Therapeutic

Drug Management
Mike Hallworth
ACB Training Course
Coventry, 17 June 2013
Pharmacokinetics
Processes involved in drug handling
Dose
Prescribed
Dose
taken
Drug
in blood
Active
site
EFFECT
Other
tissues
Excreted/
inactivated drug
concordance
absorption
Metabolism/
elimination
distribution
pharmacokinetics pharmacodynamics
Concordance (compliance)
Often poor.
Improved by simplifying regimes
Assessment:
Was Rx dispensed?
Tablet counts
Direct observation/ interview
Markers
Drug/metabolite levels
Effect
Bioavailability
Bioavailability, F = Dose absorbed
Dose administered
(IV dosing, bioavailability = 1)
First-pass metabolism
Metabolism en route from gut to systemic circulation
in the LIVER
Drugs with extensive first-pass metabolism:
Analgesics (aspirin, morphine, paracetamol, pethidine)
CNS-active drugs (chlormethiazole, chlorpromazine,
imipramine. L-dopa, nortriptyline)
Cardiovascular (glyceryl trinitrate, isosorbide dinitrate,
lignocaine, nifedipine, propanolol,
verapamil)
Respiratory (salbutamol, terbutaline)
Oral contraceptives
First-pass metabolism
One reason for apparent variations in
drug absorption between individuals
Reduced in severe liver disease
Greatly increased delivery of drug to
active site
Salt-conversion factor (S)
Factor relating to the actual
concentration of active drug in the
preparation being used
e.g. 108 mg phenytoin sodium = 100 mg
phenytoin
e.g. 200 mg aminophylline = 160 mg
theophylline
(aminophylline is the EDTA salt of theophylline, S =
0.8)
So,
DRUG ABSORBED = S x F x DOSE ADMINISTERED
Distribution
We define:
Volume of Distribution, V
d
= Amount of drug in body
Plasma concentration
Volume of distribution is the THEORETICAL VOLUME
that would contain all the drug in the body if it were
present everywhere at the same concentration that is
found in plasma
Volume of distribution
For example:
V
d
(L/kg)
Amiodarone 1.3
Digoxin 7.3
Phenytoin 0.65
Aspirin 0.14
V
d
is LOW if low lipid solubility
- high plasma protein binding
- low tissue binding
(and vice versa)
Calculation of size of loading dose
DOSE = V
d
x desired concentration
E.g. I want to give a 70 kg man a loading dose of digoxin to produce a
plasma concentration of 1.5 g/L. The bioavailability of digoxin is
0.62
DOSE x 0.62 = 7.3 x 70 x 1.5
= 1236 g
(The usual approach would be to give this in divided doses)
Metabolism and Excretion
Metabolism usually hepatic
Excretion - via kidneys into the urine
- via liver into the bile
Both these processes are encompassed
in the pharmacokinetic parameter
CLEARANCE
Clearance
Definition
The theoretical volume of blood which
can be completely cleared of drug in
unit time
(cf. creatinine clearance)
So,
RATE OF ELIMINATION = Clearance x Plasma conc.
= Cl x C
At Steady State
Rate of administration = Rate of elimination
(definition of steady state)
So,
DOSE x S x F = Cl x C

where is the dosage interval

Clearance = Dose x S x F
x C
Or,
Maintenance dose = Cl x C x
S x F
Clearance
If renal clearance of a drug is approximately
120 ml/min, this suggests that the drug is
completely cleared by the kidneys and GFR
is the only limiting factor to excretion.
If hepatic clearance is of the order of 500
1500 ml/min, this reflects hepatic blood flow
and suggests that blood flow is the limiting
factor on excretion (perfusion-limited
clearance) e.g. lignocaine, morphine.
Clearance
Frequently expressed as
Volume/unit time/kg body weight
A more accurate basis for comparison between
patients is
Volume/unit time/unit body surface area
Surface area can be determined from standard
nomograms
First-order kinetics
Rate of elimination C
(assumes Cl is independent of conc)
Amount of drug in = A
0
e
-kt
body at time t
where A
0
is the amount at time 0 and k is
the elimination rate constant - the
percentage elimination per unit time
Elimination rate constant
k = Amount cleared in unit time
Total amount in body
= Cl x C
V
d
x C
= Cl
V
d
Elimination rate constant
Often expressed in terms of half-life, t

A
o =
A
o
. e
-kt
2
ln () = - k.t

= 0.693
k
Peak and trough concentrations
Conc
Time

Peak and trough concentrations

At steady state:
C
ssmax
= S x F x Dose + C
ssmax
e
-k
V
d
C
ssmax
( 1 e
-k
) = S x F x Dose
V
d
C
ssmax =
S x F x Dose
V
d
( 1 e
-k
)
Peak and trough concentrations
C
ssmax =
S x F x Dose
V
d
( 1 e
-k
)
C
ssmin =
S x F x Dose . e
-k
V
d
( 1 e
-k
)
Plasma protein binding
Primarily to ALBUMIN and
1
acid
glycoprotein
% plasma protein binding
Lithium 0%
Gentamicin <10%
Digoxin 20%
Theophylline 60%
Carbamazepine 70-80%
Phenytoin 90-94%
Reduced plasma protein binding
Reduced protein binding (more free
drug)
Low protein (liver disease,
pregnancy, nephrotic syndrome)
Displacement (renal failure, other drugs)
Abnormal binding proteins
Concentration-dependent binding
0
50
100
150
0
Plasma
conc.
umol/L
100 200 300 400 500 600 700
GW
PHe
Dose mg/day
PHo
Non-linear (saturation) kinetics
Non-linear (saturation) kinetics
Michaelis-Menten equation
Rate of elimination = V
max
x C
K
m
+ C
If C << K
m
Rate = V
max
x C FIRST
K
m
ORDER
If C>> K
m
Rate = V
max
x C = V
max
C
ZERO ORDER
Non-linear kinetics
Phenytoin:
Km ranges from 0.5 to 15 mg/L
Vmax ranges from 3 to 12 mg/kg/day
Q1:
How much Chateau Plonque is required to put a 60 kg
woman above the legal driving limit 1 hour after
ingestion?
(assume:
Rapid ingestion and absorption
Elimination = 100 mg/kg/h
Total body water in women = 55% of total body weight
Chateau Plonque = 13% alcohol by volume
Density of ethanol = 0.8 g/mL
Atmospheric pressure at sea level = 101.325 kPa)
Therapeutic drug management
Conventional TDM
Biomarkers of drug effect
Pharmacodynamic monitoring
Pharmacogenomics
Therapeutic Drug Monitoring
Definition:
Measuring drug or metabolite concentrations in
body fluids as an aid to optimising therapy
TIAFT definition (1997):
Measurement made in the laboratory of a
parameter that, with appropriate interpretation,
will directly influence prescribing
Patient
Drug
Initial dose
Revise
dose
Effect
Plasma
concentration
Measure Measure
Interpret
Criteria for valid classical TDM
Drug has reversible action at receptor site
Dose has poor correlation with effect
Plasma concentration correlates well with
effect
Narrow therapeutic ratio
Well-established therapeutic range
Drugs for routine measurement
Established value
Aminoglycosides
Carbamazepine
Ciclosporin
Digoxin
Lithium
Methotrexate
Phenytoin
Sirolimus
Tacrolimus
Theophylline
Vancomycin
Drugs for routine measurement
Less well -established
Amiodarone
Anti-retrovirals
Caffeine
Chloramphenicol
Clozapine
Disopyramide
Flecainide
Flucytosine
Haloperidol
Lamotrigine
Mycophenolate
Olanzapine
Phenobarbital
Procainamide
Quinidine
Tricyclics
Valproate
Epilepsy
Commonest neurological disorder
Highest therapeutic potential
0.5-1% of population (0.75% UK)
50 million worldwide
5% will have fits at sometime during
life (excluding febrile convulsion)
30-50% of patients still have fits
despite Rx
Antiepileptic drugs (UK)
Bromide 1857
Phenobarbitone 1912
Phenytoin 1938
Ethosuximide 1960
Carbamazepine 1972
Valproate 1972
Clonazepam 1974
Clobazam 1978
Acetazolamide 1988
Vigabatrin 1989
Lamotrigine 1991
Gabapentin 1993
Topiramate 1996
Tiagabine 1998
Oxcarbazepine 2000
Levetiracetam 2000
Pregabalin 2004
Zonisamide 2005
Rufinamide 2007
Lacosamide 2008
Eslicarbazine 2009
Retigabine 2011
Epilepsy Rx (NICE, 2012)
ABSENCE GENERALISED FOCAL MYOCLONIC TONIC/
TONIC-CLONIC (PARTIAL) ATONIC
Ethosuximide Valproate* CBZ Valproate* Valproate*
Valproate* Lamotrigine Lamotrigine Levetiracetam
Lamotrigine Carbamazepine Levetiracetam Topiramate
Oxcarbazepine (cost)
Oxcarbazepine
Valproate* _
Clobazam Clobazam Clobazam Clobazam Lamotrigine
Clonazepam Levetiracetam Gabapentin Clonazepam Rufinamide
Topiramate Topiramate Topiramate Piracetam Topiramate
Zonisamide (Vigabatrin) Zonisamide
Levetiracetam Retigabine
* NB teratogenicity
Epilepsy - Rx
Stabilize neuronal resting potential
(mechanisms not well understood)
Inhibit excitation (Na/Ca channel blockers)
(e.g. lamotrigine, phenytoin)
Enhance inhibition (GABA enhancers)
(e.g. benzodiazepines, tiagabine, vigabatrin)
Modify cell excitability
Krebs
Glutamate Succinate
GABA
GABA-T GAD
GABA
(inhibitory)
presynaptic
neurone
Vigabatrin
(inhibition)
Tiagabine
(blocking)
Benzodiazepines
Barbiturates
(potentiation)
postsynaptic
neurone
Phenytoin
Long half-life (20 40 h, up to 100h at high concs)
timing unimportant
Saturation kinetics
Metabolism hepatic oxidation
Faster in infants/children, slower in preterm
Inc by ethanol and carbamazepine, dec by enzyme inducers (e.g.
cimetidine)
90-93% protein-bound
Side effects neurotoxicity (nausea, ataxia, drowsiness)
Target range 10-20 mg/L (40-80 umol/L)
Only a guide wide variation
Very strong case for routine monitoring
0
50
100
150
0
Plasma
conc.
umol/L
100 200 300 400 500 600 700
GW
PHe
Dose mg/day
Phenytoin
PHo
(Richens and Dunlop. 1975)
Carbamazepine
Short half-life (8-24h)
Trough samples preferable
Target range 4-10 mg/L (17-42 umol/L)
Lower limit of range difficult to define
Protein binding 22-30%
Side effects rash (5%), haematological (rare), neurotoxicity
(mild), ADH stimulation (hyponatraemia)
Induces own metabolism (hepatic oxidation)
Clearance inc by phenytoin/phenobarbitone, dec by enzyme
inhibitors
Monitor if control difficult
Active metabolite (CBZ 10,11 epoxide)
Metabolism of carbamazepine and
oxcarbazepine
N
O
NH
2
O
N
NH
2
O
Oxcarbazepine Carbamazepine
ACTIVE
N
HO
NH
2
O
N
NH
2
O
O
10-hydroxy carbazepine
ACTIVE
Carbamazepine
10,11 epoxide
ACTIVE
N
NH
2
O
HO OH
Carbamazepine
trans-diol
Vigabatrin
Gamma-vinyl GABA
Suicide inhibitor of GABA transaminase
Irreversible - long pharmacodynamic half-
life
Monitoring not helpful
Visual field defects in 30%
GABA + -ketoglutarate
Succinic semialdehyde + glutamate
Vigabatrin
Rapidly absorbed
Elimination half-life 5-
7 hours
Bioavailability 80%
Not protein-bound
Renal elimination
Chiral - only S-
enantiomer active
Visual field defects
limit use
HC
CH CH
2
H
2
N
H
2
C C
OH
O CH
2
Lamotrigine
Rapidly absorbed
Bioavailability >95%
Protein binding 55%
Half life 24 - 35 h (varies
on combination Rx)
Hepatic metabolism
Target range
<15 mg/L ??
Cl
Cl
N
N
N
NH
2
H
2
N
Topiramate
Bioavailability 85%
Protein binding 15%
Half life 20 - 30 h
Target range ?? O
CH
2
OSO
2
NH
2
O
O
CH
3
CH
3
O
O
H
3
C
H
3
C
Gabapentin
Bioavailability 60%
Not protein bound
Renal elimination
No metabolites
Half life 5 - 7h
No definite conc-
effect relationship
NH
2
COOH
Valproate
Half-life 8-15h
Wide diurnal variation (rapid absorption and elimination)
Hepatic metabolism (CBZ, phenytoin increase clearance)
Very poor evidence for target range
Clinical effect may take weeks to develop
Antiepileptic effect persists after dose stopped
Poor correlation between conc and effect
Protein binding 90-95%
Dose dependent (free fraction varies with concentration)
Displaced from protein by fatty acids (meals), aspirin
Side effects: GI, drowsiness, tremor, hepatotoxicity (in young
children), haematological. teratogenic
Monitoring generally unnecessary
Valproate - psychiatric indications
Acute mania
Acute depression ?
Prophylaxis of bipolar and schizoaffective
disorder
Valproate in mania
(Bowden et al., 1996)
-120
-100
-80
-60
-40
-20
0
20
40
60
80
0 20 40 60 80 100 120 140 160 180
Valproate, mg/L
% change
in mania
scale
Aminoglycosides
Poor oral absorption give parenterally
No metabolism or protein binding renal excretion
Half-life 2-4h (much longer in renal failure)
Toxicity nephrotoxicity and ototoxicity
Monitoring essential for control/toxicity
Extended dose interval
High peaks, low troughs
7 mg/kg gentamicin
Use TDM to determine interval, not dose (e.g.
Hartford nomogram)
Not applicable to children (?), pregnancy, ascites,
endocarditis, CF, burns, neutropenia, CrCl <20 mL/min
Extended interval aminoglycosides:
dosing (Hartford nomogram)
0
5
10
15
20
25
30
35
6.00 14.00
Ti me post dose (h)
Conc.
(mg/L)
6 10 14
Every 48h
Every 36h
Every 24h
Digoxin
Samples must be at least 6h post-dose
Other factors (e.g. K+) influence response/toxicity
Monitoring not indicated in most patients
Monitor if:
Response poor
? Toxic
? Stop drug
0
0.5
1
1.5
2
2.5
0
C/C
ss
5 10 15 20 25
Hours post dose
Digoxin post-dose
(Nicholson, 1980)
Lithium
Half-life 10-35 h (longer in elderly/poor renal function)
Not protein bound
Excreted in urine
Side effects thirst, polyuria, nephrogenic DI, hypothyroidism,
renal impairment, coma
Monitor at 12h post-dose
Target range @ 12h 0.4-0.8 mmol/L (up to 1.2 in acute Rx)
Individualise frequency of monitoring
Interactions dec clearance: thiazides, NSAIDs
Monitoring essential at start of Rx, advisable at intervals
thereafter, especially if ill/pregnant or if other drugs changed
(especially diuretics)
Theophylline
Short half-life (3-13h: 4h in smokers, 24-30 h in neonates)
trough measurements
Hepatic metabolism
Protein binding 50-65% (less in babies)
Side effects: CNS, GI, cardiac
Target range 10-20 mg/L (55-110 umol/L) (lower in babies)
Interactions: erythromycin dec clearance, enzyme inducers
(phenytoin, CBZ) inc clearance
Monitoring useful to identify undertreated patients, adjust dosage
and confirm toxicity
Compliance often erratic
Anti-retroviral drugs
Drug class Examples Action
Nucleoside/nucleotide
reverse transcription
inhibitors (NRTIs)
Zidovudine
Emtricitabine
Tenofovir
Inhibit RT by mimicking
bases and terminating
chain
Non-nucleoside RT
inhibitors (NNRTIs)
Efavirenz
Nevirapine
Inhibit RT by binding
adjacent to active site
Protease inhibitors
(PIs)
Ritonavir Bind to protease and block
HIV core maturation
Entry and fusion
inhibitors
Maraviroc
Enfuvirtide
Prevent HIV from entering
cells
Integrase inhibitors
Raltegravir Block insertion of human
proviral DNA into host DNA
Anti-retroviral drugs
Drug class Examples Action
Nucleoside/nucleotide
reverse transcription
inhibitors (NRTIs)
Zidovudine
Emtricitabine
Tenofovir
Inhibit RT by mimicking
bases and terminating
chain
Non-nucleoside RT
inhibitors (NNRTIs)
Efavirenz
Nevirapine
Inhibit RT by binding
adjacent to active site
Protease inhibitors
(PIs)
Ritonavir Bind to protease and block
HIV core maturation
Entry and fusion
inhibitors
Maraviroc
Enfuvirtide
Prevent HIV from entering
cells
Integrase inhibitors
Raltegravir Block insertion of human
proviral DNA into host DNA
TDM used
Essentials for effective TDM
Rational indication for assay
Appropriate sample
Accurate analysis
Correct interpretation
Necessary action taken
TDM - questions
Patient not responding to therapy
Could this be due to inadequate plasma concentration?
Why is plasma concentration inadequate?
Poor compliance?
Inappropriate dosage?
Rapid metabolism?
Malabsorption?
Could patients symptoms be caused by drug toxicity?
Sample
Has steady-state been reached?
(>4 to 5 half-lives after dose change)
? Appropriate timing after last dose
Interpretation
Concept of the Therapeutic Range
a guide to aim at!
Therapeutic decisions should never be
based solely on the drug concentration in
the serum
(Koch-Weser, 1972)
Pharmacogenetics
Links differences in gene structure
(polymorphisms) to drug metabolism
and response
(Genotype) (Phenotype)
Genetic Drug metabolism
variation & response
One of the most striking things
about modern medicines is how often
they fail to work
Goldstein
NEJM 6.2.2003
Variation between individuals
Pharmacogenomics and
pharmacogenetics
Pharmacogenetics
Refers to the study of inherited differences in
drug metabolism and response
Single gene/phenotype
Pharmacogenomics
Refers to the general study of genes determining
drug behaviour
Multiple genes/phenotypes
(In practice, the two terms are used
interchangeably!)
Possible pharmacokinetic consequences
of polymorphisms
Decreased first-pass effect
greater bioavailability
higher peak Cp
Reduced parent drug elimination
longer half-life
more/fewer active metabolites
Altered concentration-effect relationship
between poor and good metabolisers
Applications of pharmacogenomics
Drug development
More targeted, more powerful drugs
Individualization of therapy
The right drug and the right dose for every
patient
Predicting ADRs (& reducing mortality)
Defining susceptibility
Identifying potential addiction
Reducing cost of health care
1
Positive
Response,
Works as
intended
2
No Response,
Choose new
drug
Adverse drug reaction
3
(Michael Murphy, Gentris)
Use of PGx:
Use of PGx
Dont treat non-responders
(stratification)
Dont treat those most susceptible to
toxicity (stratification)
Adjust dose to maximise efficacy
while avoiding toxicity
Estimated cost of ADRs
US: $100 billion per year.
(Ingelman-Sundberg, 2001)
NHS: 2 billion per year
(Compass Thinktank, 2008)
Can PGx reduce ADRs?
Systematic review
(Phillips KA et al, JAMA 2001; 286: 2270-9)
- Identified 27 drugs frequently cited in ADRs
(among top 200 used in US);
- 59% of these metabolized by at least 1
enzyme with variant alleles known to cause
poor metabolism
- Conversely, only 7 - 22% of randomly
selected drugs are known to be metabolized
by enzymes with genetic variability
Clinical applications of pharmacogenetic
information
Anti-coagulation
Warfarin
Psychiatry
Tricyclic anti-
depressants
Atomoxetine
Oncology
Thiopurines
5-fluorouracil
Herceptin
(Her-2/neu)
Tamoxifen
KRAS
Cardiovascular
Statins
Pain control
Codeine, methadone
Epilepsy
Phenytoin
Risk analysis
ADRs
Disease
Etc..
Enzymes of drug metabolism
Phase 1 (oxidative) - SER
CYP 1A2 CYP2B CYP 2C9
CYP 2C19 CYP 2D6 CYP 2E1
CYP 3A4 NADPH-quinone oxidoreductase
Phase 2 (conjugative) - cytosol
Glutathione S-transferase
N-acetyltransferase
UDP-glucuronosyltransferase
Sulphotransferases
Enzymes of drug metabolism
(showing polymorphisms in humans)
Phase 1 (oxidative) - SER
CYP 1A2 CYP2B CYP 2C9
CYP 2C19 CYP 2D6 CYP 2E1
CYP 3A4 NADPH-quinone oxidoreductase
Phase 2 (conjugative) - cytosol
Glutathione S-transferase
N-acetyltransferase
UDP-glucuronosyltransferase
Sulphotransferases
CYP enzymes have different, sometimes overlapping,
substrate specificity
CYP2D6 debrisoquine
tricyclics
antipsychotics
SSRIs
anti-arrhythmics
anti-
hypertensives
morphine derivs
CYP2C19
barbiturates
tricyclics
sedatives
CYP3A4 tricyclics
antipsychotics
SSRIs
Sedatives
CYP1A2 tricyclics
antipsychotics
SSRIs
Sedatives
CYP2C9
anti-epileptics
anticoagulants
Nomenclature
Cytochrome P450 2 D 6 *4
Superfamily
Family
Subfamily
Isoenzyme
Allele variant
CYP 2C9 polymorphism
9 exons; 490 amino acids
144 359 360
CYP2C9*1 Arg Ile Asp
CYP2C9*2 Cys Ile Asp
CYP2C9*3 Arg Leu Asp
CYP2C9*4 Arg Thr Asp
CYP2C9*5 Arg Ile Glu
CYP2C9 polymorphism
CYP2C9*2 15% of Caucasians
7% of Asians
5-fold lower warfarin
clearance
CYP2C9*3 7% of Caucasians
3% of Asians
25-fold lower warfarin
clearance
Warfarin
Narrow therapeutic index
Multiple clinically important drug
interactions
Erratic safety profile
10-fold variability around dose, target
INR and side-effects
Polymorphisms account for 30-50%
of the variability in dosing
Warfarin PGx testing
CYP2C9
Metabolism of S-warfarin
*2 and *3 deficiency alleles
VKORC1 (vitamin K epoxide reductase complex subunit 1)
Target of warfarin inhibition
Converts vit K epoxide to quinone (vit K
recycling)
Deficiency (1639 G>A) means less warfarin
target and smaller dose requirement
CYP2D6
Most extensively characterised polymorphic
drug-metabolising enzyme
more than 75 allelic variants described
more than 15 encode an inactive enzyme or
no enzyme at all
other alleles encode enzyme with reduced,
normal or increased enzyme activity
Phenotyping
Phenotyping for the metabolism of
psychoactive drugs results in 4
categories
Poor metabolizers (PM)
Intermediate metabolizers (IM)
Extensive metabolizers (EM)
Ultrarapid metabolizers (UM)
(up to 13 copies of gene)
Prevalence of CYP 2D6 phenotypes
W European Chinese
PM 10% 1%
IM 40%
EM 49%
UM 1%
0.1
1
Plasma
conc/dose
(nmol/L/mg)
0 5 10 15 20 25 30 35
Time (h)
Haloperidol by debrisoquine phenotype
EM
PM
(Bertilsson, 1992)
Cancer biomarkers for Rx (Milone, 2012)
Drug Disease Marker associations
Tamoxifen Breast ca CYP2D6
Irinotecan Colon ca UGTIA1*28
5-FU Colon ca DPDY, TYMS
EGFR-specific TKIs
(erlotinib)
Non-small cell lung ca EGFR mutations
EGFR gene copy no
KRAS mutations
EGFR-specific Ab
(cetuximab)
Colon ca
Non-small cell lung ca
EGFR gene copy no
KRAS mutations
Azathioprine, 6-MP ALL, IBD TPMT
Methotrexate Lymphoma Methotrexate conc
Busulfan Myeloablation for BMT Busulfan conc/AUC
Tamoxifen survival by genotype
Kiyotani et al, J Clin Oncol 2010; 28: 1287-93
CYP2D6 ABCC2
Thiopurine drugs
Azathioprine
Prodrug for 6-mercaptopurine
Azathioprine 6-MP +
imidazole
Breakthrough in organ Tx
Extensive use as steroid-sparing agent
6-mercaptopurine
N
N
H
S
N
H
N
6-mercaptopurine
6-methyl-
mercaptopurine
6-thiouric acid
Xanthine
oxidase
TPMT
6-thioinosine 5-
monophosphate
TPMT
6-methyl
thioinosine 5-MP
6-thioxanthosine
5-MP
6-thioguanine
nucleotides
IMP
dehydrogenase
GMP
synthetase
HGPRT
0
2
4
6
8
10
12
%of
subjects
0 5 10 20
RBC TPMT activity, U/mL
TPMT Genetic Polymorphism
(Weinshilboum & Sladek, 1980)
15
10
100
1000
10
4
0 5 10 15 20
TPMT acti vity, U/mL rbc
Adult dermatology patients on azathioprine
(Lennard)
6 TGN (pmol/
8 x 10
8
rbcs)
0
20
40
60
80
100
Relapse-free
survi val (%)
0 20 40 60 80 100
50
Time (months)
Children with ALL on 6-MP
100
29 9
28
8
Rbc 6-TGN
above median
Rbc 6-TGN
below median
(Lennard, 1989)
0
2
4
6
8
10
12
% of
subjects
0 5 10 20
RBC TPMT activity, U/mL
TPMT Genetic Polymorphism
15
Severe marrow
suppression
Toxicity at
full dose
Low risk
Risk of
therapeutic
failure
TPMT genetics
TPMT coded by 27 kb gene
10 exons, located on 6p22.3
Wild-type is TPMT*1
Very low activity associated with 8 variants,
most common = TPMT*3 (55-70%)
2 point mutations
G460-A (Ala 154 - Thr)
A719-G (Tyr 240 - Cys)
=*3B
=*3C
) =*3A
TPMT genotype and phenotype
(Yates et al., Ann Intern Med 1997; 126: 608-14)
Phenotype Genotype
High activity (21) *1/*1 (21)
Intermediate activity (21) *1/*1 (1)
*1/*2 (1)
*1/*3A (18)
*1/*3C (1)
Deficient (7) *2/*2 (2)
*2/*3A (1)
*3A/*3A (3)
*3A/*3C (1)
TPMT - summary
TPMT phenotype/genotype can
prospectively identify
Deficient patients at risk of life-
threatening toxicity
Heterozygotes who will respond well to
low-dose aza therapy
Patients with high TPMT activity who will
need high doses from the start
(phenotype only)
KRAS
Gene present in colorectal cancer tumours
Important role in cell growth and tumour development
Gene can be mutated or normal in colorectal ca. cells
If KRAS is mutated, then anti-EGFR therapies such as
cetuximab are not effective and should not be used
KRAS gene mutations occur in about 40% of colorectal
ca. patients
Patients diagnosed with metastatic colon ca. should be
tested for KRAS mutation status to determine eligibility
for anti-EGFR Rx
KRAS in colorectal ca
NEJM 2004; 351:2827-31
62 y.o man with CLL
3 day h/o fatigue, dyspnoea, fever,
cough
On valproate 1500 mg/day for
epilepsy
Bilateral lower lobe pneumonia
Rx antibiotics* + codeine 25mg tds
* ceftriaxone, clarithromycin, voriconazole
Day 4: rapid deterioration of consciousness
unresponsive
pO
2
7.4 kPa; pC0
2
10.6 kPa. Ventilated
Transfer to ITU: GCS 6
Valproate 63 mg/L
Naloxone 0.4 mg iv x2 resulted in dramatic
improvement in conscious level.
Drug levels
Plasma codeine 114 ug/L
(expected level in pt with extensive
CYP2D6 metabolism = 13-75)
Plasma morphine 80 ug/L
(expected level in pt with extensive
CYP2D6 metabolism = 1-4)
CYP 2D6 genotyping
3 or more functional CYP2D6 alleles
Ultrarapid metabolism
Confirmed by phenotyping with
dextromethorphan
Codeine metabolism
Codeine Codeine-6-glucuronide
Norcodeine
CYP3A4
Morphine
Morphine-6-glucuronide
Morphine-3-glucuronide
CYP2D6
X
Strattera (atomoxetine HCl)
-prescribing information
Clopidogrel (Plavix

): FDA 2010
Effectiveness of Plavix is dependent on its activation to an
active metabolite by the cytochrome P450 (CYP) system,
principally CYP2C19
Plavix at recommended doses forms less metabolite and
has a smaller effect on platelet function in patients who are
CYP2C19 poor metabolizers.
Poor metabolizers with acute coronary syndrome or
undergoing percutaneous coronary intervention given Plavix
at recommended doses exhibit higher cardiovascular event
rates than do patients with normal CYP2C19 function.
Tests are available to identify a patient's CYP2C19
genotype; these tests can be used as an aid in determining
therapeutic strategy
Consider alternate treatment or treatment strategies in
patients identified as CYP2C19 poor metabolizers
Challenges for PGx
Ethics
Costs
Utilization
Regulatory
NACB consensus document, 2010
http://www.aacc.org/members/nacb/lmpg/pages/default.aspx
If it were not for the great variability
among individuals, medicine might as
well be a science and not an art
Sir William Osler, 1892