1
|
Salem JE, Yang T, Moslehi JJ, Waintraub X, Gandjbakhch E, Bachelot A, Hidden-Lucet F, Hulot JS, Knollmann BC, Lebrun-Vignes B, Funck-Brentano C, Glazer AM, Roden DM. Androgenic effects on ventricular repolarization: A translational study from the international pharmacovigilance database to iPSC-cardiomyocytes. Ann Endocrinol (Paris) 2020; 82:132-133. [PMID: 32171470 DOI: 10.1016/j.ando.2020.02.008] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
BACKGROUND Male hypogonadism, arising from a range of etiologies including androgen-deprivation therapies (ADTs), has been reported as a risk factor for acquired long-QT syndrome (aLQTS) and torsades de pointes (TdP). A full description of the clinical features of aLQTS associated with ADT and of underlying mechanisms is lacking. METHODS We searched the international pharmacovigilance database VigiBase for men (n=6 560 565 individual case safety reports) presenting with aLQTS, TdP, or sudden death associated with ADT. In cardiomyocytes derived from induced pluripotent stem cells from men, we studied electrophysiological effects of ADT and dihydrotestosterone. RESULTS Among subjects receiving ADT in VigiBase, we identified 184 cases of aLQTS (n=168) and/or TdP (n=68; 11% fatal), and 99 with sudden death. Of the 10 ADT drugs examined, 7 had a disproportional association (reporting odds ratio=1.4-4.7; P<0.05) with aLQTS, TdP, or sudden death. The minimum and median times to sudden death were 0.25 and 92 days, respectively. The androgen receptor antagonist enzalutamide was associated with more deaths (5430/31 896 [17%]; P<0.0001) than other ADT used for prostate cancer (4208/52 089 [8.1%]). In induced pluripotent stem cells, acute and chronic enzalutamide (25μM) significantly prolonged action potential durations (action potential duration at 90% when paced at 0.5Hz; 429.7±27.1 (control) versus 982.4±33.2 (acute, P<0.001) and 1062.3±28.9ms (chronic; P<0.001), and generated afterdepolarizations and/or triggered activity in drug-treated cells (11/20 acutely and 8/15 chronically). Enzalutamide acutely and chronically inhibited delayed rectifier potassium current, and chronically enhanced late sodium current. Dihydrotestosterone (30nM) reversed enzalutamide electrophysiological effects on induced pluripotent stem cells. CONCLUSION QT prolongation and TdP are a risk in men receiving enzalutamide and other ADTs. CLINICAL TRIAL REGISTRATION URL: https://www.clinicaltrials.gov. Unique identifier: NCT03193138.
Collapse
Affiliation(s)
- J E Salem
- Assistance Publique Hopitaux de Paris, Pitié-Salpêtriére Hospital, Departments of Pharmacology and Cardiology, UNICO-GRECO Cardio-oncology Program, Centre d'investigation clinique-1421, Pharmacovigilance Unit, Inserm, Sorbonne Université, Paris, France; Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, USA; Department of Pharmacology, Vanderbilt University Medical Center, Nashville, TN, USA.
| | - T Yang
- Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, USA; Department of Pharmacology, Vanderbilt University Medical Center, Nashville, TN, USA
| | - J J Moslehi
- Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
| | - X Waintraub
- Assistance Publique Hopitaux de Paris, Pitié-Salpêtriére Hospital, Departments of Pharmacology and Cardiology, UNICO-GRECO Cardio-oncology Program, Centre d'investigation clinique-1421, Pharmacovigilance Unit, Inserm, Sorbonne Université, Paris, France
| | - E Gandjbakhch
- Assistance Publique Hopitaux de Paris, Pitié-Salpêtriére Hospital, Departments of Pharmacology and Cardiology, UNICO-GRECO Cardio-oncology Program, Centre d'investigation clinique-1421, Pharmacovigilance Unit, Inserm, Sorbonne Université, Paris, France
| | - A Bachelot
- IE3M, Department of Endocrinology and Reproductive Medicine, and Centre de Référence des Maladies Endocriniennes Rares de la croissance et Centre des Pathologies gynécologiques Rares, Inserm, Sorbonne Université, Paris, France
| | - F Hidden-Lucet
- Assistance Publique Hopitaux de Paris, Pitié-Salpêtriére Hospital, Departments of Pharmacology and Cardiology, UNICO-GRECO Cardio-oncology Program, Centre d'investigation clinique-1421, Pharmacovigilance Unit, Inserm, Sorbonne Université, Paris, France
| | - J S Hulot
- Université Paris-Descartes, Sorbonne Paris Cité Paris Cardiovascular Research Center, Institut national de la santé et de la recherche médicale UMRS 970, Hôpital Européen Georges Pompidou, AP-HP, Paris, France
| | - B C Knollmann
- Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, USA; Department of Pharmacology, Vanderbilt University Medical Center, Nashville, TN, USA
| | - B Lebrun-Vignes
- Assistance Publique Hopitaux de Paris, Pitié-Salpêtriére Hospital, Departments of Pharmacology and Cardiology, UNICO-GRECO Cardio-oncology Program, Centre d'investigation clinique-1421, Pharmacovigilance Unit, Inserm, Sorbonne Université, Paris, France
| | - C Funck-Brentano
- Assistance Publique Hopitaux de Paris, Pitié-Salpêtriére Hospital, Departments of Pharmacology and Cardiology, UNICO-GRECO Cardio-oncology Program, Centre d'investigation clinique-1421, Pharmacovigilance Unit, Inserm, Sorbonne Université, Paris, France
| | - A M Glazer
- Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
| | - D M Roden
- Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, USA; Department of Pharmacology, Vanderbilt University Medical Center, Nashville, TN, USA; Department of Biomedical Informatics, Vanderbilt University Medical Center, Vanderbilt University Medical Center, Nashville, TN, USA
| |
Collapse
|
2
|
Salem JE, Manouchehri A, arie Bretagne M, Lebrun Vignes B, Groarke JD, Johnson DB, Yang T, Reddy NM, Funck-Brentano C, Brown JR, Roden DM, Moslehi JJ. P1591Cardiovascular toxicity of ibrutinib: a pharmacovigilance study. Eur Heart J 2019. [DOI: 10.1093/eurheartj/ehz748.0350] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Abstract
Importance
Ibrutinib, a first in class Bruton tyrosine kinase inhibitor, has revolutionized treatment for several B-cell malignancies. However, early data suggested that ibrutinib was associated with supra-ventricular arrhythmias (SVA) and bleeding. Other types of cardiovascular adverse drug reactions (CV-ADR) induced by ibrutinib have been sporadically reported.
Objective
To determine the full spectrum of CV-ADR associated with ibrutinib and provide data concerning their clinical characteristics.
Design
An observational, retrospective, pharmacovigilance study
Setting
VigiBase, the World Health Organization's pharmacovigilance database.
Main outcomes and measures
A disproportionality analysis using reporting odds-ratios (ROR) and information component (IC). IC compares observed and expected values to find associations between drugs and ADR using disproportionate Bayesian reporting; IC025 (lower end of the IC 95% credibility interval) >0 is considered statistically significant.
Exposures
Exposure to ibrutinib versus entire database.
Results
Ibrutinib was associated with higher reporting of supraventricular arrhythmias (SVA; ROR: 23.1 [21.6–24.7]; IC025:3.97), central nervous system (CNS) hemorrhagic events (ROR: 3.7 [3.4–4.1]; IC025:1.63), heart failure (HF; ROR: 3.5 [3.1–3.8]; IC025:1.46), ventricular arrhythmias (VA; ROR: 4.7 [3.7–5.9]; IC025:0.96), conduction disorders (CD; ROR: 3.5 [2.7–4.6]; IC025:0.76), CNS ischemic events (ROR: 2.2 [2.0–2.5]; IC025:0.73) and hypertension (ROR: 1.7 [1.5–1.9]; IC025:0.4). CV-ADR occurred early after ibrutinib administration, as soon as after the first dose, with a shorter median time to onset of 27.5 days (IQR: 1–138.5 days) for CD (p<0.01, Kruskal-Wallis), as compared to CNS ischemic events (51 days; IQR: 17.5–160 days, p: 0.05 vs. CD), CNS hemorrhagic events (53.5 days; IQR: 20.3–183.3 days, p: 0.03 vs. CD), HF (54 days; IQR: 20–142.8 days, p: 0.05 vs. CD), VA (70 days; IQR: 28.5–152.5 days, p: 0.03 vs. CD), SVA (74 days; (IQR: 29.5–196.5 days, p: 0.0004 vs. CD) and hypertension (164 days; IQR: 20–274 days, p: 0.04 vs. CD). CV-ADR were associated with fatalities, with rates ranging from ∼10% (SVA and VA) to ∼20% (CNS events, HF and CD). More deaths occurred when SVA cases were associated with CNS hemorrhagic and/or ischemic events compared to their absence (15/52, 28.8% vs. 88/907, 9.7%, p<0.0001, respectively).
Conclusions
Severe and occasionally fatal cardiac events related to cardiac SVA, VA, CD, HF, hypertension, CNS hemorrhagic and ischemic events occur in patients exposed to ibrutinib. These events should be considered in patient care and in clinical trial designs.
Collapse
Affiliation(s)
- J E Salem
- University Pierre & Marie Curie Paris VI, Paris, France
| | - A Manouchehri
- Vanderbilt University, clinical pharmacology, Nashville, United States of America
| | - M arie Bretagne
- Hospital Pitie-Salpetriere, CIC-Paris Est, pharmacologie médicale, Paris, France
| | - B Lebrun Vignes
- Hospital Pitie-Salpetriere, CIC-Paris Est, pharmacologie médicale, Paris, France
| | - J D Groarke
- Harvard Medical School, Cardiology, Boston, United States of America
| | - D B Johnson
- Vanderbilt University, clinical pharmacology, Nashville, United States of America
| | - T Yang
- Vanderbilt University, clinical pharmacology, Nashville, United States of America
| | - N M Reddy
- Vanderbilt University, clinical pharmacology, Nashville, United States of America
| | - C Funck-Brentano
- Hospital Pitie-Salpetriere, CIC-Paris Est, pharmacologie médicale, Paris, France
| | - J R Brown
- Harvard Medical School, Cardiology, Boston, United States of America
| | - D M Roden
- Vanderbilt University, clinical pharmacology, Nashville, United States of America
| | - J J Moslehi
- Vanderbilt University, clinical pharmacology, Nashville, United States of America
| |
Collapse
|
3
|
Salem JE, Lebrun-Vignes B, Pariente A, Shaffer CM, Malouf GG, Dureau P, Potey C, Funck-Brentano C, Roden DM, Moslehi JJ, Bretagne M. P2597Heart failure and atrial tachyarrhythmia on abiraterone: a characterization using pharmacovigilance databases. Eur Heart J 2019. [DOI: 10.1093/eurheartj/ehz748.0922] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Abstract
Background
Abiraterone and enzalutamide are recently approved androgen deprivation therapies (ADT) for metastatic prostate cancer. The cardiac safety profile for the two drugs is unknown.
Methods
Using French and World Health Organization (WHO) pharmacovigilance databases, we performed a disproportionality-analysis of suspected adverse-drug-reactions (ADR) to evaluate the reporting-odds-ratio (ROR) of cardiac ADR associated with abiraterone compared to enzalutamide, other ADT used in prostate cancer, and entire database. Clinical and demographic characterization of patients with ADT-induced cardiac ADR was performed.
Results
In the 5,759,781 ADR reports in men, 55,070 pertained to ADT. The ROR of AT for abiraterone was of 4.1 [3.1–5.3] vs. enzalutamide, 3.7 [3–4.5] vs. other ADT, and 3.2 [2.7–3.7] vs. entire database. The corresponding ROR for HF were of 2.5 [2–3], 1.5 [1.3–1.7], and 2 [1.7–2.3], respectively. Mean time to AT and HF onset was shorter on abiraterone (5.2±0.8 and 4.5±0.6 months, respectively) vs. other ADT (13.3±3.2 and 9.2±1.1 months; p<0.05). Cases on abiraterone vs. other ADT were more frequently associated with ≥2 ADR-terms including AT, HF, hypokalemia, hypertension and edema (13.6% vs. 6%, p<10–4). For abiraterone, age but not dose was associated to reporting of AT/HF vs. any other ADR.
Table 1 Number (available data) AT HF Hypokalemia Edema Hypertension Age (y) 5989 r: 0.03, p: 0.02 r: 0.05, p≤0.0001 r: 0.06, p≤0.0001 r: 0.04, p≤0.01 ns Dose of hydrocortisone equivalent (mg/day) 3828 ns ns ns r: −0.07, p≤0.001 r: −0.12, p≤0.0001 Dose of abiraterone (mg/day) 6285 ns ns ns ns ns Details concerning correlation (r) between clinical covariates and reporting for AT, HF, hypokalemia, edema and hypertension within overall adverse drug reaction on abiraterone (n: 9203) extracted from VigiBase (through 08/2017).
Time to onset
Conclusion
Compared to other ADT, abiraterone was associated with a higher reporting of AT and HF associated with hypokalemia, hypertension and edema. These findings are consistent with the hyper-mineralocorticism induced by abiraterone and not with other ADT.
Collapse
Affiliation(s)
- J E Salem
- University Pierre & Marie Curie Paris VI, Paris, France
| | - B Lebrun-Vignes
- Hospital Pitie-Salpetriere, CIC-Paris Est, pharmacologie médicale, Paris, France
| | - A Pariente
- University Hospital of Bordeaux, Bordeaux, France
| | - C M Shaffer
- Vanderbilt University, clinical pharmacology, Nashville, United States of America
| | - G G Malouf
- University Hospital of Strasbourg, Strasbourg, France
| | - P Dureau
- Hospital Pitie-Salpetriere, CIC-Paris Est, pharmacologie médicale, Paris, France
| | | | - C Funck-Brentano
- Hospital Pitie-Salpetriere, CIC-Paris Est, pharmacologie médicale, Paris, France
| | - D M Roden
- Vanderbilt University, clinical pharmacology, Nashville, United States of America
| | - J J Moslehi
- Vanderbilt University, clinical pharmacology, Nashville, United States of America
| | - M Bretagne
- Hospital Pitie-Salpetriere, CIC-Paris Est, pharmacologie médicale, Paris, France
| |
Collapse
|
4
|
Salem JE, Yang T, Moslehi JJ, Waintraub X, Gandjbakhch E, Bachelot A, Hidden-Lucet F, Hulot JS, Knollmann BC, Lebrun-Vignes B, Funck-Brentano C, Glazer AM, Roden DM. P6590Androgenic effects on ventricular repolarization: a translational study from pharmacovigilance databases to iPSC-cardiomyocytes. Eur Heart J 2019. [DOI: 10.1093/eurheartj/ehz746.1178] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Abstract
Aim
Male hypogonadism, arising from various etiologies including androgen-deprivation therapies (ADT), has been reported as a risk-factor for acquired long-QT (aLQT) and Torsades de pointe (TdP). A full description of clinical features of aLQTS associated with ADT and of underlying mechanisms are lacking.
Method and results
We searched the WHO pharmacovigilance database for men (n=6,560,565) presenting with aLQT, TdP or sudden death (SD) associated with ADT. We identified 184 cases of aLQTS and/or TdP (11% fatal), and 99 with SD. Of the 10 ADT examined, 7 had a disproportional association (reporting-OR=1.4–4.7, p<0.05) with aLQT, TdP or SD. The minimum time to SD was 0.25 days. Enzalutamide (Enza, androgen antagonist) was associated with more deaths (17%, p<0.001) than other ADT used for prostate cancer (8.1%,Table). In cardiomyocytes derived from induced pluripotent stem cells (IPS-CMs) from men, we studied electrophysiological effects of enza and dihydrotestosterone (DHT). Acute and chronic enza (25μM) prolonged action potential durations (APD90-paced0.5Hz; 414±63 (control) vs. 951±67 (acute, p<0.01) and 1028±63msec (chronic, p<0.01), and generated early/delayed afterdepolarizations and/or triggered activity in drug treated cells (4/7 acute and 3/5 chronic). Enza acutely and chronically inhibited IKr, and chronically enhanced INa-L. DHT (30nM) reversed enza effects on IPS-CMs. In 7 men with aLQT and hypogonadism, ECGs showed low amplitude, bifid T-waves typical of IKr block which resolved with testosterone.
Table 1 ndeath/ntotal (%) aLQT TdP SD n/naLQTS±TdP±SD (%) with ADT considered suspect by reporter Leuprorelin 1,871/22,113 (8.5%) 33 16 18 28/55 (50.9%) Goserelin 471/5,821 (8.1%) 8 2 15 17/22 (77.3%) Triptorelin 52/1,517 (3.4%) 6 3 2 5/8 (62.5%) Degarelix 82/2,787 (2.9%) 7 4 3 10/11 (90.9%) Bicalutamide 724/10,144 (7.1%) 23 16 11 28/41 (68.3%) Flutamide 163/4075 (4%) 4 2 3 3/7 (42.9%) Enzalutamide 5,430/31,896 (17%) 19 4 13 30/32 (93.8%) Abiraterone 1,240/14,261 (8.7%) 19 7 10 29/31 (92.5%) Finasteride 1,062/33,877 (3.1%) 52 20 32 20/87 (23%) Dutasteride 248/15,177 (1.6%) 26 7 11 5/38 (13.2%) Total ADT* 10,540/127,385 (8.3%) 168 68 99 137/283 (48.4%) Number (n) of case reports in men in the WHO international pharmacovigilance database (VigiBase) by ADT through 08/09/2018. *Some patients were on combination ADT.
Enzalutamide electrophysiology IPS-CMs
Conclusion
ADT is a risk factor for aLQT and TdP. Androgens may be useful in TdP treatment of hypogonadic men.
Acknowledgement/Funding
INSERM
Collapse
Affiliation(s)
- J E Salem
- University Pierre & Marie Curie Paris VI, Paris, France
| | - T Yang
- Vanderbilt University, clinical pharmacology, Nashville, United States of America
| | - J J Moslehi
- Vanderbilt University, clinical pharmacology, Nashville, United States of America
| | - X Waintraub
- Hospital Pitie-Salpetriere, Cardiology, Paris, France
| | - E Gandjbakhch
- Hospital Pitie-Salpetriere, Cardiology, Paris, France
| | - A Bachelot
- University Pierre & Marie Curie Paris VI, Paris, France
| | | | - J S Hulot
- Hopital Europeen Georges Pompidou- University Paris Descartes, Paris, France
| | - B C Knollmann
- Vanderbilt University, clinical pharmacology, Nashville, United States of America
| | - B Lebrun-Vignes
- Hospital Pitie-Salpetriere, CIC-Paris Est, pharmacologie médicale, Paris, France
| | - C Funck-Brentano
- Hospital Pitie-Salpetriere, CIC-Paris Est, pharmacologie médicale, Paris, France
| | - A M Glazer
- Vanderbilt University, clinical pharmacology, Nashville, United States of America
| | - D M Roden
- Vanderbilt University, clinical pharmacology, Nashville, United States of America
| |
Collapse
|
5
|
Relling MV, Krauss RM, Roden DM, Klein TE, Fowler DM, Terada N, Lin L, Riel-Mehan M, Do TP, Kubo M, Yee SW, Johnson GT, Giacomini KM. New Pharmacogenomics Research Network: An Open Community Catalyzing Research and Translation in Precision Medicine. Clin Pharmacol Ther 2017; 102:897-902. [PMID: 28795399 DOI: 10.1002/cpt.755] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2017] [Revised: 05/17/2017] [Accepted: 05/21/2017] [Indexed: 12/25/2022]
Abstract
The goal of pharmacogenomics research is to discover genetic polymorphisms that underlie variation in drug response. Increasingly, pharmacogenomics research involves large numbers of patients and the application of new technologies and methodologies to enable discovery. The Pharmacogenomics Research Network (PGRN) has become a community-driven network of investigators spanning scientific and clinical disciplines. Here, we highlight the activities and types of resources that enable PGRN members to enhance and drive basic and translational research in pharmacogenomics.
Collapse
Affiliation(s)
- M V Relling
- Department of Pharmaceutical Sciences, St. Jude Children's Research Hospital, Memphis, Tennessee, USA
| | - R M Krauss
- Children's Hospital Oakland Research Institute, Oakland, California, USA
| | - D M Roden
- Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - T E Klein
- Department of Biomedical Data Science, Stanford University, Palo Alto, California, USA
| | - D M Fowler
- Department of Genome Sciences, University of Washington, Seattle, Washington, USA.,Department of Bioengineering, University of Washington, Seattle, Washington, USA
| | - N Terada
- Department of Pathology, University of Florida College of Medicine, Gainesville, Florida, USA
| | - L Lin
- Department of Bioengineering and Therapeutic Sciences, University of California, San Francisco, San Francisco, California, USA
| | - M Riel-Mehan
- Animated Cell, Allen Institute for Cell Biology, Seattle, Washington, USA
| | - T P Do
- Animated Cell, Allen Institute for Cell Biology, Seattle, Washington, USA
| | - M Kubo
- RIKEN Center for Integrative Medical Science, Yokohama, Japan
| | - S W Yee
- Department of Bioengineering and Therapeutic Sciences, University of California, San Francisco, San Francisco, California, USA
| | - G T Johnson
- Department of Bioengineering and Therapeutic Sciences, University of California, San Francisco, San Francisco, California, USA.,Animated Cell, Allen Institute for Cell Biology, Seattle, Washington, USA
| | - K M Giacomini
- Department of Bioengineering and Therapeutic Sciences, University of California, San Francisco, San Francisco, California, USA.,Institute for Human Genetics, University of California, San Francisco, San Francisco, California, USA
| |
Collapse
|
6
|
Abstract
The manuscript "Anticoagulation Endpoints With Clinical Implementation of Warfarin Pharmacogenetic Dosing in a Real- World Setting: A Proposal for a New Pharmacogenetic Dosing Approach" describes process outcomes in an institutional program to use pharmacogenetic testing to optimize warfarin dose in a cohort of 257 patients of diverse ancestries. The strengths and weaknesses of the approach and program are discussed, along with the current and potential future status of warfarin as a model for pharmacogenetic testing.
Collapse
Affiliation(s)
- D M Roden
- Departments of Medicine, Pharmacology, and Biomedical Informatics, Oates Institute for Experimental Therapeutics, Vanderbilt University School of Medicine, Nashville, Tennessee, USA
| |
Collapse
|
7
|
Goswami S, Yee SW, Xu F, Sridhar SB, Mosley JD, Takahashi A, Kubo M, Maeda S, Davis RL, Roden DM, Hedderson MM, Giacomini KM, Savic RM. A Longitudinal HbA1c Model Elucidates Genes Linked to Disease Progression on Metformin. Clin Pharmacol Ther 2016; 100:537-547. [PMID: 27415606 PMCID: PMC5534241 DOI: 10.1002/cpt.428] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [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: 03/16/2016] [Revised: 06/20/2016] [Accepted: 06/22/2016] [Indexed: 12/20/2022]
Abstract
One-third of type-2 diabetic patients respond poorly to metformin. Despite extensive research, the impact of genetic and nongenetic factors on long-term outcome is unknown. In this study we combine nonlinear mixed effect modeling with computational genetic methodologies to identify predictors of long-term response. In all, 1,056 patients contributed their genetic, demographic, and long-term HbA1c data. The top nine variants (of 12,000 variants in 267 candidate genes) accounted for approximately one-third of the variability in the disease progression parameter. Average serum creatinine level, age, and weight were determinants of symptomatic response; however, explaining negligible variability. Two single nucleotide polymorphisms (SNPs) in CSMD1 gene (rs2617102, rs2954625) and one SNP in a pharmacologically relevant SLC22A2 gene (rs316009) influenced disease progression, with minor alleles leading to less and more favorable outcomes, respectively. Overall, our study highlights the influence of genetic factors on long-term HbA1c response and provides a computational model, which when validated, may be used to individualize treatment.
Collapse
Affiliation(s)
- S Goswami
- University of California, San Francisco, San Francisco, California, USA
| | - S W Yee
- University of California, San Francisco, San Francisco, California, USA
| | - F Xu
- Kaiser Permanente Northern California, Oakland, California, USA
| | - S B Sridhar
- Kaiser Permanente Northern California, Oakland, California, USA
| | - J D Mosley
- Vanderbilt University, Nashville, Tennessee, USA
| | - A Takahashi
- RIKEN Institute, Center for Genomic Medicine, Saitama, Japan
| | - M Kubo
- RIKEN Institute, Center for Genomic Medicine, Saitama, Japan
| | - S Maeda
- RIKEN Institute, Center for Genomic Medicine, Saitama, Japan
| | - R L Davis
- Kaiser Permanente Georgia, Atlanta, Georgia, USA
- Center for Biomedical Informatics, University of Tennessee Health Sciences Center, Memphis, Tennessee, USA
| | - D M Roden
- Vanderbilt University, Nashville, Tennessee, USA
| | - M M Hedderson
- Kaiser Permanente Northern California, Oakland, California, USA
| | - K M Giacomini
- University of California, San Francisco, San Francisco, California, USA.
| | - R M Savic
- University of California, San Francisco, San Francisco, California, USA.
| |
Collapse
|
8
|
Bush WS, Crosslin DR, Owusu‐Obeng A, Wallace J, Almoguera B, Basford MA, Bielinski SJ, Carrell DS, Connolly JJ, Crawford D, Doheny KF, Gallego CJ, Gordon AS, Keating B, Kirby J, Kitchner T, Manzi S, Mejia AR, Pan V, Perry CL, Peterson JF, Prows CA, Ralston J, Scott SA, Scrol A, Smith M, Stallings SC, Veldhuizen T, Wolf W, Volpi S, Wiley K, Li R, Manolio T, Bottinger E, Brilliant MH, Carey D, Chisholm RL, Chute CG, Haines JL, Hakonarson H, Harley JB, Holm IA, Kullo IJ, Jarvik GP, Larson EB, McCarty CA, Williams MS, Denny JC, Rasmussen‐Torvik LJ, Roden DM, Ritchie MD. Genetic variation among 82 pharmacogenes: The PGRNseq data from the eMERGE network. Clin Pharmacol Ther 2016; 100:160-9. [PMID: 26857349 PMCID: PMC5010878 DOI: 10.1002/cpt.350] [Citation(s) in RCA: 135] [Impact Index Per Article: 16.9] [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: 10/06/2015] [Revised: 01/12/2016] [Accepted: 02/04/2016] [Indexed: 12/20/2022]
Abstract
Genetic variation can affect drug response in multiple ways, although it remains unclear how rare genetic variants affect drug response. The electronic Medical Records and Genomics (eMERGE) Network, collaborating with the Pharmacogenomics Research Network, began eMERGE‐PGx, a targeted sequencing study to assess genetic variation in 82 pharmacogenes critical for implementation of “precision medicine.” The February 2015 eMERGE‐PGx data release includes sequence‐derived data from ∼5,000 clinical subjects. We present the variant frequency spectrum categorized by variant type, ancestry, and predicted function. We found 95.12% of genes have variants with a scaled Combined Annotation‐Dependent Depletion score above 20, and 96.19% of all samples had one or more Clinical Pharmacogenetics Implementation Consortium Level A actionable variants. These data highlight the distribution and scope of genetic variation in relevant pharmacogenes, identifying challenges associated with implementing clinical sequencing for drug treatment at a broader level, underscoring the importance for multifaceted research in the execution of precision medicine.
Collapse
|
9
|
Roden DM, Denny JC. Integrating electronic health record genotype and phenotype datasets to transform patient care. Clin Pharmacol Ther 2016; 99:298-305. [PMID: 26667791 PMCID: PMC4760864 DOI: 10.1002/cpt.321] [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] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2015] [Revised: 12/11/2015] [Accepted: 12/11/2015] [Indexed: 12/16/2022]
Abstract
The Health Information Technology for Economic and Clinical Health (HITECH) Act of 2009 mandates the development and implementation of electronic health record (EHR) systems across the country. While a primary goal is to improve the care of individual patients, EHRs are also key enabling resources for a vision of individualized (or personalized or precision) medicine: the aggregation of multiple EHRs within or across healthcare systems should allow discovery of patient subsets that have unusual and definable clinical trajectories that deviate importantly from the expected response in a "typical" patient. The spectrum of such personalized care can then extend from prevention to choice of medication to intensity or nature of follow-up.
Collapse
Affiliation(s)
- D M Roden
- Department of Medicine, Vanderbilt University School of Medicine, Nashville, Tennessee, USA
- Department of Biomedical Informatics, Vanderbilt University School of Medicine, Nashville, Tennessee, USA
- Department of Pharmacology, Vanderbilt University School of Medicine, Nashville, Tennessee, USA
| | - J C Denny
- Department of Medicine, Vanderbilt University School of Medicine, Nashville, Tennessee, USA
- Department of Biomedical Informatics, Vanderbilt University School of Medicine, Nashville, Tennessee, USA
| |
Collapse
|
10
|
Peterson JF, Field JR, Unertl KM, Schildcrout JS, Johnson DC, Shi Y, Danciu I, Cleator JH, Pulley JM, McPherson JA, Denny JC, Laposata M, Roden DM, Johnson KB. Physician response to implementation of genotype-tailored antiplatelet therapy. Clin Pharmacol Ther 2016; 100:67-74. [PMID: 26693963 DOI: 10.1002/cpt.331] [Citation(s) in RCA: 41] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2015] [Revised: 11/20/2015] [Accepted: 12/17/2015] [Indexed: 01/07/2023]
Abstract
Physician responses to genomic information are vital to the success of precision medicine initiatives. We prospectively studied a pharmacogenomics implementation program for the propensity of clinicians to select antiplatelet therapy based on CYP2C19 loss-of-function variants in stented patients. Among 2,676 patients, 514 (19.2%) were found to have a CYP2C19 variant affecting clopidogrel metabolism. For the majority (93.6%) of the cohort, cardiologists received active and direct notification of CYP2C19 status. Over 12 months, 57.6% of poor metabolizers and 33.2% of intermediate metabolizers received alternatives to clopidogrel. CYP2C19 variant status was the most influential factor impacting the prescribing decision (hazard ratio [HR] in poor metabolizers 8.1, 95% confidence interval [CI] [5.4, 12.2] and HR 5.0, 95% CI [4.0, 6.3] in intermediate metabolizers), followed by patient age and type of stent implanted. We conclude that cardiologists tailored antiplatelet therapy for a minority of patients with a CYP2C19 variant and considered both genomic and nongenomic risks in their clinical decision-making.
Collapse
Affiliation(s)
- J F Peterson
- Department of Biomedical Informatics, Vanderbilt University School of Medicine, Nashville, Tennessee, USA.,Department of Medicine, Vanderbilt University School of Medicine, Nashville, Tennessee, USA
| | - J R Field
- Institute of Clinical and Translational Research, Vanderbilt University School of Medicine, Nashville, Tennessee, USA
| | - K M Unertl
- Department of Biomedical Informatics, Vanderbilt University School of Medicine, Nashville, Tennessee, USA
| | - J S Schildcrout
- Department of Biostatistics, Vanderbilt University School of Medicine, Nashville, Tennessee, USA.,Department of Anesthesiology, Vanderbilt University School of Medicine, Nashville, Tennessee, USA
| | - D C Johnson
- Department of Pharmacy, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Y Shi
- Department of Biostatistics, Vanderbilt University School of Medicine, Nashville, Tennessee, USA
| | - I Danciu
- Department of Biomedical Informatics, Vanderbilt University School of Medicine, Nashville, Tennessee, USA.,Institute of Clinical and Translational Research, Vanderbilt University School of Medicine, Nashville, Tennessee, USA
| | - J H Cleator
- Department of Medicine, Vanderbilt University School of Medicine, Nashville, Tennessee, USA.,Department of Pharmacology, Vanderbilt University School of Medicine, Nashville, Tennessee, USA
| | - J M Pulley
- Institute of Clinical and Translational Research, Vanderbilt University School of Medicine, Nashville, Tennessee, USA
| | - J A McPherson
- Department of Medicine, Vanderbilt University School of Medicine, Nashville, Tennessee, USA
| | - J C Denny
- Department of Biomedical Informatics, Vanderbilt University School of Medicine, Nashville, Tennessee, USA.,Department of Medicine, Vanderbilt University School of Medicine, Nashville, Tennessee, USA
| | - M Laposata
- Department of Pathology, Microbiology, and Immunology, Vanderbilt University School of Medicine, Nashville, Tennessee, USA
| | - D M Roden
- Department of Medicine, Vanderbilt University School of Medicine, Nashville, Tennessee, USA.,Department of Pharmacology, Vanderbilt University School of Medicine, Nashville, Tennessee, USA
| | - K B Johnson
- Department of Biomedical Informatics, Vanderbilt University School of Medicine, Nashville, Tennessee, USA.,Department of Pediatrics, Vanderbilt University School of Medicine, Nashville, Tennessee, USA
| |
Collapse
|
11
|
Ramsey LB, Johnson SG, Caudle KE, Haidar CE, Voora D, Wilke RA, Maxwell WD, McLeod HL, Krauss RM, Roden DM, Feng Q, Cooper-DeHoff RM, Gong L, Klein TE, Wadelius M, Niemi M. The clinical pharmacogenetics implementation consortium guideline for SLCO1B1 and simvastatin-induced myopathy: 2014 update. Clin Pharmacol Ther 2014; 96:423-8. [PMID: 24918167 PMCID: PMC4169720 DOI: 10.1038/clpt.2014.125] [Citation(s) in RCA: 291] [Impact Index Per Article: 29.1] [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: 03/31/2014] [Accepted: 06/04/2014] [Indexed: 11/08/2022]
Abstract
Simvastatin is among the most commonly used prescription medications for cholesterol reduction. A single coding single-nucleotide polymorphism, rs4149056T>C, in SLCO1B1 increases systemic exposure to simvastatin and the risk of muscle toxicity. We summarize evidence from the literature supporting this association and provide therapeutic recommendations for simvastatin based on SLCO1B1 genotype. This article is an update to the 2012 Clinical Pharmacogenetics Implementation Consortium guideline for SLCO1B1 and simvastatin-induced myopathy.
Collapse
Affiliation(s)
- L B Ramsey
- Pharmaceutical Sciences Department, St. Jude Children's Research Hospital, Memphis, Tennessee, USA
| | - S G Johnson
- Skaggs School of Pharmacy and Pharmaceutical Sciences, University of Colorado, Denver, Colorado, USA
- Clinical Pharmacy Services, Kaiser Permanente Colorado, Denver, Colorado, USA
| | - K E Caudle
- Pharmaceutical Sciences Department, St. Jude Children's Research Hospital, Memphis, Tennessee, USA
| | - C E Haidar
- Pharmaceutical Sciences Department, St. Jude Children's Research Hospital, Memphis, Tennessee, USA
| | - D Voora
- Department of Medicine, Duke University, Durham, North Carolina, USA
| | - R A Wilke
- IMAGENETICS, Sanford Medical Center, Fargo, North Dakota, USA
- Department of Medicine, University of North Dakota, Fargo, North Dakota, USA
| | - W D Maxwell
- Department of Clinical Pharmacy and Outcomes Sciences, South Carolina College of Pharmacy, Columbia, South Carolina, USA
| | - H L McLeod
- Personalized Medicine Institute, Moffitt Cancer Center, Tampa, Florida, USA
| | - R M Krauss
- Atherosclerosis Research, Children's Hospital Oakland Research Institute, Oakland, California, USA
| | - D M Roden
- Oates Institute for Experimental Therapeutics, Vanderbilt University Medical Center, Nashville, Tennessee, USA
- Department of Medicine, Division of Clinical Pharmacology, Vanderbilt University, Nashville, Tennessee, USA
| | - Q Feng
- Oates Institute for Experimental Therapeutics, Vanderbilt University Medical Center, Nashville, Tennessee, USA
- Department of Medicine, Division of Clinical Pharmacology, Vanderbilt University, Nashville, Tennessee, USA
| | - R M Cooper-DeHoff
- Department of Pharmacotherapy and Translational Research, Center for Pharmacogenomics and Division of Cardiovascular Medicine, University of Florida, Gainesville, Florida, USA
| | - L Gong
- Department of Genetics, Stanford University, Palo Alto, California, USA
| | - T E Klein
- Department of Genetics, Stanford University, Palo Alto, California, USA
| | - M Wadelius
- Department of Medical Sciences, Clinical Pharmacology and Science for Life Laboratory, Uppsala University, Uppsala, Sweden
| | - M Niemi
- Department of Clinical Pharmacology, University of Helsinki and HUSLAB, Helsinki University Central Hospital, Helsinki, Finland
- King Abdulaziz University , Jeddah, Saudi Arabia
| |
Collapse
|
12
|
Naidoo D, Wu AC, Brilliant MH, Denny J, Ingram C, Kitchner TE, Linneman JG, McGeachie MJ, Roden DM, Shaffer CM, Shah A, Weeke P, Weiss ST, Xu H, Medina MW. A polymorphism in HLA-G modifies statin benefit in asthma. Pharmacogenomics J 2014; 15:272-7. [PMID: 25266681 PMCID: PMC4379135 DOI: 10.1038/tpj.2014.55] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/06/2014] [Revised: 07/04/2014] [Accepted: 08/13/2014] [Indexed: 11/16/2022]
Abstract
Several reports have shown that statin treatment benefits patients with asthma, however inconsistent effects have been observed. The mir-152 family (148a, 148b and 152) has been implicated in asthma. These microRNAs suppress HLA-G expression, and rs1063320, a common SNP in the HLA-G 3’UTR which is associated with asthma risk, modulates miRNA binding. We report that statins up-regulate mir-148b and 152, and affect HLA-G expression in an rs1063320 dependent fashion. In addition, we found that individuals who carried the G minor allele of rs1063320 had reduced asthma related exacerbations (emergency department visits, hospitalizations or oral steroid use) compared to non-carriers (p=0.03) in statin users ascertained in the Personalized Medicine Research Project at the Marshfield Clinic (n=421). These findings support the hypothesis that rs1063320 modifies the effect of statin benefit in asthma, and thus may contribute to variation in statin efficacy for the management of this disease.
Collapse
Affiliation(s)
- D Naidoo
- Atherosclerosis Research, Children's Hospital Oakland Research Institute, Oakland, CA, USA
| | - A C Wu
- Department of Population Medicine, Harvard Medical School, Boston, MA, USA
| | - M H Brilliant
- Center for Human Genetics, Marshfield Clinic Research Foundation, Marshfield, WI, USA
| | - J Denny
- 1] Department of Medical Bioinformatics, Vanderbilt University School of Medicine, Nashville, TN, USA [2] Department of Medicine, Vanderbilt University, Nashville, TN, USA
| | - C Ingram
- Department of Medicine, Vanderbilt University, Nashville, TN, USA
| | - T E Kitchner
- Center for Human Genetics, Marshfield Clinic Research Foundation, Marshfield, WI, USA
| | - J G Linneman
- Biomedical Informatics Research Center, Marshfield Clinic Research Foundation, Marshfield, WI, USA
| | - M J McGeachie
- Channing Division of Network Medicine, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA
| | - D M Roden
- Division of Clinical Pharmacology, Department of Medicine, Vanderbilt University School of Medicine, Nashville, TN, USA
| | - C M Shaffer
- Department of Medicine, Vanderbilt University, Nashville, TN, USA
| | - A Shah
- Department of Medicine, Vanderbilt University, Nashville, TN, USA
| | - P Weeke
- 1] Department of Medicine, Vanderbilt University, Nashville, TN, USA [2] Department of Cardiology, Copenhagen University Hospital, Gentofte, Denmark
| | - S T Weiss
- Channing Division of Network Medicine, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA
| | - H Xu
- School of Biomedical Informatics, The University of Texas Health Science Center at Houston, Houston, TX, USA
| | - M W Medina
- Atherosclerosis Research, Children's Hospital Oakland Research Institute, Oakland, CA, USA
| |
Collapse
|
13
|
Rasmussen-Torvik LJ, Stallings SC, Gordon AS, Almoguera B, Basford MA, Bielinski SJ, Brautbar A, Brilliant MH, Carrell DS, Connolly JJ, Crosslin DR, Doheny KF, Gallego CJ, Gottesman O, Kim DS, Leppig KA, Li R, Lin S, Manzi S, Mejia AR, Pacheco JA, Pan V, Pathak J, Perry CL, Peterson JF, Prows CA, Ralston J, Rasmussen LV, Ritchie MD, Sadhasivam S, Scott SA, Smith M, Vega A, Vinks AA, Volpi S, Wolf WA, Bottinger E, Chisholm RL, Chute CG, Haines JL, Harley JB, Keating B, Holm IA, Kullo IJ, Jarvik GP, Larson EB, Manolio T, McCarty CA, Nickerson DA, Scherer SE, Williams MS, Roden DM, Denny JC. Design and anticipated outcomes of the eMERGE-PGx project: a multicenter pilot for preemptive pharmacogenomics in electronic health record systems. Clin Pharmacol Ther 2014; 96:482-9. [PMID: 24960519 PMCID: PMC4169732 DOI: 10.1038/clpt.2014.137] [Citation(s) in RCA: 176] [Impact Index Per Article: 17.6] [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: 02/28/2014] [Accepted: 06/13/2014] [Indexed: 11/09/2022]
Abstract
We describe here the design and initial implementation of the eMERGE-PGx project. eMERGE-PGx, a partnership of the eMERGE and PGRN consortia, has three objectives : 1) Deploy PGRNseq, a next-generation sequencing platform assessing sequence variation in 84 proposed pharmacogenes, in nearly 9,000 patients likely to be prescribed drugs of interest in a 1–3 year timeframe across several clinical sites; 2) Integrate well-established clinically-validated pharmacogenetic genotypes into the electronic health record with associated clinical decision support and assess process and clinical outcomes of implementation; and 3) Develop a repository of pharmacogenetic variants of unknown significance linked to a repository of EHR-based clinical phenotype data for ongoing pharmacogenomics discovery. We describe site-specific project implementation and anticipated products, including genetic variant and phenotype data repositories, novel variant association studies, clinical decision support modules, clinical and process outcomes, approaches to manage incidental findings, and patient and clinician education methods.
Collapse
Affiliation(s)
- L J Rasmussen-Torvik
- Department of Preventive Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - S C Stallings
- Vanderbilt Institute for Clinical and Translational Research, Nashville, Tennessee, USA
| | - A S Gordon
- Department of Genome Sciences, University of Washington, Seattle, Washington, USA
| | - B Almoguera
- Center for Applied Genomics, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - M A Basford
- Vanderbilt Institute for Clinical and Translational Research, Nashville, Tennessee, USA
| | - S J Bielinski
- Division of Epidemiology, Department of Health Sciences Research, Mayo Clinic, Rochester, Minnesota, USA
| | - A Brautbar
- Center for Human Genetics, Marshfield Clinic Research Foundation, Marshfield, Wisconsin, USA
| | - M H Brilliant
- Center for Human Genetics, Marshfield Clinic Research Foundation, Marshfield, Wisconsin, USA
| | - D S Carrell
- Group Health Research Institute, Seattle, Washington, USA
| | - J J Connolly
- Center for Applied Genomics, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - D R Crosslin
- Department of Genome Sciences, University of Washington, Seattle, Washington, USA
| | - K F Doheny
- Center for Inherited Disease Research, Institute of Genetic Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - C J Gallego
- Division of Medical Genetics, University of Washington, Seattle, Washington, USA
| | - O Gottesman
- The Charles Bronfman Institute for Personalized Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - D S Kim
- Department of Genome Sciences, University of Washington, Seattle, Washington, USA
| | - K A Leppig
- Group Health Research Institute, Seattle, Washington, USA
| | - R Li
- Division of Genomic Medicine, National Human Genome Research Institute, Bethesda, Maryland, USA
| | - S Lin
- Biomedical Informatics Research Center, Marshfield Clinic Research Foundation, Marshfield, Wisconsin, USA
| | - S Manzi
- Division of Genetics and Genomics, Boston Children's Hospital, Boston, Massachusetts, USA
| | - A R Mejia
- The Charles Bronfman Institute for Personalized Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - J A Pacheco
- Center for Genetic Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - V Pan
- Center for Genetic Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - J Pathak
- Division of Biomedical Statistics and Informatics, Department of Health Sciences Research, Mayo Clinic, Rochester, Minnesota, USA
| | - C L Perry
- Division of Genetics and Genomics, Boston Children's Hospital, Boston, Massachusetts, USA
| | - J F Peterson
- Department of Biomedical Informatics and Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - C A Prows
- 1] Division Human Genetics, Department of Pediatrics, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA [2] Division of Clinical Pharmacology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | - J Ralston
- Group Health Research Institute, Seattle, Washington, USA
| | - L V Rasmussen
- Department of Preventive Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - M D Ritchie
- Department of Biochemistry and Molecular Biology, The Pennsylvania State University, State College, Pennsylvania, USA
| | - S Sadhasivam
- 1] Department of Anesthesia, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA [2] Department of Pediatrics, College of Medicine, University of Cincinnati, Cincinnati, Ohio, USA
| | - S A Scott
- Department of Genetics and Genomic Sciences, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - M Smith
- Center for Genetic Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - A Vega
- Mount Sinai Faculty Practice Associates Primary Care Program, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - A A Vinks
- 1] Department of Pediatrics, College of Medicine, University of Cincinnati, Cincinnati, Ohio, USA [2] Division of Clinical Pharmacology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | - S Volpi
- Division of Genomic Medicine, National Human Genome Research Institute, Bethesda, Maryland, USA
| | - W A Wolf
- 1] Division of Genetics and Genomics, Boston Children's Hospital, Boston, Massachusetts, USA [2] Department of Pediatrics, Harvard Medical School, Boston, Massachusetts, USA
| | - E Bottinger
- The Charles Bronfman Institute for Personalized Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - R L Chisholm
- Center for Genetic Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - C G Chute
- Department of Health Sciences Research, Mayo Clinic, Rochester, Minnesota, USA
| | - J L Haines
- Center for Human Genetics Research, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - J B Harley
- 1] Department of Pediatrics, College of Medicine, University of Cincinnati, Cincinnati, Ohio, USA [2] Cincinnati Children's Hospital Medical Center, University of Cincinnati, Cincinnati, Ohio, USA [3] US Department of Veterans Affairs Medical Center, Cincinnati, Ohio, USA
| | - B Keating
- Center for Applied Genomics, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - I A Holm
- 1] Division of Genetics and Genomics, Boston Children's Hospital, Boston, Massachusetts, USA [2] Department of Pediatrics, Harvard Medical School, Boston, Massachusetts, USA [3] The Manton Center for Orphan Disease Research, Boston Children's Hospital, Boston, Massachusetts, USA
| | - I J Kullo
- Division of Cardiovascular Diseases, Mayo Clinic, Rochester, Minnesota, USA
| | - G P Jarvik
- Division of Medical Genetics, University of Washington, Seattle, Washington, USA
| | - E B Larson
- Group Health Research Institute, Seattle, Washington, USA
| | - T Manolio
- Division of Genomic Medicine, National Human Genome Research Institute, Bethesda, Maryland, USA
| | - C A McCarty
- Essentia Institute of Rural Health, Duluth, Minnesota, USA
| | - D A Nickerson
- Department of Genome Sciences, University of Washington, Seattle, Washington, USA
| | - S E Scherer
- Human Genome Sequencing Center, Baylor College of Medicine, Houston, Texas, USA
| | - M S Williams
- Genomic Medicine Institute, Geisinger Health System, Danville, Pennsylvania, USA
| | - D M Roden
- 1] Department of Pharmacology, Vanderbilt University School of Medicine, Nashville, Tennessee, USA [2] Department of Medicine, Vanderbilt University School of Medicine, Nashville, Tennessee, USA
| | - J C Denny
- 1] Department of Biomedical Informatics and Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA [2] Department of Medicine, Vanderbilt University School of Medicine, Nashville, Tennessee, USA
| |
Collapse
|
14
|
Goswami S, Yee SW, Stocker S, Mosley JD, Kubo M, Castro R, Mefford JA, Wen C, Liang X, Witte J, Brett C, Maeda S, Simpson MD, Hedderson MM, Davis RL, Roden DM, Giacomini KM, Savic RM. Genetic variants in transcription factors are associated with the pharmacokinetics and pharmacodynamics of metformin. Clin Pharmacol Ther 2014; 96:370-9. [PMID: 24853734 DOI: 10.1038/clpt.2014.109] [Citation(s) in RCA: 47] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2014] [Accepted: 05/07/2014] [Indexed: 12/26/2022]
Abstract
One-third of type 2 diabetes patients do not respond to metformin. Genetic variants in metformin transporters have been extensively studied as a likely contributor to this high failure rate. Here, we investigate, for the first time, the effect of genetic variants in transcription factors on metformin pharmacokinetics (PK) and response. Overall, 546 patients and healthy volunteers contributed their genome-wide, pharmacokinetic (235 subjects), and HbA1c data (440 patients) for this analysis. Five variants in specificity protein 1 (SP1), a transcription factor that modulates the expression of metformin transporters, were associated with changes in treatment HbA1c (P < 0.01) and metformin secretory clearance (P < 0.05). Population pharmacokinetic modeling further confirmed a 24% reduction in apparent clearance in homozygous carriers of one such variant, rs784888. Genetic variants in other transcription factors, peroxisome proliferator-activated receptor-α and hepatocyte nuclear factor 4-α, were significantly associated with HbA1c change only. Overall, our study highlights the importance of genetic variants in transcription factors as modulators of metformin PK and response.
Collapse
Affiliation(s)
- S Goswami
- Department of Bioengineering and Therapeutic Sciences, University of California, San Francisco, San Francisco, California, USA
| | - S W Yee
- Department of Bioengineering and Therapeutic Sciences, University of California, San Francisco, San Francisco, California, USA
| | - S Stocker
- Department of Bioengineering and Therapeutic Sciences, University of California, San Francisco, San Francisco, California, USA
| | - J D Mosley
- Department of Pharmacology and Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - M Kubo
- Center of Genomic Medicine, RIKEN, Yokohama City, Japan
| | - R Castro
- Department of Bioengineering and Therapeutic Sciences, University of California, San Francisco, San Francisco, California, USA
| | - J A Mefford
- Department of Bioengineering and Therapeutic Sciences, University of California, San Francisco, San Francisco, California, USA
| | - C Wen
- Department of Bioengineering and Therapeutic Sciences, University of California, San Francisco, San Francisco, California, USA
| | - X Liang
- Department of Bioengineering and Therapeutic Sciences, University of California, San Francisco, San Francisco, California, USA
| | - J Witte
- Department of Bioengineering and Therapeutic Sciences, University of California, San Francisco, San Francisco, California, USA
| | - C Brett
- Department of Anesthesiology, University of California, San Francisco, San Francisco, California, USA
| | - S Maeda
- Center of Genomic Medicine, RIKEN, Yokohama City, Japan
| | - M D Simpson
- Marshfield Clinic Research Foundation, Marshfield, Wisconsin, USA
| | - M M Hedderson
- Division of Research, Kaiser Permanente Northern California, Oakland, California, USA
| | - R L Davis
- Center for Health Research Southeast, Kaiser Permanente Georgia, Atlanta, Georgia, USA
| | - D M Roden
- Department of Pharmacology and Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - K M Giacomini
- Department of Bioengineering and Therapeutic Sciences, University of California, San Francisco, San Francisco, California, USA
| | - R M Savic
- Department of Bioengineering and Therapeutic Sciences, University of California, San Francisco, San Francisco, California, USA
| |
Collapse
|
15
|
Wei WQ, Feng Q, Jiang L, Waitara MS, Iwuchukwu OF, Roden DM, Jiang M, Xu H, Krauss RM, Rotter JI, Nickerson DA, Davis RL, Berg RL, Peissig PL, McCarty CA, Wilke RA, Denny JC. Characterization of statin dose response in electronic medical records. Clin Pharmacol Ther 2013; 95:331-8. [PMID: 24096969 DOI: 10.1038/clpt.2013.202] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2013] [Accepted: 09/25/2013] [Indexed: 01/14/2023]
Abstract
Efforts to define the genetic architecture underlying variable statin response have met with limited success, possibly because previous studies were limited to effect based on a single dose. We leveraged electronic medical records (EMRs) to extract potency (ED50) and efficacy (Emax) of statin dose-response curves and tested them for association with 144 preselected variants. Two large biobanks were used to construct dose-response curves for 2,026 and 2,252 subjects on simvastatin and atorvastatin, respectively. Atorvastatin was more efficacious, was more potent, and demonstrated less interindividual variability than simvastatin. A pharmacodynamic variant emerging from randomized trials (PRDM16) was associated with Emax for both. For atorvastatin, Emax was 51.7 mg/dl in subjects homozygous for the minor allele vs. 75.0 mg/dl for those homozygous for the major allele. We also identified several loci associated with ED50. The extraction of rigorously defined traits from EMRs for pharmacogenetic studies represents a promising approach to further understand the genetic factors contributing to drug response.
Collapse
Affiliation(s)
- W-Q Wei
- Department of Biomedical Informatics, Vanderbilt University, Nashville, Tennessee, USA
| | - Q Feng
- Department of Medicine, Vanderbilt University, Nashville, Tennessee, USA
| | - L Jiang
- Department of Molecular Physiology and Biophysics, Center for Human Genetics Research, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - M S Waitara
- Department of Medicine, Vanderbilt University, Nashville, Tennessee, USA
| | - O F Iwuchukwu
- Department of Medicine, Vanderbilt University, Nashville, Tennessee, USA
| | - D M Roden
- 1] Department of Medicine, Vanderbilt University, Nashville, Tennessee, USA [2] Department of Pharmacology, Vanderbilt University School of Medicine, Nashville, Tennessee, USA [3] Oates Institute for Experimental Therapeutics, Vanderbilt University School of Medicine, Nashville, Tennessee, USA [4] Office of Personalized Medicine, Vanderbilt University School of Medicine, Nashville, Tennessee, USA
| | - M Jiang
- Department of Biomedical Informatics, University of Texas, Houston, Texas, USA
| | - H Xu
- Department of Biomedical Informatics, University of Texas, Houston, Texas, USA
| | - R M Krauss
- Children's Hospital Oakland Research Institute, Oakland, California, USA
| | - J I Rotter
- Institute for Translational Genomics and Population Sciences, Los Angeles BioMedical Research Institute and Department of Pediatrics, Harbor-UCLA Medical Center, Torrance, Califonia, USA
| | - D A Nickerson
- Department of Genome Sciences, University of Washington, Seattle, Washington, USA
| | - R L Davis
- Kaiser Permanente Georgia, Center for Health Research Southeast, Atlanta, Georgia, USA
| | - R L Berg
- Biomedical Informatics Research Center, Marshfield Clinic Research Foundation, Marshfield, Wisconsin, USA
| | - P L Peissig
- Biomedical Informatics Research Center, Marshfield Clinic Research Foundation, Marshfield, Wisconsin, USA
| | - C A McCarty
- Essentia Institute of Rural Health, Duluth, Minnesota, USA
| | - R A Wilke
- Department of Internal Medicine, Sanford Healthcare, Fargo, North Dakota, USA
| | - J C Denny
- Department of Biomedical Informatics, Vanderbilt University, Nashville, Tennessee, USA
| |
Collapse
|
16
|
Bennett JS, Stroud DM, Becker JR, Roden DM. Proliferation of embryonic cardiomyocytes in zebrafish requires the sodium channel scn5Lab. Genesis 2013; 51:562-74. [PMID: 23650201 DOI: 10.1002/dvg.22400] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2013] [Revised: 03/24/2013] [Accepted: 04/29/2013] [Indexed: 12/30/2022]
Abstract
In mice, homozygous deletion of the cardiac sodium channel Scn5a results in defects in cardiac morphology and embryonic death before robust sodium current can be detected. In zebrafish, morpholino knockdown of cardiac sodium channel orthologs scn5Laa and scn5Lab perturbs specification of precardiac mesoderm and inhibits growth of the embryonic heart. It is not known which developmental processes are perturbed by sodium channel knockdown and whether reduced cell number is from impaired migration of cardiac progenitors into the heart, impaired myocyte proliferation, or both. We found that embryos deficient in scn5Lab displayed defects in primary cardiogenesis specific to loss of nkx2.5, but not nkx2.7. We generated kaede reporter fish and demonstrated that embryos treated with anti-scn5Lab morpholino showed normal secondary differentiation of cardiomyocytes at the arterial pole between 30 and 48 h post-fertilization. However, while proliferating myocytes were readily detected at 48 hpf in wild type embryos, there were no BrdU-positive cardiomyocytes in embryos subjected to anti-scn5Lab treatment. Proliferating myocytes were present in embryos injected with anti-tnnt2 morpholino to phenocopy the silent heart mutation, and absent in embryos injected with anti-tnnt2 and anti-scn5Lab morpholinos, indicating cardiac contraction is not required for the loss of proliferation. These data demonstrate that the role of scn5Lab in later heart growth does not involve contribution of the secondary heart field, but rather proliferation of cardiomyocytes, and appears unrelated to the role of the channel in cardiac electrogenesis.
Collapse
Affiliation(s)
- J S Bennett
- Program in Human Genetics, Vanderbilt University School of Medicine, Nashville, Tennessee, USA
| | | | | | | |
Collapse
|
17
|
Scott SA, Sangkuhl K, Stein CM, Hulot JS, Mega JL, Roden DM, Klein TE, Sabatine MS, Johnson JA, Shuldiner AR. Clinical Pharmacogenetics Implementation Consortium guidelines for CYP2C19 genotype and clopidogrel therapy: 2013 update. Clin Pharmacol Ther 2013; 94:317-23. [PMID: 23698643 DOI: 10.1038/clpt.2013.105] [Citation(s) in RCA: 655] [Impact Index Per Article: 59.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2013] [Accepted: 05/06/2013] [Indexed: 01/07/2023]
Abstract
Cytochrome P450 (CYP)2C19 catalyzes the bioactivation of the antiplatelet prodrug clopidogrel, and CYP2C19 loss-of-function alleles impair formation of active metabolites, resulting in reduced platelet inhibition. In addition, CYP2C19 loss-of-function alleles confer increased risks for serious adverse cardiovascular (CV) events among clopidogrel-treated patients with acute coronary syndromes (ACSs) undergoing percutaneous coronary intervention (PCI). Guideline updates include emphasis on appropriate indication for CYP2C19 genotype-directed antiplatelet therapy, refined recommendations for specific CYP2C19 alleles, and additional evidence from an expanded literature review (updates at http://www.pharmgkb.org).
Collapse
Affiliation(s)
- S A Scott
- Department of Genetics and Genomic Sciences, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | | | | | | | | | | | | | | | | | | | | |
Collapse
|
18
|
Shuldiner AR, Relling MV, Peterson JF, Hicks JK, Freimuth RR, Sadee W, Pereira NL, Roden DM, Johnson JA, Klein TE, Shuldiner AR, Vesely M, Robinson SW, Ambulos N, Stass SA, Kelemen MD, Brown LA, Pollin TI, Beitelshees AL, Zhao RY, Pakyz RE, Palmer K, Alestock T, O'Neill C, Maloney K, Branham A, Sewell D, Relling MV, Crews K, Hoffman J, Cross S, Haidar C, Baker D, Hicks JK, Bell G, Greeson F, Gaur A, Reiss U, Huettel A, Cheng C, Gajjar A, Pappo A, Howard S, Hudson M, Pui CH, Jeha S, Evans WE, Broeckel U, Altman RB, Gong L, Whirl-Carrillo M, Klein TE, Sadee W, Manickam K, Sweet KM, Embi PJ, Roden D, Peterson J, Denny J, Schildcrout J, Bowton E, Pulley J, Beller M, Mitchell J, Danciu I, Price L, Pereira NL, Weinshilboum R, Wang L, Johnson JA, Nelson D, Clare-Salzler M, Elsey A, Burkley B, Langaee T, Liu F, Nessl D, Dong HJ, Lesko L, Freimuth RR, Chute CG. The Pharmacogenomics Research Network Translational Pharmacogenetics Program: overcoming challenges of real-world implementation. Clin Pharmacol Ther 2013; 94:207-10. [PMID: 23588301 DOI: 10.1038/clpt.2013.59] [Citation(s) in RCA: 138] [Impact Index Per Article: 12.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2013] [Accepted: 03/14/2013] [Indexed: 11/09/2022]
Affiliation(s)
- A R Shuldiner
- Program in Personalized and Genomic Medicine and Department of Medicine, University of Maryland School of Medicine, Baltimore, Maryland, USA.
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
19
|
McGregor TL, Van Driest SL, Brothers KB, Bowton EA, Muglia LJ, Roden DM. Inclusion of pediatric samples in an opt-out biorepository linking DNA to de-identified medical records: pediatric BioVU. Clin Pharmacol Ther 2012; 93:204-11. [PMID: 23281421 DOI: 10.1038/clpt.2012.230] [Citation(s) in RCA: 33] [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] [Indexed: 11/09/2022]
Abstract
The Vanderbilt DNA repository, BioVU, links DNA from leftover clinical blood samples to de-identified electronic medical records (EMRs). After initiating adult sample collection, pediatric extension required consideration of ethical concerns specific to pediatrics and implementation of specialized DNA extraction methods. In the first year of pediatric sample collection, more than 11,000 samples from individuals younger than 18 years were included. We compared data from the pediatric BioVU cohort with those from the overall Vanderbilt University Medical Center pediatric population and found similar demographic characteristics; however, the BioVU cohort had higher rates of select diseases, medication exposures, and laboratory testing, demonstrating enriched representation of severe or chronic disease. The fact that the sample accumulation is not balanced may accelerate research in some cohorts while limiting the study of relatively benign conditions and the accrual of unaffected and unbiased control samples. BioVU represents a feasible model for pediatric DNA biobanking but involves both ethical and practical considerations specific to the pediatric population.
Collapse
Affiliation(s)
- T L McGregor
- Department of Pediatrics, Vanderbilt University and the Monroe Carell Jr. Children's Hospital at Vanderbilt, Nashville, Tennessee, USA
| | | | | | | | | | | |
Collapse
|
20
|
Denny JC, Schildcrout JS, Pulley JM, Roden DM. Response to “Doubt About the Feasibility of Preemptive Genotyping”. Clin Pharmacol Ther 2012; 93:234. [DOI: 10.1038/clpt.2012.223] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
|
21
|
Stocker SL, Morrissey KM, Yee SW, Castro RA, Xu L, Dahlin A, Ramirez AH, Roden DM, Wilke RA, McCarty CA, Davis RL, Brett CM, Giacomini KM. The effect of novel promoter variants in MATE1 and MATE2 on the pharmacokinetics and pharmacodynamics of metformin. Clin Pharmacol Ther 2012; 93:186-94. [PMID: 23267855 DOI: 10.1038/clpt.2012.210] [Citation(s) in RCA: 144] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Interindividual variation in response to metformin, first-line therapy for type 2 diabetes, is substantial. Given that transporters are determinants of metformin pharmacokinetics, we examined the effects of promoter variants in both multidrug and toxin extrusion protein 1 (MATE1) (g.-66T → C, rs2252281) and MATE2 (g.-130G → A, rs12943590) on variation in metformin disposition and response. The pharmacokinetics and glucose-lowering effects of metformin were assessed in healthy volunteers (n = 57) receiving metformin. The renal and secretory clearances of metformin were higher (22% and 26%, respectively) in carriers of variant MATE2 who were also MATE1 reference (P < 0.05). Both MATE genotypes were associated with altered post-metformin glucose tolerance, with variant carriers of MATE1 and MATE2 having an enhanced (P < 0.01) and reduced (P < 0.05) response, respectively. Consistent with these results, patients with diabetes (n = 145) carrying the MATE1 variant showed enhanced metformin response. These findings suggest that promoter variants of MATE1 and MATE2 are important determinants of metformin disposition and response in healthy volunteers and diabetic patients.
Collapse
Affiliation(s)
- S L Stocker
- Department of Bioengineering and Therapeutic Sciences, University of California, San Francisco, San Francisco, California, USA
| | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
22
|
Roden DM, Xu H, Denny JC, Wilke RA. Electronic medical records as a tool in clinical pharmacology: opportunities and challenges. Clin Pharmacol Ther 2012; 91:1083-86. [PMID: 22534870 DOI: 10.1038/clpt.2012.42] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
The development and increasing sophistication of electronic medical record (EMR) systems hold the promise of not only improving patient care but also providing unprecedented opportunities for discovery in the fields of basic, translational, and implementation sciences. Clinical pharmacology research in the EMR environment has only recently started to become a reality, with EMRs becoming increasingly populated, methods to mine drug response and other phenotypes becoming more sophisticated, and links being established with DNA repositories.
Collapse
Affiliation(s)
- D M Roden
- Department of Medicine, Vanderbilt University School of Medicine, Nashville, Tennessee, USA.
| | | | | | | |
Collapse
|
23
|
Wilke RA, Ramsey LB, Johnson SG, Maxwell WD, McLeod HL, Voora D, Krauss RM, Roden DM, Feng Q, Cooper-Dehoff RM, Gong L, Klein TE, Wadelius M, Niemi M. The clinical pharmacogenomics implementation consortium: CPIC guideline for SLCO1B1 and simvastatin-induced myopathy. Clin Pharmacol Ther 2012; 92:112-7. [PMID: 22617227 PMCID: PMC3384438 DOI: 10.1038/clpt.2012.57] [Citation(s) in RCA: 260] [Impact Index Per Article: 21.7] [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: 02/09/2012] [Revised: 05/23/2012] [Accepted: 03/28/2012] [Indexed: 11/08/2022]
Abstract
Cholesterol reduction from statin therapy has been one of the greatest public health successes in modern medicine. Simvastatin is among the most commonly used prescription medications. A non-synonymous coding single-nucleotide polymorphism (SNP), rs4149056, in SLCO1B1 markedly increases systemic exposure to simvastatin and the risk of muscle toxicity. This guideline explores the relationship between rs4149056 (c.521T>C, p.V174A) and clinical outcome for all statins. The strength of the evidence is high for myopathy with simvastatin. We limit our recommendations accordingly.
Collapse
Affiliation(s)
- R A Wilke
- Oates Institute for Experimental Therapeutics, Vanderbilt University Medical Center, Nashville, Tennessee, USA.
| | | | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
24
|
Schildcrout JS, Denny JC, Bowton E, Gregg W, Pulley JM, Basford MA, Cowan JD, Xu H, Ramirez AH, Crawford DC, Ritchie MD, Peterson JF, Masys DR, Wilke RA, Roden DM. Optimizing drug outcomes through pharmacogenetics: a case for preemptive genotyping. Clin Pharmacol Ther 2012; 92:235-42. [PMID: 22739144 DOI: 10.1038/clpt.2012.66] [Citation(s) in RCA: 154] [Impact Index Per Article: 12.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
Routine integration of genotype data into drug decision making could improve patient safety, particularly if many relevant genetic variants can be assayed simultaneously before prescribing the target drug. The frequency of opportunities for pharmacogenetic prescribing and the potential adverse events (AEs) mitigated are unknown. We examined the frequency with which 56 medications with known outcomes influenced by variant alleles were prescribed in a cohort of 52,942 medical home patients at Vanderbilt University Medical Center (VUMC). Within a 5-year window, we estimated that 64.8% (95% confidence interval (CI): 64.4-65.2%) of individuals were exposed to at least one medication with an established pharmacogenetic association. Using previously published results for six medications with severe, well-characterized, genetically linked AEs, we estimated that 383 events (95% CI, 212-552) could have been prevented with an effective preemptive genotyping program. Our results suggest that multiplexed, preemptive genotyping may represent an efficient alternative approach to current single-use ("reactive") methods and may also improve safety.
Collapse
Affiliation(s)
- J S Schildcrout
- Department of Biostatistics, Vanderbilt University School of Medicine, Nashville, TN, USA
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
25
|
Pulley JM, Denny JC, Peterson JF, Bernard GR, Vnencak-Jones CL, Ramirez AH, Delaney JT, Bowton E, Brothers K, Johnson K, Crawford DC, Schildcrout J, Masys DR, Dilks HH, Wilke RA, Clayton EW, Shultz E, Laposata M, McPherson J, Jirjis JN, Roden DM. Operational implementation of prospective genotyping for personalized medicine: the design of the Vanderbilt PREDICT project. Clin Pharmacol Ther 2012; 92:87-95. [PMID: 22588608 DOI: 10.1038/clpt.2011.371] [Citation(s) in RCA: 301] [Impact Index Per Article: 25.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
The promise of "personalized medicine" guided by an understanding of each individual's genome has been fostered by increasingly powerful and economical methods to acquire clinically relevant information. We describe the operational implementation of prospective genotyping linked to an advanced clinical decision-support system to guide individualized health care in a large academic health center. This approach to personalized medicine entails engagement between patient and health-care provider, identification of relevant genetic variations for implementation, assay reliability, point-of-care decision support, and necessary institutional investments. In one year, approximately 3,000 patients, most of whom were scheduled for cardiac catheterization, were genotyped on a multiplexed platform that included genotyping for CYP2C19 variants that modulate response to the widely used antiplatelet drug clopidogrel. These data are deposited into the electronic medical record (EMR), and point-of-care decision support is deployed when clopidogrel is prescribed for those with variant genotypes. The establishment of programs such as this is a first step toward implementing and evaluating strategies for personalized medicine.
Collapse
Affiliation(s)
- J M Pulley
- Department of Medical Administration, Vanderbilt University School of Medicine, Nashville, Tennessee, USA
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
26
|
Delaney JT, Ramirez AH, Bowton E, Pulley JM, Basford MA, Schildcrout JS, Shi Y, Zink R, Oetjens M, Xu H, Cleator JH, Jahangir E, Ritchie MD, Masys DR, Roden DM, Crawford DC, Denny JC. Predicting clopidogrel response using DNA samples linked to an electronic health record. Clin Pharmacol Ther 2011; 91:257-63. [PMID: 22190063 DOI: 10.1038/clpt.2011.221] [Citation(s) in RCA: 79] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
Variants in ABCB1 and CYP2C19 have been identified as predictors of cardiac events during clopidogrel therapy initiated after myocardial infarction (MI) or percutaneous coronary intervention (PCI). In addition, PON1 has recently been associated with stent thrombosis. The reported effects of these variants have not yet been replicated in a real-world setting. We used BioVU, the Vanderbilt DNA repository linked to de-identified electronic health records (EHRs), to find data on patients who were on clopidogrel treatment after an MI and/or a PCI; among these, we identified those who had experienced one or more recurrent cardiac events while on treatment (cases, n = 225) and those who had not experienced any cardiac event while on treatment (controls, n = 468). We found that CYP2C19*2 (hazard ratio (HR) 1.54, 95% confidence interval (CI) 1.16-2.06, P = 0.003) and ABCB1 (HR 1.28, 95% CI 1.04-1.57, P = 0.018), but not PON1 (HR 0.91, 95% CI 0.73-1.12, P = 0.370), were associated with recurrent events. In this population, genetic signals for clopidogrel resistance in ABCB1 and CYP2C19 were replicated, supporting the use of EHRs for pharmacogenomic studies. Our data do not show an association between PON1 and recurrent cardiovascular events.
Collapse
Affiliation(s)
- J T Delaney
- Department of Medicine, Vanderbilt University, Nashville, Tennessee, USA
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
27
|
Johnson JA, Cavallari LH, Beitelshees AL, Lewis JP, Shuldiner AR, Roden DM. Pharmacogenomics: application to the management of cardiovascular disease. Clin Pharmacol Ther 2011; 90:519-31. [PMID: 21918509 PMCID: PMC3190669 DOI: 10.1038/clpt.2011.179] [Citation(s) in RCA: 42] [Impact Index Per Article: 3.2] [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] [Indexed: 01/08/2023]
Abstract
The past decade has seen substantial advances in cardiovascular pharmacogenomics. Genetic determinants of response to clopidogrel and warfarin have been defined, resulting in changes to the product labels for these drugs that suggest the use of genetic information as a guide for therapy. Genetic tests are available, as are guidelines for incorporation of genetic information into patient-care decisions. These guidelines and the literature supporting them are reviewed herein. Significant advances have also been made in the pharmacogenomics of statin-induced myopathy and the response to β-blockers in heart failure, although the clinical applications of these findings are less clear. Other areas hold promise, including the pharmacogenomics of antihypertensive drugs, aspirin, and drug-induced long-QT syndrome (diLQTS). The potential value of pharmacogenomics in the discovery and development of new drugs is also described. In summary, pharmacogenomics has current applications in the management of cardiovascular disease, with clinically relevant data continuing to mount.
Collapse
Affiliation(s)
- J A Johnson
- Department of Pharmacotherapy and Translational Research and Center for Pharmacogenomics, University of Florida, Gainesville, Florida, USA.
| | | | | | | | | | | |
Collapse
|
28
|
|
29
|
Wilke RA, Xu H, Denny JC, Roden DM, Krauss RM, McCarty CA, Davis RL, Skaar T, Lamba J, Savova G. The emerging role of electronic medical records in pharmacogenomics. Clin Pharmacol Ther 2011; 89:379-86. [PMID: 21248726 DOI: 10.1038/clpt.2010.260] [Citation(s) in RCA: 130] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
Abstract
Health-care information technology and genotyping technology are both advancing rapidly, creating new opportunities for medical and scientific discovery. The convergence of these two technologies is now facilitating genetic association studies of unprecedented size within the context of routine clinical care. As a result, the medical community will soon be presented with a number of novel opportunities to bring functional genomics to the bedside in the area of pharmacotherapy. By linking biological material to comprehensive medical records, large multi-institutional biobanks are now poised to advance the field of pharmacogenomics through three distinct mechanisms: (i) retrospective assessment of previously known findings in a clinical practice-based setting, (ii) discovery of new associations in huge observational cohorts, and (iii) prospective application in a setting capable of providing real-time decision support. This review explores each of these translational mechanisms within a historical framework.
Collapse
Affiliation(s)
- R A Wilke
- Department of Medicine, Division of Clinical Pharmacology, Vanderbilt University Medical Center, Nashville, Tennessee, USA.
| | | | | | | | | | | | | | | | | | | |
Collapse
|
30
|
Klein TE, Altman RB, Eriksson N, Gage BF, Kimmel SE, Lee MTM, Limdi NA, Page D, Roden DM, Wagner MJ, Caldwell MD, Johnson JA. Estimation of the warfarin dose with clinical and pharmacogenetic data. N Engl J Med 2009; 360:753-64. [PMID: 19228618 PMCID: PMC2722908 DOI: 10.1056/nejmoa0809329] [Citation(s) in RCA: 1078] [Impact Index Per Article: 71.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
BACKGROUND Genetic variability among patients plays an important role in determining the dose of warfarin that should be used when oral anticoagulation is initiated, but practical methods of using genetic information have not been evaluated in a diverse and large population. We developed and used an algorithm for estimating the appropriate warfarin dose that is based on both clinical and genetic data from a broad population base. METHODS Clinical and genetic data from 4043 patients were used to create a dose algorithm that was based on clinical variables only and an algorithm in which genetic information was added to the clinical variables. In a validation cohort of 1009 subjects, we evaluated the potential clinical value of each algorithm by calculating the percentage of patients whose predicted dose of warfarin was within 20% of the actual stable therapeutic dose; we also evaluated other clinically relevant indicators. RESULTS In the validation cohort, the pharmacogenetic algorithm accurately identified larger proportions of patients who required 21 mg of warfarin or less per week and of those who required 49 mg or more per week to achieve the target international normalized ratio than did the clinical algorithm (49.4% vs. 33.3%, P<0.001, among patients requiring < or = 21 mg per week; and 24.8% vs. 7.2%, P<0.001, among those requiring > or = 49 mg per week). CONCLUSIONS The use of a pharmacogenetic algorithm for estimating the appropriate initial dose of warfarin produces recommendations that are significantly closer to the required stable therapeutic dose than those derived from a clinical algorithm or a fixed-dose approach. The greatest benefits were observed in the 46.2% of the population that required 21 mg or less of warfarin per week or 49 mg or more per week for therapeutic anticoagulation.
Collapse
|
31
|
McBride BF, Yang T, Roden DM. Influence of the G2677T/C3435T haplotype of MDR1 on P-glycoprotein trafficking and ibutilide-induced block of HERG. Pharmacogenomics J 2009; 9:194-201. [PMID: 19204737 DOI: 10.1038/tpj.2009.1] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
The drug efflux pump P-glycoprotein possesses two common and often linked polymorphisms that result in variable drug action. G2677T results in A893S, whereas C3435T is synonymous and has been reported to alter protein folding. We tested the effect of these MDR1 variants on Human Ether-Related A Go-Go (HERG) block by ibutilide in CHO cells 48 h following transient transfection with an IRES-dsRed vector containing MDR1, G2677T MDR1, G2677T/C3435T MDR1 or an empty bicistronic site and an IRES-GFP vector containing HERG (KCNH2). Cotransfection of MDR1 variants had no effect on I(Kr) amplitude at baseline. Cells cotransfected with MDR1-G2677T showed resistance to ibutilide vs HERG alone (IC(50): 105.3+/-1.42 nM vs 27.4+/-2.5 nM; P<0.0001), consistent with the idea that A893S attenuates I(Kr) block by enhancing drug efflux and thus reducing the drug available to interact with the channel binding site. However, G2677T/C3435T cells showed ibutilide sensitivity similar to cells expressing HERG alone (IC(50): 22.2+/-0.9 nM). Immunostaining showed that the C3435T variant did not traffic to the cell surface. Coculture with fexofenadine(1 microM), an MDR1 substrate known to rescue misfolding in other membrane proteins, restored cell surface expression of MDR1 G2677T/C3435T and restored resistance to block HERG by ibutilide 200 nM (98.5+/-0.98% vs 42.3+/-2.2%, P<0.001). The non-synonymous MDR1 variant G2677 T (A893S) confers resistance to ibutilide block of I(Kr), which is mitigated by the C3435T polymorphism through reduced protein expression, an effect that can be restored by coculture with fexofenadine. These data identify ibutilide as an MDR1 substrate and further support the concept that variable drug transport function can modulate the action of HERG blockers.
Collapse
Affiliation(s)
- B F McBride
- Department of Pharmacology and Medicine, Vanderbilt University School of Medicine, Nashville, TN 37232-0575, USA
| | | | | |
Collapse
|
32
|
Abstract
The term torsade de pointes refers to polymorphic ventricular tachycardia that occurs in the setting of an abnormally long QT interval. While the most common cause is treatment with QT prolonging drugs, torsade de pointes also occurs in the congenital long QT syndromes and in the setting of acquired heart block or severe electrolyte disturbance, notably hypokalemia. Among QT prolonging drugs that cause torsade de pointes, both antiarrhythmics and "noncardioactive" drugs have been recognized. The electrocardiographic features of torsade de pointes include labile QT intervals, prominent U waves, and a "pause-dependent" onset of the arrhythmia. Treatment consists of recognition of the syndrome, correction of underlying electrolyte abnormalities, and withdrawal of any offending drugs. Magnesium, isoproterenol, or cardiac pacing provides specific antiarrhythmic therapy in torsade de pointes.
Collapse
Affiliation(s)
- D M Roden
- Vanderbilt University School of Medicine, Department of Medicine, Nashville, Tennessee 37232-6602, USA
| |
Collapse
|
33
|
Yang P, Koopmann TT, Pfeufer A, Jalilzadeh S, Schulze-Bahr E, Kääb S, Wilde AA, Roden DM, Bezzina CR. Polymorphisms in the cardiac sodium channel promoter displaying variant in vitro expression activity. Eur J Hum Genet 2007; 16:350-7. [PMID: 18059420 DOI: 10.1038/sj.ejhg.5201952] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Abstract
Variable transcription of the cardiac sodium channel gene is a candidate mechanism determining arrhythmia susceptibility. We have previously cloned and characterized the core promoter and flanking region of SCN5A, encoding the cardiac sodium channel. Loss-of-function mutations in this gene have been reported in approximately 20% of patients with Brugada syndrome, an inherited cardiac electrical disorder associated with a high incidence of life-threatening arrhythmias. In this study, we identified DNA variants in the proximal 2.8 kb promoter region of SCN5A and determined their frequency in 1,121 subjects. This population consisted of 88 Brugada syndrome patients with no SCN5A coding region mutation, and 1,033 anonymized subjects from various ethnicities. Variant promoter activity was assayed in CHO cells and neonatal cardiomyocytes by transient transfection of promoter-reporter constructs. Single-nucleotide polymorphisms (SNPs) were identified at approximately 1/200 base pairs which are: 11 in the 5'-flanking region, 1 in exon 1, and 5 in intron 1. In addition, a haplotype consisting of two SNPs in complete linkage disequilibrium was identified. Minor allele frequencies were >5% in at least one ethnic panel at 5/19 polymorphic sites. In vitro functional analysis in cardiomyocytes identified four variants with significantly (P<0.05) reduced reporter activity (up to 63% reduction). The largest changes were seen with c.-225-1790 G>A, which reduced reporter activity by 62.8% in CHO cells and 55% in cardiomyocytes. From these results, we can conclude that the SCN5A core promoter includes multiple DNA polymorphisms with altered in vitro activity, further supporting the concept of interindividual variability in transcription of this cardiac ion channel gene.
Collapse
Affiliation(s)
- P Yang
- Vanderbilt University School of Medicine, Nashville, TN 37232-0575, USA
| | | | | | | | | | | | | | | | | |
Collapse
|
34
|
Giacomini KM, Brett CM, Altman RB, Benowitz NL, Dolan ME, Flockhart DA, Johnson JA, Hayes DF, Klein T, Krauss RM, Kroetz DL, McLeod HL, Nguyen AT, Ratain MJ, Relling MV, Reus V, Roden DM, Schaefer CA, Shuldiner AR, Skaar T, Tantisira K, Tyndale RF, Wang L, Weinshilboum RM, Weiss ST, Zineh I. The pharmacogenetics research network: from SNP discovery to clinical drug response. Clin Pharmacol Ther 2007; 81:328-45. [PMID: 17339863 PMCID: PMC5006950 DOI: 10.1038/sj.clpt.6100087] [Citation(s) in RCA: 186] [Impact Index Per Article: 10.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
The NIH Pharmacogenetics Research Network (PGRN) is a collaborative group of investigators with a wide range of research interests, but all attempting to correlate drug response with genetic variation. Several research groups concentrate on drugs used to treat specific medical disorders (asthma, depression, cardiovascular disease, addiction of nicotine, and cancer), whereas others are focused on specific groups of proteins that interact with drugs (membrane transporters and phase II drug-metabolizing enzymes). The diverse scientific information is stored and annotated in a publicly accessible knowledge base, the Pharmacogenetics and Pharmacogenomics Knowledge base (PharmGKB). This report highlights selected achievements and scientific approaches as well as hypotheses about future directions of each of the groups within the PGRN. Seven major topics are included: informatics (PharmGKB), cardiovascular, pulmonary, addiction, cancer, transport, and metabolism.
Collapse
Affiliation(s)
- K M Giacomini
- Department of Biopharmaceutical Sciences, University of California San Francisco, San Francisco, California, USA.
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
35
|
Abstract
The concept that antiarrhythmic drugs can exacerbate the cardiac rhythm disturbance being treated, or generate entirely new clinical arrhythmia syndromes, is not new. Abnormal cardiac rhythms due to digitalis or quinidine have been recognized for decades. This phenomenon, termed "proarrhythmia," was generally viewed as a clinical curiosity, since it was thought to be rare and unpredictable. However, the past 20 years have seen the recognition that proarrhythmia is more common than previously appreciated in certain populations, and can in fact lead to substantially increased mortality during long-term antiarrhythmic therapy. These findings, in turn, have moved proarrhythmia from a clinical curiosity to the centerpiece of antiarrhythmic drug pharmacology in at least two important respects. First, clinicians now select antiarrhythmic drug therapy in a particular patient not simply to maximize efficacy, but very frequently to minimize the likelihood of proarrhythmia. Second, avoiding proarrhythmia has become a key element of contemporary new antiarrhythmic drug development. Further, recognition of the magnitude of the problem has led to important advances in understanding basic mechanisms. While the phenomenon of proarrhythmia remains unpredictable in an individual patient, it can no longer be viewed as "idiosyncratic." Rather, gradations of risk can be assigned based on the current understanding of mechanisms, and these will doubtless improve with ongoing research at the genetic, molecular, cellular, whole heart, and clinical levels.
Collapse
Affiliation(s)
- D M Roden
- Division of Clinical Pharmacology, Vanderbilt University School of Medicine, 532 Medical Research Building I, Nashville, TN 37232, USA.
| | | |
Collapse
|
36
|
Abstract
Marked QT prolongation and torsades de pointes can occur not only in the congenital long QT syndromes (LQTSs) but also as a consequence of environmental stimuli, notably administration of certain drugs. A key feature of this 'acquired' form of the LQTS has been its unpredictable nature. That is, although risk factors have been identified in series of patients, they have not been terribly useful in addressing risk in an individual patient. Normal cardiac repolarization depends critically on the interplay of multiple ion currents, and these provide some redundancy, or 'reserve', to protect against excessive QT prolongation by drugs. We have proposed that lesions in these repolarizing mechanisms can remain subclinical but nevertheless increase risk on drug exposure, and have termed this situation 'reduced repolarization reserve'. The evidence in support of this concept is presented, and the known and potential contributions by genetic variants to risk is examined. Assessing variability in susceptibility to acquired LQTS provides a framework for analysis of other complex gene-environment interactions.
Collapse
Affiliation(s)
- D M Roden
- Department of Medicine and Pharmacology, Oates Institute for Experimental Therapeutics, Vanderbilt University School of Medicine, Nashville, TN 37232, USA.
| |
Collapse
|
37
|
Affiliation(s)
- D M Roden
- Department of Medicine, Vanderbilt University School of Medicine, Nashville, Tennessee 37232-6602, USA.
| |
Collapse
|
38
|
|
39
|
Abstract
The long QT-related arrhythmia torsades de pointes (TdP) can arise with mutations in HERG and during treatment with drugs that block cardiac I Kr, the current encoded by HERG. Multiple test systems have been used to assess drug block of I Kr. This study evaluated the I Kr blocking potency of a series of antiarrhythmics associated with a range of clinical risks of TdP in two such systems: mouse AT-1 cells (in which I Kr is the major repolarizing current) and Ltk cells transiently transfected with HERG (n = 4-10 cells per drug). For each compound, the concentration required to produce 50% block of I Kr or HERG tail currents (IC 50 ) was determined. There was an excellent correlation ( r = 0.98, p < 10 -5 ) between values obtained in the two systems. However, the relation between the liability of a drug to cause TdP appeared dissociated from I Kr blocking potency. Quinidine, dofetilide, ibutilide, procainamide, and disopyramide are all associated with TdP, but only the first three were potent blockers (IC 50 < or = 1 microM ), whereas procainamide and disopyramide were not (IC 50 > 50 microM ). Conversely, verapamil and amiodarone, drugs not associated with TdP, were also blockers (IC 50 < or = 1 microM ). We conclude that I Kr blocking potency can be readily assessed in either AT-1 cells or systems in which HERG is heterologously expressed. However, not all drugs causing TdP are potent I Kr blockers, and I Kr block is not necessarily associated with TdP. Other properties of these drugs, therefore, contribute to their propensity to cause TdP.
Collapse
Affiliation(s)
- T Yang
- Vanderbilt University School of Medicine, Nashville, TN 37232-6602, USA
| | | | | |
Collapse
|
40
|
Abstract
BACKGROUND Mutations in the cardiac sodium (Na) channel gene (SCN5A) give rise to the congenital long-QT syndrome (LQT3) and the Brugada syndrome. Na channel blockade by antiarrhythmic drugs improves the QT interval prolongation in LQT3 but worsens the Brugada syndrome ST-segment elevation. Although Na channel blockade has been proposed as a treatment for LQT3, flecainide also evokes "Brugada-like" ST-segment elevation in LQT3 patients. Here, we examine how Na channel inactivation gating defects in LQT3 and Brugada syndrome elicit proarrhythmic sensitivity to flecainide. METHODS AND RESULTS We measured whole-cell Na current (I(Na)) from tsA-201 cells transfected with DeltaKPQ, a LQT3 mutation, and 1795insD, a mutation that provokes both the LQT3 and Brugada syndromes. The 1795insD and DeltaKPQ channels both exhibited modified inactivation gating (from the closed state), thus potentiating tonic I(Na) block. Flecainide (1 micromol/L) tonic block was only 16.8+/-3.0% for wild type but was 58.0+/-6.0% for 1795insD (P<0.01) and 39.4+/-8.0% (P<0.05) for DeltaKPQ. In addition, the 1795insD mutation delayed recovery from inactivation by enhancing intermediate inactivation, with a 4-fold delay in recovery from use-dependent flecainide block. CONCLUSIONS We have linked 2 inactivation gating defects ("closed-state" fast inactivation and intermediate inactivation) to flecainide sensitivity in patients carrying LQT3 and Brugada syndrome mutations. These results provide a mechanistic rationale for predicting proarrhythmic sensitivity to flecainide based on the identification of specific SCN5A inactivation gating defects.
Collapse
Affiliation(s)
- P C Viswanathan
- Department of Anesthesiology, Vanderbilt University, Nashville, Tennessee, USA
| | | | | | | | | | | |
Collapse
|
41
|
Abstract
Drugs are widely recognized to vary in the beneficial and undesirable effects they produce in human subjects. The understanding that variants (polymorphisms and mutations) in the human genome are common and may well modulate both disease and its response to drugs, is a critical new concept in understanding mechanisms of drug action and their variability in human subjects. Variability can arise because of variability in genes encoding molecules of drug disposition, in genes encoding molecules that drugs target, or in genes that modulate the overall activity of the complex biological systems within which drugs act. The evolving understanding of the genetic basis of variability in response to drugs used in the treatment of sudden cardiac death has important implications not only for the treatment of patients who have survived an episode, but also for helping formulate a framework for further understanding mechanisms of drug action at the genetic level.
Collapse
Affiliation(s)
- D M Roden
- Division of Clinical Pharmacology, Vanderbilt University School of Medicine, 532 Medical Research Building I, Nashville, TN 37232, USA.
| |
Collapse
|
42
|
|
43
|
Mazur A, Anderson ME, Bonney S, Roden DM. Pause-dependent polymorphic ventricular tachycardia during long-term treatment with dofetilide: a placebo-controlled, implantable cardioverter-defibrillator-based evaluation. J Am Coll Cardiol 2001; 37:1100-5. [PMID: 11263615 DOI: 10.1016/s0735-1097(01)01106-8] [Citation(s) in RCA: 46] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
OBJECTIVES To compare the incidence of pause-dependent polymorphic ventricular tachycardia (PVT) in patients with implantable cardioverter-defibrillators (ICDs) randomly assigned to the QT-prolonging antiarrhythmic dofetilide or placebo. BACKGROUND Drug-related torsade de pointes (TdP) is usually recognized within days of initiating therapy, but its incidence during long-term therapy is unknown. METHODS We assessed the frequency of TdP and ICD electrograms compatible with TdP in a multicenter study that randomized ICD patients to placebo (n = 87) or dofetilide (n = 87). As reported elsewhere, the number of patients with a primary trial end point (ICD intervention for VT or ventricular fibrillation) was similar in the two groups. For this analysis, a qualifying event was TdP (on electrocardiogram) or an intracardiac electrogram showing pause-dependent PVT. RESULTS A total of 620 electrograms obtained in 131 patients were analyzed blindly by prospectively defined criteria for episodes of pause-dependent polymorphic VT. These were identified in 15/87 (17%) patients receiving dofetilide and 5/87 (6%) patients on placebo (p < 0.05). Five of these episodes were early (<3 days), all of which were TdP on dofetilide. There were 15 late events, 10 on dofetilide and five on placebo (p = 0.29). The median time to a late event was 22 days (range 6 to 107 days) for dofetilide and 99 days (range 34 to 207 days) for placebo. CONCLUSIONS Pause-dependent PVT was more common among patients receiving dofetilide, although total VT incidence was similar in the two groups. These data suggest that in ICD patients either long-term dofetilide therapy is associated with an increased risk of TdP or the drug alters VT morphology.
Collapse
Affiliation(s)
- A Mazur
- Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | | | | | | |
Collapse
|
44
|
Anderson ME, Mazur A, Yang T, Roden DM. Potassium current antagonist properties and proarrhythmic consequences of quinolone antibiotics. J Pharmacol Exp Ther 2001; 296:806-10. [PMID: 11181910] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/19/2023] Open
Abstract
Quinolones are clinically important antibiotic drugs. One quinolone antibiotic, sparfloxacin (SPX), has been recently reported to increase the QT interval, and another quinolone, grepafloxacin (GRX), was withdrawn because it induced torsade de pointes (TdP), a polymorphic ventricular tachycardia (VT) linked to excessive QT interval prolongation. To determine whether SPX, GRX, and other recently developed quinolones, gatifloxacin (GAT) and moxifloxacin (MOX), have similar, potentially deleterious, properties we compared these agents in two ways. First, we measured their relative antagonist potency against the rapid component of the delayed rectifier K(+) current (I(Kr)), and second we determined the QT interval prolongation and inducibility of VT and TdP using a well established in vivo rabbit arrhythmia model. All of these agents are I(Kr) antagonists with the following IC(50) values (mean +/- S.E.) for I(Kr) block: SPX, 0.23 +/- 0.07 microM; MOX, 0.75 +/- 0.31 microM; GAT, 26.5 +/- 13.4 microM; and GRX, 27.2 +/- 11.6 microM. All agents also increased the maximum QT interval (mean +/- S.E.) from baseline (241 +/- 10 ms): SPX, 370 +/- 30 ms; MOX, 270 +/- 30 ms; GRX, 280 +/- 25 ms; and GAT, 255 +/- 23 ms. No agents caused TdP during a standard 30-min observation period, but SPX-treated animals developed nonsustained VT (three of six) and TdP (one of six) during an extended 60-min observation period. These findings show that I(Kr) block may be a common feature of many quinolone antibiotics, and that the proarrhythmic consequences vary according to I(Kr) antagonist potency, but are also influenced by additional, unidentified factors.
Collapse
Affiliation(s)
- M E Anderson
- Vanderbilt University Medical Center, Department of Internal Medicine and Pharmacology, Divisions of Clinical Pharmacology and Cardiovascular Medicine, Nashville, Tennessee 37232-6300, USA.
| | | | | | | |
Collapse
|
45
|
|
46
|
Abstract
INTRODUCTION Salt restriction results in endogenous sympathetic activation, and we previously showed that plasma concentrations of quinidine measured after oral drug administration are increased during a low-salt diet. However, it is not known whether, independent of effects on plasma concentration, the extent to which quinidine prolongs the QT interval also is modulated by changes in endogenous sympathetic activity. METHODS AND RESULTS In these studies, we evaluated quinidine concentration-QT relations during low-salt (10 mEq/day for 8 days) and high-salt (400 mEq/day for 8 days) diets, with or without beta blockade in normal volunteers. In the absence of beta blockade, the concentration producing a fixed (15%) increase in QTc was significantly lower with salt restriction: 1.2 +/- 0.4 microg/mL (low salt) versus 2.2 +/- 0.4 microg/mL (high salt) (P < 0.01). With beta blockade, this difference was abolished: 1.9 +/- 0.3 microg/mL (low salt + beta blockade) versus 2.1 +/- 0.3 microg/mL (high salt + beta blockade). QT morphologic abnormalities including bifid T waves and U waves were abolished with beta-adrenergic blockade. CONCLUSION Sympathetic activation by a low-salt diet not only modulates drug disposition but also increases sensitivity to drug-induced QT prolongation.
Collapse
Affiliation(s)
- D Darbar
- Department of Medicine, Vanderbilt University School of Medicine, Nashville, Tennessee, 37232-6602, USA
| | | | | | | |
Collapse
|
47
|
|
48
|
Abstract
Point cathodal stimulation of cardiac tissue was shown previously to produce both a dog-bone shaped virtual cathode transverse to the muscle fibers and two longitudinal virtual anodes. We hypothesize that virtual anodes can cause a region of delayed activation, separating two regions of early activation caused by the virtual cathode. Using a high-density electrode array in 42 superfused epicardial slices from 14 canine left ventricles, we observed regions of early and delayed activation and different pathways of retrograde propagation corresponding to the earlier patterns. Retrograde propagation was seen from the transversely located early activation area through areas of delayed activation toward the cathode, and from the early activation area toward the cathode directly. These pathways caused a wide dispersion in the direction of retrograde propagation (2 degrees +/- 31 degrees, n = 179, relative to the fast axis of threshold activation; radial velocity: 0.5 +/- 0.2 m/s, n = 95, in 12 slices from 8 hearts with stimuli of 330 micros, 0.8-30 mA). Delayed activations were observed 0 degrees +/- 6 degrees (n = 32) from the axis in 23 maps (at differing stimulation strengths) recorded in 13 slices from 10 hearts. We conclude that point cathodal stimulation induce delayed activation along the fiber axis and retrograde propagation both along and transverse to the axis.
Collapse
Affiliation(s)
- J Wu
- Department of Physics & Astronomy, Vanderbilt University, Nashville, TN, USA.
| | | | | |
Collapse
|
49
|
Sesti F, Abbott GW, Wei J, Murray KT, Saksena S, Schwartz PJ, Priori SG, Roden DM, George AL, Goldstein SA. A common polymorphism associated with antibiotic-induced cardiac arrhythmia. Proc Natl Acad Sci U S A 2000; 97:10613-8. [PMID: 10984545 PMCID: PMC27073 DOI: 10.1073/pnas.180223197] [Citation(s) in RCA: 319] [Impact Index Per Article: 13.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
Abstract
Drug-induced long QT syndrome (LQTS) is a prevalent disorder of uncertain etiology that predisposes to sudden death. KCNE2 encodes MinK-related peptide 1 (MiRP1), a subunit of the cardiac potassium channel I(Kr) that has been associated previously with inherited LQTS. Here, we examine KCNE2 in 98 patients with drug-induced LQTS, identifying three individuals with sporadic mutations and a patient with sulfamethoxazole-associated LQTS who carried a single-nucleotide polymorphism (SNP) found in approximately 1.6% of the general population. While mutant channels showed diminished potassium flux at baseline and wild-type drug sensitivity, channels with the SNP were normal at baseline but inhibited by sulfamethoxazole at therapeutic levels that did not affect wild-type channels. We conclude that allelic variants of MiRP1 contribute to a significant fraction of cases of drug-induced LQTS through multiple mechanisms and that common sequence variations that increase the risk of life-threatening drug reactions can be clinically silent before drug exposure.
Collapse
Affiliation(s)
- F Sesti
- Departments of Pediatrics and Cellular and Molecular Physiology, Boyer Center for Molecular Medicine, Yale University School of Medicine, New Haven, CT 06536, USA
| | | | | | | | | | | | | | | | | | | |
Collapse
|
50
|
|