Pharmacogenetics & Polymorfism

Akhmad Edy Purwoko

Bagian Farmakologi & Toksikologi
FKIK - UMY
Master of Basic Medical Science
Yogyakarta, July 2010
 Problems with Rx Drugs

We are all different

Most of us are treated in the same way
Trial and error
 Implications
Money: Thousands spent on ineffective
medications
Death/sickness: 2.2 million serious cases
and over 100,000 deaths.
 Limitations of
pharmacotreatment?

Why is pharmacotreatment effective in

some patients but lacks efficacy in others?

Why suffer some patients from severe

adverse drug reactions but others not?
 Serious Adverse Drug Events Reported
to the Food and Drug Administration, 1998-2005
 Adverse drug effects as cause of
hospitalization
7% of patients are hospitalized due to adverse drug
events
JAMA 1998, 279:1200-1205
Additional duration of hospitalization : 2.2 days
Additional costs : 3.000,- US$
JAMA 1997, 277:307-311
In departments of psychiatry the proportion of
patients hospitalized due to adverse drug events is
estimated with 16%
 Efficacy of Drug
Treatment
Alzheimer 30
Analgetics (COX-2) 80
Asthma 60
Arrhythmias 60
Depression 62
Diabetes mellitus 57
Hepatitis C 47
Incontinence 40
Migraine (acute) 52
Migraine (prophylaxis) 50
Oncology 25
Osteoporosis 48
Rheumatoid Arthritis 50
Schizophrenia 60
 Solution?
Pharmacogenomics: The study of
how an individuals genetic
inheritance affects the bodys
response to drugs.
 What is pharmacogenomics?

It is the study of how an individuals

genetic inheritance affects the
bodys response to drugs

PHARMACOLOGY + GENETIC
PHARMACOLOGY GENETIC

PHARMACOGENETIC
PHARMACOGENETIC

PHARMACOGENOMIC
PHARMACOGENOMIC

http://www.ornl.gov/hgmis/medicine/pharma.html
 Pharmacogenomics
The study of genome-derived data,
including human genetic variation,
RNA and protein expression
differences, to predict drug response
in individual patients or groups of
patients.
Pharmacogenomics includes Pharmacogenetics
 History of Pharmacogenomics

L.H. Snyder was the first to report an unusual

response to PHENYLTHIOUREA in a study
involving 800 families comprising 2043 people.
Those who cannot taste (PTU) are said to
exhibit idiosyncratic reaction to this
compound (Ohio J Sci 32:436,1932)
 History of Pharmacogenomics
1953 : Watson and Crick describe DNAs double helix. Bonicke et al describe
slow and rapid acetylation of isoniazid
1956 : Alving et al discover a genetic link to haemolytic reactions to
primaquine
1957 : Motulsky proposes that inheritance might explain many individual
differences in the efficacy of drugs and in the occurrence of adverse drug
reactions
1959 : Vogel introduces the term Pharmacogenetics to indicate the
influence of heredity on drug response
1960 : Evans establishes the genetic control of isoniazid acetylation
1990 : Human genome project is started and completed 2003
 History of Pharmacogenomics

1962 : Kalow publishes the first

monograph on
pharmacogenetics
PHARMACOGENETICS :
Heredity and the response to
drugs
 History of Pharmacogenomics
In 1975, several laboratory scientists at
St.Marys Hospital Medical School in London
each ingested a 40 mg dose of debrisoquine,
an anti hypertensive drug then in clinical use.
While the majority of the researchers reported
no adverse side effects
Robert L. Smith experienced dizziness and
suffered from about of orthostatic
hypotension that lasted several days (A.
Mahgoub et al., Lancet 1977;2:584-6)
What is Pharmacogenomics?
Pharmacogenomics can be
defined as the comprehensive
compilation of information about
genomic sequences and
sequence variants, and the
application of this information to
understanding individual
variations in drug responses
Pharmacogenetics-
Pharmacogenomics
Clinical Goals
1. Avoid adverse drug reactions
2. Maximize drug efficacy
3. Select responsive patients
 The treatment based on
pharmacogenetics is drug specific

Specific
genotype
DNA
Blood sample
Combine
Specific
drug

Effective drug treatment

Master of Basic Medical Science
Yogyakarta, July 2010
 European Medicines Agency
(EMEA) 15 November 2007
The Use of Genomics in Cardiovascular
Clinical Intervention Trials

Needed documents review of the scientific matters concerning

the use of genomic data in assessing therapeutic efficacy and
tolerance of drugs in cardiovascular
clinical intervention trials, focusing on
genetic association with clinical endpoints.
 Classic concept of pharmacogenetics

Observation:
Occurrence of different phenotypes

Goal:
Identification of allelic variants, associated with differrent phenotypes

Extensive Metabolizers
Toxic area

Concentration
Frequency

Therapeutic area
Poor
Metabolizers

Time
Debrisoquine Metabolic ratio
 Hypothesis
Weak metabolism may cause adverse drug events
(active metabolites are generated to a smaller extent)
Accelerated metabolism may cause lower or lack of any
drug effects

Rau et al. Clin Pharmacol Ther 2004; 75:386-393; Kawanishi et al. Eur J Clin
Rau et al. Clin Pharmacol Ther 2004; 75:386-393 Pharmacol 2004;59:803-807
 Treatment with amitriptyline:
Risk of adverse effects in relation to the combined
CYP2D6/CYP2C19 genotype

Steimer et al. Clin Chem 2005

 CYP2D6 genotype based
dose recommendations for antidepressants

Kirchheiner et al. Acta Psych. Scand. 2001: 103; 1-21

 Pharmacogenomics

Pharmacodynamics
Pharmacokinetics
Receptor affinity
Drug transport
Signal
Drug metabolism transduction
Regulation

Exogenous factors
Genetic variations in drug response
and drug toxicity may result from
Genetic variation in drug metabolizing enzymes
Phase I enzymes e.g. Cytochromes P450
Phase II enzymes e.g. Thiopurine S-methyltransferase
N-acetyltransferases
Genetic variation in drug targets
Beta-adrenergic receptor
Angiotensin Converting Enzyme
Dopamine receptor
Genetic variation in drug efflux/drug transporters
P-glycoprotien
MRPs

Genetic variation in disease modifying genes

HER2
HLA
 Why do pharmacogenomics
research in Indonesia?
Evidence for ethnic differences in the response
to drugs have practical importance. Indonesia
consists of more than 350 ethnics that shown
different language, culture, environment.
High population densities.
Most of the drugs used in Indonesia produced
and clinically tested in USA and Europe that
might be not fit to our genetic backgrounds.
 Pharmacogenomics of CYP2C19
CYP2C19 is the isoenzymes of cytochrome p450
that catalyze hydroxylation of several
important groups of drugs
Genetic variations of CYP2C19 gene affects the
metabolism of the drugs therapeutic
management
Genetic variations of CYP2C19 shows
interethnic variation
 Polymorphisms of Drug Metabolizing Enzymes

Frequent (>1-2%) Rare (<1%)

CYP2A6 Flavin monooxygenase

CYP2C8 (FMO3, fish odor syndrome)
CYP2C9 DPD (dihydropyrimidine dehydrogenase)
CYP2C19 (mephenytoin-type) TPMT (thiopurin S-methyltransferase)
CYP2D6 (debrisoquine/sparteine-type) Succinyl-Cholinesterase
CYP3A5
CYP3A7
NAT1 & 2 (arylamine N-acetyltransferases)
ADH1 (alcohol dehydrogenase type I)
ALDH2 (aldehyde dehydrogenase)
Paraoxonase
UGT1A1 (UDP-glucuronyltransferase 1A1)
GSTs (glutathione-S-transferases)
Evans and Relling, Science 1999, 286:487-491
 CYP2D6 polymorphism
involve in the metabolism of about 30% of all prescribed drugs

Master of Basic Medical Science

Yogyakarta, July 2010
 Common CYP2D6 alleles
More than 70 alleles have been identified
CYP2D6*1 1 2 4 5 6 7 8 9
3
Normal activity

CYP2D6*2
Normal activity
G1661C C2850T G4180C
CYP2D6*4
No activity
C100T G1661C G1846A G4180C

CYP2D6*10
Decrease activity
C100T G1661C G4180C

CYP2D6*17
Decrease activity
C1023T G1661C C2850T G4180C

CYP2D6*2 X N
Increase activity G1661C C2850T G4180C
 Pharmaceutical substrates
of CYP2C19
Drug Reference

Amitriptyline Melstrom et al, 1988

Barbiturates Adedoyin et al, 1994
Chlorproguanil Wright et al, 1995
Citalopram Sindrup et al, 1993
Clomipramine Nielsen et al, 1994
Diazepam Bertillson et al, 1989
Imipramine Haefeli et al, 1990
Mephenytoin de Morias et al, 1994
Omeprazole Anderson et al, 1992
Proguanil Anderson et al, 1990
Propranolol Ward et al, 1989
 Effect of CYP2D6 phenotypes on
pharmacokinetics of CYP2D6 substrates
PM IM EM UM
Difference in the distribution of debrisoquin / 4-hydroxydebrisoquin
metabolic ratio among Asians and Caucasians

Individual with low CYP2D6 activity

(PM) : high metabolic ratio

Master of Basic Medical Science

Yogyakarta, July 2010
Ethnic variations in Codeine metabolism
Ethnic differences in pharmacokinetics of haloperidol

Serum haloperidol and prolactin

concentrations were measured in male
Caucasians, American-born Asians, and
foreign-born Asians after administration
of haloperidol

Haloperidol concentrations
were similar between the two
Asian groups. but significantly
higher than those observed in
Caucasians

Lin et al., J Clin Psychopharmacol. 1988;8:195-201

Ethnic differences in pharmacodynamics of haloperidol

Prolactin concentrations in
both Asian groups were
higher than the Caucasians

These results indicate that

both pharmacokinetics and
pharmacodynamics of
haloperidol were difference
between Caucasians and
Asians

Lin et al., J Clin Psychopharmacol. 1988;8:195-201

Frequency of CYP2C19 PMs in various
ethnics

2-4% 3%

3%

3-5% 6% 18-20%
13%
2% 5%
11 %
15-18%
22%
5% 23%
4%
15%
8% 70%
Aborigines 26%

Master of Basic Medical Science

Yogyakarta, July 2010
Interethnic variations of
CYP2C19 genotype
 CYP2C19 Genotype Frequencies
in Indonesia Populations

80

70

60 M elayu
Batak
50 Kajang
40 Sunda
Jawa
30
Dayak
20 Bima
Bugis
10

0
EM IM PM
Prevalence of CYP2C19 genotype within Geographically
Dispersed Populations

100
90 Caucasian
80 Saudi Arabian
70 African
Korean
60
Japanese
50
Chinese
40 Philippine
30 Aboriginal Australia
20 Indonesia

10 Thailand
Vanuatu
0
EM IM PM
 0.04 Korean Japanese
Chinese

Thailand
Philippines

Kajang

Dayak
Malay
Caucasian

11 Bugis

Sunda
Javanese
Bima
Saudi Arabian Vanuatu

Australian Aborigine
Master of Basic Medical Science
Yogyakarta, July 2010 Yusuf .I et al, Adv Exp Med B
 CYP2D6 is an Enzyme with
Polymorphisms

Approximately 70 nucleotide polymorphisms are known

Four phenotype subpopulations of metabolizer
Poor metabolizer (PM)
Intermediate metabolizer (IM)
Extensive metabolizer (EM)
Ultra rapid metabolizer (UM)
Variations according to racial background
More than 65 commonly used drugs are substrates
Codeine is a well known substrate
 Medical and Public Health Implications
The most significant potential impact of CYP2C19 PM in patient care,
therefore, would be in SEA where there is a combination of high
population densities and significantly increased risk associated with PM.
The recognition of the high frequency of IM and PM individuals amongst
SEA is important for medical practitioners in SEA but also those in Europe,
Middle East, and USA where the frequencies of EM individuals
predominate.
Racial differences in the response to drugs not only have practical
importance for the choice and dose of drugs but should also alert
physicians to the important underlying genetic determinants of drug
response if used in populations with different genetic backgrounds.
 Urinary Excretion of Proguanil
and Cycloguanil
80

Proguanil
URINARY EXCRETION (% dose)

60 Cycloguanil

40

20

0 EM IM PM
Application of pharmacogenomics in clinical practice

25-30% of breast tumor specimens 1.0 All patients

show amplification/overexpression

Overall survival
of erbB2/HER2/neu
0.5
P=0.002

c-erbB-2 negative (80/28)

c-erbB-2 positive (30/19)
0.0
0 60 120 180
Months
Agrup et al. Breast Cancer Res Treat 2000
Impact of polymorphic drug metabolizing enzymes for
cancer therapies

Enzyme Drug Poor Relevance

metabolizers
CYP2D6 Tamoxifen 7-10% possible
CYP2C19 Cyclophosphamide 3-5% unclear
DPD 5-Fluorouracil <1% weak
TPMT Azathioprine, 6-MP 0.6% high
UGT1A1 Irinotecan 10-15% high
Pharmacogenomics Current Applications

Examples
Oncology (PK + PD)
Psychiatry (PK)
Cardiovascular Diseases (PK + PD)
Transplantation surgery (PK)
Pain treatment (PK + PD)
high evidence
moderate evidence
increasing evidence
increasing evidence
currently low moderate
evidence
Proposed dose of anti-psychotics for patients
with different CYP2D6 phenotypes

Kirchheiner et al., Psychiatry 2004, 9:442-473

Limitations of pharmacogenetics

Although there is a huge number of

studies, pharmacogenetics has been
accepted only in a few cases in clinical
practice
 Limitations of pharmacogenetics

Possible reasons:

Lack of knowledge on the clinical outcome need of

prospective studies
Low positive predictive value of a single genetic trait
Complex genetic background
Minor clinical relevance (e.g. there is an influence on
the kinetic, but the clinical outcome is not affected)
Availability of alternative drugs, bypassing
polymorphic pathways
Costs - Time - Ethical issues
 Individualized therapy: fact or fiction?

Individual drug target selection in oncological diseases is performed

already to date in cases of over-expression of cancer-related genes:

Estrogen receptor (tamoxifen)

HER2/neu (trastuzumab)
EGFR1 (gefitinib)
BCR-ABL (imatinib)

Individual dose adaptation of chemotherapeutics should be performed in

cases related to clearly polymorphic drug metabolizing enzymes

TPMT (azathioprine, 6-mercatopurine)

UGT1A1 (irinotecan)
Approaches to Drug Innovation: Genetics

Can pharmacogenomics
contribute to
identification of novel drug
targets
facilitated drug development
salvage of less effective
drugs
optimized drug treatment
Individualized
.....? treatment versus one fits all
Pharmacogenomics as recognized by the politics

US senator Barack Obama proposed a Genomics and

Personalized Medicine Act of 2006, which should it be
enacted, would establish a Genomics and personalized
Medicine Interacting Working Group to coordinate
personalized medicine efforts, fund genomics research to
improve drug safety and establish a US Biobanking Research
Initiative,
Nature 2007;447:661-678
 Genome-wide scan for seven diseases
Bipolar disorder

Coronary artery disease

Crohnss disease

Hypertension

Rheumatoid arthritris

Type I diabetes

Type II diabetes

Nature 2007;447:661-678
 Pharmacogenomics in drug
development

Drug
DrugR&D
R&DPhase
Phase Pharmacogenomics
Pharmacogenomics
Target
Targetidentification
identification Discovery
Discoveryand
andvalidation
validationofofdisease
diseasegenes
genes
High
Highthroughput
throughputscreening
screening Screening
Screeningofofpolymorphisms,
polymorphisms,modulating
modulating
optimization
optimization(phase
(phase0)
0) compund
compundbinding
bindingproperties
properties
Phase
PhaseI I Preselection
Preselectione.g.
e.g.of
ofknown
knownCYPs
CYPs
Phase
PhaseIIII Selection
Selectionofofknown
knownSNPs
SNPs
Phase
PhaseIII
III Identification
IdentificationofofSNPs,
SNPs,involved
involvedinindrug-response
drug-response
and
andside
sideeffects
effects
Phase
PhaseIV
IV Identification
IdentificationofofSNPs,
SNPs,involved
involvedinindrug-response
drug-response
and
andside
sideeffects,
effects,individualized
individualizedtherapy
therapy
New
Newindications
indications

according to Essioux et al. 2002

 Pharmacogenomics-based
new therapeutic concepts

helps to identify reasons of inter-individual variability in drug response

helps to identify the important factors being involved in
pharmacokinetics and pharmacodynamics
But, the positive predictive value of genetic traits is often low
There is a strong need of prospective outcome studies
Selected genetic traits should be considered in pharmacotherapy
already now
Use of multi-genetic signatures should be preferred (microarrays)
Consideration of novel genetic traits identified in whole genome scans
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