts. The observed gain in MRP identified indicates that efforts should be intensified to facilitate and improve consideration of drug–diagnosis-related MRP by improving data sharing and communication between pharmacists and physicians caring for nursing home residents.
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De Pretis F, van Gils M, Forsberg MM. A smart hospital-driven approach to precision pharmacovigilance. Trends Pharmacol Sci 2022; 43:473-481. [PMID: 35490032 DOI: 10.1016/j.tips.2022.03.009] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2021] [Revised: 02/25/2022] [Accepted: 03/22/2022] [Indexed: 01/03/2023]
Abstract
Researchers, regulatory agencies, and the pharmaceutical industry are moving towards precision pharmacovigilance as a comprehensive framework for drug safety assessment, at the service of the individual patient, by clustering specific risk groups in different databases. This article explores its implementation by focusing on: (i) designing a new data collection infrastructure, (ii) exploring new computational methods suitable for drug safety data, and (iii) providing a computer-aided framework for distributed clinical decisions with the aim of compiling a personalized information leaflet with specific reference to a drug's risks and adverse drug reactions. These goals can be achieved by using 'smart hospitals' as the principal data sources and by employing methods of precision medicine and medical statistics to supplement current public health decisions.
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Affiliation(s)
- Francesco De Pretis
- VTT Technical Research Centre of Finland Ltd, 70210 Kuopio, Finland; Department of Communication and Economics, University of Modena and Reggio Emilia, 42121 Reggio Emilia, Italy.
| | - Mark van Gils
- Faculty of Medicine and Health Technology, Tampere University, 33720 Tampere, Finland
| | - Markus M Forsberg
- VTT Technical Research Centre of Finland Ltd, 70210 Kuopio, Finland; School of Pharmacy, University of Eastern Finland, 70211 Kuopio, Finland
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Just KS. [Current Challenges in Pharmacotherapy]. Anasthesiol Intensivmed Notfallmed Schmerzther 2021; 56:652-665. [PMID: 34704243 DOI: 10.1055/a-1226-4647] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
Analysis of preoperative medication is used to assess the benefit and risk associated with continuing or discontinuing medication before and during surgery. Identifying adverse drug reactions and assessing its risks often leads to uncertainty. Typical challenges are medication underuse, but also overuse occurs and is often more difficult to recognize, especially in the context of drug interactions and individual patient characteristics.Typical consequences of multi-medication and medical overuse may include an increased potential for drug interactions, an increased risk of adverse drug reactions and medication errors, and in particular in older adults, geriatric syndromes may occur or worsen. Adverse drug reactions may occur as a result of the dose administered and as an effect of time of exposure. Older, multi-morbid, and multi-medicated patients are often affected by adverse drug reactions. For drugs primarily metabolized via the phase I enzymes CYP2D6, CYP2C9, or CYP2C19, pharmacogenetically rapid or slow metabolism may result in altered drug exposures. Clinically relevant pharmacokinetic drug interactions frequently occur with drugs primarily metabolized via the phase I enzyme CYP3A4.
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Individualized versus Standardized Risk Assessment in Patients at High Risk for Adverse Drug Reactions (The IDrug Randomized Controlled Trial)-Never Change a Running System? Pharmaceuticals (Basel) 2021; 14:ph14101056. [PMID: 34681280 PMCID: PMC8538435 DOI: 10.3390/ph14101056] [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: 09/23/2021] [Revised: 10/08/2021] [Accepted: 10/11/2021] [Indexed: 11/17/2022] Open
Abstract
The aim of this study was to compare effects of an individualized with a standardized risk assessment for adverse drug reactions to improve drug treatment with antithrombotic drugs in older adults. A randomized controlled trial was conducted in general practitioner (GP) offices. Patients aged 60 years and older, multi-morbid, taking antithrombotic drugs and at least one additional drug continuously were randomized to individualized and standardized risk assessment groups. Patients were followed up for nine months. A composite endpoint defined as at least one bleeding, thromboembolic event or death reported via a trigger list was used. Odds ratios (OR) and 95% confidence intervals (CI) were calculated. In total, N = 340 patients were enrolled from 43 GP offices. Patients in the individualized risk assessment group met the composite endpoint more often than in the standardized group (OR 1.63 [95%CI 1.02-2.63]) with multiple adjustments. The OR was higher in patients on phenprocoumon treatment (OR 1.99 [95%CI 1.05-3.76]), and not significant on DOAC treatment (OR 1.52 [95%CI 0.63-3.69]). Pharmacogenenetic variants of CYP2C9, 2C19 and VKORC1 were not observed to be associated with the composite endpoint. The results of this study may indicate that the time point for implementing individualized risk assessments is of importance.
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Just KS, Dormann H, Freitag M, Schurig M, Böhme M, Steffens M, Scholl C, Seufferlein T, Graeff I, Schwab M, Stingl JC. CYP2D6 in the Brain: Potential Impact on Adverse Drug Reactions in the Central Nervous System-Results From the ADRED Study. Front Pharmacol 2021; 12:624104. [PMID: 34025403 PMCID: PMC8138470 DOI: 10.3389/fphar.2021.624104] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2020] [Accepted: 04/19/2021] [Indexed: 12/15/2022] Open
Abstract
Cytochrome P450 (CYP) 2D6 is a polymorphic enzyme expressed in the central nervous system (CNS), important in drug metabolism and with a potentially constitutive role in CNS function such as vigilance. This study aimed to analyze variability in CYP2D6 activity linked to vigilance-related adverse drug reactions (ADRs) in the CNS. A dataset of N = 2939 ADR cases of the prospective multicenter observational trial in emergency departments (EDs) (ADRED; trial registration: DRKS-ID: DRKS00008979) was analyzed. Dizziness as the most frequent reported CNS ADR symptom (12.7% of patients, n = 372) related to vigilance was chosen as the outcome. The association of dizziness with CYP2D6 activity markers was analyzed. The number of CYP2D6 substrates taken, a CYP2D6 saturation score (no, moderate, and strong saturation), a CYP2D6 saturation/inhibition score (no, weak, moderate, and strong), and composed CYP2D6 activity using a genotyped subsample (n = 740) calculating additive effects of genotype and CYP2D6 saturation by drug exposure were used as CYP2D6 activity markers. Effects were compared to other frequent nonvigilance-related CNS ADR symptoms (syncope and headache). Secondary analyses were conducted to control for other ADR symptoms frequently associated with dizziness (syncope, nausea, and falls). The majority of all patients (64.5%, n = 1895) took at least one drug metabolized by CYP2D6. Around a third took a CNS drug (32.5%, n = 955). The chance to present with drug-related dizziness to the ED increased with each CYP2D6 substrate taken by OR 1.11 [1.01–1.23]. Presenting with drug-related dizziness was more likely with CYP2D6 saturation and saturation/inhibition (both OR 1.27 [1.00–1.60]). The composed CYP2D6 activity was positively associated with dizziness (p = 0.028), while poorer activity affected patients more often with dizziness as an ADR. In contrast, nonvigilance-related ADR symptoms such as syncope and nausea were not consistently significantly associated with CYP2D6 activity markers. This study shows an association between the number of CYP2D6 substrates, the predicted CYP2D6 activity, and the occurrence of dizziness as a CNS ADR symptom. As dizziness is a vigilance-related CNS symptom, patients with low CYP2D6 activity might be more vulnerable to drug-related dizziness. This study underlines the need for understanding individual drug metabolism activity and individual risks for ADRs.
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Affiliation(s)
- Katja S Just
- Institute of Clinical Pharmacology, University Hospital of RWTH Aachen, Aachen, Germany
| | - Harald Dormann
- Central Emergency Department, Hospital Fürth, Fürth, Germany
| | - Mathias Freitag
- Department of Geriatric Medicine, University Hospital of RWTH Aachen, Aachen, Germany
| | - Marlen Schurig
- Research Department, Federal Institute of Drugs and Medical Devices, Bonn, Germany
| | - Miriam Böhme
- Research Department, Federal Institute of Drugs and Medical Devices, Bonn, Germany
| | - Michael Steffens
- Research Department, Federal Institute of Drugs and Medical Devices, Bonn, Germany
| | - Catharina Scholl
- Research Department, Federal Institute of Drugs and Medical Devices, Bonn, Germany
| | - Thomas Seufferlein
- Internal Medicine Emergency Department, Ulm University Medical Centre, Ulm, Germany
| | - Ingo Graeff
- Interdisciplinary Emergency Department (INZ), University Hospital of Bonn, Bonn, Germany
| | - Matthias Schwab
- Dr. Margarete Fischer-Bosch-Institute of Clinical Pharmacology, Stuttgart, Germany.,Department of Clinical Pharmacology, University of Tuebingen, Tuebingen, Germany.,Department of Pharmacy and Biochemistry, University of Tuebingen, Tuebingen, Germany
| | - Julia C Stingl
- Institute of Clinical Pharmacology, University Hospital of RWTH Aachen, Aachen, Germany
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de Vries FM, Stingl JC, Breteler MMB. Polypharmacy, potentially inappropriate medication and pharmacogenomics drug exposure in the Rhineland Study. Br J Clin Pharmacol 2021; 87:2732-2756. [PMID: 33232531 DOI: 10.1111/bcp.14671] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2020] [Revised: 11/06/2020] [Accepted: 11/16/2020] [Indexed: 01/03/2023] Open
Abstract
AIM High medication use may contribute to the efficiency of drug therapy in general, but it could also increase the burden of adverse drug reactions. We aimed to assess medication use and the prevalence of three risk factors for adverse drug reactions: the use of polypharmacy, potentially inappropriate medication in the elderly and pharmacogenomic polymorphisms affecting the metabolism of drugs. METHODS Cross-sectional interview-based medication data (including over-the-counter drugs) was collected in a large population-based cohort (≥30 years of age) in Bonn, Germany. RESULTS Analyses were based on the first 5000 participants of the Rhineland Study (mean age 55 years, 57% women). Of our participants, 66.0% reported the use of a drug regularly, which increased to 87.4% in participants aged ≥65 years (n = 1301). The rates of use of polypharmacy, potentially inappropriate medication and pharmacogenomic drugs were 15.9%, 6.4% and 20.5%, respectively. In participants <65 years, 16.0% (95% CI 14.8, 17.3) had at least one risk factor. In participants aged ≥65 years, 54.1% (95% CI 51.4, 56.8) had at least one and 27.4% (95% CI 25.0, 29.9) had at least two risk factors. Extrapolating these numbers to the German population implies that around 9 million of the 17 million individuals aged 65 years or older are potentially at an elevated risk for adverse drug reactions, of which 4.6 million are at a potentially highly elevated risk for adverse drug reactions. CONCLUSION Our study shows that drug use is common and the individual risk for an adverse drug reaction in our population is high. This suggests room for improvement in general medication use.
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Affiliation(s)
- Folgerdiena M de Vries
- Population Health Sciences, German Center for Neurodegenerative Diseases (DZNE), Bonn, Germany
| | - Julia C Stingl
- Institute of Clinical Pharmacology, University Hospital of RWTH Aachen, Aachen, Germany
| | - Monique M B Breteler
- Population Health Sciences, German Center for Neurodegenerative Diseases (DZNE), Bonn, Germany.,Institute for Medical Biometry, Informatics and Epidemiology (IMBIE), Faculty of Medicine, University of Bonn, Bonn, Germany
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