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
Analgetics (COX-2)
Asthma
Arrhythmias
Depression
Diabetes mellitus
Hepatitis C
Incontinence
Migraine (acute)
Migraine (prophylaxis)
Oncology
Osteoporosis
Rheumatoid Arthritis
Schizophrenia

30
80
60
60
62
57
47
40
52
50
25
48
50
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
PHARMACOLOGY

GENETIC
GENETIC

PHARMACOGENETIC
PHARMACOGENETIC
PHARMACOGENOMIC
PHARMACOGENOMIC
http://www.ornl.gov/hgmis/medicine/pharma.html

Pharmacogeno
mics
The study of genomederived data, including
human genetic variation,
RNA and protein
expression differences, to
predict drug response in
individualincludes
patients
or
Pharmacogenomics
Pharmacogenetics
groups of patients.

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;2:5846)

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

PharmacogeneticsPharmacogenomics
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
Blood
sample

DNA

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

Poor
Metabolizers

Debrisoquine Metabolic ratio

Toxic area

Concentration

Frequency

Extensive Metabolizers

Therapeutic area

Time

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

Rau et al. Clin Pharmacol Ther 2004; 75:386-393; Kawanishi

et al. Eur J Clin 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

Pharmacogeno
mics

Pharmacokinetics
Drug transport
Drug metabolism
Exogenous

Pharmacodyn
amics
Receptor
affinity
Signal
transduction
Regulation

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

lymorphisms 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, 286:487491

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
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
Barbiturates
Chlorproguanil
Citalopram
Clomipramine
Diazepam
Imipramine
Mephenytoin
Omeprazole
Proguanil
Propranolol

Melstrom et al, 1988

Adedoyin et al, 1994
Wright et al, 1995
Sindrup et al, 1993
Nielsen et al, 1994
Bertillson et al, 1989
Haefeli et al, 1990
de Morias et al, 1994
Anderson et al, 1992
Anderson et al, 1990
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;8:195-20

Frequency of CYP2C19 PMs in various

ethnics

2-4%

3%
3%

3-5%

18-20%

6%
2%

5%

13%
15-18%

11 %

22%

5%
4%
8%

23%
15%

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

Melayu

50

Batak
Kajang
Sunda
Jawa

40
30

Dayak
Bima

20

Bugis

10
0
EM

IM

PM

Prevalence of CYP2C19 genotype within

Geographically Dispersed Populations
100
90

Caucasian

80

Saudi Arabian

70

African

60

Korean
Japanese

50

Chinese

40

Philippine

30

Aboriginal Australia

20

Indonesia

10

Thailand
Vanuatu

0
EM

IM

PM

Chinese

0.04

Korean

Japanese

Thailand
Philippines
Kajang
Malay

Dayak

Caucasian
Bugis

11
Sunda
Javanese
Saudi Arabian

Bima

Vanuatu

Australian Aborigine

Master of Basic Medical Science

Yusuf
Yogyakarta, July 2010

.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

URINARY EXCRETION (% dose)

80

60

Proguanil
Cycloguanil

40

20

EM

IM

PM

Application of pharmacogenomics in clinical practice

All patients

1.0

Overall survival

25-30% of breast tumor specimens

show amplification/overexpression
of erbB2/HER2/neu

0.5

P=0.002
c-erbB-2 negative (80/28)
c-erbB-2 positive (30/19)

0.0

60

120

Months

180

Agrup et al. Breast Cancer Res Treat 2000

Impact of polymorphic drug metabolizing

enzymes for cancer therapies

Enzyme

Drug

Poor
metabolizers

Relevance

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

rmacogenomics Current Applicatio

Examples
Oncology (PK + PD)

high evidence

Psychiatry (PK)

moderate evidence

Cardiovascular Diseases (PK + PD)

increasing evidence
Transplantation surgery (PK)

increasing evidence

Pain treatment (PK + PD)

moderate

currently low
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

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)

roaches to Drug Innovation: Genetic

Can pharmacogenomics
contribute to
identification of novel drug
targets
facilitated drug development
salvage of less effective
drugs
optimized drug treatment

.....?
vidualized
treatment versus one fit

armacogenomics 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

nome-wide scan for seven diseas

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
Target
Targetidentification
identification

Pharmacogenomics
Pharmacogenomics
Discovery
Discoveryand
andvalidation
validationofofdisease
diseasegenes
genes

High
Highthroughput
throughputscreening
screening
optimization
optimization(phase
(phase0)
0)

Screening
Screeningofofpolymorphisms,
polymorphisms,modulating
modulating
compund
compundbinding
bindingproperties
properties

Phase
PhaseI I
Phase
PhaseIIII

Preselection
Preselectione.g.
e.g.of
ofknown
knownCYPs
CYPs
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

THANK YOU