Clinical implications of pharmacogenetic research
S:t Petersburg April 4, 2008
Professor Leif BertilssonDept. of Clinical PharmacologyKarolinska University Hospital, HuddingeSweden
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Pharmacogenetics
Pharmacogenomics
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Drug transporters
Drug metabolising enzymes
Drug receptors
Drug receptor effectors
Drug response
Polymorphic impact on drug response
Drug
Metabolites
+
+++
+
+
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* Five probe drugs in the cocktail developed at Karolinska Institutet
CarbamazepinePhenytoinRifampicin
Ketoconazole
ErythromycinMidazolamQuinine*
AlprazolamCyclosporine ADiazepamTriazolam
CYP3A4
ArtemisininRifampicinTobaccosmoking
Inducers
ParoxetineQuinidine
FluvoxamineSulphaphena-zole
FluvoxamineInhibitors
Debrisoquine*Sparteine
MephenytoinOmeprazole*
Losartan*Caffeine*Melatonin
Markerdrugs
Most antidepressantsMost antipsychoticsCodeineMetoprolol
CitalopramDiazepamOmeprazoleProguanil
PhenytoinTolbutamideWarfarin (S)
AmitriptylineClomipramineClozapineFluvoxamine
Substrates
CYP2D6CYP2C19CYP2C9CYP1A2
The major human drug metabolising cytochrome P450 (CYP) enzymes
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Interethnic differences in the hydroxylation of debrisoquine
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Johansson et al., PNAS 90:1945-51, 1993, Aklillu et al., JPET 278: 441-6, 1996
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Dalén et al, 1998
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Frequency of subjects having duplicated/ multiduplicated CYP2D6 genes
Sweden 1-2 %Dahl et al, 1995Denmark 0.8 %Bathum et al, 1998Germany 3.6 %Sachse et al, 1997Spain (Badajoz) 7.0 %Agundez et al, 1995Spain (Zaragoza) 10 % Bernal et al, 1998Saudi Arabia 20 % McLellan et al, 1997Ethiopia 29 % Aklillu et al, 1996Los Angeles, USA
Caucasians 4.3 %London et al, 1997African-Americans 4.9 %London et al,
1997
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Prevalence of the CYP2D6 genotypes in 81 depressed Swedish patients refractory to
treatment with CYP2D6 substrateantidepressant drugs
81 (100%)All
8 (9.9%)Duplication
2 (2.5%)PM
71 (87.6%)EM
Number of patientsCYP2D6 genotype
Kawanishi et al 2004
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* Five probe drugs in the cocktail developed at Karolinska Institutet
CarbamazepinePhenytoinRifampicin
Ketoconazole
ErythromycinMidazolamQuinine*
AlprazolamCyclosporine ADiazepamTriazolam
CYP3A4
ArtemisininRifampicinTobaccosmoking
Inducers
ParoxetineQuinidine
FluvoxamineSulphaphena-zole
FluvoxamineInhibitors
Debrisoquine*Sparteine
MephenytoinOmeprazole*
Losartan*Caffeine*Melatonin
Markerdrugs
Most antidepressantsMost antipsychoticsCodeineMetoprolol
CitalopramDiazepamOmeprazoleProguanil
PhenytoinTolbutamideWarfarin (S)
AmitriptylineClomipramineClozapineFluvoxamine
Substrates
CYP2D6CYP2C19CYP2C9CYP1A2
The major human drug metabolising cytochrome P450 (CYP) enzymes
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Similarity among the CYP3A proteins
CYP3A5 CYP3A7 CYP3A43
CYP3A4 84.1 88.1 75.8CYP3A5 *** 81.9 75.8CYP3A7 *** 71.5CYP3A43 ***
Gellner et al 2001
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Plasma concentrations of cholesterol and 4-hydroxycholesterol in patients treated with different antiepileptics
Antiepileptic drug Cholesterol 4Hydroxycholesterol
nmol/l ng/ml
Valproate (n = 15) 4.5 0.8 28 15
Carbamazepine (n = 15) 5.8 1.5 240 142
Phenytoin (n = 10) 5.1 1.0 214 154
Phenobarbital (n = 5) 4.9 1.1 239 226
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4β-Hydroxycholesterol in three populations
Mean Mean±SE Mean±SD
T AN SW E KO R
population
10
15
20
30
40
50
60
4β-hydroxycholesterol (ng/m
L)
n= 138 n= 159 n= 149
p<0.000001 p<0.01
p<0.000001
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Haplotype frequencies
*3
6986A>G
*6
14690>A
*7
27131-27132insT
Swedes Koreans Tanzanians
CYP3A5*1 A G T 0.07 0.17 0.53
CYP3A5*3 G* G T 0.93 0.80 0.17
CYP3A5*6 A A* T - - 0.18
CYP3A5*7 A G TT* - - 0.12
CYP3A5*3 + *7 G* G TT* - 0.03
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Impact of CYP3A5 on 4β-hydroxycholesterol
Number of CYP3A5*1 alleles
Mean Mean±SE Mean±SD
0 1 2 0 1 2 0 1 2
10
15
20
30
40
5060
4β-h
ydro
xych
oles
tero
l (ng
/mL)
Tanzanians (136) Swedes (136) Koreans (146)
p<0.000001
p<0.000001
p<0.00001
p<0.000001
p<0.0001 p<0.005
p<0.005
n=36 67 33 117 18 1 98 43 5
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* Five probe drugs in the cocktail developed at Karolinska Institutet
CarbamazepinePhenytoinRifampicin
Ketoconazole
ErythromycinMidazolamQuinine*
AlprazolamCyclosporine ADiazepamTriazolam
CYP3A4
ArtemisininRifampicinTobaccosmoking
Inducers
ParoxetineQuinidine
FluvoxamineSulphaphena-zole
FluvoxamineInhibitors
Debrisoquine*Sparteine
MephenytoinOmeprazole*
Losartan*Caffeine*Melatonin
Markerdrugs
Most antidepressantsMost antipsychoticsCodeineMetoprolol
CitalopramDiazepamOmeprazoleProguanil
PhenytoinTolbutamideWarfarin (S)
AmitriptylineClomipramineClozapineFluvoxamine
Substrates
CYP2D6CYP2C19CYP2C9CYP1A2
The major human drug metabolising cytochrome P450 (CYP) enzymes
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Inhibition of metoprolol metabolism and potentiation of
its effects by paroxetine in routinely treated patients with
acute myocardial infarction (AMI)
Ksenia Goryachkina, Aleksandra Bubello, Svetlana Boldueva,
Svetlana Babak, Ulf Bergman, Leif Bertilsson
Eur. J. Clin. Pharmacol. 2008;64:275-282
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Methods:•187 patients (61% men, age 60±11 years (36-85) with confirmed AMI•CYP2D6 *3,*4, and gene duplication •Metoprolol and α-hydroxy metoprolol concentrations were measured in plasma 0,2,6 and 12 hours after metoprolol intake •Heart rate and blood pressure was measured at the times of sampling•Clinical variables were taken from case histories (baseline and discharge heart rate, metoprolol dose at discharge, concomitant diseases, severity of AMI, heart failure etc)
0 1 2 340
50
60
70
80
90
dis
char
ge
HR
b/m
in
number of functional CYP2D6 alleles
Heart rates on the adjusted metoprolol dosewere higher with more functional alleles (p<0.05)
Pharmacodynamics:Pharmacokinetics:
0 1 2 31
10
100
1000
10000
number of functional CYP2D6 alleles
met
opro
lol c
once
ntra
tion
AU
CnM
ol*h
/mg/
kg
Metoprolol plasma concentration AUCIs determined by CYP2D6 genotype
P<0.001
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Goryachkina et al, 2008
0 1 2 3 4 5 6 7 8 9 10 11 120
100
200
300
**
****** **
before paroxetine
on paroxetine
-hydroxy metoprolol
0 1 2 3 4 5 6 7 8 9 10 11 120
200
400
600
on paroxetine
before paroxetine
**
*****
**
metoprololP
lasm
a c
on
cen
trati
on
nM
/mg
/kg
Hours post dose
0 1 2 3 4 5 6 7 8 9 10 11 1250
55
60
65
70
75
80
* *
* *
* * *
on paroxetine
before paroxetine
hours post-dose
me
an
he
art
ra
te
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Active CYP2D6 genes in AMI patients withoutventricular rhythm disturbances (VRD) (n=177)and with VDR (N=23) in hospitalized Russian patients
Goryachkina et al, 2008
CYP2D6 duplication 4/173 (2 %) 5/18 (22 %)
p = 0.0002
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Bertilsson et al: Debrisoquine hydroxylation and personality, Lancet 1989
Poor hydroxylators had significantly lower scores in the Karolinska psychasthenia scale (p<0.05) and had a higher frequency of extreme responses (p<0.01) than extensive hydroxylators. Low psychasthenia scores imply high vitality, alertness, efficiency, and ease of decision-making. The poor hydroxylators’ lack of hesitation was also reflected in the more frequent choice of extremes. These personality characteristics agreed well with the impression we had before our study.