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Poweleit EA, Vaughn SE, Desta Z, Dexheimer JW, Strawn JR, Ramsey LB. Machine Learning-Based Prediction of Escitalopram and Sertraline Side Effects With Pharmacokinetic Data in Children and Adolescents. Clin Pharmacol Ther 2024; 115:860-870. [PMID: 38297828 PMCID: PMC11046530 DOI: 10.1002/cpt.3184] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2023] [Accepted: 01/04/2024] [Indexed: 02/02/2024]
Abstract
Selective serotonin reuptake inhibitors (SSRI) are the first-line pharmacologic treatment for anxiety and depressive disorders in children and adolescents. Many patients experience side effects that are difficult to predict, are associated with significant morbidity, and can lead to treatment discontinuation. Variation in SSRI pharmacokinetics could explain differences in treatment outcomes, but this is often overlooked as a contributing factor to SSRI tolerability. This study evaluated data from 288 escitalopram-treated and 255 sertraline-treated patients ≤ 18 years old to develop machine learning models to predict side effects using electronic health record data and Bayesian estimated pharmacokinetic parameters. Trained on a combined cohort of escitalopram- and sertraline-treated patients, a penalized logistic regression model achieved an area under the receiver operating characteristic curve (AUROC) of 0.77 (95% confidence interval (CI): 0.66-0.88), with 0.69 sensitivity (95% CI: 0.54-0.86), and 0.82 specificity (95% CI: 0.72-0.87). Medication exposure, clearance, and time since the last dose increase were among the top features. Individual escitalopram and sertraline models yielded an AUROC of 0.73 (95% CI: 0.65-0.81) and 0.64 (95% CI: 0.55-0.73), respectively. Post hoc analysis showed sertraline-treated patients with activation side effects had slower clearance (P = 0.01), which attenuated after accounting for age (P = 0.055). These findings raise the possibility that a machine learning approach leveraging pharmacokinetic data can predict escitalopram- and sertraline-related side effects. Clinicians may consider differences in medication pharmacokinetics, especially during dose titration and as opposed to relying on dose, when managing side effects. With further validation, application of this model to predict side effects may enhance SSRI precision dosing strategies in youth.
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Affiliation(s)
- Ethan A. Poweleit
- Division of Biomedical Informatics, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH, USA
- Department of Biomedical Informatics, University of Cincinnati, College of Medicine, Cincinnati, OH, USA
- Division of Research in Patient Services, Department of Pediatrics, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH, USA
- Division of Clinical Pharmacology, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH, USA
| | - Samuel E. Vaughn
- Department of Pediatrics, University of Cincinnati, College of Medicine, Cincinnati, OH
- Division of Child and Adolescent Psychiatry, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH, USA
- Department of Psychiatry and Behavioral Neuroscience, University of Cincinnati, College of Medicine, Cincinnati, OH, USA
| | - Zeruesenay Desta
- Division of Clinical Pharmacology, Indiana University, School of Medicine, Indianapolis, IN
| | - Judith W. Dexheimer
- Division of Biomedical Informatics, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH, USA
- Department of Pediatrics, University of Cincinnati, College of Medicine, Cincinnati, OH
- Division of Emergency Medicine, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH
| | - Jeffrey R. Strawn
- Division of Clinical Pharmacology, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH, USA
- Department of Pediatrics, University of Cincinnati, College of Medicine, Cincinnati, OH
- Division of Child and Adolescent Psychiatry, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH, USA
- Department of Psychiatry and Behavioral Neuroscience, University of Cincinnati, College of Medicine, Cincinnati, OH, USA
| | - Laura B. Ramsey
- Department of Psychiatry and Behavioral Neuroscience, University of Cincinnati, College of Medicine, Cincinnati, OH, USA
- Division of Clinical Pharmacology, Toxicology & Therapeutic Innovation, Children’s Mercy Kansas City, Kansas City, MO, USA
- School of Medicine, University of Missouri-Kansas City, Kansas City, Missouri, USA
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Miles N, Masters A, Desta Z, Goldman JL, Suppes SL, Tillman EM. Multidisciplinary Approach to Deciphering Etoposide Infusion Reactions and Potential Role of Polyethersulfone Filter Membranes. J Pediatr Pharmacol Ther 2023; 28:643-648. [PMID: 38025152 PMCID: PMC10681083 DOI: 10.5863/1551-6776-28.7.643] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2022] [Accepted: 03/07/2023] [Indexed: 12/01/2023]
Abstract
PURPOSE Etoposide, a topoisomerase II inhibitor used clinically to treat cancer, has been associated with severe anaphylactic infusion related adverse drug reactions (ADRs). In a previous study we identified a hydrophilic polyethersulfone filter as a possible cause of increased rates of pediatric etoposide infusion reactions. In this multidisciplinary follow-up analytical study, we aimed to assess the chemical structure of etoposide after passing through the same hydrophilic polyethersulfone filter. METHODS An etoposide 0.4 mg/mL infusion was prepared under aseptic conditions and then passed through a standard IV infusion set with an in-line filter in place. Samples were taken in triplicate using a needle-less access system to include sampling sites directly from the IV bag port and from the IV tubing both before and after the in-line filter. Samples were diluted into mobile phase, then an aliquot was injected into a high-performance liquid chromatography mass spectrometry HPLC-MS (Thermo TSQ Quantum Ultra) system coupled to a Diode Array Detector (DAD) (Thermo Dionex Ultimate 3000). Etoposide was monitored using a selected reaction monitoring scan (SRM) of 606.2/228.8 and wavelengths of 210, 220, 254, and 280 nm for 30 minutes. RESULTS No detectable differences were observed upon comparing the three samples. Based on these results, a chemical change in etoposide resulting from an in-line filter is unlikely to be the primary cause of increased rates of infusion reactions. CONCLUSION Pharmacists working in healthcare systems, observe many ADRs, but rarely have the resources necessary to investigate the potential etiology or causality. This report highlights importance of multi-disciplinary collaboration to investigate serious ADRs.
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Affiliation(s)
- Nicholas Miles
- Division of Clinical Pharmacology (NM, ZD, ET), Indiana University School of Medicine, Indianapolis, IN
| | - Andi Masters
- Indiana University Comprehensive Cancer Center (AM), Indiana University School of Medicine, Indianapolis, IN
| | - Zeruesenay Desta
- Division of Clinical Pharmacology (NM, ZD, ET), Indiana University School of Medicine, Indianapolis, IN
| | - Jennifer L. Goldman
- Department of Pediatrics (JLG), Children's Mercy Hospital and the University of Missouri-Kansas City, Kansas City, MO
| | - Sarah L. Suppes
- Division of Clinical Pharmacology (SLS), Toxicology, and Therapeutic Innovation, Children's Mercy Hospital, Kansas City, MO
| | - Emma M. Tillman
- Division of Clinical Pharmacology (NM, ZD, ET), Indiana University School of Medicine, Indianapolis, IN
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Eadon MT, Rosenman MB, Zhang P, Fulton CR, Callaghan JT, Holmes AM, Levy KD, Gupta SK, Haas DM, Vuppalanchi R, Benson EA, Kreutz RP, Tillman EM, Shugg T, Pierson RC, Gufford BT, Pratt VM, Zang Y, Desta Z, Dexter PR, Skaar TC. The INGENIOUS trial: Impact of pharmacogenetic testing on adverse events in a pragmatic clinical trial. Pharmacogenomics J 2023; 23:169-177. [PMID: 37689822 PMCID: PMC10805517 DOI: 10.1038/s41397-023-00315-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/22/2023] [Revised: 08/20/2023] [Accepted: 08/23/2023] [Indexed: 09/11/2023]
Abstract
Adverse drug events (ADEs) account for a significant mortality, morbidity, and cost burden. Pharmacogenetic testing has the potential to reduce ADEs and inefficacy. The objective of this INGENIOUS trial (NCT02297126) analysis was to determine whether conducting and reporting pharmacogenetic panel testing impacts ADE frequency. The trial was a pragmatic, randomized controlled clinical trial, adapted as a propensity matched analysis in individuals (N = 2612) receiving a new prescription for one or more of 26 pharmacogenetic-actionable drugs across a community safety-net and academic health system. The intervention was a pharmacogenetic testing panel for 26 drugs with dosage and selection recommendations returned to the health record. The primary outcome was occurrence of ADEs within 1 year, according to modified Common Terminology Criteria for Adverse Events (CTCAE). In the propensity-matched analysis, 16.1% of individuals experienced any ADE within 1-year. Serious ADEs (CTCAE level ≥ 3) occurred in 3.2% of individuals. When combining all 26 drugs, no significant difference was observed between the pharmacogenetic testing and control arms for any ADE (Odds ratio 0.96, 95% CI: 0.78-1.18), serious ADEs (OR: 0.91, 95% CI: 0.58-1.40), or mortality (OR: 0.60, 95% CI: 0.28-1.21). However, sub-group analyses revealed a reduction in serious ADEs and death in individuals who underwent pharmacogenotyping for aripiprazole and serotonin or serotonin-norepinephrine reuptake inhibitors (OR 0.34, 95% CI: 0.12-0.85). In conclusion, no change in overall ADEs was observed after pharmacogenetic testing. However, limitations incurred during INGENIOUS likely affected the results. Future studies may consider preemptive, rather than reactive, pharmacogenetic panel testing.
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Affiliation(s)
- Michael T Eadon
- Indiana University School of Medicine, Department of Medicine, Indianapolis, IN, USA
| | - Marc B Rosenman
- Ann & Robert H. Lurie Children's Hospital of Chicago, and Northwestern University Feinberg School of Medicine, Chicago, IL, 60611, USA
| | - Pengyue Zhang
- Indiana University School of Medicine, Department of Biostatistics and Heath Data Science, Indianapolis, IN, USA
| | - Cathy R Fulton
- Luddy School of Informatics, Computing, and Engineering, Indianapolis, IN, 46202, USA
| | - John T Callaghan
- Indiana University School of Medicine, Department of Medicine, Indianapolis, IN, USA
| | - Ann M Holmes
- Indiana University Richard M. Fairbanks School of Public Health, Indianapolis, IN, 46202, USA
| | - Kenneth D Levy
- Indiana University School of Medicine, Department of Medicine, Indianapolis, IN, USA
| | - Samir K Gupta
- Indiana University School of Medicine, Department of Medicine, Indianapolis, IN, USA
| | - David M Haas
- Indiana University School of Medicine, Department of Obstetrics and Gynecology, Indianapolis, IN, USA
| | - Raj Vuppalanchi
- Indiana University School of Medicine, Department of Medicine, Indianapolis, IN, USA
| | - Eric A Benson
- Indiana University School of Medicine, Department of Medicine, Indianapolis, IN, USA
| | - Rolf P Kreutz
- Indiana University School of Medicine, Department of Medicine, Indianapolis, IN, USA
| | - Emma M Tillman
- Indiana University School of Medicine, Department of Medicine, Indianapolis, IN, USA
| | - Tyler Shugg
- Indiana University School of Medicine, Department of Medicine, Indianapolis, IN, USA
| | - Rebecca C Pierson
- Indiana University School of Medicine, Department of Medicine, Indianapolis, IN, USA
- Indiana University School of Medicine, Department of Obstetrics and Gynecology, Indianapolis, IN, USA
- Community Fertility Specialty Care, Indianapolis, IN, USA
| | - Brandon T Gufford
- Indiana University School of Medicine, Department of Medicine, Indianapolis, IN, USA
| | - Victoria M Pratt
- Indiana University School of Medicine, Department of Medical and Molecular Genetics, Indianapolis, IN, USA
| | - Yong Zang
- Indiana University School of Medicine, Department of Biostatistics and Heath Data Science, Indianapolis, IN, USA
| | - Zeruesenay Desta
- Indiana University School of Medicine, Department of Medicine, Indianapolis, IN, USA
| | - Paul R Dexter
- Indiana University School of Medicine, Department of Medicine, Indianapolis, IN, USA
| | - Todd C Skaar
- Indiana University School of Medicine, Department of Medicine, Indianapolis, IN, USA.
- Indiana University School of Medicine, Department of Medical and Molecular Genetics, Indianapolis, IN, USA.
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Poweleit EA, Taylor ZL, Mizuno T, Vaughn SE, Desta Z, Strawn JR, Ramsey LB. Escitalopram and Sertraline Population Pharmacokinetic Analysis in Pediatric Patients. Clin Pharmacokinet 2023; 62:1621-1637. [PMID: 37755681 PMCID: PMC11003701 DOI: 10.1007/s40262-023-01294-8] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/27/2023] [Indexed: 09/28/2023]
Abstract
BACKGROUND AND OBJECTIVE Escitalopram and sertraline are commonly prescribed for anxiety and depressive disorders in children and adolescents. The pharmacokinetics (PK) of these medications have been evaluated in adults and demonstrate extensive variability, but studies in pediatric patients are limited. Therefore, we performed a population PK analysis for escitalopram and sertraline in children and adolescents to characterize the effects of demographic, clinical, and pharmacogenetic factors on drug exposure. METHODS A PK dataset was generated by extracting data from the electronic health record and opportunistic sampling of escitalopram- and sertraline-treated psychiatrically hospitalized pediatric patients aged 5-18 years. A population PK analysis of escitalopram and sertraline was performed using NONMEM. Concentration-time profiles were simulated using MwPharm++ to evaluate how covariates included in the final models influence medication exposure and compared to adult therapeutic reference ranges. RESULTS The final escitalopram cohort consisted of 315 samples from 288 patients, and the sertraline cohort consisted of 265 samples from 255 patients. A one-compartment model with a proportional residual error model best described the data for both medications. For escitalopram, CYP2C19 phenotype and concomitant CYP2C19 inhibitors affected apparent clearance (CL/F), and normalizing CL/F and apparent volume of distribution (V/F) to body surface area (BSA) improved estimations. The final escitalopram model estimated CL/F and V/F at 14.2 L/h/1.73 m2 and 428 L/1.73 m2, respectively. For sertraline, CYP2C19 phenotype and concomitant CYP2C19 inhibitors influenced CL/F, and empirical allometric scaling of patient body weight on CL/F and V/F was significant. The final sertraline model estimated CL/F and V/F at 124 L/h/70 kg and 4320 L/70 kg, respectively. Normalized trough concentrations (Ctrough) for CYP2C19 poor metabolizers taking escitalopram were 3.98-fold higher compared to normal metabolizers (151.1 ng/mL vs 38.0 ng/mL, p < 0.0001), and normalized Ctrough for CYP2C19 poor metabolizers taking sertraline were 3.23-fold higher compared to normal, rapid, and ultrarapid metabolizers combined (121.7 ng/mL vs 37.68 ng/mL, p < 0.0001). Escitalopram- and sertraline-treated poor metabolizers may benefit from a dose reduction of 50-75% and 25-50%, respectively, to normalize exposure to other phenotypes. CONCLUSION To our knowledge, this is the largest population PK analysis of escitalopram and sertraline in pediatric patients. Significant PK variability for both medications was observed and was largely explained by CYP2C19 phenotype. Slower CYP2C19 metabolizers taking escitalopram or sertraline may benefit from dose reductions given increased exposure.
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Affiliation(s)
- Ethan A Poweleit
- Division of Biomedical Informatics, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
- Department of Biomedical Informatics, College of Medicine, University of Cincinnati, Cincinnati, OH, USA
- Division of Research in Patient Services, Department of Pediatrics, Cincinnati Children's Hospital Medical Center, 3333 Burnet Avenue, MLC 6018, Cincinnati, OH, 45229, USA
- Division of Clinical Pharmacology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Zachary L Taylor
- Division of Clinical Pharmacology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Tomoyuki Mizuno
- Division of Clinical Pharmacology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
- Department of Pediatrics, College of Medicine, University of Cincinnati, Cincinnati, OH, USA
| | - Samuel E Vaughn
- Department of Pediatrics, College of Medicine, University of Cincinnati, Cincinnati, OH, USA
- Division of Child and Adolescent Psychiatry, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Zeruesenay Desta
- Division of Clinical Pharmacology, School of Medicine, Indiana University, Indianapolis, IN, USA
| | - Jeffrey R Strawn
- Division of Child and Adolescent Psychiatry, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
- Division of Clinical Pharmacology, School of Medicine, Indiana University, Indianapolis, IN, USA
- Department of Psychiatry and Behavioral Neuroscience, College of Medicine, University of Cincinnati, Cincinnati, OH, USA
| | - Laura B Ramsey
- Division of Research in Patient Services, Department of Pediatrics, Cincinnati Children's Hospital Medical Center, 3333 Burnet Avenue, MLC 6018, Cincinnati, OH, 45229, USA.
- Division of Clinical Pharmacology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA.
- Department of Pediatrics, College of Medicine, University of Cincinnati, Cincinnati, OH, USA.
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Powell NR, Liang T, Ipe J, Cao S, Skaar TC, Desta Z, Qian HR, Ebert PJ, Chen Y, Thomas MK, Chalasani N. Clinically important alterations in pharmacogene expression in histologically severe nonalcoholic fatty liver disease. Nat Commun 2023; 14:1474. [PMID: 36927865 PMCID: PMC10020163 DOI: 10.1038/s41467-023-37209-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2022] [Accepted: 03/07/2023] [Indexed: 03/18/2023] Open
Abstract
Polypharmacy is common in patients with nonalcoholic fatty liver disease (NAFLD) and previous reports suggest that NAFLD is associated with altered drug disposition. This study aims to determine if patients with NAFLD are at risk for altered drug response by characterizing changes in hepatic mRNA expression of genes mediating drug disposition (pharmacogenes) across the histological NAFLD severity spectrum. We utilize RNA-seq for 93 liver biopsies with histologically staged NAFLD Activity Score (NAS), fibrosis stage, and steatohepatitis (NASH). We identify 37 significant pharmacogene-NAFLD severity associations including CYP2C19 downregulation. We chose to validate CYP2C19 due to its actionability in drug prescribing. Meta-analysis of 16 independent studies demonstrate that CYP2C19 is significantly downregulated to 46% in NASH, to 58% in high NAS, and to 43% in severe fibrosis. Our data demonstrate the downregulation of CYP2C19 in NAFLD which supports developing personalized medicine approaches for drugs sensitive to metabolism by the CYP2C19 enzyme.
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Affiliation(s)
- Nicholas R Powell
- Indiana University School of Medicine, Department of Medicine, Division of Clinical Pharmacology, Indianapolis, IN, USA
| | - Tiebing Liang
- Indiana University School of Medicine, Department of Medicine, Division of Gastroenterology Hepatology, Indianapolis, IN, USA
| | - Joseph Ipe
- Indiana University School of Medicine, Department of Medicine, Division of Clinical Pharmacology, Indianapolis, IN, USA
| | - Sha Cao
- Indiana University School of Medicine, Department of Medicine, Division of Gastroenterology Hepatology, Indianapolis, IN, USA
| | - Todd C Skaar
- Indiana University School of Medicine, Department of Medicine, Division of Clinical Pharmacology, Indianapolis, IN, USA
| | - Zeruesenay Desta
- Indiana University School of Medicine, Department of Medicine, Division of Clinical Pharmacology, Indianapolis, IN, USA
| | | | | | - Yu Chen
- Eli Lilly and Company, Indianapolis, IN, USA
| | | | - Naga Chalasani
- Indiana University School of Medicine, Department of Medicine, Division of Gastroenterology Hepatology, Indianapolis, IN, USA.
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Haddad TC, Suman V, Giridhar KV, Moreno-Aspitia A, Northfelt D, Ernst B, Sideras K, O’Sullivan CC, Singh R, Desta Z, Taraba J, Goodnature B, Goetz MP, Wang L, Ingle JN. Abstract OT1-04-02: Anastrozole dose escalation for optimal estrogen suppression in postmenopausal early stage breast cancer: A prospective trial. Cancer Res 2023. [DOI: 10.1158/1538-7445.sabcs22-ot1-04-02] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/06/2023]
Abstract
Abstract
Introduction: We performed matched case-control studies utilizing cohorts of postmenopausal women with ER+ breast cancer receiving adjuvant aromatase inhibitors (AI) on MA.27 [anastrozole, exemestane] or PreFace [letrozole] to assess the association between estrogen suppression after 6 months of treatment and an early breast cancer (EBC) event within 5 years of AI initiation (Clin Cancer Res 2020;26:2986-98). We found a significant 3.0-fold increase in risk of an EBC event for those taking anastrozole with levels of estrone (E1) ≥1.3 pg/mL and estradiol (E2) ≥0.5 pg/mL, but not for exemestane or letrozole. Given these findings we designed a prospective pharmacodynamic (PD) study to evaluate the impact of anastrozole (1 mg/day: ANA1) on E1 and E2 levels, and among those with inadequate estrogen suppression (IES: E1 ≥1.3 pg/mL and E2 ≥0.5 pg/mL), to evaluate the safety and PD efficacy of high-dose anastrozole (10 mg/day: ANA10), which has been found to be safe in prior clinical trials (Cancer 1998;83:1142-52). Methods: Post-menopausal women with stage I-III, ER ≥1% positive/HER2-negative breast cancer who were candidates for anastrozole were eligible after completion of locoregional therapy and chemotherapy, as clinically indicated. Women who were pre-menopausal at diagnosis were not eligible. All patients received 8-10 weeks of ANA1, after which those with adequate estrogen suppression (AES: E1< 1.3 pg/mL or E2< 0.5 pg/mL) came off study. Those with IES went on to receive ANA10 for 8-10 weeks, followed by letrozole (2.5 mg/day: LET) for 8-10 weeks. All patients were managed at their treating oncologist’s discretion following study discontinuation. E1 and E2 blood levels were measured pre-treatment and after completion of each treatment cycle by a CLIA-approved liquid chromatography with tandem mass spectrometry in the Immunochemical Core Laboratory at Mayo Clinic. With a sample size of 29 patients with IES after ANA1, a one-sided binomial test of proportions with a significance level of 0.05 will have an 87% chance of rejecting the proportion with AES after ANA10 is at most 25% (Ho) when the true proportion is at least 50%. Specifically, the null hypothesis is rejected if the number of women with AES after ANA10 is 12 or more. Data lock was July 6, 2022. Results: Of the 161 women enrolled from April 2020 through May 2022, 3 withdrew consent prior to start of ANA1 and 2 were ineligible; thus, 156 women comprised the study cohort. Median patient age was 64 years (range 44-86), 10% of patients were of Hispanic ethnicity and/or non-white race, and 15% received chemotherapy. Six patients remain on ANA1, and 10 discontinued ANA1 due to refusal (7), adverse event (AE) (2), or COVID-19 (1). Forty-one of the remaining 140 patients (29.3%; 95%CI: 21.9-37.6%) had IES with ANA1. Nine of these 41 patients did not go on to ANA10 due to refusal (6) or AE (3). Of the 32 patients who started ANA10, 8 remain on treatment, 5 discontinued due to refusal (3) or AE (1-grade 2 urinary tract infection; 1-grade 1 palpitations), and 19 had a blood draw 45 days or more after starting ANA10. No grade 3-5 AEs or grade 2 hot flashes or arthralgias were reported. Of these 19 patients, 14 achieved AES with ANA10 (73.7%; 95%CI: 48.8-90.9%). All 19 patients switched to LET of which 3 remain on treatment, 1 is missing E1/E2 data, and 15 had a blood draw 45 days or more after starting LET. Of these 15 patients, 10 maintained AES, 2 acquired AES with LET, and 3 no longer had AES. Anastrozole and letrozole drug levels will be reported at the meeting. Conclusions: Approximately 29% of postmenopausal women with ER+/HER2- BC receiving adjuvant anastrozole 1 mg/daily had IES. A majority of these patients achieved AES with dose escalation to ANA10 without tolerability issues. E1 and E2 levels are logical biomarkers given the mechanism of action of anastrozole, and further study utilizing them to determine the optimal dose of anastrozole for a given patient should be performed.
Citation Format: Tufia C. Haddad, Vera Suman, Karthik V. Giridhar, Alvaro Moreno-Aspitia, Donald Northfelt, Brenda Ernst, Kostandinos Sideras, Ciara C. O’Sullivan, Ravinder Singh, Zeruesenay Desta, Jodi Taraba, Barbara Goodnature, Matthew P. Goetz, Liewei Wang, James N. Ingle. Anastrozole dose escalation for optimal estrogen suppression in postmenopausal early stage breast cancer: A prospective trial [abstract]. In: Proceedings of the 2022 San Antonio Breast Cancer Symposium; 2022 Dec 6-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2023;83(5 Suppl):Abstract nr OT1-04-02.
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Affiliation(s)
| | | | | | | | | | | | | | | | | | | | | | - Barbara Goodnature
- 12Mayo Clinic Breast Cancer Specialized Program of Research Excellence, Rochester, Minnesota
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Bamfo NO, Lu JB, Desta Z. Stereoselective Metabolism of Bupropion to Active Metabolites in Cellular Fractions of Human Liver and Intestine. Drug Metab Dispos 2023; 51:54-66. [PMID: 35512805 PMCID: PMC9832377 DOI: 10.1124/dmd.122.000867] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2022] [Revised: 03/07/2022] [Accepted: 04/12/2022] [Indexed: 01/14/2023] Open
Abstract
Striking stereoselective disposition of the antidepressant and smoking cessation aid bupropion (BUP) and its active metabolites observed clinically influence patients' response to BUP therapy and its clinically important drug-drug interactions (DDI) with CYP2D6 substrates. However, understanding of the biochemical mechanisms responsible is incomplete. This study comprehensively examined hepatic and extrahepatic stereoselective metabolism of BUP in vitro Racemic-, R-, and S-BUP were incubated separately with pooled cellular fractions of human liver [microsomes (HLMs), S9 fractions (HLS9s), and cytosols (HLCs)] and intestinal [microsomes (HIMs), S9 fractions (HIS9s), and cytosols (HICs)] and cofactors. Formations of diastereomers of 4-hydroxyBUP (OHBUP), threohydroBUP (THBUP), and erythrohydroBUP (EHBUP) were quantified using a novel chiral ultra-high performance liquid chromatography/tandem mass spectrometry method. Racemic BUP (but not R- or S-BUP) was found suitable to determine stereoselective metabolism of BUP; both enantiomers showed complete racemization. Compared with that of RR-THBUP, the in vitro intrinsic clearance (Clint) for the formation of SS-THBUP was 42-, 19-, and 8.3-fold higher in HLMs, HLS9 fractions, and HLCs, respectively; Clint for the formation of SS-OHBUP and RS-EHBUP was also higher (2.7- to 3.9-fold) than their R-derived counterparts. In cellular fractions of human intestine, ≥ 95% of total reduction was accounted by the formation of RR-THBUP. Ours is the first to demonstrate marked stereoselective reduction of BUP in HLCs, HIMs, HIS9 fractions, and HICs, providing the first evidence for tissue- and cellular fraction-dependent stereoselective metabolism of BUP. These data may serve as the first critical step toward understanding factors dictating BUP's stereoselective disposition, effects, and DDI risks. SIGNIFICANCE STATEMENT: This work provides a deeper insight into bupropion (BUP) stereoselective oxidation and reduction to active metabolites in cellular fractions of human liver and intestine tissues. The results demonstrate tissue- and cellular fraction-dependent stereospecific metabolism of BUP. These data may improve prediction of BUP stereoselective disposition and understanding of BUP's effects and CYP2D6-dependent drug-drug interaction in vivo.
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Affiliation(s)
- Nadia O Bamfo
- Division of Clinical Pharmacology, Indiana University School of Medicine, Indianapolis, Indiana
| | - Jessica Bl Lu
- Division of Clinical Pharmacology, Indiana University School of Medicine, Indianapolis, Indiana
| | - Zeruesenay Desta
- Division of Clinical Pharmacology, Indiana University School of Medicine, Indianapolis, Indiana
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Hertz DL, Douglas JA, Miller RM, Kidwell KM, Gersch CL, Desta Z, Storniolo AM, Stearns V, Skaar TC, Hayes DF, Henry NL, Rae JM. Genome-wide association study of aromatase inhibitor discontinuation due to musculoskeletal symptoms. Support Care Cancer 2022; 30:8059-8067. [PMID: 35776183 PMCID: PMC9529953 DOI: 10.1007/s00520-022-07243-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2022] [Accepted: 06/20/2022] [Indexed: 10/17/2022]
Abstract
OBJECTIVE Aromatase inhibitors (AIs) are commonly used to treat hormone receptor positive (HR +) breast cancer. AI-induced musculoskeletal syndrome (AIMSS) is a common toxicity that causes AI treatment discontinuation. The objective of this genome-wide association study (GWAS) was to identify genetic variants associated with discontinuation of AI therapy due to AIMSS and attempt to replicate previously reported associations. METHODS In the Exemestane and Letrozole Pharmacogenetics (ELPh) study, postmenopausal patients with HR + non-metastatic breast cancer were randomized to letrozole or exemestane. Genome-wide genotyping of germline DNA was conducted followed by imputation. Each imputed variant was tested for association with time-to-treatment discontinuation due to AIMSS using a Cox proportional hazards model assuming additive genetic effects and adjusting for age, baseline pain score, prior taxane treatment, and AI arm. Secondary analyses were conducted within each AI arm and analyses of candidate variants previously reported to be associated with AIMSS risk. RESULTS Four hundred ELPh participants were included in the combined analysis. Two variants surpassed the genome-wide significance level in the primary analysis (p value < 5 × 10-8), an intronic variant (rs79048288) within CCDC148 (HR = 4.42, 95% CI: 2.67-7.33) and an intergenic variant (rs912571) upstream of PPP1R14C (HR = 0.30, 95% CI: 0.20-0.47). In the secondary analysis, rs74418677, which is known to be associated with expression of SUPT20H, was significantly associated with discontinuation of letrozole therapy due to AIMSS (HR = 5.91, 95% CI: 3.16-11.06). We were able to replicate associations for candidate variants previously reported to be associated with AIMSS in this cohort, but were not able to replicate associations for any other variants previously reported in other patient cohorts. CONCLUSIONS Our GWAS findings identify several candidate variants that may be associated with AIMSS risk from AI generally or letrozole specifically. Validation of these associations in independent cohorts is needed before translating these findings into clinical practice to improve treatment outcomes in patients with HR + breast cancer.
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Affiliation(s)
- Daniel L Hertz
- Department of Clinical Pharmacy, University of Michigan College of Pharmacy, 428 Church St., Room 3054, Ann Arbor, MI, 48109-1065, USA.
| | - Julie A Douglas
- Department of Mathematics and Statistics, Skidmore College, Saratoga Springs, NY, 12866, USA
- Department of Human Genetics, University of Michigan Medical School, Ann Arbor, MI, USA
| | - Robert M Miller
- Department of Mathematics and Statistics, Skidmore College, Saratoga Springs, NY, 12866, USA
| | - Kelley M Kidwell
- Department of Biostatistics, University of Michigan School of Public Health, Ann Arbor, MI, USA
| | - Christina L Gersch
- Department of Internal Medicine, Division of Hematology/Oncology, University of Michigan Medical School, Ann Arbor, MI, USA
| | | | | | - Vered Stearns
- Johns Hopkins School of Medicine, Baltimore, MD, USA
| | - Todd C Skaar
- Indiana University School of Medicine, Indianapolis, IN, USA
| | - Daniel F Hayes
- Department of Internal Medicine, Division of Hematology/Oncology, University of Michigan Medical School, Ann Arbor, MI, USA
| | - N Lynn Henry
- Department of Internal Medicine, Division of Hematology/Oncology, University of Michigan Medical School, Ann Arbor, MI, USA
| | - James M Rae
- Department of Internal Medicine, Division of Hematology/Oncology, University of Michigan Medical School, Ann Arbor, MI, USA
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Gufford BT, Metzger IF, Bamfo NO, Benson EA, Masters AR, Lu JBL, Desta Z.
Influence of CYP2B6 Pharmacogenetics on Stereoselective Inhibition and Induction of Bupropion Metabolism by Efavirenz in Healthy Volunteers.
. J Pharmacol Exp Ther 2022; 382:JPET-AR-2022-001277. [PMID: 35798386 PMCID: PMC9426761 DOI: 10.1124/jpet.122.001277] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2022] [Revised: 06/12/2022] [Accepted: 06/14/2022] [Indexed: 11/22/2022] Open
Abstract
We investigated the acute and chronic effects of efavirenz, a widely used antiretroviral drug, and CYP2B6 genotypes on the disposition of racemic and stereoisomers of bupropion (BUP) and its active metabolites, 4-hydroxyBUP, threohydroBUP and erythrohydroBUP. The primary objective of this study was to test how multiple processes unique to the efavirenz-CYP2B6 genotype interaction influence the extent of efavirenz-mediated drug-drug interaction (DDI) with the CYP2B6 probe substrate BUP. In a three-phase, sequential, open-label study, healthy volunteers (N=53) were administered a single 100 mg oral dose of BUP alone (control phase), with a single 600 mg oral efavirenz dose (inhibition phase), and after 17-days pretreatment with efavirenz (600 mg/day) (induction phase). Compared to the control phase, we show for the first time that efavirenz significantly decreases and chronically increases the exposure of hydroxyBUP and its diastereomers, respectively, and these interactions were CYP2B6 genotype dependent. Chronic efavirenz enhances the elimination of racemic BUP and its enantiomers as well as of threo- and erythro-hydroBUP and their diastereomers, suggesting additional novel mechanisms underlying efavirenz interaction with BUP. The effects of efavirenz and genotypes were nonstereospecific. In conclusion, acute and chronic administration of efavirenz inhibits and induces CYP2B6 activity. Efavirenz-BUP interaction is complex involving time- and CYP2B6 genotype-dependent inhibition and induction of primary and secondary metabolic pathways. Our findings highlight important implications to the safety and efficacy of BUP, study design considerations for future efavirenz interactions, and individualized drug therapy based on CYP2B6 genotypes. Significance Statement The effects of acute and chronic doses of efavirenz on the disposition of racemic and stereoisomers of BUP and its active metabolites were investigated in healthy volunteers. Efavirenz causes an acute inhibition, but chronic induction of CYP2B6 in a genotype dependent manner. Chronic efavirenz induces BUP reduction and the elimination of BUP active metabolites. Efavirenz's effects were non-stereospecific. These data reveal novel mechanisms underlying efavirenz DDI with BUP and provide important insights into time- and CYP2B6 genotype dependent DDIs.
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Affiliation(s)
| | | | - Nadia O Bamfo
- Division of Clinical Pharmacology, Indiana University School of Medicine, United States
| | - Eric A Benson
- Medicine, Indiana University School of Medicine, United States
| | - Andrea R Masters
- Melvin and Bren Simon Comprehensive Cancer Center Clinical Pharmacology Analytical Core, Indiana University School of Medicine, United States
| | - Jessica Bo Li Lu
- Division of Clinical Pharmacology, Indiana University School of Medicine, United States
| | - Zeruesenay Desta
- Medicine/Division of Clinical Pharmacology, Indiana University School of Medicine, United States
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10
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Oyungu E, El Kebbi O, Vreeman R, Nyandiko W, Monahan PO, Tu W, Khaitan A, Desta Z, Slogrove AL, Humphrey JM, Were E, Patel RC, Carlucci JG, Wools-Kaloustian K, McHenry MS. Predicting neurodevelopmental risk in children born to mothers living with HIV in Kenya: protocol for a prospective cohort study (Tabiri Study). BMJ Open 2022; 12:e061051. [PMID: 35379648 PMCID: PMC8981283 DOI: 10.1136/bmjopen-2022-061051] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
INTRODUCTION For the growing number of children with in utero and postpartum exposure to HIV and/or antiretrovirals, it is unclear which exposures or risk factors play a significant role in predicting worse neurodevelopmental outcomes. This protocol describes a prospective longitudinal cohort study of infants born to mothers living with HIV and those born to mothers without HIV. We will determine which risk factors are most predictive of child neurodevelopment at 24 months. We aim to create a risk assessment tool to help predict which children are at risk for worse neurodevelopment outcomes. METHODS AND ANALYSIS This study leverages an existing Kenyan cohort to prospectively enrol 500 children born to mothers living with HIV and 500 to those without HIV (n=1000 total) and follow them from birth to age 24 months. The following factors will be measured every 6 months: infectious morbidity and biological/sociodemographic/psychosocial risk factors. We will compare these factors between the two groups. We will then measure and compare neurodevelopment within children in both groups at 24 months of age using the Child Behaviour Checklist and the Bayley Scales of Infant and Toddler Development, third edition. Finally, we will use generalised linear mixed modelling to quantify associations with neurodevelopment and create a risk assessment tool for children ≤24 months. ETHICS AND DISSEMINATION The study is approved by the Moi University's Institutional Research and Ethics Committee (IREC/2021/55; Approval #0003892), Kenya's National Commission for Science, Technology and Innovation (NACOSTI, Reference #700244) and Indiana University's Institutional Review Board (IRB Protocol #110990). This study carries minimal risk to the children and their mothers, and all mothers will provide written consent for participation in the study. Results will be disseminated to maternal child health clinics within Uasin Gishu County, Kenya and via papers submitted to peer-reviewed journals and presentation at international conferences.
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Affiliation(s)
- Eren Oyungu
- Department of Medical Physiology, Moi University College of Health Sciences, Eldoret, Kenya
- Academic Model Providing Access to Healthcare, Eldoret, Kenya
| | - Ola El Kebbi
- Department of Emergency Medicine, American University of Beirut, Beirut, Lebanon
| | - Rachel Vreeman
- Academic Model Providing Access to Healthcare, Eldoret, Kenya
- Arnold Institute for Global Health, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Winstone Nyandiko
- Academic Model Providing Access to Healthcare, Eldoret, Kenya
- Department of Child Health, Moi University College of Health Sciences, Eldoret, Kenya
| | - Patrick O Monahan
- Department of Biostatistics, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Wanzhu Tu
- Department of Biostatistics, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Alka Khaitan
- Department of Pediatrics, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Zeruesenay Desta
- Department of Clinical Pharmacology, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Amy L Slogrove
- Department of Paediatrics & Child Health, Faculty of Medicine & Health Sciences, Stellenbosch University, Stellenbosch, South Africa
| | - John M Humphrey
- Academic Model Providing Access to Healthcare, Eldoret, Kenya
- Department of Medicine, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Edwin Were
- Academic Model Providing Access to Healthcare, Eldoret, Kenya
- Division of Obstetrics and Gynecology, Moi University College of Health Sciences, Eldoret, Kenya
| | - Rena C Patel
- University of Washington School of Medicine, Seattle, Washington, USA
| | - James G Carlucci
- Department of Pediatrics, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Kara Wools-Kaloustian
- Academic Model Providing Access to Healthcare, Eldoret, Kenya
- Department of Medicine, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Megan S McHenry
- Academic Model Providing Access to Healthcare, Eldoret, Kenya
- Department of Pediatrics, Indiana University School of Medicine, Indianapolis, Indiana, USA
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11
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Shugg T, Ly RC, Rowe EJ, Philips S, Hyder MA, Radovich M, Rosenman MB, Pratt VM, Callaghan JT, Desta Z, Schneider BP, Skaar TC. Clinical Opportunities for Germline Pharmacogenetics and Management of Drug-Drug Interactions in Patients With Advanced Solid Cancers. JCO Precis Oncol 2022; 6:e2100312. [PMID: 35201852 PMCID: PMC9848543 DOI: 10.1200/po.21.00312] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2021] [Revised: 10/26/2021] [Accepted: 01/26/2022] [Indexed: 01/22/2023] Open
Abstract
PURPOSE Precision medicine approaches, including germline pharmacogenetics (PGx) and management of drug-drug interactions (DDIs), are likely to benefit patients with advanced cancer who are frequently prescribed multiple concomitant medications to treat cancer and associated conditions. Our objective was to assess the potential opportunities for PGx and DDI management within a cohort of adults with advanced cancer. METHODS Medication data were collected from the electronic health records for 481 subjects since their first cancer diagnosis. All subjects were genotyped for variants with clinically actionable recommendations in Clinical Pharmacogenetics Implementation Consortium guidelines for 13 pharmacogenes. DDIs were defined as concomitant prescription of strong inhibitors or inducers with sensitive substrates of the same drug-metabolizing enzyme and were assessed for six major cytochrome P450 (CYP) enzymes. RESULTS Approximately 60% of subjects were prescribed at least one medication with Clinical Pharmacogenetics Implementation Consortium recommendations, and approximately 14% of subjects had an instance for actionable PGx, defined as a prescription for a drug in a subject with an actionable genotype. The overall subject-level prevalence of DDIs and serious DDIs were 50.3% and 34.8%, respectively. Serious DDIs were most common for CYP3A, CYP2D6, and CYP2C19, occurring in 24.9%, 16.8%, and 11.7% of subjects, respectively. When assessing PGx and DDIs together, approximately 40% of subjects had at least one opportunity for a precision medicine-based intervention and approximately 98% of subjects had an actionable phenotype for at least one CYP enzyme. CONCLUSION Our findings demonstrate numerous clinical opportunities for germline PGx and DDI management in adults with advanced cancer.
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Affiliation(s)
- Tyler Shugg
- Division of Clinical Pharmacology, Department of Medicine, Indiana University School of Medicine, Indianapolis, IN
| | - Reynold C. Ly
- Division of Clinical Pharmacology, Department of Medicine, Indiana University School of Medicine, Indianapolis, IN
| | - Elizabeth J. Rowe
- Division of Clinical Pharmacology, Department of Medicine, Indiana University School of Medicine, Indianapolis, IN
| | - Santosh Philips
- Division of Clinical Pharmacology, Department of Medicine, Indiana University School of Medicine, Indianapolis, IN
| | - Mustafa A. Hyder
- Division of Clinical Pharmacology, Department of Medicine, Indiana University School of Medicine, Indianapolis, IN
| | - Milan Radovich
- Division of Hematology/Oncology, Department of Medicine, Indiana University School of Medicine, Indianapolis, IN
| | - Marc B. Rosenman
- Ann & Robert H. Lurie Children's Hospital of Chicago and Institute of Public Health, Feinberg School of Medicine, Northwestern University, Chicago, IL
| | - Victoria M. Pratt
- Department of Medical and Molecular Genetics, Indiana University School of Medicine, Indianapolis, IN
| | - John T. Callaghan
- Division of Clinical Pharmacology, Department of Medicine, Indiana University School of Medicine, Indianapolis, IN
- Department of Pharmacology and Toxicology, Indiana University School of Medicine, Indianapolis, INPreprint version available on MedRXiv, https://www.medrxiv.org/content/10.1101/2021.08.23.21262496v1.full-text
| | - Zeruesenay Desta
- Division of Clinical Pharmacology, Department of Medicine, Indiana University School of Medicine, Indianapolis, IN
| | - Bryan P. Schneider
- Division of Hematology/Oncology, Department of Medicine, Indiana University School of Medicine, Indianapolis, IN
| | - Todd C. Skaar
- Division of Clinical Pharmacology, Department of Medicine, Indiana University School of Medicine, Indianapolis, IN
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12
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Hertz DL, Douglas JA, Kidwell KM, Gersch CL, Desta Z, Storniolo AM, Stearns V, Skaar TC, Hayes DF, Henry NL, Rae JM. Genome-wide association study of letrozole plasma concentrations identifies non-exonic variants that may affect CYP2A6 metabolic activity. Pharmacogenet Genomics 2021; 31:116-123. [PMID: 34096894 PMCID: PMC8185249 DOI: 10.1097/fpc.0000000000000429] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
OBJECTIVES Letrozole is a nonsteroidal aromatase inhibitor used to treat hormone-receptor-positive breast cancer. Variability in letrozole efficacy and toxicity may be partially attributable to variable systemic drug exposure, which may be influenced by germline variants in the enzymes responsible for letrozole metabolism, including cytochrome P450 2A6 (CYP2A6). The objective of this genome-wide association study (GWAS) was to identify polymorphisms associated with steady-state letrozole concentrations. METHODS The Exemestane and Letrozole Pharmacogenetics (ELPh) Study randomized postmenopausal patients with hormone-receptor-positive nonmetastatic breast cancer to letrozole or exemestane treatment. Germline DNA was collected pretreatment and blood samples were collected after 1 or 3 months of treatment to measure steady-state letrozole (and exemestane) plasma concentrations via HPLC/MS. Genome-wide genotyping was conducted on the Infinium Global Screening Array (>650 000 variants) followed by imputation. The association of each germline variant with age- and BMI-adjusted letrozole concentrations was tested in self-reported white patients via linear regression assuming an additive genetic model. RESULTS There were 228 patients who met the study-specific inclusion criteria and had both DNA and letrozole concentration data for this GWAS. The association for one genotyped polymorphism (rs7937) with letrozole concentration surpassed genome-wide significance (P = 5.26 × 10-10), explaining 13% of the variability in untransformed steady-state letrozole concentrations. Imputation around rs7937 and in silico analyses identified rs56113850, a variant in the CYP2A6 intron that may affect CYP2A6 expression and activity. rs7937 was associated with age- and BMI-adjusted letrozole levels even after adjusting for genotype-predicted CYP2A6 metabolic phenotype (P = 3.86 × 10-10). CONCLUSION Our GWAS findings confirm that steady-state letrozole plasma concentrations are partially determined by germline polymorphisms that affect CYP2A6 activity, including variants near rs7937 such as the intronic rs56113850 variant. Further research is needed to confirm whether rs56113850 directly affects CYP2A6 activity and to integrate nonexonic variants into CYP2A6 phenotypic activity prediction systems.
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Affiliation(s)
- Daniel L Hertz
- Department of Clinical Pharmacy, University of Michigan College of Pharmacy, Ann Arbor, Michigan
| | - Julie A Douglas
- Department of Human Genetics, University of Michigan Medical School, University of Michigan, Ann Arbor, Michigan
- Department of Mathematics and Statistics, Skidmore College, Saratoga Springs, New York
| | - Kelley M Kidwell
- Department of Biostatistics, University of Michigan School of Public Health, University of Michigan, Ann Arbor, Michigan
| | - Christina L Gersch
- Department of Internal Medicine, Division of Hematology/Oncology, University of Michigan Medical School, University of Michigan, Ann Arbor, Michigan
| | - Zeruesenay Desta
- Department of Medicine, Division of Clinical Pharmacology, Indiana University School of Medicine, Indianapolis, Indiana
| | - Ana-Maria Storniolo
- Department of Medicine, Division of Clinical Pharmacology, Indiana University School of Medicine, Indianapolis, Indiana
| | - Vered Stearns
- Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins School of Medicine, Baltimore, Maryland, USA
| | - Todd C Skaar
- Department of Medicine, Division of Clinical Pharmacology, Indiana University School of Medicine, Indianapolis, Indiana
| | - Daniel F Hayes
- Department of Internal Medicine, Division of Hematology/Oncology, University of Michigan Medical School, University of Michigan, Ann Arbor, Michigan
| | - N Lynn Henry
- Department of Internal Medicine, Division of Hematology/Oncology, University of Michigan Medical School, University of Michigan, Ann Arbor, Michigan
| | - James M Rae
- Department of Internal Medicine, Division of Hematology/Oncology, University of Michigan Medical School, University of Michigan, Ann Arbor, Michigan
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Desta Z, El-Boraie A, Gong L, Somogyi AA, Lauschke VM, Dandara C, Klein K, Miller NA, Klein TE, Tyndale RF, Whirl-Carrillo M, Gaedigk A. PharmVar GeneFocus: CYP2B6. Clin Pharmacol Ther 2021; 110:82-97. [PMID: 33448339 DOI: 10.1002/cpt.2166] [Citation(s) in RCA: 31] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2020] [Accepted: 12/21/2020] [Indexed: 12/12/2022]
Abstract
The Pharmacogene Variation Consortium (PharmVar) catalogs star (*) allele nomenclature for the polymorphic human CYP2B6 gene. Genetic variation within the CYP2B6 gene locus impacts the metabolism or bioactivation of clinically important drugs. Of particular importance are efficacy and safety concerns regarding: efavirenz, which is used for the treatment of HIV type-1 infection; methadone, a mainstay in the treatment of opioid use disorder and as an analgesic; ketamine, used as an antidepressant and analgesic; and bupropion, which is prescribed to treat depression and for smoking cessation. This GeneFocus provides a comprehensive overview and summary of CYP2B6 and describes how haplotype information catalogued by PharmVar is utilized by the Pharmacogenomics Knowledgebase (PharmGKB) and the Clinical Pharmacogenetics Implementation Consortium (CPIC).
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Affiliation(s)
- Zeruesenay Desta
- Division of Clinical Pharmacology, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Ahmed El-Boraie
- Centre for Addiction and Mental Health and Departments of Pharmacology & Toxicology, and Psychiatry, University of Toronto, Toronto, Canada
| | - Li Gong
- Department of Biomedical Data Science, Stanford University, Stanford, California, USA
| | - Andrew A Somogyi
- Discipline of Pharmacology, Adelaide Medical School, University of Adelaide, Adelaide, Australia
| | - Volker M Lauschke
- Department of Physiology and Pharmacology, Karolinska Institutet, Stockholm, Sweden
| | - Collet Dandara
- Division of Human Genetics, Department of Pathology & Institute of Infectious Disease and Molecular Medicine, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa
| | - Kathrin Klein
- Dr. Margarete Fischer-Bosch-Institute of Clinical Pharmacology, Stuttgart, Germany.,University of Tuebingen, Tuebingen, Germany
| | - Neil A Miller
- Genomic Medicine Center, Children's Mercy, Kansas City, Missouri, USA.,School of Medicine, University of Missouri-Kansas City, Kansas City, Missouri, USA
| | - Teri E Klein
- Department of Biomedical Data Science, Stanford University, Stanford, California, USA
| | - Rachel F Tyndale
- Centre for Addiction and Mental Health and Departments of Pharmacology & Toxicology, and Psychiatry, University of Toronto, Toronto, Canada
| | | | - Andrea Gaedigk
- Division of Clinical Pharmacology, Toxicology & Therapeutic Innovation, Children's Mercy, Kansas City, Missouri, USA.,School of Medicine, University of Missouri-Kansas City, Kansas City, Missouri, USA
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14
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Titus-Lay EN, Jaynes HA, Tomaselli Muensterman E, Walroth TA, Ott CA, Desta Z, Williams G, Moe PR, Wilbrandt M, Tisdale JE. Methadone-associated QT interval prolongation in patients undergoing maintenance therapy in an urban opioid treatment program. Pharmacotherapy 2021; 41:238-246. [PMID: 33345336 DOI: 10.1002/phar.2498] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2020] [Revised: 11/27/2020] [Accepted: 11/27/2020] [Indexed: 11/11/2022]
Abstract
STUDY OBJECTIVE Methadone is associated with QT interval prolongation and torsades de pointes. The objective of this study was to (a) determine the incidence of QT interval prolongation among patients on maintenance methadone therapy in an urban opioid treatment program (OTP), (b) compare characteristics of patients who developed methadone-associated QT prolongation with those who did not develop QT prolongation, and (c) investigate the relationship between QT interval prolongation and stereospecific serum methadone and metabolite [2-ethylidene-1,5-dimethyl-3,3-diphenylpyrrolidine (EDDP)] concentrations. DESIGN Prospective study. SETTING Urban opioid treatment program (OTP). PATIENTS n = 93 patients on maintenance methadone therapy in an urban OTP. INTERVENTION Patients underwent a 12-lead electrocardiogram (ECG) prior to initiating methadone and again during steady-state maintenance methadone therapy. In a subset (n = 43), blood was obtained to determine serum (S)- and (R)-methadone and (S)- and (R)-EDDP concentrations, which were compared in patients who developed Bazett's-corrected QT (QTc) prolongation [≥470 ms (men) or ≥480 ms (women) and/or ≥60 ms lengthening from pretreatment value] with those who did not have QTc prolongation. MEASUREMENTS AND MAIN RESULTS Mean [± standard deviation (SD)] age was 36 ± 12 years; 73% were female, and 74% were white. QTc prolongation occurred in 14 (15.1%) patients. Patients who developed QTc prolongation were older (41 ± 13 vs. 35 ± 9 years, p = 0.03) and had a longer pre-methadone QTc compared with those who did not have QTc prolongation (429 ± 11 vs. 420 ± 20 ms, respectively, p = 0.02). Serum (S)-methadone concentrations were higher in patients with QTc prolongation compared to patients without prolongation (199 ± 81 vs. 128 ± 68 ng/ml, respectively, p = 0.01), whereas the difference in serum (R)-methadone concentrations between the groups did not reach significance (189 ± 68 vs. 125 ± 60 ng/ml, respectively, p = 0.08). Serum (R)-methadone concentrations correlated with QTc intervals [R2 = 0.15 (95% confidence interval (CI) 0.11-0.62, p = 0.0009)]. The correlation between serum (S)-methadone concentrations and QTc did not reach significance [R2 = 0.08 (95% CI -0.01 to 0.54, p = 0.06)]. Serum (S)-and (R)-EDDP concentrations were not significantly different between the groups and did not significantly correlate with QTc intervals. CONCLUSIONS Approximately 15% of patients taking maintenance methadone therapy developed QT interval prolongation. Both serum (S)- and (R)-methadone concentrations, but not (S)- or (R)-EDDP, contribute to methadone-associated QT prolongation.
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Affiliation(s)
- Erika N Titus-Lay
- Department of Pharmacy, Eskenazi Health, Indianapolis, Indiana, USA.,College of Pharmacy, Purdue University, Indianapolis, Indiana, USA.,College of Pharmacy, California Northstate University, Elk Grove, California, USA
| | - Heather A Jaynes
- College of Pharmacy, Purdue University, Indianapolis, Indiana, USA
| | - Elena Tomaselli Muensterman
- College of Pharmacy, Purdue University, Indianapolis, Indiana, USA.,AbbVie Inc., North Chicago, Illinois, USA
| | - Todd A Walroth
- Department of Pharmacy, Eskenazi Health, Indianapolis, Indiana, USA
| | - Carol A Ott
- Department of Pharmacy, Eskenazi Health, Indianapolis, Indiana, USA.,College of Pharmacy, Purdue University, Indianapolis, Indiana, USA.,School of Medicine, Indiana University, Indianapolis, Indiana, USA
| | - Zeruesenay Desta
- School of Medicine, Indiana University, Indianapolis, Indiana, USA
| | | | - Paul R Moe
- Sandra Eskenazi Health Mental Health Center Opioid Treatment Program, Indianapolis, Indiana, USA
| | - Michelle Wilbrandt
- Sandra Eskenazi Health Mental Health Center Opioid Treatment Program, Indianapolis, Indiana, USA
| | - James E Tisdale
- College of Pharmacy, Purdue University, Indianapolis, Indiana, USA.,School of Medicine, Indiana University, Indianapolis, Indiana, USA
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15
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Ipe J, Li R, Metzger IF, Bo Li Lu J, Gufford BT, Desta Z, Liu Y, Skaar TC. Circulating miRNAs as Biomarkers for CYP2B6 Enzyme Activity. Clin Pharmacol Ther 2020; 109:485-493. [PMID: 32772362 DOI: 10.1002/cpt.2018] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2020] [Accepted: 07/16/2020] [Indexed: 01/08/2023]
Abstract
The CYP2B6 gene is highly polymorphic and its activity shows wide interindividual variability. However, substantial variability in CYP2B6 activity remains unexplained by the known CYP2B6 genetic variations. Circulating, cell-free micro RNAs (miRNAs) may serve as biomarkers of hepatic enzyme activity. CYP2B6 activity in 72 healthy volunteers was determined using the disposition of efavirenz as a probe drug. Circulating miRNA expression was quantified from baseline plasma samples. A linear model consisting of the effects of miRNA expression, genotype-determined metabolizer status, and demographic information was developed to predict CYP2B6 activity. Expression of 2,510 miRNAs were quantified out of which 7 miRNAs, together with the CYP2B6-genotypic metabolizer status and demographics, was shown to be predictive markers for CYP2B6 activity. The reproducibility of the model was evaluated by cross-validation. The average Pearson's correlation (R) between the predicted and observed maximum plasma concentration (Cmax ) ratios of efavirenz and its metabolite-8-OH efavirenz using the linear model with all features (7 miRNA + metabolizer status + age + sex + race) was 0.6702. Similar results were also observed using area under the curve (AUC) ratios (Pearson correlation's R = 0.6035). Thus, at least 36% (R2 ) of the variability of in vivo CYP2B6 activity was explained using this model. This is a significant improvement over the models using only the genotype-based metabolizer status or the demographic information, which explained only 6% or less of the variability of in vivo CYP2B6 activity. Our results, therefore, demonstrate that circulating plasma miRNAs can be valuable biomarkers for in vivo CYP2B6 activity.
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Affiliation(s)
- Joseph Ipe
- Division of Clinical Pharmacology, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Rudong Li
- Department of Medical and Molecular Genetics, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Ingrid F Metzger
- Division of Clinical Pharmacology, Indiana University School of Medicine, Indianapolis, Indiana, USA.,Department of Medical and Molecular Genetics, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Jessica Bo Li Lu
- Division of Clinical Pharmacology, Indiana University School of Medicine, Indianapolis, Indiana, USA.,Department of Medical and Molecular Genetics, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Brandon T Gufford
- Division of Clinical Pharmacology, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Zeruesenay Desta
- Division of Clinical Pharmacology, Indiana University School of Medicine, Indianapolis, Indiana, USA.,Department of Medical and Molecular Genetics, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Yunlong Liu
- Department of Medical and Molecular Genetics, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Todd C Skaar
- Division of Clinical Pharmacology, Indiana University School of Medicine, Indianapolis, Indiana, USA.,Department of Medical and Molecular Genetics, Indiana University School of Medicine, Indianapolis, Indiana, USA
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16
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Lima JJ, Thomas CD, Barbarino J, Desta Z, Van Driest SL, El Rouby N, Johnson JA, Cavallari LH, Shakhnovich V, Thacker DL, Scott SA, Schwab M, Uppugunduri CRS, Formea CM, Franciosi JP, Sangkuhl K, Gaedigk A, Klein TE, Gammal RS, Furuta T. Clinical Pharmacogenetics Implementation Consortium (CPIC) Guideline for CYP2C19 and Proton Pump Inhibitor Dosing. Clin Pharmacol Ther 2020; 109:1417-1423. [PMID: 32770672 DOI: 10.1002/cpt.2015] [Citation(s) in RCA: 127] [Impact Index Per Article: 31.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2020] [Accepted: 07/15/2020] [Indexed: 12/27/2022]
Abstract
Proton pump inhibitors (PPIs) are widely used for acid suppression in the treatment and prevention of many conditions, including gastroesophageal reflux disease, gastric and duodenal ulcers, erosive esophagitis, Helicobacter pylori infection, and pathological hypersecretory conditions. Most PPIs are metabolized primarily by cytochrome P450 2C19 (CYP2C19) into inactive metabolites, and CYP2C19 genotype has been linked to PPI exposure, efficacy, and adverse effects. We summarize the evidence from the literature and provide therapeutic recommendations for PPI prescribing based on CYP2C19 genotype (updates at www.cpicpgx.org). The potential benefits of using CYP2C19 genotype data to guide PPI therapy include (i) identifying patients with genotypes predictive of lower plasma exposure and prescribing them a higher dose that will increase the likelihood of efficacy, and (ii) identifying patients on chronic therapy with genotypes predictive of higher plasma exposure and prescribing them a decreased dose to minimize the risk of toxicity that is associated with long-term PPI use, particularly at higher plasma concentrations.
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Affiliation(s)
- John J Lima
- Center for Pharmacogenomics and Translational Research, Nemours Children's Health, Jacksonville, Florida, USA
| | - Cameron D Thomas
- Department of Pharmacotherapy and Translational Research, and Center for Pharmacogenomics and Precision Medicine, College of Pharmacy, University of Florida, Gainesville, Florida, USA
| | - Julia Barbarino
- Department of Biomedical Data Science, Stanford University, Stanford, California, USA
| | - Zeruesenay Desta
- Department of Medicine, Division of Clinical Pharmacology, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Sara L Van Driest
- Departments of Pediatrics and Medicine, Vanderbilt University School of Medicine, Nashville, Tennessee, USA
| | - Nihal El Rouby
- Department of Pharmacotherapy and Translational Research, and Center for Pharmacogenomics and Precision Medicine, College of Pharmacy, University of Florida, Gainesville, Florida, USA.,Division of Pharmacy Practice & Administrative Sciences, University of Cincinnati James Winkle College of Pharmacy, Cincinnati, Ohio, USA
| | - Julie A Johnson
- Department of Pharmacotherapy and Translational Research, and Center for Pharmacogenomics and Precision Medicine, College of Pharmacy, University of Florida, Gainesville, Florida, USA
| | - Larisa H Cavallari
- Department of Pharmacotherapy and Translational Research, and Center for Pharmacogenomics and Precision Medicine, College of Pharmacy, University of Florida, Gainesville, Florida, USA
| | - Valentina Shakhnovich
- Division of Clinical Pharmacology, Toxicology, and Therapeutic Innovation, Children's Mercy Kansas City and University of Missouri Kansas City School of Medicine, Kansas City, Missouri, USA.,Division of Gastroenterology, Hepatology, and Nutrition, Children's Mercy Kansas City, Kansas City, Missouri, USA.,Center for Children's Healthy Lifestyles & Nutrition, Kansas City, Missouri, USA
| | - David L Thacker
- Department of Clinical Pharmacology, Indiana University School of Medicine, Indianapolis, Indiana, USA.,Translational Software, Bellevue, Washington, USA
| | - Stuart A Scott
- Department of Genetics and Genomic Sciences, Icahn School of Medicine at Mount Sinai, New York, New York, USA.,Sema4, Stamford, Connecticut, USA
| | - Matthias Schwab
- Dr Margarete Fischer-Bosch-Institute of Clinical Pharmacology, Stuttgart, Germany.,Department of Clinical Pharmacology, University Hospital, Tuebingen, Germany.,Department of Pharmacy and Biochemistry, University of Tuebingen, Tuebingen, Germany
| | - Chakradhara Rao S Uppugunduri
- CANSEARCH Research Laboratory, Department of Pediatrics, Gynecology, and Obstetrics, Faculty of Medicine, University of Geneva, Geneva, Switzerland.,Oncology-Hematology Unit, Department of Pediatrics, Gynecology, and Obstetrics, Geneva University Hospital, Geneva, Switzerland
| | - Christine M Formea
- Department of Pharmacy Services and Intermountain Precision Genomics, Intermountain Healthcare, Salt Lake City, Utah, USA
| | - James P Franciosi
- Division of Gastroenterology, Hepatology, and Nutrition, Nemours Children's Hospital, Orlando, Florida, USA.,Department of Pediatrics, University of Central Florida College of Medicine, Orlando, Florida, USA
| | - Katrin Sangkuhl
- Department of Biomedical Data Science, Stanford University, Stanford, California, USA
| | - Andrea Gaedigk
- Division of Clinical Pharmacology, Toxicology, and Therapeutic Innovation, Children's Mercy Kansas City and University of Missouri Kansas City School of Medicine, Kansas City, Missouri, USA
| | - Teri E Klein
- Department of Biomedical Data Science, Stanford University, Stanford, California, USA
| | - Roseann S Gammal
- Department of Pharmacy Practice, MCPHS University School of Pharmacy, Boston, Massachusetts, USA.,Department of Pharmaceutical Sciences, St Jude Children's Research Hospital, Memphis, Tennessee, USA
| | - Takahisa Furuta
- Center for Clinical Research, Hamamatsu University School of Medicine, Hamamatsu, Shizuoka, Japan
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17
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Strawn JR, Mills JA, Schroeder H, Mossman SA, Varney ST, Ramsey LB, Poweleit EA, Desta Z, Cecil K, DelBello MP. Escitalopram in Adolescents With Generalized Anxiety Disorder: A Double-Blind, Randomized, Placebo-Controlled Study. J Clin Psychiatry 2020; 81:20m13396. [PMID: 32857933 PMCID: PMC7504974 DOI: 10.4088/jcp.20m13396] [Citation(s) in RCA: 39] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/20/2020] [Accepted: 07/27/2020] [Indexed: 12/21/2022]
Abstract
BACKGROUND Selective serotonin reuptake inhibitors (SSRIs) are commonly used to treat pediatric anxiety disorders, including generalized anxiety disorder (GAD); however, their efficacy and tolerability are difficult to predict. This study evaluated the efficacy and tolerability of escitalopram in adolescents with GAD (DSM-IV-TR) and the impact of variants in HTR2A and serotonin transporter (SLC6A4) genes and cytochrome P450 2C19 (CYP2C19) phenotypes on response as well as CYP2C19 phenotype on escitalopram pharmacokinetics from February 2015 through November 2018. METHODS Patients were treated with escitalopram (forced titration to 15 mg/d, then flexible titration to 20 mg/d) (n = 26, mean ± SD age: 14.8 ± 1.7 years) or placebo (n = 25, mean ± SD age: 14.9 ± 1.6 years) for 8 weeks. Outcomes were the change in scores on the Pediatric Anxiety Rating Scale (PARS) and Clinical Global Impressions (CGI) scales as well as vital signs and adverse events. Plasma escitalopram and desmethylcitalopram area under the curve during 24 hours (AUC0-24) and maximum concentration (Cmax) were determined and compared across CYP2C19 phenotypes. RESULTS Escitalopram was superior to placebo for mean ± SD baseline-to-endpoint change in PARS (-8.65 ± 1.3 vs -3.52 ± 1.1, P = .005) and CGI scores, and increasing CYP2C19 metabolism was associated with decreases in escitalopram Cmax (P = .07) and AUC0-24 (P < .05). Vital signs, corrected QT interval, and adverse events were similar in patients who received escitalopram and placebo. CONCLUSIONS Escitalopram reduces anxiety symptoms, and pharmacogenetics variables influence the trajectory and magnitude of improvement. Variation in CYP2C19 metabolism accounts for significant differences in escitalopram pharmacokinetics, raising the possibility that CYP2C19 phenotype should be considered when prescribing escitalopram. TRIAL REGISTRATION ClinicalTrials.gov identifier: NCT02818751.
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Affiliation(s)
- Jeffrey R Strawn
- University of Cincinnati, Department of Psychiatry, Box 670559, Cincinnati, OH 45267-0559.
- Department of Psychiatry, College of Medicine, University of Cincinnati, Cincinnati, Ohio, USA
| | - Jeffrey A Mills
- Department of Economics, Lindner College of Business, University of Cincinnati, Cincinnati, Ohio, USA
| | - Heidi Schroeder
- Department of Psychiatry, College of Medicine, University of Cincinnati, Cincinnati, Ohio, USA
| | - Sarah A Mossman
- Department of Psychiatry, College of Medicine, University of Cincinnati, Cincinnati, Ohio, USA
| | - Sara T Varney
- Department of Psychiatry, College of Medicine, University of Cincinnati, Cincinnati, Ohio, USA
| | - Laura B Ramsey
- Department of Pediatrics, Divisions of Clinical Pharmacology & Research in Patient Services, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | - Ethan A Poweleit
- Department of Pediatrics, Divisions of Clinical Pharmacology & Research in Patient Services, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | - Zeruesenay Desta
- Division of Clinical Pharmacology, Department of Medicine, Indiana University School of Medicine, Indianapolis, Indiana,
| | - Kim Cecil
- Imaging Research Center, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | - Melissa P DelBello
- Department of Psychiatry, College of Medicine, University of Cincinnati, Cincinnati, Ohio, USA
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18
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Hertz DL, Douglas J, Kidwell KM, Gersch CL, Desta Z, Storniolo AM, Stearns V, Skaar TC, Hayes DF, Henry NL, Rae JM. Genome-wide association study of steady-state letrozole concentration in patients with breast cancer. J Clin Oncol 2020. [DOI: 10.1200/jco.2020.38.15_suppl.538] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
538 Background: Letrozole is a non-steroidal aromatase inhibitor (AI) used to treat hormone receptor positive (HR+) breast cancer. Variability in letrozole efficacy and toxicity may be partially attributable to variable systemic drug exposure, which may be influenced by germline variants in the enzymes responsible for letrozole metabolism, including CYP2A6. The objective of this genome-wide association study (GWAS) was to identify genetic variants that affect steady state letrozole concentrations. Methods: The Exemestane and Letrozole Pharmacogenetics (ELPh) Study randomized 503 post-menopausal patients with HR+ non-metastatic breast cancer to exemestane or letrozole treatment. Germline DNA was collected pre-treatment and blood samples were collected after 1 or 3 months of treatment to measure steady-state letrozole concentration via HPLC/MS. Genome-wide genotyping was conducted on the Infinium Global Screening Array to the Haplotype Reference Panel ( > 2 million variants). The association of each polymorphism with square-root transformed letrozole concentration was tested in self-reported white patients via linear regression using the standard alpha for genome-wide significance (α = 5x10−8) assuming an additive genetic model and correcting for age and body mass index. Results: 228 patients met inclusion criteria and had all necessary data. Each variant allele of rs7937 a patient carried increased their letrozole concentration ~22.9 ng/mL (standard error = 4.01, p = 3.51x10−8, Table) and this variant explained 13% of the variability in letrozole concentrations. rs7937 is located ~50 kB upstream of CYP2A6, and has previously been identified in GWAS of CYP2A6-related phenotypes, including nicotine metabolism and lung cancer. Conclusions: This GWAS confirmed that steady-state letrozole concentrations are partially determined by germline polymorphisms affecting CYP2A6 activity. If letrozole concentrations affect treatment efficacy or toxicity, CYP2A6 genetics may be useful to individualize letrozole dosing to improve clinical outcomes in patients with HR+ breast cancer. [Table: see text]
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Affiliation(s)
| | | | | | | | | | | | - Vered Stearns
- The Sidney Kimmel Comprehensive Cancer Center at Johns Hopkins School of Medicine, Baltimore, MD
| | - Todd C. Skaar
- Indiana University School of Medicine, Indianapolis, IN
| | | | - Norah Lynn Henry
- University of Michigan Rogel Cancer Center and SWOG, Ann Arbor, MI
| | - James M. Rae
- University of Michigain Health System, Ann Arbor, MI
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19
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Al Batran R, Gopal K, Capozzi ME, Chahade JJ, Saleme B, Tabatabaei-Dakhili SA, Greenwell AA, Niu J, Almutairi M, Byrne NJ, Masson G, Kim R, Eaton F, Mulvihill EE, Garneau L, Masters AR, Desta Z, Velázquez-Martínez CA, Aguer C, Crawford PA, Sutendra G, Campbell JE, Dyck JRB, Ussher JR. Pimozide Alleviates Hyperglycemia in Diet-Induced Obesity by Inhibiting Skeletal Muscle Ketone Oxidation. Cell Metab 2020; 31:909-919.e8. [PMID: 32275862 DOI: 10.1016/j.cmet.2020.03.017] [Citation(s) in RCA: 32] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/29/2019] [Revised: 01/31/2020] [Accepted: 03/24/2020] [Indexed: 02/08/2023]
Abstract
Perturbations in carbohydrate, lipid, and protein metabolism contribute to obesity-induced type 2 diabetes (T2D), though whether alterations in ketone body metabolism influence T2D pathology is unknown. We report here that activity of the rate-limiting enzyme for ketone body oxidation, succinyl-CoA:3-ketoacid-CoA transferase (SCOT/Oxct1), is increased in muscles of obese mice. We also found that the diphenylbutylpiperidine pimozide, which is approved to suppress tics in individuals with Tourette syndrome, is a SCOT antagonist. Pimozide treatment reversed obesity-induced hyperglycemia in mice, which was phenocopied in mice with muscle-specific Oxct1/SCOT deficiency. These actions were dependent on pyruvate dehydrogenase (PDH/Pdha1) activity, the rate-limiting enzyme of glucose oxidation, as pimozide failed to alleviate hyperglycemia in obese mice with a muscle-specific Pdha1/PDH deficiency. This work defines a fundamental contribution of enhanced ketone body oxidation to the pathology of obesity-induced T2D, while suggesting pharmacological SCOT inhibition as a new class of anti-diabetes therapy.
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Affiliation(s)
- Rami Al Batran
- Faculty of Pharmacy and Pharmaceutical Sciences, University of Alberta, Edmonton, AB, Canada; Alberta Diabetes Institute, University of Alberta, Edmonton, AB, Canada; Cardiovascular Research Centre, University of Alberta, Edmonton, AB, Canada
| | - Keshav Gopal
- Faculty of Pharmacy and Pharmaceutical Sciences, University of Alberta, Edmonton, AB, Canada; Alberta Diabetes Institute, University of Alberta, Edmonton, AB, Canada; Cardiovascular Research Centre, University of Alberta, Edmonton, AB, Canada
| | - Megan E Capozzi
- Duke Molecular Physiology Institute, Duke University, Durham, NC, USA
| | - Jadin J Chahade
- Faculty of Pharmacy and Pharmaceutical Sciences, University of Alberta, Edmonton, AB, Canada; Alberta Diabetes Institute, University of Alberta, Edmonton, AB, Canada; Cardiovascular Research Centre, University of Alberta, Edmonton, AB, Canada
| | - Bruno Saleme
- Department of Medicine, University of Alberta, Edmonton, AB, Canada
| | | | - Amanda A Greenwell
- Faculty of Pharmacy and Pharmaceutical Sciences, University of Alberta, Edmonton, AB, Canada; Alberta Diabetes Institute, University of Alberta, Edmonton, AB, Canada; Cardiovascular Research Centre, University of Alberta, Edmonton, AB, Canada
| | - Jingjing Niu
- Duke Molecular Physiology Institute, Duke University, Durham, NC, USA
| | - Malak Almutairi
- Faculty of Pharmacy and Pharmaceutical Sciences, University of Alberta, Edmonton, AB, Canada; Alberta Diabetes Institute, University of Alberta, Edmonton, AB, Canada; Cardiovascular Research Centre, University of Alberta, Edmonton, AB, Canada
| | - Nikole J Byrne
- Alberta Diabetes Institute, University of Alberta, Edmonton, AB, Canada; Cardiovascular Research Centre, University of Alberta, Edmonton, AB, Canada; Department of Pediatrics, University of Alberta, Edmonton, AB, Canada
| | - Grant Masson
- Alberta Diabetes Institute, University of Alberta, Edmonton, AB, Canada; Cardiovascular Research Centre, University of Alberta, Edmonton, AB, Canada; Department of Pediatrics, University of Alberta, Edmonton, AB, Canada
| | - Ryekjang Kim
- Faculty of Pharmacy and Pharmaceutical Sciences, University of Alberta, Edmonton, AB, Canada; Alberta Diabetes Institute, University of Alberta, Edmonton, AB, Canada; Cardiovascular Research Centre, University of Alberta, Edmonton, AB, Canada
| | - Farah Eaton
- Faculty of Pharmacy and Pharmaceutical Sciences, University of Alberta, Edmonton, AB, Canada; Alberta Diabetes Institute, University of Alberta, Edmonton, AB, Canada; Cardiovascular Research Centre, University of Alberta, Edmonton, AB, Canada
| | - Erin E Mulvihill
- Department of Biochemistry, Microbiology & Immunology, University of Ottawa, Ottawa, ON, Canada; University of Ottawa Heart Institute, Ottawa, ON, Canada
| | - Léa Garneau
- Department of Biochemistry, Microbiology & Immunology, University of Ottawa, Ottawa, ON, Canada; Institut du Savoir Montfort, Ottawa, ON, Canada
| | - Andrea R Masters
- Indiana University School of Medicine, Indiana University Melvin and Bren Simon Cancer Center, Indianapolis, IN, USA
| | - Zeruesenay Desta
- Department of Medicine, Division of Clinical Pharmacology, Indianapolis, IN, USA
| | | | - Céline Aguer
- Department of Biochemistry, Microbiology & Immunology, University of Ottawa, Ottawa, ON, Canada; Institut du Savoir Montfort, Ottawa, ON, Canada; School of Human Kinetics, University of Ottawa, Ottawa, ON, Canada
| | - Peter A Crawford
- Division of Molecular Medicine, Department of Medicine, Department of Biochemistry, Molecular Biology, and Biophysics, University of Minnesota, Minneapolis, MN, USA
| | | | | | - Jason R B Dyck
- Alberta Diabetes Institute, University of Alberta, Edmonton, AB, Canada; Cardiovascular Research Centre, University of Alberta, Edmonton, AB, Canada; Department of Pediatrics, University of Alberta, Edmonton, AB, Canada
| | - John R Ussher
- Faculty of Pharmacy and Pharmaceutical Sciences, University of Alberta, Edmonton, AB, Canada; Alberta Diabetes Institute, University of Alberta, Edmonton, AB, Canada; Cardiovascular Research Centre, University of Alberta, Edmonton, AB, Canada.
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20
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Dempsey JM, Kidwell KM, Gersch CL, Pesch AM, Desta Z, Storniolo AM, Stearns V, Skaar TC, Hayes DF, Henry NL, Rae JM, Hertz DL. Effects of SLCO1B1 polymorphisms on plasma estrogen concentrations in women with breast cancer receiving aromatase inhibitors exemestane and letrozole. Pharmacogenomics 2020; 20:571-580. [PMID: 31190621 DOI: 10.2217/pgs-2019-0020] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
Abstract
Aim: This study tested for associations between SLCO1B1 polymorphisms and circulating estrogen levels in women with breast cancer treated with letrozole or exemestane. Patients & methods: Postmenopausal women with hormone-receptor positive breast cancer were genotyped for SLCO1B1*5 (rs4149056) and rs10841753. Pretreatment and on-treatment plasma estrogens and aromatase inhibitor (AI) concentrations were measured. Regression analyses were performed to test for pharmacogenetic associations with estrogens and drug concentrations. Results: SLCO1B1*5 was associated with elevated pretreatment estrone sulfate and an increased risk of detectable estrone concentrations after 3 months of AI treatment. Conclusion: These findings suggest SLCO1B1 polymorphisms may have an effect on estrogenic response to AI treatment, and therefore may adversely impact the anticancer effectiveness of these agents.
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Affiliation(s)
- Jacqueline M Dempsey
- Department of Clinical Pharmacy, University of Michigan College of Pharmacy, Ann Arbor, MI 48109-1065, USA
| | - Kelley M Kidwell
- Department of Biostatistics, School of Public Health, University of Michigan, Ann Arbor, MI 48109, USA
| | - Christina L Gersch
- Department of Internal Medicine, Division of Hematology/Oncology, Medical School, University of Michigan, Ann Arbor, MI 48109, USA
| | - Andrea M Pesch
- Department of Internal Medicine, Division of Hematology/Oncology, Medical School, University of Michigan, Ann Arbor, MI 48109, USA
| | - Zeruesenay Desta
- Department of Medicine, Indiana University, Indianapolis, IN 46202, USA
| | | | - Vered Stearns
- Department of Oncology, Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University, Baltimore, MD 21231, USA
| | - Todd C Skaar
- Department of Medicine, Indiana University, Indianapolis, IN 46202, USA
| | - Daniel F Hayes
- Department of Internal Medicine, Division of Hematology/Oncology, Medical School, University of Michigan, Ann Arbor, MI 48109, USA
| | - N Lynn Henry
- Department of Internal Medicine, Division of Hematology/Oncology, Medical School, University of Michigan, Ann Arbor, MI 48109, USA
| | - James M Rae
- Department of Internal Medicine, Division of Hematology/Oncology, Medical School, University of Michigan, Ann Arbor, MI 48109, USA
| | - Daniel L Hertz
- Department of Clinical Pharmacy, University of Michigan College of Pharmacy, Ann Arbor, MI 48109-1065, USA
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21
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Jim HSL, Hoogland AI, Han HS, Culakova E, Heckler C, Janelsins M, Williams GC, Bower J, Cole S, Desta Z, Babilonia MB, Morrow G, Peppone L. A randomized placebo-controlled trial of bupropion for Cancer-related fatigue: Study design and procedures. Contemp Clin Trials 2020; 91:105976. [PMID: 32147571 PMCID: PMC7263969 DOI: 10.1016/j.cct.2020.105976] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2019] [Revised: 02/27/2020] [Accepted: 03/02/2020] [Indexed: 11/18/2022]
Abstract
BACKGROUND Cancer-related fatigue is a significant problem and is associated with poor quality of life. Behavioral interventions include exercise and cognitive-behavioral therapy, which survivors may be unwilling or unable to adopt. Pharmacologic interventions (e.g., selective serotonin reuptake inhibitors) have been disappointing. One potential therapy is the antidepressant bupropion, a norepinephrine-dopamine reuptake inhibitor that targets both inflammation and the hypothalamic-pituitary-adrenal axis. The current study is intended to provide a rigorous test of the efficacy and tolerability of bupropion for cancer-related fatigue. METHODS A randomized, double-blind, placebo-controlled trial will examine the effects of bupropion on cancer-related fatigue. The trial will be conducted nationwide through the University of Rochester Medical Center (URMC) National Cancer Institute Community Oncology Research Program (NCORP). Disease-free breast cancer survivors (n = 422) who completed chemotherapy and/or radiotherapy 12-60 months previously and report significant fatigue will be randomized 1:1 to receive bupropion (300 mg/day) or placebo. Outcomes will be assessed at baseline and the 12-week follow-up. The primary outcome, fatigue, will be measured with the Functional Assessment of Chronic Illness Therapy - Fatigue (FACIT-F). Secondary outcomes include quality of life, depression, and drug tolerability. Exploratory outcomes include cognition and symptomatology. Potential biological mechanisms and genetic moderators of cancer-related fatigue will also be explored. DISCUSSION This study is the first placebo-controlled trial to our knowledge to evaluate bupropion for cancer-related fatigue. Positive results could revolutionize the treatment of cancer-related fatigue, as bupropion is safe, inexpensive, widely-available, and may be more tolerable and acceptable for many patients than current, limited treatment options.
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Affiliation(s)
| | | | | | - Eva Culakova
- University of Rochester Medical Center, Rochester, NY, USA
| | | | | | | | - Julienne Bower
- University of California Los Angeles, Los Angeles, CA, USA
| | - Stephen Cole
- University of California Los Angeles, Los Angeles, CA, USA
| | | | | | - Gary Morrow
- University of Rochester Medical Center, Rochester, NY, USA
| | - Luke Peppone
- University of Rochester Medical Center, Rochester, NY, USA
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22
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Ingle JN, Cairns J, Suman VJ, Shepherd LE, Fasching PA, Hoskin TL, Singh RJ, Desta Z, Kalari KR, Ellis MJ, Goss PE, Chen BE, Volz B, Barman P, Carlson EE, Haddad T, Goetz MP, Goodnature B, Cuellar ME, Walters MA, Correia C, Kaufmann SH, Weinshilboum RM, Wang L. Anastrozole has an Association between Degree of Estrogen Suppression and Outcomes in Early Breast Cancer and is a Ligand for Estrogen Receptor α. Clin Cancer Res 2020; 26:2986-2996. [PMID: 32098767 DOI: 10.1158/1078-0432.ccr-19-3091] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2019] [Revised: 01/07/2020] [Accepted: 02/21/2020] [Indexed: 11/16/2022]
Abstract
PURPOSE To determine if the degree of estrogen suppression with aromatase inhibitors (AI: anastrozole, exemestane, letrozole) is associated with efficacy in early-stage breast cancer, and to examine for differences in the mechanism of action between the three AIs. EXPERIMENTAL DESIGN Matched case-control studies [247 matched sets from MA.27 (anastrozole vs. exemestane) and PreFace (letrozole) trials] were undertaken to assess whether estrone (E1) or estradiol (E2) concentrations after 6 months of adjuvant therapy were associated with risk of an early breast cancer event (EBCE). Preclinical laboratory studies included luciferase activity, cell proliferation, radio-labeled ligand estrogen receptor binding, surface plasmon resonance ligand receptor binding, and nuclear magnetic resonance assays. RESULTS Women with E1 ≥1.3 pg/mL and E2 ≥0.5 pg/mL after 6 months of AI treatment had a 2.2-fold increase in risk (P = 0.0005) of an EBCE, and in the anastrozole subgroup, the increase in risk of an EBCE was 3.0-fold (P = 0.001). Preclinical laboratory studies examined mechanisms of action in addition to aromatase inhibition and showed that only anastrozole could directly bind to estrogen receptor α (ERα), activate estrogen response element-dependent transcription, and stimulate growth of an aromatase-deficient CYP19A1-/- T47D breast cancer cell line. CONCLUSIONS This matched case-control clinical study revealed that levels of estrone and estradiol above identified thresholds after 6 months of adjuvant anastrozole treatment were associated with increased risk of an EBCE. Preclinical laboratory studies revealed that anastrozole, but not exemestane or letrozole, is a ligand for ERα. These findings represent potential steps towards individualized anastrozole therapy.
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Affiliation(s)
- James N Ingle
- Division of Medical Oncology, Department of Oncology, Mayo Clinic, Rochester, Minnesota.
| | - Junmei Cairns
- Division of Clinical Pharmacology, Department of Molecular Pharmacology and Experimental Therapeutics, Mayo Clinic, Rochester, Minnesota
| | - Vera J Suman
- Division of Biomedical Statistics and Informatics, Department of Health Sciences Research, Mayo Clinic, Rochester, Minnesota
| | | | - Peter A Fasching
- Department of Gynecology and Obstetrics, Comprehensive Cancer Center Erlangen-EMN, University Hospital, Erlangen, Germany
| | - Tanya L Hoskin
- Division of Biomedical Statistics and Informatics, Department of Health Sciences Research, Mayo Clinic, Rochester, Minnesota
| | - Ravinder J Singh
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, Minnesota
| | - Zeruesenay Desta
- Division of Clinical Pharmacology, Department of Medicine, Indiana University School of Medicine, Indianapolis, Indiana
| | - Krishna R Kalari
- Division of Biomedical Statistics and Informatics, Department of Health Sciences Research, Mayo Clinic, Rochester, Minnesota
| | - Matthew J Ellis
- Department of Medicine, Baylor University College of Medicine, Houston, Texas
| | - Paul E Goss
- Massachusetts General Hospital Cancer Center, Harvard University, Boston, Massachusetts
| | | | - Bernhard Volz
- Department of Business Informatics, University of Applied Sciences Ansbach, Ansbach, Germany
| | - Poulami Barman
- Division of Biomedical Statistics and Informatics, Department of Health Sciences Research, Mayo Clinic, Rochester, Minnesota
| | - Erin E Carlson
- Division of Biomedical Statistics and Informatics, Department of Health Sciences Research, Mayo Clinic, Rochester, Minnesota
| | - Tufia Haddad
- Division of Medical Oncology, Department of Oncology, Mayo Clinic, Rochester, Minnesota
| | - Matthew P Goetz
- Division of Medical Oncology, Department of Oncology, Mayo Clinic, Rochester, Minnesota
| | - Barbara Goodnature
- Patient advocate, Mayo Clinic Breast Cancer Specialized Program of Research Excellence, Rochester, Minnesota
| | - Matthew E Cuellar
- Institute for Therapeutics Discovery and Development, University of Minnesota, Minneapolis, Minnesota
| | - Michael A Walters
- Institute for Therapeutics Discovery and Development, University of Minnesota, Minneapolis, Minnesota
| | - Cristina Correia
- Division of Clinical Pharmacology, Department of Molecular Pharmacology and Experimental Therapeutics, Mayo Clinic, Rochester, Minnesota
| | - Scott H Kaufmann
- Division of Clinical Pharmacology, Department of Molecular Pharmacology and Experimental Therapeutics, Mayo Clinic, Rochester, Minnesota.,Division of Oncology Research, Mayo Clinic, Rochester, Minnesota
| | - Richard M Weinshilboum
- Division of Clinical Pharmacology, Department of Molecular Pharmacology and Experimental Therapeutics, Mayo Clinic, Rochester, Minnesota
| | - Liewei Wang
- Division of Clinical Pharmacology, Department of Molecular Pharmacology and Experimental Therapeutics, Mayo Clinic, Rochester, Minnesota.
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Collins KS, Metzger IF, Gufford BT, Lu JB, Medeiros EB, Pratt VM, Skaar TC, Desta Z. Influence of Uridine Diphosphate Glucuronosyltransferase Family 1 Member A1 and Solute Carrier Organic Anion Transporter Family 1 Member B1 Polymorphisms and Efavirenz on Bilirubin Disposition in Healthy Volunteers. Drug Metab Dispos 2020; 48:169-175. [PMID: 31888882 DOI: 10.1124/dmd.119.089052] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2019] [Accepted: 12/20/2019] [Indexed: 12/12/2022] Open
Abstract
Chronic administration of efavirenz is associated with decreased serum bilirubin levels, probably through induction of UGT1A1 We assessed the impact of efavirenz monotherapy and UGT1A1 phenotypes on total, conjugated, and unconjugated serum bilirubin levels in healthy volunteers. Healthy volunteers were enrolled into a clinical study designed to address efavirenz pharmacokinetics, drug interactions, and pharmacogenetics. Volunteers received multiple oral doses (600 mg/day for 17 days) of efavirenz. Serum bilirubin levels were obtained at study entry and 1 week after completion of the study. DNA genotyping was performed for UGT1A1 [*80 (C>T), *6 (G>A), *28 (TA7), *36 (TA5), and *37 (TA8)] and for SLCO1B1 [*5 (521T>C) and *1b (388A>G] variants. Diplotype predicted phenotypes were classified as normal, intermediate, and slow metabolizers. Compared with bilirubin levels at screening, treatment with efavirenz significantly reduced total, conjugated, and unconjugated bilirubin. After stratification by UGT1A1 phenotypes, there was a significant decrease in total bilirubin among all phenotypes, conjugated bilirubin among intermediate metabolizers, and unconjugated bilirubin among normal and intermediate metabolizers. The data also show that UGT1A1 genotype predicts serum bilirubin levels at baseline, but this relationship is lost after efavirenz treatment. SLCO1B1 genotypes did not predict bilirubin levels at baseline or after efavirenz treatment. Our data suggest that efavirenz may alter bilirubin disposition mainly through induction of UGT1A1 metabolism and efflux through multidrug resistance-associated protein 2. SIGNIFICANCE STATEMENT: Efavirenz likely alters the pharmacokinetics of coadministered drugs, potentially causing lack of efficacy or increased adverse effects, as well as the disposition of endogenous compounds relevant in homeostasis through upregulation of UGT1A1 and multidrug resistance-associated protein 2. Measurement of unconjugated and conjugated bilirubin during new drug development may provide mechanistic understanding regarding enzyme and transporters modulated by the new drug.
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Affiliation(s)
- Kimberly S Collins
- Department of Medicine, Division of Clinical Pharmacology (K.S.C., I.F.M., B.T.G., J.L., T.C.S., Z.D.), and Department of Medical and Molecular Genetics (E.B.M., V.M.P.), Indiana University School of Medicine, Indianapolis, Indiana
| | - Ingrid F Metzger
- Department of Medicine, Division of Clinical Pharmacology (K.S.C., I.F.M., B.T.G., J.L., T.C.S., Z.D.), and Department of Medical and Molecular Genetics (E.B.M., V.M.P.), Indiana University School of Medicine, Indianapolis, Indiana
| | - Brandon T Gufford
- Department of Medicine, Division of Clinical Pharmacology (K.S.C., I.F.M., B.T.G., J.L., T.C.S., Z.D.), and Department of Medical and Molecular Genetics (E.B.M., V.M.P.), Indiana University School of Medicine, Indianapolis, Indiana
| | - Jessica B Lu
- Department of Medicine, Division of Clinical Pharmacology (K.S.C., I.F.M., B.T.G., J.L., T.C.S., Z.D.), and Department of Medical and Molecular Genetics (E.B.M., V.M.P.), Indiana University School of Medicine, Indianapolis, Indiana
| | - Elizabeth B Medeiros
- Department of Medicine, Division of Clinical Pharmacology (K.S.C., I.F.M., B.T.G., J.L., T.C.S., Z.D.), and Department of Medical and Molecular Genetics (E.B.M., V.M.P.), Indiana University School of Medicine, Indianapolis, Indiana
| | - Victoria M Pratt
- Department of Medicine, Division of Clinical Pharmacology (K.S.C., I.F.M., B.T.G., J.L., T.C.S., Z.D.), and Department of Medical and Molecular Genetics (E.B.M., V.M.P.), Indiana University School of Medicine, Indianapolis, Indiana
| | - Todd C Skaar
- Department of Medicine, Division of Clinical Pharmacology (K.S.C., I.F.M., B.T.G., J.L., T.C.S., Z.D.), and Department of Medical and Molecular Genetics (E.B.M., V.M.P.), Indiana University School of Medicine, Indianapolis, Indiana
| | - Zeruesenay Desta
- Department of Medicine, Division of Clinical Pharmacology (K.S.C., I.F.M., B.T.G., J.L., T.C.S., Z.D.), and Department of Medical and Molecular Genetics (E.B.M., V.M.P.), Indiana University School of Medicine, Indianapolis, Indiana
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24
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Liu SN, Gufford BT, Lu JBL, Bushman LR, Anderson PL, Bergstrom RF, Desta Z, Gupta SK. Inhibitory Effects of Probenecid on Pharmacokinetics of Tenofovir Disoproxil Fumarate and Emtricitabine for On-Demand HIV Preexposure Prophylaxis. Clin Pharmacol Ther 2019; 107:1200-1208. [PMID: 31675437 DOI: 10.1002/cpt.1714] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2019] [Accepted: 10/28/2019] [Indexed: 11/10/2022]
Abstract
In a randomized, crossover pharmacokinetic study in healthy volunteers (N = 14), a single dose of 2 g probenecid (PRO)-boosted 600 mg tenofovir disoproxil fumarate (TDF)/400 mg emtricitabine (FTC) (test (T) +PRO) was compared with the current on-demand HIV preexposure prophylaxis from the IPERGAY study (a 600 mg TDF/400 mg FTC on day 1 and 300 mg TDF/200 mg FTC on days 2 and 3) (control, C IPERGAY). PRO increased mean single-dose area under the plasma concentration-time curve extrapolated to infinity (AUC0-∞,SD ) of tenofovir (TFV) and FTC by 61% and 68%, respectively. The TFV-diphosphate (TFV-DP) concentrations in peripheral blood mononuclear cells were higher (~30%) at 24 hours in T +PRO but then fell significantly lower (~40%) at 72 hours compared with C IPERGAY. The interaction between FTC and PRO was unexpected and novel. Further study is needed to determine if this PRO-boosted TDF/FTC regimen would be clinically effective.
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Affiliation(s)
- Stephanie N Liu
- Division of Clinical Pharmacology, Department of Medicine, School of Medicine, Indiana University, Indianapolis, Indiana, USA
| | - Brandon T Gufford
- Division of Clinical Pharmacology, Department of Medicine, School of Medicine, Indiana University, Indianapolis, Indiana, USA
| | - Jessica Bo Li Lu
- Division of Clinical Pharmacology, Department of Medicine, School of Medicine, Indiana University, Indianapolis, Indiana, USA
| | - Lane R Bushman
- Department of Pharmaceutical Sciences, Skaggs School of Pharmacy and Pharmaceutical Sciences, University of Colorado, Aurora, Colorado, USA
| | - Peter L Anderson
- Department of Pharmaceutical Sciences, Skaggs School of Pharmacy and Pharmaceutical Sciences, University of Colorado, Aurora, Colorado, USA
| | - Richard F Bergstrom
- Division of Clinical Pharmacology, Department of Medicine, School of Medicine, Indiana University, Indianapolis, Indiana, USA
| | - Zeruesenay Desta
- Division of Clinical Pharmacology, Department of Medicine, School of Medicine, Indiana University, Indianapolis, Indiana, USA
| | - Samir K Gupta
- Division of Infectious Diseases, Department of Medicine, School of Medicine, Indiana University, Indianapolis, Indiana, USA
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25
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Liu SN, Desta Z, Gufford BT. Probenecid-Boosted Tenofovir: A Physiologically-Based Pharmacokinetic Model-Informed Strategy for On-Demand HIV Preexposure Prophylaxis. CPT Pharmacometrics Syst Pharmacol 2019; 9:40-47. [PMID: 31749296 PMCID: PMC6966182 DOI: 10.1002/psp4.12481] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/09/2019] [Accepted: 11/03/2019] [Indexed: 11/28/2022]
Abstract
Multiple doses of tenofovir disoproxil fumarate (TDF) together with emtricitabine is effective for HIV preexposure prophylaxis (PrEP). TDF is converted to tenofovir (TFV) in circulation, which is subsequently cleared via tubular secretion by organic ion transporters (OATs; OAT1 and OAT3). Using in vitro kinetic parameters for TFV and the OAT1 and OAT3 inhibitor probenecid, a bottom‐up physiologically‐based pharmacokinetic model was successfully developed for the first time that accurately describes the probenecid–TFV interaction. This model predicted an increase in TFV plasma exposure by 60%, which was within 15% of the observed clinical pharmacokinetic data, and a threefold decrease in renal cells exposure following coadministration of a 600 mg TDF dose with 2 g probenecid. When compared with multiple‐dose regimens, a single‐dose probenecid‐boosted TDF regimen may be effective for HIV PrEP and improve adherence and safety by minimizing TFV‐induced nephrotoxicity by reducing TFV accumulation in renal cells.
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Affiliation(s)
- Stephanie N Liu
- Division of Clinical Pharmacology, Department of Medicine, School of Medicine, Indiana University, Indianapolis, Indiana, USA
| | - Zeruesenay Desta
- Division of Clinical Pharmacology, Department of Medicine, School of Medicine, Indiana University, Indianapolis, Indiana, USA
| | - Brandon T Gufford
- Division of Clinical Pharmacology, Department of Medicine, School of Medicine, Indiana University, Indianapolis, Indiana, USA
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26
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Metzger IF, Dave N, Kreutz Y, Lu JB, Galinsky RE, Desta Z. CYP2B6 Genotype-Dependent Inhibition of CYP1A2 and Induction of CYP2A6 by the Antiretroviral Drug Efavirenz in Healthy Volunteers. Clin Transl Sci 2019; 12:657-666. [PMID: 31339646 PMCID: PMC6853154 DOI: 10.1111/cts.12671] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2019] [Accepted: 06/10/2019] [Indexed: 01/11/2023] Open
Abstract
We investigated the effect of efavirenz on the activities of cytochrome P450 (CYP)1A2, CYP2A6, xanthine oxidase (XO), and N-acetyltransferase 2 (NAT2), using caffeine as a probe. A single 150 mg oral dose of caffeine was administered to healthy volunteers (n = 58) on two separate occasions; with a single 600 mg oral dose of efavirenz and after treatment with 600 mg/day efavirenz for 17 days. Caffeine and its metabolites in plasma and urine were quantified using liquid chromatography/tandem-mass spectrometry. DNA was genotyped for CYP2B6*4 (785A>G), CYP2B6*9 (516G>T), and CYP2B6*18 (983T>C) alleles using TaqMan assays. Relative to single-dose efavirenz treatment, multiple doses of efavirenz decreased CYP1A2 (by 38%) and increased CYP2A6 (by 85%) activities (P < 0.05); XO and NAT2 activities were unaffected. CYP2B6*6*6 genotype was associated with lower CYP1A2 activity following both single and multiple doses of efavirenz. No similar association was noted for CYP2A6 activity. This is the first report showing that efavirenz reduces hepatic CYP1A2 and suggesting chronic efavirenz exposure likely enhances the elimination of CYP2A6 substrates. This is also the first to report the extent of efavirenz-CYP1A2 interaction may be efavirenz exposure-dependent and CYP2B6 genotype-dependent.
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Affiliation(s)
- Ingrid F. Metzger
- Division of Clinical PharmacologyDepartment of MedicineIndiana University School of MedicineIndianapolisIndianaUSA
| | - Nimita Dave
- Division of Clinical PharmacologyDepartment of MedicineIndiana University School of MedicineIndianapolisIndianaUSA
- Blueprint MedicinesCambridgeMassachusettsUSA
| | - Yvonne Kreutz
- Division of Clinical PharmacologyDepartment of MedicineIndiana University School of MedicineIndianapolisIndianaUSA
| | - Jessica B.L. Lu
- Division of Clinical PharmacologyDepartment of MedicineIndiana University School of MedicineIndianapolisIndianaUSA
| | - Raymond E. Galinsky
- Division of Clinical PharmacologyDepartment of MedicineIndiana University School of MedicineIndianapolisIndianaUSA
- School of PharmacyPurdue UniversityWest LafayetteIndianaUSA
| | - Zeruesenay Desta
- Division of Clinical PharmacologyDepartment of MedicineIndiana University School of MedicineIndianapolisIndianaUSA
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27
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Desta Z, Gammal RS, Gong L, Whirl-Carrillo M, Gaur AH, Sukasem C, Hockings J, Myers A, Swart M, Tyndale RF, Masimirembwa C, Iwuchukwu OF, Chirwa S, Lennox J, Gaedigk A, Klein TE, Haas DW. Clinical Pharmacogenetics Implementation Consortium (CPIC) Guideline for CYP2B6 and Efavirenz-Containing Antiretroviral Therapy. Clin Pharmacol Ther 2019; 106:726-733. [PMID: 31006110 DOI: 10.1002/cpt.1477] [Citation(s) in RCA: 105] [Impact Index Per Article: 21.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2019] [Accepted: 04/12/2019] [Indexed: 01/11/2023]
Abstract
The HIV type-1 nonnucleoside reverse transcriptase inhibitor, efavirenz, is widely used to treat HIV type-1 infection. Efavirenz is predominantly metabolized into inactive metabolites by cytochrome P450 (CYP)2B6, and patients with certain CYP2B6 genetic variants may be at increased risk for adverse effects, particularly central nervous system toxicity and treatment discontinuation. We summarize the evidence from the literature and provide therapeutic recommendations for efavirenz prescribing based on CYP2B6 genotypes.
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Affiliation(s)
- Zeruesenay Desta
- Department of Medicine, Division of Clinical Pharmacology, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Roseann S Gammal
- Department of Pharmacy Practice, Massachusetts College of Pharmacy and Health Sciences University School of Pharmacy, Boston, Massachusetts, USA.,Department of Pharmaceutical Sciences, St. Jude Children's Research Hospital, Memphis, Tennessee, USA
| | - Li Gong
- Department of Biomedical Data Science, Stanford University, Stanford, California, USA
| | | | - Aditya H Gaur
- Department of Infectious Diseases, St. Jude Children's Research Hospital, Memphis, Tennessee, USA
| | - Chonlaphat Sukasem
- Division of Pharmacogenomics and Personalized Medicine, Faculty of Medicine Ramathibodi Hospital, Department of Pathology, Mahidol University, Bangkok, Thailand.,Laboratory for Pharmacogenomics, Faculty of Medicine Ramathibodi Hospital, Somdech Phra Debaratana Medical Center, Bangkok, Thailand
| | - Jennifer Hockings
- Department of Pharmacy and Genomic Medicine Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Alan Myers
- Department of Diagnostic & Biomedical Sciences, The University of Texas Health Sciences Center School of Dentistry, Houston, Texas, USA
| | - Marelize Swart
- Department of Medicine, Division of Clinical Pharmacology, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Rachel F Tyndale
- Centre for Addiction and Mental Health, University of Toronto, Toronto, Ontario, Canada
| | - Collen Masimirembwa
- African Institute of Biomedical Science & Technology, Wilkins Hospital, Harare, Zimbabwe
| | - Otito F Iwuchukwu
- Division of Pharmaceutical Sciences, Fairleigh Dickinson University School of Pharmacy, Florham Park, New Jersey, USA
| | - Sanika Chirwa
- Department of Internal Medicine, Meharry Medical College School of Medicine, Nashville, Tennessee, USA
| | - Jeffrey Lennox
- Division of Infectious Diseases, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Andrea Gaedigk
- Division of Clinical Pharmacology, Toxicology, & Therapeutic Innovation, Children's Mercy Kansas City, Kansas City, Missouri, USA
| | - Teri E Klein
- Department of Biomedical Data Science, Stanford University, Stanford, California, USA
| | - David W Haas
- Department of Internal Medicine, Meharry Medical College School of Medicine, Nashville, Tennessee, USA.,Departments of Medicine, Pharmacology, Pathology, Microbiology, & Immunology, Vanderbilt University School of Medicine, Nashville, Tennessee, USA
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28
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Dudenkov TM, Liu D, Cairns J, Devarajan S, Zhuang Y, Ingle JN, Buzdar AU, Robson ME, Kubo M, Batzler A, Barman P, Jenkins GD, Carlson EE, Goetz MP, Northfelt DW, Moreno-Aspitia A, Desta Z, Reid JM, Kalari KR, Wang L, Weinshilboum RM. Anastrozole Aromatase Inhibitor Plasma Drug Concentration Genome-Wide Association Study: Functional Epistatic Interaction Between SLC38A7 and ALPPL2. Clin Pharmacol Ther 2019; 106:219-227. [PMID: 30648747 PMCID: PMC6612579 DOI: 10.1002/cpt.1359] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2018] [Accepted: 12/13/2018] [Indexed: 01/13/2023]
Abstract
Anastrozole is a widely prescribed aromatase inhibitor for the therapy of estrogen receptor positive (ER+) breast cancer. We performed a genome‐wide association study (GWAS) for plasma anastrozole concentrations in 687 postmenopausal women with ER+ breast cancer. The top single‐nucleotide polymorphism (SNP) signal mapped across SLC38A7 (rs11648166, P = 2.3E‐08), which we showed to encode an anastrozole influx transporter. The second most significant signal (rs28845026, P = 5.4E‐08) mapped near ALPPL2 and displayed epistasis with the SLC38A7 signal. Both of these SNPs were cis expression quantitative trait loci (eQTL)s for these genes, and patients homozygous for variant genotypes for both SNPs had the highest drug concentrations, the highest SLC38A7 expression, and the lowest ALPPL2 expression. In summary, our GWAS identified a novel gene encoding an anastrozole transporter, SLC38A7, as well as epistatic interaction between SNPs in that gene and SNPs near ALPPL2 that influenced both the expression of the transporter and anastrozole plasma concentrations.
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Affiliation(s)
- Tanda M Dudenkov
- Division of Clinical Pharmacology, Department of Molecular Pharmacology and Experimental Therapeutics, Mayo Clinic, Rochester, Minnesota, USA
| | - Duan Liu
- Division of Clinical Pharmacology, Department of Molecular Pharmacology and Experimental Therapeutics, Mayo Clinic, Rochester, Minnesota, USA
| | - Junmei Cairns
- Division of Clinical Pharmacology, Department of Molecular Pharmacology and Experimental Therapeutics, Mayo Clinic, Rochester, Minnesota, USA
| | - Sandhya Devarajan
- Division of Clinical Pharmacology, Department of Molecular Pharmacology and Experimental Therapeutics, Mayo Clinic, Rochester, Minnesota, USA
| | - Yongxian Zhuang
- Division of Clinical Pharmacology, Department of Molecular Pharmacology and Experimental Therapeutics, Mayo Clinic, Rochester, Minnesota, USA
| | - James N Ingle
- Division of Medical Oncology, Department of Oncology, Mayo Clinic, Rochester, Minnesota, USA
| | - Aman U Buzdar
- Department of Breast Oncology, MD Anderson Cancer Center, Houston, Texas, USA
| | - Mark E Robson
- Breast Medicine Service, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Michiaki Kubo
- RIKEN Center for Integrative Medical Sciences, Yokohama City, Japan
| | - Anthony Batzler
- Division of Biomedical Statistics and Informatics, Department of Health Sciences Research, Mayo Clinic, Rochester, Minnesota, USA
| | - Poulami Barman
- Division of Biomedical Statistics and Informatics, Department of Health Sciences Research, Mayo Clinic, Rochester, Minnesota, USA
| | - Gregory D Jenkins
- Division of Biomedical Statistics and Informatics, Department of Health Sciences Research, Mayo Clinic, Rochester, Minnesota, USA
| | - Erin E Carlson
- Division of Biomedical Statistics and Informatics, Department of Health Sciences Research, Mayo Clinic, Rochester, Minnesota, USA
| | - Matthew P Goetz
- Division of Medical Oncology, Department of Oncology, Mayo Clinic, Rochester, Minnesota, USA
| | - Donald W Northfelt
- Division of Hematology/Oncology, Department of Internal Medicine, Mayo Clinic, Scottsdale, Arizona, USA
| | - Alvaro Moreno-Aspitia
- Division of Hematology/Oncology, Department of Internal Medicine, Mayo Clinic, Jacksonville, Florida, USA
| | - Zeruesenay Desta
- Division of Clinical Pharmacology, Department of Medicine, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Joel M Reid
- Division of Clinical Pharmacology, Department of Molecular Pharmacology and Experimental Therapeutics, Mayo Clinic, Rochester, Minnesota, USA
| | - Krishna R Kalari
- Division of Biomedical Statistics and Informatics, Department of Health Sciences Research, Mayo Clinic, Rochester, Minnesota, USA
| | - Liewei Wang
- Division of Clinical Pharmacology, Department of Molecular Pharmacology and Experimental Therapeutics, Mayo Clinic, Rochester, Minnesota, USA
| | - Richard M Weinshilboum
- Division of Clinical Pharmacology, Department of Molecular Pharmacology and Experimental Therapeutics, Mayo Clinic, Rochester, Minnesota, USA
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29
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Liu SN, Lu JBL, Watson CJW, Lazarus P, Desta Z, Gufford BT. Mechanistic Assessment of Extrahepatic Contributions to Glucuronidation of Integrase Strand Transfer Inhibitors. Drug Metab Dispos 2019; 47:535-544. [PMID: 30804050 DOI: 10.1124/dmd.118.085035] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2018] [Accepted: 02/21/2019] [Indexed: 12/24/2022] Open
Abstract
Integrase strand transfer inhibitor (INSTI)-based regimens dominate initial human immunodeficiency virus treatment. Most INSTIs are metabolized predominantly via UDP-glucuronosyltransferases (UGTs). For drugs predominantly metabolized by UGTs, including INSTIs, in vitro data recovered from human liver microsomes (HLMs) alone often underpredict human oral clearance. While several factors may contribute, extrahepatic glucuronidation may contribute to this underprediction. Thus, we comprehensively characterized the kinetics for the glucuronidation of INSTIs (cabotegravir, dolutegravir, and raltegravir) using pooled human microsomal preparations from liver (HLMs), intestine (HIMs), and kidney (HKMs) tissues; human embryonic kidney 293 cells expressing individual UGTs; and recombinant UGTs. In vitro glucuronidation of cabotegravir (HLMs≈HKMs>>>HIMs), dolutegravir (HLMs>HIMs>>HKMs), and raltegravir (HLMs>HKMs>> HIMs) occurred in hepatic and extrahepatic tissues. The kinetic data from expression systems suggested the major enzymes in each tissue: hepatic UGT1A9 > UGT1A1 (dolutegravir and raltegravir) and UGT1A1 (cabotegravir), intestinal UGT1A3 > UGT1A8 > UGT1A1 (dolutegravir) and UGT1A8 > UGT1A1 (raltegravir), and renal UGT1A9 (dolutegravir and raltegravir). Enzymes catalyzing cabotegravir glucuronidation in the kidney and intestine could not be identified unequivocally. Using data from dolutegravir glucuronidation as a prototype, a "bottom-up" physiologically based pharmacokinetic model was developed in a stepwise approach and predicted dolutegravir oral clearance within 4.5-fold (hepatic data only), 2-fold (hepatic and intestinal data), and 32% (hepatic, intestinal, and renal data). These results suggest clinically meaningful glucuronidation of dolutegravir in tissues other than the liver. Incorporation of additional novel mechanistic and physiologic underpinnings of dolutegravir metabolism along with in silico approaches appears to be a powerful tool to accurately predict the clearance of dolutegravir from in vitro data.
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Affiliation(s)
- Stephanie N Liu
- Division of Clinical Pharmacology, Department of Medicine, School of Medicine, Indiana University, Indianapolis, Indiana (S.N.L., J.B.L.L., Z.D., B.T.G.) and Department of Pharmaceutical Sciences, College of Pharmacy and Pharmaceutical Sciences, Washington State University, Spokane, Washington (C.J.W.W., P.L.)
| | - Jessica Bo Li Lu
- Division of Clinical Pharmacology, Department of Medicine, School of Medicine, Indiana University, Indianapolis, Indiana (S.N.L., J.B.L.L., Z.D., B.T.G.) and Department of Pharmaceutical Sciences, College of Pharmacy and Pharmaceutical Sciences, Washington State University, Spokane, Washington (C.J.W.W., P.L.)
| | - Christy J W Watson
- Division of Clinical Pharmacology, Department of Medicine, School of Medicine, Indiana University, Indianapolis, Indiana (S.N.L., J.B.L.L., Z.D., B.T.G.) and Department of Pharmaceutical Sciences, College of Pharmacy and Pharmaceutical Sciences, Washington State University, Spokane, Washington (C.J.W.W., P.L.)
| | - Philip Lazarus
- Division of Clinical Pharmacology, Department of Medicine, School of Medicine, Indiana University, Indianapolis, Indiana (S.N.L., J.B.L.L., Z.D., B.T.G.) and Department of Pharmaceutical Sciences, College of Pharmacy and Pharmaceutical Sciences, Washington State University, Spokane, Washington (C.J.W.W., P.L.)
| | - Zeruesenay Desta
- Division of Clinical Pharmacology, Department of Medicine, School of Medicine, Indiana University, Indianapolis, Indiana (S.N.L., J.B.L.L., Z.D., B.T.G.) and Department of Pharmaceutical Sciences, College of Pharmacy and Pharmaceutical Sciences, Washington State University, Spokane, Washington (C.J.W.W., P.L.)
| | - Brandon T Gufford
- Division of Clinical Pharmacology, Department of Medicine, School of Medicine, Indiana University, Indianapolis, Indiana (S.N.L., J.B.L.L., Z.D., B.T.G.) and Department of Pharmaceutical Sciences, College of Pharmacy and Pharmaceutical Sciences, Washington State University, Spokane, Washington (C.J.W.W., P.L.)
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30
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Fulton CR, Zang Y, Desta Z, Rosenman MB, Holmes AM, Decker BS, Zhang Y, T Callaghan J, Pratt VM, Levy KD, Gufford BT, Dexter PR, Skaar TC, Eadon MT. Drug-gene and drug-drug interactions associated with tramadol and codeine therapy in the INGENIOUS trial. Pharmacogenomics 2019; 20:397-408. [PMID: 30784356 DOI: 10.2217/pgs-2018-0205] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
Abstract
Background: Tramadol and codeine are metabolized by CYP2D6 and are subject to drug-gene and drug-drug interactions. Methods: This interim analysis examined prescribing behavior and efficacy in 102 individuals prescribed tramadol or codeine while receiving pharmaco-genotyping as part of the INGENIOUS trial (NCT02297126). Results: Within 60 days of receiving tramadol or codeine, clinicians more frequently prescribed an alternative opioid in ultrarapid and poor metabolizers (odds ratio: 19.0; 95% CI: 2.8-160.4) as compared with normal or indeterminate metabolizers (p = 0.01). After adjusting the CYP2D6 activity score for drug-drug interactions, uncontrolled pain was reported more frequently in individuals with reduced CYP2D6 activity (odds ratio: 0.50; 95% CI: 0.25-0.94). Conclusion: Phenoconversion for drug-drug and drug-gene interactions is an important consideration in pharmacogenomic implementation; drug-drug interactions may obscure the potential benefits of genotyping.
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Affiliation(s)
- Cathy R Fulton
- Department of Medicine, Indiana University School of Medicine, Indianapolis, IN 46202, USA.,Department of Health Informatics, Indiana University School of Informatics and Computing, Indianapolis, IN 46202, USA
| | - Yong Zang
- Department of Biostatistics, Indiana University School of Medicine, Indianapolis, IN 46202, USA
| | - Zeruesenay Desta
- Department of Medicine, Indiana University School of Medicine, Indianapolis, IN 46202, USA
| | - Marc B Rosenman
- Department of Medicine, Indiana University School of Medicine, Indianapolis, IN 46202, USA.,Ann & Robert H Lurie Children's Hospital of Chicago, Chicago, IL 60611, USA.,Department of Pediatrics, Northwestern University Feinberg School of Medicine, Chicago, IL 60611, USA
| | - Ann M Holmes
- Richard M Fairbanks School of Public Health, Indiana University-Purdue University Indianapolis, IN 46202, USA
| | - Brian S Decker
- Department of Medicine, Indiana University School of Medicine, Indianapolis, IN 46202, USA
| | - Yifei Zhang
- Department of Biostatistics, Indiana University School of Medicine, Indianapolis, IN 46202, USA
| | - John T Callaghan
- Regenstrief Institute for Health Care, Indianapolis, IN 46202, USA
| | - Victoria M Pratt
- Department of Medicine, Indiana University School of Medicine, Indianapolis, IN 46202, USA
| | - Kenneth D Levy
- Department of Medicine, Indiana University School of Medicine, Indianapolis, IN 46202, USA
| | - Brandon T Gufford
- Department of Medicine, Indiana University School of Medicine, Indianapolis, IN 46202, USA
| | - Paul R Dexter
- Department of Medicine, Indiana University School of Medicine, Indianapolis, IN 46202, USA.,Richard L Roudebush Veteran Affairs Medical Center, Indianapolis, IN 46202, USA
| | - Todd C Skaar
- Department of Medicine, Indiana University School of Medicine, Indianapolis, IN 46202, USA
| | - Michael T Eadon
- Department of Medicine, Indiana University School of Medicine, Indianapolis, IN 46202, USA
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Wu H, Lu D, Hyder M, Zhang S, Quinney SK, Desta Z, Li L. DrugMetab: An Integrated Machine Learning and Lexicon Mapping Named Entity Recognition Method for Drug Metabolite. CPT Pharmacometrics Syst Pharmacol 2018; 7:709-717. [PMID: 30033622 PMCID: PMC6263660 DOI: 10.1002/psp4.12340] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2018] [Accepted: 06/25/2018] [Indexed: 11/29/2022] Open
Abstract
Drug metabolites (DMs) are critical in pharmacology research areas, such as drug metabolism pathways and drug-drug interactions. However, there is no terminology dictionary containing comprehensive drug metabolite names, and there is no named entity recognition (NER) algorithm focusing on drug metabolite identification. In this article, we developed a novel NER system, DrugMetab, to identify DMs from the PubMed abstracts. DrugMetab utilizes the features characterized from the Part-of-Speech, drug index, and pre/suffix, and determines DMs within context. To evaluate the performance, a gold-standard corpus was manually constructed. In this task, DrugMetab with sequential minimal optimization (SMO) classifier achieves 0.89 precision, 0.77 recall, and 0.83 F-measure in the internal testing set; and 0.86 precision, 0.85 recall, and 0.86 F-measure in the external validation set. We further compared the performance between DrugMetab and whatizitChemical, which was designed for identifying small molecules or chemical entities. DrugMetab outperformed whatizitChemical, which had a lower recall rate of 0.65.
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Affiliation(s)
- Heng‐Yi Wu
- Department of Biomedical InformaticsCollege of MedicineThe Ohio State UniversityColumbusOhioUSA
| | - Deshun Lu
- Center for Computational Biology and BioinformaticsSchool of MedicineIndiana UniversityIndianapolisIndianaUSA
| | - Mustafa Hyder
- Division of Clinical PharmacologySchool of MedicineIndiana UniversityIndianapolisIndianaUSA
| | - Shijun Zhang
- Department of Biomedical InformaticsCollege of MedicineThe Ohio State UniversityColumbusOhioUSA
| | - Sara K. Quinney
- Division of Clinical PharmacologySchool of MedicineIndiana UniversityIndianapolisIndianaUSA
| | - Zeruesenay Desta
- Division of Clinical PharmacologySchool of MedicineIndiana UniversityIndianapolisIndianaUSA
| | - Lang Li
- Department of Biomedical InformaticsCollege of MedicineThe Ohio State UniversityColumbusOhioUSA
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Burgess KS, Ipe J, Swart M, Metzger IF, Lu J, Gufford BT, Thong N, Desta Z, Gaedigk R, Pearce RE, Gaedigk A, Liu Y, Skaar TC. Variants in the CYP2B6 3'UTR Alter In Vitro and In Vivo CYP2B6 Activity: Potential Role of MicroRNAs. Clin Pharmacol Ther 2018; 104:130-138. [PMID: 28960269 PMCID: PMC5871545 DOI: 10.1002/cpt.892] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2017] [Revised: 09/20/2017] [Accepted: 09/22/2017] [Indexed: 01/07/2023]
Abstract
CYP2B6*6 and CYP2B6*18 are the most clinically important variants causing reduced CYP2B6 protein expression and activity. However, these variants do not account for all variability in CYP2B6 activity. Emerging evidence has shown that genetic variants in the 3'UTR may explain variable drug response by altering microRNA regulation. Five 3'UTR variants were associated with significantly altered efavirenz AUC0-48 (8-OH-EFV/EFV) ratios in healthy human volunteers. The rs70950385 (AG>CA) variant, predicted to create a microRNA binding site for miR-1275, was associated with a 33% decreased CYP2B6 activity among normal metabolizers (AG/AG vs. CA/CA (P < 0.05)). In vitro luciferase assays were used to confirm that the CA on the variant allele created a microRNA binding site causing an 11.3% decrease in activity compared to the AG allele when treated with miR-1275 (P = 0.0035). Our results show that a 3'UTR variant contributes to variability in CYP2B6 activity.
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Affiliation(s)
- Kimberly S. Burgess
- Department of Pharmacology & Toxicology, Indiana University School of Medicine, Indianapolis, IN
- Department of Medicine, Division of Clinical Pharmacology, Indiana University School of Medicine, Indianapolis, IN
| | - Joseph Ipe
- Department of Medicine, Division of Clinical Pharmacology, Indiana University School of Medicine, Indianapolis, IN
| | - Marelize Swart
- Department of Medicine, Division of Clinical Pharmacology, Indiana University School of Medicine, Indianapolis, IN
| | - Ingrid F. Metzger
- Department of Medicine, Division of Clinical Pharmacology, Indiana University School of Medicine, Indianapolis, IN
| | - Jessica Lu
- Department of Medicine, Division of Clinical Pharmacology, Indiana University School of Medicine, Indianapolis, IN
| | - Brandon T. Gufford
- Department of Medicine, Division of Clinical Pharmacology, Indiana University School of Medicine, Indianapolis, IN
| | - Nancy Thong
- Department of Medicine, Division of Clinical Pharmacology, Indiana University School of Medicine, Indianapolis, IN
| | - Zeruesenay Desta
- Department of Medicine, Division of Clinical Pharmacology, Indiana University School of Medicine, Indianapolis, IN
| | - Roger Gaedigk
- Division of Clinical Pharmacology, Toxicology and Therapeutic Innovation, Children’s Mercy Kansas City, Kansas City, MO
| | - Robin E. Pearce
- Division of Clinical Pharmacology, Toxicology and Therapeutic Innovation, Children’s Mercy Kansas City, Kansas City, MO
| | - Andrea Gaedigk
- Division of Clinical Pharmacology, Toxicology and Therapeutic Innovation, Children’s Mercy Kansas City, Kansas City, MO
| | - Yunlong Liu
- Department of Medical & Molecular Genetics, Indiana University School of Medicine, Indianapolis, IN
- Center for Computational Biology and Bioinformatics, Indiana University School of Medicine, Indianapolis, IN
| | - Todd C. Skaar
- Department of Medicine, Division of Clinical Pharmacology, Indiana University School of Medicine, Indianapolis, IN
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Dempsey JM, Kidwell KM, Gersch CL, Desta Z, Storniolo AM, Stearns V, Skaar TC, Hayes DF, Henry NL, Rae JM, Hertz DL. Association of a low-expression SLCO1B1 polymorphism with estrogen concentrations before and during aromatase inhibitor treatment for breast cancer. J Clin Oncol 2018. [DOI: 10.1200/jco.2018.36.15_suppl.543] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Affiliation(s)
| | | | | | | | | | - Vered Stearns
- Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins School of Medicine,, Baltimore, MD
| | - Todd C Skaar
- Indiana University School of Medicine, Indianapolis, MD
| | - Daniel F. Hayes
- University of Michigan Comprehensive Cancer Center, Ann Arbor, MI
| | - Norah Lynn Henry
- Huntsman Cancer Institute, University of Utah, and SWOG, Salt Lake City, UT
| | - James M. Rae
- University of Michigain Health System, Ann Arbor, MI
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Gufford BT, Robarge JD, Eadon MT, Gao H, Lin H, Liu Y, Desta Z, Skaar TC. Rifampin modulation of xeno- and endobiotic conjugating enzyme mRNA expression and associated microRNAs in human hepatocytes. Pharmacol Res Perspect 2018; 6:e00386. [PMID: 29610665 PMCID: PMC5869567 DOI: 10.1002/prp2.386] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2017] [Accepted: 01/12/2018] [Indexed: 01/06/2023] Open
Abstract
Rifampin is a pleiotropic inducer of multiple drug metabolizing enzymes and transporters. This work utilized a global approach to evaluate rifampin effects on conjugating enzyme gene expression with relevance to human xeno‐ and endo‐biotic metabolism. Primary human hepatocytes from 7 subjects were treated with rifampin (10 μmol/L, 24 hours). Standard methods for RNA‐seq library construction, EZBead preparation, and NextGen sequencing were used to measure UDP‐glucuronosyl transferase UGT, sulfonyltransferase SULT, N acetyltransferase NAT, and glutathione‐S‐transferase GST mRNA expression compared to vehicle control (0.01% MeOH). Rifampin‐induced (>1.25‐fold) mRNA expression of 13 clinically important phase II drug metabolizing genes and repressed (>1.25‐fold) the expression of 3 genes (P < .05). Rifampin‐induced miRNA expression changes correlated with mRNA changes and miRNAs were identified that may modulate conjugating enzyme expression. NAT2 gene expression was most strongly repressed (1.3‐fold) by rifampin while UGT1A4 and UGT1A1 genes were most strongly induced (7.9‐ and 4.8‐fold, respectively). Physiologically based pharmacokinetic modeling (PBPK) was used to simulate the clinical consequences of rifampin induction of CYP3A4‐ and UGT1A4‐mediated midazolam metabolism. Simulations evaluating isolated UGT1A4 induction predicted increased midazolam N‐glucuronide exposure (~4‐fold) with minimal reductions in parent midazolam exposure (~10%). Simulations accounting for simultaneous induction of both CYP3A4 and UGT1A4 predicted a ~10‐fold decrease in parent midazolam exposure with only a ~2‐fold decrease in midazolam N‐glucuronide metabolite exposure. These data reveal differential effects of rifampin on the human conjugating enzyme transcriptome and potential associations with miRNAs that form the basis for future mechanistic studies to elucidate the interplay of conjugating enzyme regulatory elements.
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Affiliation(s)
- Brandon T Gufford
- Department of Medicine Division of Clinical Pharmacology Indiana University School of Medicine Indianapolis IN
| | - Jason D Robarge
- Department of Medicine Division of Clinical Pharmacology Indiana University School of Medicine Indianapolis IN
| | - Michael T Eadon
- Department of Medicine Division of Clinical Pharmacology Indiana University School of Medicine Indianapolis IN
| | - Hongyu Gao
- Department of Medical and Molecular Genetics Indiana University School of Medicine Indianapolis IN
| | - Hai Lin
- Department of Medical and Molecular Genetics Indiana University School of Medicine Indianapolis IN
| | - Yunlong Liu
- Department of Medical and Molecular Genetics Indiana University School of Medicine Indianapolis IN
| | - Zeruesenay Desta
- Department of Medicine Division of Clinical Pharmacology Indiana University School of Medicine Indianapolis IN
| | - Todd C Skaar
- Department of Medicine Division of Clinical Pharmacology Indiana University School of Medicine Indianapolis IN
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Skaar TC, Desta Z. CYP2D6 and Endoxifen in Tamoxifen Therapy: A Tribute to David A. Flockhart. Clin Pharmacol Ther 2018; 103:755-757. [PMID: 29473149 DOI: 10.1002/cpt.1039] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2017] [Revised: 01/23/2018] [Accepted: 01/25/2018] [Indexed: 11/11/2022]
Abstract
This issue of Clinical Pharmacology & Therapeutics (CPT) includes the Clinical Pharmacogenetics Implementation Consortium (CPIC) guideline for using CYP2D6 genotyping to guide tamoxifen therapy for breast cancer patients. CYP2D6 metabolizes tamoxifen to its more active metabolite, endoxifen, and patients with reduced CYP2D6 activity have reduced circulating endoxifen concentrations. In this associated commentary, we recognize and honor the late Dr. David Flockhart, who began the research and made early fundamental discoveries on tamoxifen that have now resulted in this guideline.
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Affiliation(s)
- Todd C Skaar
- Indiana University School of Medicine, Department of Medicine, Division of Clinical Pharmacology, Indianapolis, Indiana, USA
| | - Zeruesenay Desta
- Indiana University School of Medicine, Department of Medicine, Division of Clinical Pharmacology, Indianapolis, Indiana, USA
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36
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Marcath LA, Deal AM, Van Wieren E, Danko W, Walko CM, Ibrahim JG, Weck KE, Jones DR, Desta Z, McLeod HL, Carey LA, Irvin WJ, Hertz DL. Comprehensive assessment of cytochromes P450 and transporter genetics with endoxifen concentration during tamoxifen treatment. Pharmacogenet Genomics 2017; 27:402-409. [PMID: 28877533 PMCID: PMC5659294 DOI: 10.1097/fpc.0000000000000311] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
OBJECTIVES Tamoxifen bioactivation to endoxifen is mediated primarily by CYP2D6; however, considerable variability remains unexplained. Our aim was to perform a comprehensive assessment of the effect of genetic variation in tamoxifen-relevant enzymes and transporters on steady-state endoxifen concentrations. PATIENTS AND METHODS Comprehensive genotyping of CYP enzymes and transporters was performed using the iPLEX ADME PGx Pro Panel in 302 tamoxifen-treated breast cancer patients. Predicted activity phenotype for 19 enzymes and transporters were analyzed for univariate association with endoxifen concentration, and then adjusted for CYP2D6 and clinical covariates. RESULTS In univariate analysis, higher activity of CYP2C8 (regression β=0.22, P=0.020) and CYP2C9 (β=0.20, P=0.04), lower body weight (β=-0.014, P<0.0001), and endoxifen measurement during winter (each β<-0.39, P=0.002) were associated with higher endoxifen concentrations. After adjustment for the CYP2D6 diplotype, weight, and season, CYP2C9 remained significantly associated with higher concentrations (P=0.02), but only increased the overall model R by 1.3%. CONCLUSION Our results further support a minor contribution of CYP2C9 genetic variability toward steady-state endoxifen concentrations. Integration of clinician and genetic variables into individualized tamoxifen dosing algorithms would marginally improve their accuracy and potentially enhance tamoxifen treatment outcomes.
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Affiliation(s)
- Lauren A Marcath
- aDepartment of Clinical Pharmacy, University of Michigan College of Pharmacy, Ann Arbor, Michigan bUNC Lineberger Comprehensive Cancer Center, University of North Carolina, Chapel Hill, North Carolina cDeBartolo Family Personalized Medicine Institute, Moffitt Cancer Center, Tampa, Florida dDepartment of Clinical Pharmacology, Indiana University, Indianapolis, Indiana eBon Secours Cancer Institute, Richmond, Virginia, USA
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Hertz DL, Speth KA, Kidwell KM, Gersch CL, Desta Z, Storniolo AM, Stearns V, Skaar TC, Hayes DF, Henry NL, Rae JM. Variable aromatase inhibitor plasma concentrations do not correlate with circulating estrogen concentrations in post-menopausal breast cancer patients. Breast Cancer Res Treat 2017; 165:659-668. [PMID: 28643023 PMCID: PMC5709190 DOI: 10.1007/s10549-017-4346-x] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2017] [Accepted: 06/16/2017] [Indexed: 01/13/2023]
Abstract
PURPOSE The aromatase inhibitors (AI) exemestane (EXE), letrozole (LET), and anastrozole suppress estrogen biosynthesis, and are effective treatments for estrogen receptor (ER)-positive breast cancer. Prior work suggests that anastrozole blood concentrations are associated with the magnitude of estrogen suppression. The objective of this study was to determine whether the magnitude of estrogen suppression, as determined by plasma estradiol (E2) concentrations, in EXE or LET treated patients is associated with plasma AI concentrations. METHODS Five hundred post-menopausal women with ER-positive breast cancer were enrolled in the prospective Exemestane and Letrozole Pharmacogenetic (ELPh) Study conducted by the COnsortium on BReast cancer phArmacogomics (COBRA) and randomly assigned to either drug. Estrogen concentrations were measured at baseline and after 3 months of AI treatment and drug concentrations were measured after 1 or 3 months. EXE or LET concentrations were compared with 3-month E2 concentration or the change from baseline to 3 months using several complementary statistical procedures. RESULTS Four-hundred patients with on-treatment E2 and AI concentrations were evaluable (EXE n = 200, LET n = 200). Thirty (7.6%) patients (EXE n = 13, LET n = 17) had 3-month E2 concentrations above the lower limit of quantification (LLOQ) (median: 4.75; range: 1.42-63.8 pg/mL). EXE and LET concentrations were not associated with on-treatment E2 concentrations or changes in E2 concentrations from baseline (all p > 0.05). CONCLUSIONS Steady-state plasma AI concentrations do not explain variability in E2 suppression in post-menopausal women receiving EXE or LET therapy, in contrast with prior evidence in anastrozole treated patients.
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Affiliation(s)
- Daniel L Hertz
- Department of Clinical Pharmacy, University of Michigan College of Pharmacy, 428 Church St. Room 3054, Ann Arbor, MI, 48109-1065, USA.
- Breast Oncology Program, University of Michigan Comprehensive Cancer Center, Ann Arbor, USA.
| | - Kelly A Speth
- Department of Biostatistics, University of Michigan School of Public Health, Ann Arbor, USA
| | - Kelley M Kidwell
- Breast Oncology Program, University of Michigan Comprehensive Cancer Center, Ann Arbor, USA
- Department of Biostatistics, University of Michigan School of Public Health, Ann Arbor, USA
| | - Christina L Gersch
- Breast Oncology Program, University of Michigan Comprehensive Cancer Center, Ann Arbor, USA
- Department of Internal Medicine, Division of Hematology/Oncology, University of Michigan Medical School, Ann Arbor, USA
| | | | | | | | - Todd C Skaar
- Indiana University School of Medicine, Indianapolis, USA
| | - Daniel F Hayes
- Breast Oncology Program, University of Michigan Comprehensive Cancer Center, Ann Arbor, USA
- Department of Internal Medicine, Division of Hematology/Oncology, University of Michigan Medical School, Ann Arbor, USA
| | - N Lynn Henry
- Breast Oncology Program, University of Michigan Comprehensive Cancer Center, Ann Arbor, USA
- Department of Internal Medicine, Division of Hematology/Oncology, University of Michigan Medical School, Ann Arbor, USA
- Huntsman Cancer Institute, University of Utah Health Care, Salt Lake City, UT, USA
| | - James M Rae
- Breast Oncology Program, University of Michigan Comprehensive Cancer Center, Ann Arbor, USA
- Department of Internal Medicine, Division of Hematology/Oncology, University of Michigan Medical School, Ann Arbor, USA
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Pierson RC, Gufford BT, Desta Z, Eadon MT. Clinical and educational impact of pharmacogenomics testing: a case series from the INGENIOUS trial. Pharmacogenomics 2017; 18:835-841. [PMID: 28594278 DOI: 10.2217/pgs-2017-0042] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
Pharmacogenomic testing has become increasingly widespread. However, there remains a need to bridge the gap between test results and providers lacking the expertise required to interpret these results. The Indiana Genomics Implementation trial is underway at our institution to examine total healthcare cost and patient outcomes after genotyping in a safety-net healthcare system. As part of the study, trial investigators and clinical pharmacology fellows interpret genotype results, review patient histories and medication lists and evaluate potential drug-drug interactions. We present a case series of patients in whom pharmacogenomic consultations aided providers in appropriately applying pharmacogenomic results within the clinical context. Formal consultations not only provide valuable patient care information but educational opportunities for the fellows to cement pharmacogenomic concepts.
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Affiliation(s)
- Rebecca C Pierson
- Department of Obstetrics, Gynecology & Women's Health, University of Louisville, KY 40202, USA
| | - Brandon T Gufford
- Department of Medicine, Division of Clinical Pharmacology, Indiana University, IN 46202, USA
| | - Zeruesenay Desta
- Department of Medicine, Division of Clinical Pharmacology, Indiana University, IN 46202, USA
| | - Michael T Eadon
- Department of Medicine, Division of Clinical Pharmacology, Indiana University, IN 46202, USA.,Department of Medicine, Division of Nephrology, Indiana University, IN 46202, USA
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Hertz DL, Kidwell KM, Speth KA, Gersch CL, Desta Z, Storniolo AM, Stearns V, Skaar TC, Hayes DF, Henry NL, Rae JM. Is incomplete estradiol suppression during aromatase inhibitor treatment in post-menopausal patients with breast cancer due to insufficient systemic drug concentrations? J Clin Oncol 2017. [DOI: 10.1200/jco.2017.35.15_suppl.1063] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
1063 Background: Aromatase inhibitors (AI) suppress estrogen biosynthesis and are effective treatments for estrogen receptor (ER)-positive breast cancer. In a prospectively enrolled cohort we observed a subset of post-menopausal women who exhibit high plasma estradiol (E2) concentrations during AI treatment, which could potentially contribute to treatment failure. We tested the hypothesis that incomplete E2 suppression is due to insufficient systemic AI concentrations. Methods: Five hundred post-menopausal women with ER-positive breast cancer were randomized to daily exemestane (Exe) 25 mg or letrozole (Let) 2.5 mg. Plasma E2 was measured using GC/MS/MS (lower limit of quantification (LLOQ) = 1.25 pg/mL) at baseline and after 3 months. Let and Exe plasma concentrations measured after 1 or 3 months were compared with the magnitude of E2 depletion using four complementary statistical procedures to assess associations of drug concentrations with: 1) a binary outcome of E2 suppression below LLOQ (logistic regression), 2) 3-month E2 concentrations (linear regression), 3) absolute change from baseline in E2 concentrations (Spearman correlation), and 4) an ordinal outcome defined by E2: decreased to below LLOQ, decreased but not to LLOQ, stayed the same, or increased from baseline (cumulative logistic regression). Results: 397 patients with E2 and AI concentration measurements were evaluable (Exe n = 199, Let n = 198). Thirty (7.6%) patients (Exe n = 13, Let n = 17) had E2 concentrations above the LLOQ at 3 months (range: 1.42-63.8 pg/mL). Exe and Let concentrations were not associated with achievement of unmeasurable E2 concentrations, on-treatment E2 concentrations, E2 change from baseline, or ordinal groupings of E2 change (all p > 0.05). In a parallel analysis there was no association of estrone-sulfate and drug concentrations (data not shown). Conclusions: Our results suggest that circulating drug concentrations do not explain incomplete E2 suppression in women receiving AI therapy. Additional studies are underway to determine whether age, body mass and genetic variation in the aromatase enzyme influence AI treatment response.
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Affiliation(s)
| | | | | | | | | | | | - Vered Stearns
- School of Medicine and The Sidney Kimmel Comprehensive Cancer Center at Johns Hopkins, Baltimore, MD
| | - Todd C Skaar
- Indiana University School of Medicine, Indianapolis, MD
| | - Daniel F. Hayes
- University of Michigan Comprehensive Cancer Center, Ann Arbor, MI
| | | | - James M. Rae
- University of Michigain Health System, Ann Arbor, MI
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Hertz DL, Kidwell KM, Gersch CL, Desta Z, Storniolo AM, Stearns V, Skaar TC, Hayes DF, Henry NL, Rae JM. Abstract P6-09-11: Genetic variation in CYP3A affects steady-state exemestane concentrations but does not explain inter-race difference. Cancer Res 2017. [DOI: 10.1158/1538-7445.sabcs16-p6-09-11] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Abstract
Background: Exemestane is a third generation steroidal aromatase inhibitor (AI) used for the treatment of estrogen receptor (ER) positive breast cancer in postmenopausal women. Differences in AI treatment efficacy and side effects may be due, in part, to variability in drug exposure. We previously reported that patients who self-report as white and those who carry the low-activity CYP3A4*22 single nucleotide polymorphism (SNP) have increased exemestane steady-state concentrations. Additional SNPs in CYP3A may contribute to pharmacokinetic variability and explain this inter-race difference. CYP3A5*3 (rs776746) is a non-expresser genotype that is far more common in European (minor allele frequency (MAF)∼0.94) than African (MAF∼0.18) individuals. CYP3A7*1C (rs45446698) is believed to tag adult expression of the fetal CYP3A7 enzyme and is relatively uncommon in tested cohorts (European MAF=0.04, African MAF<0.01). The objective of this secondary analysis was to determine whether these additional CYP3A SNPs contribute to variability in steady state exemestane concentrations and explain the inter-race difference.
Methods: 500 patients were randomly assigned to either drug on the Exemestane and Letrozole Pharmacogenetics (ELPh) Study. Clinical data and DNA were collected at baseline and blood samples were collected after 1 or 3 months of treatment to measure steady-state exemestane concentration via HPLC/MS. Genotyping for CYP3A5*3 and CYP3A7*1C was performed via Taqman Allelic Discrimination. Pharmacogenetic association with log-transformed concentrations were tested for each variant by inclusion in a multivariable model with CYP3A4*22 and self-reported race, assuming additive genetic effect, using Tobit regression to censor concentrations below the lower limit of quantification. SNPs with suggestive p-values <0.10 were included in a multivariable model with relevant covariates (AST or ALT>40, body mass index (BMI), and prior chemotherapy) to assess their independent contribution.
Results: In 231 evaluable patients there was a suggestive trend toward lower steady-state exemestane concentrations for CYP3A7*1C carriers (6.3 vs. 8.0 ng/mL) in the model including CYP3A4*22 and race (p=0.083). In the final multivariable model each CYP3A7*1C allele decreased exemestane concentration 31.5% (p=0.035, Table 1). CYP3A5*3 was not associated with exemestane concentration (p>0.2).
Multivariable Model of Exemestane Concentration % change in concentration (95% CI)p-valueCYP3A4*22 (rs35599367)64.5% (23%, 120%)0.0008CYP3A7*1C (rs45446698)-31.5% (-52%, -2.6%)0.035Self-Reported White47.2% (9.0%, 99%)0.012AST or ALT>4041.3% (1.0%, 98%)0.044BMI-0.9% (-2.4%, 0.55%)0.22Prior Chemotherapy-23.5% (-37%, -7.6%)0.006CI: Confidence Interval
Conclusions: Patients with breast cancer who carry CYP3A7*1C have lower steady-state exemestane concentrations but this association does not explain the greater concentrations in self-reported white patients. Ongoing analyses will determine whether exemestane concentration predicts treatment efficacy or toxicity, and if so, whether genetic and clinical factors can be useful for individualizing dosing to optimize outcomes. CYP3A7*1C should be prioritized for analyses of pharmacokinetic variability of other CYP3A substrates.
Citation Format: Hertz DL, Kidwell KM, Gersch CL, Desta Z, Storniolo AM, Stearns V, Skaar TC, Hayes DF, Henry NL, Rae JM. Genetic variation in CYP3A affects steady-state exemestane concentrations but does not explain inter-race difference [abstract]. In: Proceedings of the 2016 San Antonio Breast Cancer Symposium; 2016 Dec 6-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2017;77(4 Suppl):Abstract nr P6-09-11.
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Affiliation(s)
- DL Hertz
- University of Michigan, Ann Arbor, MI; Indiana University; Johns Hopkins University
| | - KM Kidwell
- University of Michigan, Ann Arbor, MI; Indiana University; Johns Hopkins University
| | - CL Gersch
- University of Michigan, Ann Arbor, MI; Indiana University; Johns Hopkins University
| | - Z Desta
- University of Michigan, Ann Arbor, MI; Indiana University; Johns Hopkins University
| | - AM Storniolo
- University of Michigan, Ann Arbor, MI; Indiana University; Johns Hopkins University
| | - V Stearns
- University of Michigan, Ann Arbor, MI; Indiana University; Johns Hopkins University
| | - TC Skaar
- University of Michigan, Ann Arbor, MI; Indiana University; Johns Hopkins University
| | - DF Hayes
- University of Michigan, Ann Arbor, MI; Indiana University; Johns Hopkins University
| | - NL Henry
- University of Michigan, Ann Arbor, MI; Indiana University; Johns Hopkins University
| | - JM Rae
- University of Michigan, Ann Arbor, MI; Indiana University; Johns Hopkins University
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Cardoso JDO, Oliveira RV, Lu JBL, Desta Z. In Vitro Metabolism of Montelukast by Cytochrome P450s and UDP-Glucuronosyltransferases. Drug Metab Dispos 2016; 43:1905-16. [PMID: 26374173 DOI: 10.1124/dmd.115.065763] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Montelukast has been recommended as a selective in vitro and in vivo probe of cytochrome P450 (P450) CYP2C8 activity, but its selectivity toward this enzyme remains unclear. We performed detailed characterization of montelukast metabolism in vitro using human liver microsomes (HLMs), expressed P450s, and uridine 5'-diphospho-glucuronosyltransferases (UGTs). Kinetic and inhibition experiments performed at therapeutically relevant concentrations reveal that CYP2C8 and CYP2C9 are the principal enzymes responsible for montelukast 36-hydroxylation to 1,2-diol. CYP3A4 was the main catalyst of montelukast sulfoxidation and stereoselective 21-hydroxylation, and multiple P450s participated in montelukast 25-hydroxylation. We confirmed direct glucuronidation of montelukast to an acyl-glucuronide. We also identified a novel peak that appears consistent with an ether-glucuronide. Kinetic analysis in HLMs and experiments in expressed UGTs indicate that both metabolites were exclusively formed by UGT1A3. Comparison of in vitro intrinsic clearance in HLMs suggest that direct glucuronidation may play a greater role in the overall metabolism of montelukast than does P450-mediated oxidation, but the in vivo contribution of UGT1A3 needs further testing. In conclusion, our in vitro findings provide new insight toward montelukast metabolism. The utility of montelukast as a probe of CYP2C8 activity may be compromised owing to involvement of multiple P450s and UGT1A3 in its metabolism.
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Abdelhady AM, Shugg T, Thong N, Lu JBL, Kreutz Y, Jaynes HA, Robarge JD, Tisdale JE, Desta Z, Overholser BR. Efavirenz Inhibits the Human Ether-A-Go-Go Related Current (hERG) and Induces QT Interval Prolongation in CYP2B6*6*6 Allele Carriers. J Cardiovasc Electrophysiol 2016; 27:1206-1213. [PMID: 27333947 DOI: 10.1111/jce.13032] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/12/2016] [Revised: 06/06/2016] [Accepted: 06/08/2016] [Indexed: 11/29/2022]
Abstract
BACKGROUND Efavirenz (EFV) has been associated with torsade de pointes despite marginal QT interval lengthening. Since EFV is metabolized by the cytochrome P450 (CYP) 2B6 enzyme, we hypothesized that EFV would lengthen the rate-corrected QT (QTcF) interval in carriers of the CYP2B6*6 decreased functional allele. OBJECTIVE The primary objective of this study was to evaluate EFV-associated QT interval changes with regard to CYP2B6 genotype and to explore mechanisms of QT interval lengthening. METHODS EFV was administered to healthy volunteers (n = 57) as a single 600 mg dose followed by multiple doses to steady-state. Subjects were genotyped for known CYP2B6 alleles and ECGs and EFV plasma concentrations were obtained serially. Whole-cell, voltage-clamp experiments were performed on cells stably expressing hERG and exposed to EFV in the presence and absence of CYP2B6 expression. RESULTS EFV demonstrated a gene-dose effect and exceeded the FDA criteria for QTcF interval prolongation in CYP2B6*6/*6 carriers. The largest mean time-matched differences ∆∆QTcF were observed at 6 hours (14 milliseconds; 95% CI [1; 27]), 12 hours (18 milliseconds; 95% CI [-4; 40]), and 18 hours (6 milliseconds; 95% CI [-1; 14]) in the CYP2B6*6/*6 genotype. EFV concentrations exceeding 0.4 μg/mL significantly inhibited outward hERG tail currents (P < 0.05). CONCLUSIONS This study demonstrates that homozygous carriers of CYP2B6*6 allele may be at increased risk for EFV-induced QTcF interval prolongation via inhibition of hERG.
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Affiliation(s)
- Ahmed M Abdelhady
- Department of Pharmacy Practice, College of Pharmacy, Purdue University, West Lafayette
| | - Tyler Shugg
- Department of Pharmacy Practice, College of Pharmacy, Purdue University, West Lafayette
| | - Nancy Thong
- Division of Clinical Pharmacology, School of Medicine, Indiana University, Indianapolis, Indiana, USA
| | - Jessica Bo Li Lu
- Division of Clinical Pharmacology, School of Medicine, Indiana University, Indianapolis, Indiana, USA
| | - Yvonne Kreutz
- Division of Clinical Pharmacology, School of Medicine, Indiana University, Indianapolis, Indiana, USA
| | - Heather A Jaynes
- Department of Pharmacy Practice, College of Pharmacy, Purdue University, West Lafayette
| | - Jason D Robarge
- Division of Clinical Pharmacology, School of Medicine, Indiana University, Indianapolis, Indiana, USA
| | - James E Tisdale
- Department of Pharmacy Practice, College of Pharmacy, Purdue University, West Lafayette.,Division of Clinical Pharmacology, School of Medicine, Indiana University, Indianapolis, Indiana, USA
| | - Zeruesenay Desta
- Division of Clinical Pharmacology, School of Medicine, Indiana University, Indianapolis, Indiana, USA
| | - Brian R Overholser
- Department of Pharmacy Practice, College of Pharmacy, Purdue University, West Lafayette. .,Division of Clinical Pharmacology, School of Medicine, Indiana University, Indianapolis, Indiana, USA.
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Masters AR, Gufford BT, Lu JBL, Metzger IF, Jones DR, Desta Z. Chiral Plasma Pharmacokinetics and Urinary Excretion of Bupropion and Metabolites in Healthy Volunteers. J Pharmacol Exp Ther 2016; 358:230-8. [PMID: 27255113 DOI: 10.1124/jpet.116.232876] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2016] [Accepted: 06/01/2016] [Indexed: 11/22/2022] Open
Abstract
Bupropion, widely used as an antidepressant and smoking cessation aid, undergoes complex metabolism to yield numerous metabolites with unique disposition, effect, and drug-drug interactions (DDIs) in humans. The stereoselective plasma and urinary pharmacokinetics of bupropion and its metabolites were evaluated to understand their potential contributions to bupropion effects. Healthy human volunteers (n = 15) were administered a single oral dose of racemic bupropion (100 mg), which was followed by collection of plasma and urine samples and determination of bupropion and metabolite concentrations using novel liquid chromatography-tandem mass spectrometry assays. Time-dependent, elimination rate-limited, stereoselective pharmacokinetics were observed for all bupropion metabolites. Area under the plasma concentration-time curve from zero to infinity ratios were on average approximately 65, 6, 6, and 4 and Cmax ratios were approximately 35, 6, 3, and 0.5 for (2R,3R)-/(2S,3S)-hydroxybupropion, R-/S-bupropion, (1S,2R)-/(1R,2S)-erythrohydrobupropion, and (1R,2R)-/(1S,2S)-threohydrobupropion, respectively. The R-/S-bupropion and (1R,2R)-/(1S,2S)-threohydrobupropion ratios are likely indicative of higher presystemic metabolism of S- versus R-bupropion by carbonyl reductases. Interestingly, the apparent renal clearance of (2S,3S)-hydroxybupropion was almost 10-fold higher than that of (2R,3R)-hydroxybupropion. The prediction of steady-state pharmacokinetics demonstrated differential stereospecific accumulation [partial area under the plasma concentration-time curve after the final simulated bupropion dose (300-312 hours) from 185 to 37,447 nM⋅h] and elimination [terminal half-life of approximately 7-46 hours] of bupropion metabolites, which may explain observed stereoselective differences in bupropion effect and DDI risk with CYP2D6 at steady state. Further elucidation of bupropion and metabolite disposition suggests that bupropion is not a reliable in vivo marker of CYP2B6 activity. In summary, to our knowledge, this is the first comprehensive report to provide novel insight into mechanisms underlying bupropion disposition by detailing the stereoselective pharmacokinetics of individual bupropion metabolites, which will enhance clinical understanding of bupropion's effects and DDIs with CYP2D6.
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Affiliation(s)
- Andrea R Masters
- Division of Clinical Pharmacology, Department of Medicine, Indiana University School of Medicine, Indianapolis, Indiana
| | - Brandon T Gufford
- Division of Clinical Pharmacology, Department of Medicine, Indiana University School of Medicine, Indianapolis, Indiana
| | - Jessica Bo Li Lu
- Division of Clinical Pharmacology, Department of Medicine, Indiana University School of Medicine, Indianapolis, Indiana
| | - Ingrid F Metzger
- Division of Clinical Pharmacology, Department of Medicine, Indiana University School of Medicine, Indianapolis, Indiana
| | - David R Jones
- Division of Clinical Pharmacology, Department of Medicine, Indiana University School of Medicine, Indianapolis, Indiana
| | - Zeruesenay Desta
- Division of Clinical Pharmacology, Department of Medicine, Indiana University School of Medicine, Indianapolis, Indiana
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Hertz DL, Deal A, Ibrahim JG, Walko CM, Weck KE, Anderson S, Magrinat G, Olajide O, Moore S, Raab R, Carrizosa DR, Corso S, Schwartz G, Graham M, Peppercorn JM, Jones DR, Desta Z, Flockhart DA, Evans JP, McLeod HL, Carey LA, Irvin WJ. Tamoxifen Dose Escalation in Patients With Diminished CYP2D6 Activity Normalizes Endoxifen Concentrations Without Increasing Toxicity. Oncologist 2016; 21:795-803. [PMID: 27226358 DOI: 10.1634/theoncologist.2015-0480] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2015] [Accepted: 02/23/2016] [Indexed: 01/13/2023] Open
Abstract
BACKGROUND Polymorphic CYP2D6 is primarily responsible for metabolic activation of tamoxifen to endoxifen. We previously reported that by increasing the daily tamoxifen dose to 40 mg/day in CYP2D6 intermediate metabolizer (IM), but not poor metabolizer (PM), patients achieve endoxifen concentrations similar to those of extensive metabolizer patients on 20 mg/day. We expanded enrollment to assess the safety of CYP2D6 genotype-guided dose escalation and investigate concentration differences between races. METHODS PM and IM breast cancer patients currently receiving tamoxifen at 20 mg/day were enrolled for genotype-guided escalation to 40 mg/day. Endoxifen was measured at baseline and after 4 months. Quality-of-life data were collected using the Functional Assessment of Cancer Therapy-Breast (FACT-B) and Breast Cancer Prevention Trial Menopausal Symptom Scale at baseline and after 4 months. RESULTS In 353 newly enrolled patients, genotype-guided dose escalation eliminated baseline concentration differences in IM (p = .08), but not PM (p = .009), patients. Endoxifen concentrations were similar in black and white patients overall (p = .63) and within CYP2D6 phenotype groups (p > .05). In the quality-of-life analysis of 480 patients, dose escalation did not meaningfully diminish quality of life; in fact, improvements were seen in several measures including the FACT Breast Cancer subscale (p = .004) and limitations in range of motion (p < .0001) in IM patients. CONCLUSION Differences in endoxifen concentration during treatment can be eliminated by doubling the tamoxifen dose in IM patients, without an appreciable effect on quality of life. Validation of the association between endoxifen concentration and efficacy or prospective demonstration of improved efficacy is necessary to warrant clinical uptake of this personalized treatment strategy. IMPLICATIONS FOR PRACTICE This secondary analysis of a prospective CYP2D6 genotype-guided tamoxifen dose escalation study confirms that escalation to 40 mg/day in patients with low-activity CYP2D6 phenotypes (poor or intermediate metabolizers) increases endoxifen concentrations without any obvious increases in treatment-related toxicity. It remains unknown whether endoxifen concentration is a useful predictor of tamoxifen efficacy, and thus, there is no current role in clinical practice for CYP2D6 genotype-guided tamoxifen dose adjustment. If future studies confirm the importance of endoxifen concentrations for tamoxifen efficacy and report a target concentration, this study provides guidance for a dose-adjustment approach that could maximize efficacy while maintaining patient quality of life.
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Affiliation(s)
| | - Allison Deal
- University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Joseph G Ibrahim
- University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | | | - Karen E Weck
- University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Steven Anderson
- Laboratory Corporation of America, Burlington, North Carolina, USA
| | - Gustav Magrinat
- Moses Cone Health Cancer Center, Greensboro, North Carolina, USA
| | | | - Susan Moore
- REX Hematology Oncology Associates, Raleigh, North Carolina, USA
| | - Rachel Raab
- Brody School of Medicine at East Carolina University, Greenville, North Carolina, USA
| | | | - Steven Corso
- Palmetto Hematology Oncology, Spartanburg, South Carolina, USA
| | - Garry Schwartz
- Levine Cancer Institute Concord, Concord, North Carolina, USA
| | - Mark Graham
- Waverly Hematology/Oncology, Cary, North Carolina, USA
| | | | | | | | | | - James P Evans
- University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | | | - Lisa A Carey
- University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - William J Irvin
- University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA Bon Secours Cancer Institute, Richmond, Virginia, USA
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Van Wieren E, Kidwell KM, Desta Z, McLeod HL, Carey LA, Irvin WJ, Hertz DL. Assessment of a clinical and genetic algorithm to predict endoxifen concentration. J Clin Oncol 2016. [DOI: 10.1200/jco.2016.34.15_suppl.e12021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Affiliation(s)
| | | | | | | | - Lisa A. Carey
- The University of North Carolina at Chapel Hill, Chapel Hill, NC
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Benson EA, Eadon MT, Desta Z, Liu Y, Lin H, Burgess KS, Segar MW, Gaedigk A, Skaar TC. Rifampin Regulation of Drug Transporters Gene Expression and the Association of MicroRNAs in Human Hepatocytes. Front Pharmacol 2016; 7:111. [PMID: 27199754 PMCID: PMC4845040 DOI: 10.3389/fphar.2016.00111] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2016] [Accepted: 04/12/2016] [Indexed: 01/30/2023] Open
Abstract
UNLABELLED Membrane drug transporters contribute to the disposition of many drugs. In human liver, drug transport is controlled by two main superfamilies of transporters, the solute carrier transporters (SLC) and the ATP Binding Cassette transporters (ABC). Altered expression of these transporters due to drug-drug interactions can contribute to differences in drug exposure and possibly effect. In this study, we determined the effect of rifampin on gene expression of hundreds of membrane transporters along with all clinically relevant drug transporters. METHODS In this study, primary human hepatocytes (n = 7 donors) were cultured and treated for 24 h with rifampin and vehicle control. RNA was isolated from the hepatocytes, mRNA expression was measured by RNA-seq, and miRNA expression was analyzed by Taqman OpenArray. The effect of rifampin on the expression of selected transporters was also tested in kidney cell lines. The impact of rifampin on the expression of 410 transporter genes from 19 different transporter gene families was compared with vehicle control. RESULTS Expression patterns of 12 clinically relevant drug transporter genes were changed by rifampin (FDR < 0.05). For example, the expressions of ABCC2, ABCB1, and ABCC3 were increased 1.9-, 1.7-, and 1.2-fold, respectively. The effects of rifampin on four uptake drug transporters (SLCO1B3, SLC47A1, SLC29A1, SLC22A9) were negatively correlated with the rifampin effects on specific microRNA expression (SLCO1B3/miR-92a, SLC47A1/miR-95, SLC29A1/miR-30d#, and SLC22A9/miR-20; r < -0.79; p < 0.05). Seven hepatic drug transporter genes (SLC22A1, SLC22A5, SLC15A1, SLC29A1, SLCO4C1, ABCC2, and ABCC4), whose expression was altered by rifampin in hepatocytes, were also present in a renal proximal tubular cell line, but in renal cells rifampin did not alter their gene expression. PXR expression was very low in the kidney cells; this may explain why rifampin induces gene expression in a tissue-specific manner. CONCLUSION Rifampin alters the expression of many of the clinically relevant hepatic drug transporters, which may provide a rational basis for understanding rifampin-induced drug-drug interactions reported in vivo. The relevance of its effect on many other transporters remains to be studied.
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Affiliation(s)
- Eric A Benson
- Division of Clinical Pharmacology, Department of Medicine, Indiana University School of Medicine Indianapolis, IN, USA
| | - Michael T Eadon
- Division of Clinical Pharmacology, Department of Medicine, Indiana University School of Medicine Indianapolis, IN, USA
| | - Zeruesenay Desta
- Division of Clinical Pharmacology, Department of Medicine, Indiana University School of Medicine Indianapolis, IN, USA
| | - Yunlong Liu
- Department of Medical and Molecular Genetics, Indiana University School of Medicine Indianapolis, IN, USA
| | - Hai Lin
- Department of Medical and Molecular Genetics, Indiana University School of Medicine Indianapolis, IN, USA
| | - Kimberly S Burgess
- Department of Pharmacology and Toxicology, Indiana University School of Medicine Indianapolis, IN, USA
| | - Matthew W Segar
- Department of Medical and Molecular Genetics, Indiana University School of Medicine Indianapolis, IN, USA
| | - Andrea Gaedigk
- Division of Clinical Pharmacology, Toxicology and Therapeutic Innovation, Children's Mercy Kansas City and School of Medicine, University of Missouri-Kansas City Kansas City, MO, USA
| | - Todd C Skaar
- Division of Clinical Pharmacology, Department of Medicine, Indiana University School of Medicine Indianapolis, IN, USA
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Eadon MT, Desta Z, Levy KD, Decker BS, Pierson RC, Pratt VM, Callaghan JT, Rosenman MB, Carpenter JS, Holmes AM, McDonald CA, Benson EA, Patil AS, Vuppalanchi R, Gufford BT, Dave N, Robarge JD, Hyder MA, Haas DM, Kreutz RP, Dexter PR, Skaar TC, Flockhart DA. Implementation of a pharmacogenomics consult service to support the INGENIOUS trial. Clin Pharmacol Ther 2016; 100:63-6. [PMID: 26850569 DOI: 10.1002/cpt.347] [Citation(s) in RCA: 50] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2015] [Accepted: 01/31/2016] [Indexed: 12/19/2022]
Abstract
Hospital systems increasingly utilize pharmacogenomic testing to inform clinical prescribing. Successful implementation efforts have been modeled at many academic centers. In contrast, this report provides insights into the formation of a pharmacogenomics consultation service at a safety-net hospital, which predominantly serves low-income, uninsured, and vulnerable populations. The report describes the INdiana GENomics Implementation: an Opportunity for the UnderServed (INGENIOUS) trial and addresses concerns of adjudication, credentialing, and funding.
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Affiliation(s)
- M T Eadon
- Department of Medicine, Indiana University, Indianapolis, Indiana, USA
| | - Z Desta
- Department of Medicine, Indiana University, Indianapolis, Indiana, USA
| | - K D Levy
- Department of Medicine, Indiana University, Indianapolis, Indiana, USA
| | - B S Decker
- Department of Medicine, Indiana University, Indianapolis, Indiana, USA
| | - R C Pierson
- Department of Medicine, Indiana University, Indianapolis, Indiana, USA
| | - V M Pratt
- Department of Medical and Molecular Genetics, Indiana University, Indianapolis, Indiana, USA
| | - J T Callaghan
- Department of Medicine, Indiana University, Indianapolis, Indiana, USA.,Department of Veterans Affairs, Indianapolis, Indiana, USA
| | - M B Rosenman
- Department of Pediatrics, Northwestern University, Chicago, Illinois, USA
| | - J S Carpenter
- School of Nursing, Indiana University, Indianapolis, Indiana, USA
| | - A M Holmes
- Fairbanks School of Public Health, Indiana University, Indianapolis, Indiana, USA
| | - C A McDonald
- Department of Medicine, Indiana University, Indianapolis, Indiana, USA
| | - E A Benson
- Department of Medicine, Indiana University, Indianapolis, Indiana, USA
| | - A S Patil
- Department of Medicine, Indiana University, Indianapolis, Indiana, USA.,Department of Obstetrics and Gynecology, Indiana University, Indianapolis, Indiana, USA
| | - R Vuppalanchi
- Department of Medicine, Indiana University, Indianapolis, Indiana, USA
| | - B T Gufford
- Department of Medicine, Indiana University, Indianapolis, Indiana, USA
| | - N Dave
- Department of Medicine, Indiana University, Indianapolis, Indiana, USA
| | - J D Robarge
- Department of Medicine, Indiana University, Indianapolis, Indiana, USA
| | - M A Hyder
- Department of Medicine, Indiana University, Indianapolis, Indiana, USA
| | - D M Haas
- Department of Obstetrics and Gynecology, Indiana University, Indianapolis, Indiana, USA
| | - R P Kreutz
- Department of Medicine, Indiana University, Indianapolis, Indiana, USA
| | - P R Dexter
- Regenstrief Institute for Health Care, Indiana University, Indianapolis, Indiana, USA
| | - T C Skaar
- Department of Medicine, Indiana University, Indianapolis, Indiana, USA
| | - D A Flockhart
- Department of Medicine, Indiana University, Indianapolis, Indiana, USA
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Masters AR, McCoy M, Jones DR, Desta Z. Stereoselective method to quantify bupropion and its three major metabolites, hydroxybupropion, erythro-dihydrobupropion, and threo-dihydrobupropion using HPLC-MS/MS. J Chromatogr B Analyt Technol Biomed Life Sci 2016; 1015-1016:201-208. [PMID: 26946423 DOI: 10.1016/j.jchromb.2016.02.018] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2015] [Revised: 01/15/2016] [Accepted: 02/14/2016] [Indexed: 10/22/2022]
Abstract
Bupropion metabolites formed via oxidation and reduction exhibit pharmacological activity, but little is known regarding their stereoselective disposition. A novel stereoselective liquid chromatography-tandem mass spectrometry (LC-MS/MS) method was developed to separate and quantify enantiomers of bupropion, 4-hydroxybupropion, and erythro- and threo-dihydrobupropion. Liquid-liquid extraction was implemented to extract all analytes from 50 μL human plasma. Acetaminophen (APAP) was used as an internal standard. The analytes were separated on a Lux 3 μ Cellulose-3 250×4.6 mm column by methanol: acetonitrile: ammonium bicarbonate: ammonium hydroxide gradient elution and monitored using an ABSciex 5500 QTRAP triple-quadrupole mass spectrometer equipped with electrospray ionization probe in positive mode. Extraction efficiency for all analytes was ≥70%. The stability at a single non-extracted concentration for over 48 h at ambient temperature resulted in less than 9.8% variability for all analytes. The limit of quantification (LOQ) for enantiomers of bupropion and 4-hydroxybupropion was 0.3 ng/mL, while the LOQ for enantiomers of erythro- and threo-hydrobupropion was 0.15 ng/mL. The intra-day precision and accuracy estimates for enantiomers of bupropion and its metabolites ranged from 3.4% to 15.4% and from 80.6% to 97.8%, respectively, while the inter-day precision and accuracy ranged from 6.1% to 19.9% and from 88.5% to 99.9%, respectively. The current method was successfully implemented to determine the stereoselective pharmacokinetics of bupropion and its metabolites in 3 healthy volunteers administered a single 100mg oral dose of racemic bupropion. This novel, accurate, and precise HPLC-MS/MS method should enhance further research into bupropion stereoselective metabolism and drug interactions.
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Affiliation(s)
- Andrea R Masters
- Indiana University School of Medicine, Indiana University Melvin and Bren Simon Cancer Center, RR208, 699 Riley Hospital Drive, Indianapolis, IN 46202, United States.
| | - Michael McCoy
- Phenomenex, 411 Madrid Avenue, Torrance, CA 90501, United States.
| | - David R Jones
- Department of Medicine, Division of Clinical Pharmacology, RR 208, 699 Riley Hospital Drive, Indianapolis, IN 46202, United States.
| | - Zeruesenay Desta
- Department of Medicine, Division of Clinical Pharmacology, R2 402, 950 West Walnut Avenue, Indianapolis, IN 46202, United States.
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Hertz DL, Kidwell KM, Seewald NJ, Gersch CL, Desta Z, Flockhart DA, Storniolo AM, Stearns V, Skaar TC, Hayes DF, Henry NL, Rae JM. Abstract P5-12-05: CYP3A4*22 polymorphism is associated with increased exemestane concentrations in postmenopausal breast cancer patients. Cancer Res 2016. [DOI: 10.1158/1538-7445.sabcs15-p5-12-05] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Abstract
Background: Exemestane is a second generation steroidal aromatase inhibitor (AI) used for the treatment of estrogen receptor (ER) positive breast cancer in postmenopausal women. Variability in AI treatment efficacy and side effects seen across patients may be due, in part, to inter-patient differences in drug exposure. This exposure variability is likely caused by patient genetics factors, such as single nucleotide polymorphisms (SNPs) in drug metabolizing enzymes, or clinical factors such as patient body size, organ function, and comorbidities. The objective of this secondary correlative analysis was to identify genetic and clinical characteristics that affect steady state exemestane concentration, with a specific focus on the influence of inherited genetic variants and baseline hepatic function.
Methods: 500 patients were enrolled on the Exemestane and Letrozole Pharmacogenetics (ELPh) Study and randomized to either drug. Clinical data and DNA were collected at baseline and blood samples were collected after 1 or 3 months of treatment to measure steady-state exemestane concentration via HPLC/MS. Genotyping was performed on a custom Sequenom MassARRAY iPLEX that included the recently discovered low activity CYP3A4*22 (rs35599367) SNP and several other SNPs with putative functional consequence in enzymes thought to be involved in exemestane metabolism (CYP1A1/2, CYP1B1, CYP3A4, CYP4A11, AKR1C3/4, AKR7A2). Our primary hypothesis was that patients carrying CYP3A4*22 variants would have higher serum exemestane concentrations. Other SNPs and clinical characteristics (hepatic and renal function, age, body mass index (BMI), time of sample collection, prior chemotherapy) were assessed for independent association, and then adjusted for in a multivariable tobit regression model for CYP3A4*22 on log-transformed censored exemestane concentration.
Results: 246 (225 randomized to exemestane arm, 21 crossed-over from letrozole arm) patients had exemestane steady state levels and were evaluable in this analysis. As hypothesized, the CYP3A4*22 polymorphism (minor allele frequency=0.06) was associated with a 54% increase in exemestane concentration (95% CI: 14% - 109%, p<0.01). Exemestane concentration was 44% greater in patients who had evidence of hepatic impairment (AST or ALT>40) at baseline (95% CI: 2% - 104%, p=0.02), 1% lower per unit increase in BMI (95% CI: 0% - 3%, p=0.05), and 20% lower in patients who received prior chemotherapy (95% CI: 4% - 34%, p=0.03). Age, renal impairment, and other SNPs were not associated with exemestane concentration. After adjustment for significant clinical covariates the CYP3A4*22 SNP remained significant (p<0.01).
Conclusions: Genetic and clinical predictors of exemestane concentration were discovered in a large cohort of prospectively enrolled estrogen responsive breast cancer patients. Ongoing analyses will determine whether the variability in exemestane concentration was associated with downstream effects on estrogen depletion or treatment-related toxicity. If so, these genetic and clinical characteristics could be useful for individualizing dosing of exemestane to ensure that all patients are receiving maximal benefit with minimal toxicity.
Citation Format: Hertz DL, Kidwell KM, Seewald NJ, Gersch CL, Desta Z, Flockhart DA, Storniolo AM, Stearns V, Skaar TC, Hayes DF, Henry NL, Rae JM. CYP3A4*22 polymorphism is associated with increased exemestane concentrations in postmenopausal breast cancer patients. [abstract]. In: Proceedings of the Thirty-Eighth Annual CTRC-AACR San Antonio Breast Cancer Symposium: 2015 Dec 8-12; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2016;76(4 Suppl):Abstract nr P5-12-05.
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Affiliation(s)
- DL Hertz
- University of Michigan, Ann Arbor, MI; Indiana University; Johns Hopkins University
| | - KM Kidwell
- University of Michigan, Ann Arbor, MI; Indiana University; Johns Hopkins University
| | - NJ Seewald
- University of Michigan, Ann Arbor, MI; Indiana University; Johns Hopkins University
| | - CL Gersch
- University of Michigan, Ann Arbor, MI; Indiana University; Johns Hopkins University
| | - Z Desta
- University of Michigan, Ann Arbor, MI; Indiana University; Johns Hopkins University
| | - DA Flockhart
- University of Michigan, Ann Arbor, MI; Indiana University; Johns Hopkins University
| | - AM Storniolo
- University of Michigan, Ann Arbor, MI; Indiana University; Johns Hopkins University
| | - V Stearns
- University of Michigan, Ann Arbor, MI; Indiana University; Johns Hopkins University
| | - TC Skaar
- University of Michigan, Ann Arbor, MI; Indiana University; Johns Hopkins University
| | - DF Hayes
- University of Michigan, Ann Arbor, MI; Indiana University; Johns Hopkins University
| | - NL Henry
- University of Michigan, Ann Arbor, MI; Indiana University; Johns Hopkins University
| | - JM Rae
- University of Michigan, Ann Arbor, MI; Indiana University; Johns Hopkins University
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