Genetic polymorphisms in drug-metabolizing enzymes and drug targets

Past, present and future perspectives of therapeutic drug monitoring in India

Therapeutic drug monitoring (TDM) is the clinical practice of performing drug assays and interpreting results to maintain constant therapeutic concentrations in patients' bloodstream. Conventional TDM was started way back in the 1960s and served to optimise pharmacotherapy by maximising therapeutic efficacy by evaluating efficacy failure and monitoring drug compliance, while minimising adverse events, in drugs with a narrow therapeutic range. Currently, the scope of TDM has been extended to additional indications which are of importance to India. Apart from the conventional indications, TDM can also help combat drug resistance amongst patients treated with antimicrobials, including anti-tubercular drugs and critically ill patients with compromised pharmacokinetics. TDM is also indicated for patients on antiretroviral drugs under specific clinical scenarios and is of high importance to India. Target concentration intervention (TCI) and apriori TDM (by merging TDM with pharmacogenomics) are emerging fields explored in developed nations. The authors sought to assess the evolution of TDM in India and evaluate the potential impact of newer indications in rationalising pharmacotherapy. In the mid-1980s, TDM was presented to India. Despite showing some initial progress, its use is limited to conventional indications. Its utility is also challenged by cost and higher reliance on conventional prescribing practices. However, the newer indications such as antimicrobial resistance, tuberculosis and HIV, with their high prevalence in developing nations, present an opportunity for the growth of TDM in these countries. Indian clinician's awareness and buoyant demands alongside expert contributions from clinical pharmacologists could widen its scope.

Pharmacogenetic Testing in Acute and Chronic Pain: A Preliminary Study

Background and Objectives: Pain is one of the most common symptoms that weighs on life’s quality and health expenditure. In a reality where increasingly personalized therapies are needed, the early use of genetic tests that highlights the individual response to analgesic drugs could be a valuable help in clinical practice. The aim of this preliminary study is to observe if the therapy set to 5 patients suffering of chronic or acute pain is concordant to the Pharmacogenetic test (PGT) results. Materials and Methods: This preliminary study compares the genetic results of pharmacological effectiveness and tolerability analyzed by the genetic test Neurofarmagen Analgesia^®, with the results obtained in clinical practice of 5 patients suffering from acute and chronic pain. Results: Regarding the genetic results of the 5 samples analyzed, 2 reports were found to be completely comparable with the evidences of the clinical practice, while in 3 reports the profile of tolerability and effectiveness were partially discordant. Conclusion: In light of the data not completely overlapping with results observed in clinical practice, further studies would be appropriate in order to acquire more information on the use of Neurofarmagen in routine clinical settings.

Pediatric Formulations: Knowledge Gaps Limiting the Expedited Preclinical to Clinical Translation in Children

Traditionally, drug discovery and development research have been primarily focused on the mitigation of disease treatment for the general adult population, often overlooking the medical needs of pediatric patients. While remarkable progress toward the discovery of better medicines has been made, the pharmacological differences between children and adults are often neglected as part of the translation process. In fact, until recently, children have been considered therapeutic orphans due to the lack of significant drug discovery, formulation development, and dosage form design specifically tailored for pediatric patients. Perhaps the least understood is the significant physiological changes that occur during the maturation process from birth to adulthood. It requires careful considerations to achieve age-specific-desired therapeutic outcomes with minimal toxicity. This introduces considerable risk into the preclinical and clinical testing of new medicaments, which until recently, was avoided based on the conventional approach where a demonstration of safe and efficacious use in adults over several years potentially would minimize the chance of adverse juvenile responses. However, the lack of appropriate drug products for children has led to off-label use of adult medicines with potential life-threatening adverse reactions and health complications. Recent developments and future considerations regarding pediatric drug discovery and development using a patient-centric approach in the context of ontogenic biopharmaceutical considerations are discussed below.

Comprehensive biochemical analysis of rare prostacyclin receptor variants: study of association of signaling with coronary artery obstruction

Currently, pharmacogenetic studies are at an impasse as the low prevalence (<2%) of most variants hinder their pharmacogenetic analysis with population sizes often inadequate for sufficiently powered studies. Grouping rare mutations by functional phenotype rather than mutation site can potentially increase sample size. Using human population-based studies (n = 1,761) to search for dysfunctional human prostacyclin receptor (hIP) variants, we recently discovered 18 non-synonymous mutations, all with frequencies less than 2% in our study cohort. Eight of the 18 had defects in binding, activation, and/or protein stability/folding. Mutations (M113T, L104R, and R279C) in three highly conserved positions demonstrated severe misfolding manifested by impaired binding and activation of cell surface receptors. To assess for association with coronary artery disease, we performed a case-control study comparing coronary angiographic results from patients with reduced cAMP production arising from the non-synonymous mutations (n = 23) with patients with non-synonymous mutations that had no reduction in cAMP (n = 17). Major coronary artery obstruction was significantly increased in the dysfunctional mutation group in comparison with the silent mutations. We then compared the 23 dysfunctional receptor patients with 69 age- and risk factor-matched controls (1:3). This verified the significantly increased coronary disease in the non-synonymous dysfunctional variant cohort. This study demonstrates the potential utility of in vitro functional characterization in predicting clinical phenotypes and represents the most comprehensive characterization of human prostacyclin receptor genetic variants to date.

Understanding CYP2D6 interactions

Owing to the polymorphic nature of CYP2D6, clinically significant issues can arise when drugs rely on that enzyme either for clearance, or metabolism to an active metabolite. Available screening methods to determine if the compound is likely to cause drug-drug interactions, or is likely to be a victim of inhibition of CYP2D6 by other compounds will be described. Computational models and examples will be given on strategies to design out the CYP2D6 liabilities for both heme-binding compounds and non-heme-binding compounds.

In vitro biotransformation of amitriptyline and imipramine with rat hepatic S9 fraction: evaluation of the toxicity with Spirotox and Thamnotoxkit F Tests

Pharmaceutical products, as well as their related metabolites, end up in the aquatic environment after use. Little is known about the effects and the hazard of exposure to drugs for aquatic organisms. This study was designed to assess the ecotoxicity of amitriptyline (AMI), imipramine (IMI), and their metabolites. The tested drugs were very toxic to the protozoan Spirostomum ambiguum and the crustacean Thamnocephalus platyurus with the LC50 values around 1 mg l(-1). Moreover, simple additivity occurs between the drugs and their N-desmethyl metabolites. Tested compounds were incubated with S9 rat hepatocyte fraction at 37 degrees C for 4 hours. Unchanged drugs and metabolites were determined using high-pressure liquid chromatography-photodiode array detector. AMI and IMI were biotransformed almost completely. Three AMI and IMI metabolites were detected: desmethyl-, didesmethyl-, and N-oxide. The toxicity of the deproteinated reaction mixtures (TU) was compared to the toxicity equivalency units (TEU) calculated based on the concentrations of the drugs and their LC50 values. It has been demonstrated that the toxicity of mixture of metabolites to Spirotox and Thamnotoxkit F is higher than the predicted value calculated from the concentrations of the drugs and their N-desmethylated derivatives in the sample. The results indicate that the harmfulness of the drug metabolites should be taken into consideration in the ecotoxicological studies.

Evaluation of the in vitro biotransformation of fluoxetine with HPLC, mass spectrometry and ecotoxicological tests

Fluoxetine (FLU) is potent and highly selective serotonin-reuptake inhibitor used in the treatment of major depression. The FLU is apparently the most acute toxic pharmaceutical reported so far for aquatic organisms. Very little is known about possible toxicity of its metabolites. Ingested drugs are excreted to the environment in a biologically active form, either as the parent substance or as an active metabolite. This study was designated to assess the ecotoxicity of FLU and its metabolites. FLU and norfluoxetine (NFLU) were very toxic to applied bioassays with LC50 around 0.5 mg l(-1). The compounds affected only slightly stronger the protozoan Spirostomum ambiguum than the crustacean Thamnocephalus platyurus in the 24 h lethality tests. NFLU was 50% more toxic than FLU in both bioassays. FLU was metabolised in vitro with S9 rat liver fraction. The composition of the reaction mixtures was assessed with HPLC-PAD and MS, and their toxicity was evaluated with the bioassays. The chemical analysis showed besides FLU and NFLU the presence of 4-trifluoromethylphenol, which was much less toxic to the bioassays. Predicted toxicity values were calculated on the base of the FLU and NFLU concentrations in the samples and EC50, and LC50's of the pure compounds. The toxicity of the solutions received during the metabolism of FLU can be predicted based on the concept of concentration addition. The results give the strong indication on the importance of investigation not only parent drugs but also their metabolites.

Arginine (CGC) codon targeting in the human prostacyclin receptor gene (PTGIR) and G-protein coupled receptors (GPCR)

The human prostacyclin receptor (hIP) has recently been recognized as an important seven transmembrane G-protein coupled receptor that plays critical roles in atheroprevention and cardioprotection. To date, four non-synonymous genetic variants have been identified, two of which occur at the same Arg amino acid position (R212H, R212C). This observation instigated further genetic screening for prostacyclin receptor variants on 1455 human genomic samples. A total of 31 distinct genetic variants were detected, with 6 (19%) involving Arg residues. Distinct differences in location and frequencies of genetic variants were noted between Caucasian, Asian, Hispanic and African Americans, with the most changes noted in the Asian cohort. From the sequencing results, three Arg-targeted changes at the same 212 position within the third cytoplasmic loop of the human prostacyclin (hIP) receptor were detected: 1) R212C (CGC-->TGC), 2) R212H (CGC-->CAC), and 3) R212R (CGC-->CGT). Three additional Arg codon variants (all exhibiting the same CGC to TGC change) were also detected, R77C, R215C, and R279C. Analysis (GPCR and SNP databases) of 200 other GPCRs, with recorded non-synonymous mutations, confirmed a high frequency of Arg-targeted missense mutations, particularly within the important cytoplasmic domain. Preferential nucleotide changes (at Arg codons), were observed involving cytosine (C) to thymine (T) (pyrimidine to pyrimidine), as well as guanine (G) to adenine (A) (purine to purine) (p<0.001, Pearson's goodness-of-fit test). Such targeting of Arg residues, leading to significant changes in coding amino acid size and/or charge, may have potentially-important structural and evolutionary implications on the hIP and GPCRs in general. In the case of the human prostacyclin receptor, such alterations may reduce the cardio-, vasculo-, and cytoprotective effects of prostacyclin.

Outcomes in newly diagnosed localization-related epilepsies

A total of 558 patients with a range of localization-related epilepsy syndromes starting treatment in a single centre were followed over a period of up to 20 years. Overall, 343 (62%) patients became seizure free for 12 months or more (responders), 92% of whom (57% of total population) remained in remission until the end of follow-up. Only 27 (5%) responders relapsed and subsequently developed refractory epilepsy. The remaining 215 (38%) patients never became seizure free for any 12-month period. There were no significant differences in outcome between cryptogenic (56% remission) and symptomatic (57% remission) epilepsies. Patients with underlying cortical atrophy (71% remission; p<0.05) or cerebrovascular disease (70% remission; p<0.01) did better, while those with traumatic brain injury (35% remission; p<0.001) did worse than the remainder of the symptomatic group. Remission rates in patients with cortical dysplasias (60%), hippocampal atrophy (50%) and primary brain tumors (52%) appeared no different from those with other symptomatic epilepsies. Overall, 20-40% patients with each epilepsy syndrome reported no further seizures after starting AED treatment including 21% with hippocampal atrophy and 33% with cortical dysplasia. More than 50% of patients developing localization-related epilepsy during adolescence or in adulthood had a good outcome. Prognosis in those with underlying hippocampal atrophy or cortical dysplasia was not always bad.

Present and future of rapid and/or high-throughput methods for nucleic acid testing

BACKGROUND

Behind the success of 'completing' the human genome project was a more than 30-year history of technical innovations for nucleic acid testing.

METHODS

Discovery of specific restriction endonucleases and reverse transcriptase was followed shortly by the development of the first diagnostic nucleic acid tests in the early 1970s. Introduction of Southern, Northern and dot blotting and DNA sequencing later in the 1970s considerably advanced the diagnostic capabilities. Nevertheless, it was the discovery of the polymerase chain reaction (PCR) in 1985 that led to an exponential growth in molecular biology and the introduction of practicable nucleic acid tests in the routine laboratory. The past two decades witnessed a continuing explosion of technological innovations in molecular diagnostics. In addition to classic PCR and reverse transcriptase PCR, numerous variations of PCR and alternative amplification techniques along with an ever-increasing variety of detection chemistries, closed tube (homogeneous) assays, and automated systems were developed. Discovery of real-time quantitative PCR and the development of oligonucleotide microarrays, the 'DNA chip', in the 1990s heralded the beginning of another revolution in molecular biology and diagnostics that is still in progress.

Rhabdomyolysis and compartment syndrome with coadministration of risperidone and simvastatin

We report a case of rhabdomyolysis and acute compartment syndrome of the lower extremity in a schizophrenic patient taking risperidone following the addition of simvastatin to treat hyperlipidemia. We suspect that disrupted drug metabolism, resulting from interactions with cytochrome P450 enzymes, rapidly elevated drug plasma levels, which then led to muscle toxicity. Clinicians who pharmacologically treat medical comorbidities in patients receiving atypical antipsychotics must be proactive in anticipating potential drug-drug interactions.

Clinical Pharmacology

The dose of a drug is a major determinant of its safety, and establishing a safe dose of a novel drug is a prime objective during clinical development. The design of pre-marketing clinical trials precludes the representation of important subpopulations such as children, the elderly and people with co-morbidities. Therefore, postmarketing surveillance (PMS) activities are required to monitor the safety profile of drugs in real clinical practice. Furthermore, individual variations in pharmacogenetic profiles, the immune system, drug metabolic pathways and drug-drug interactions are also important factors in the occurrence of adverse drug reactions. Thus, the safety of a drug is a major clinical consideration before and after it is marketed. A multidisciplinary approach is required to enhance the safety profile of drugs at all stages of development, including PMS activities. Clinical pharmacology encompasses a range of disciplines and forms the backbone of drug safety consideration during clinical drug development. In this review we give an overview of the clinical drug development process and consider its limitations. We present a discussion of several aspects of clinical pharmacology and their application to enhancing drug safety. Pharmacokinetic-pharmacodynamic modelling provides a method of predicting a clinically safe dose; consideration of drug pharmacokinetics in special populations may enhance safe therapeutics in a wider spectrum of patients, while pharmacogenetics provides the possibility of genotype-specific therapeutics. Pharmacovigilance activities are also discussed. Given the complex nature and unpredictability of type B reactions, PMS activities are crucial in managing the risks drugs pose to the general population. The various aspects of clinical pharmacology discussed make a strong case for this field as the backbone of optimising and promoting safe development and use of drugs.

Impaired receptor binding and activation associated with a human prostacyclin receptor polymorphism

The human prostacyclin receptor (hIP) is a seven transmembrane-spanning G-protein-coupled receptor that plays an important role in vascular homeostasis. Recent genetic analyses (SNP database, NCBI) have revealed the first two polymorphisms within the coding sequence, V25M and R212H. Here we present structure-function characterizations of these polymorphisms at physiological pH (7.4) and at an acidic pH (6.8) that would be encountered during stress such as renal, respiratory, or heart failure. Through a series of competition binding and G-protein activation assays (measured by cAMP production), we determined that the V25M polymorph exhibited agonist binding and G-protein activation similar to wild-type receptor at normal pH (7.4). However, the R212H variant demonstrated a significant decrease in binding affinity at lower pH (R212H at pH 7.4, K(i) = 2.2 +/- 1.2 nm; pH 6.8 K(i) = 45.6 +/- 12.0 nm). The R212H polymorph also exhibited abnormal activation at both pH 7.4 and pH 6.8 (pH 7.4, R212H EC(50) = 2.8 +/- 0.5 nm versus wild-type hIP EC(50) = 0.5 +/- 0.1 nm; pH 6.8, R212H EC(50) = 3.2 +/- 1.6 nm versus wild-type hIP EC(50) = 0.5 +/- 0.2 nm). Polymorphisms of the human prostacyclin receptor potentially may be important predictors of disease progress during biological stressors such as acidosis in which urgent correction of bodily pH may be required to restore normal hemostasis and vasodilation. This study provides the mechanistic basis for further research into genetic risk factors and pharmacogenetics of cardiovascular disease associated with hIP.

The era of genomics: impact on sepsis clinical trial design

OBJECTIVE

This article aims to address the predictable impact of genetics on the design of clinical trials in the field of critical care medicine, with emphasis on the pathophysiology of sepsis and its treatment.

DATA SOURCES

Published articles reporting studies on sepsis and septic shock or assessing the influence of genetics and pharmacogenomics in the treatment of critical illnesses.

DATA ANALYSIS

Because most common diseases including sepsis have been shown to be influenced by inherited differences in our genes, completion of the Human Genome Project and the concomitant publication of the human single nucleotide polymorphism map both contribute to change our approach to medicine. Advances in genotyping techniques and bioinformatics enabling detection of single nucleotide polymorphisms have caused an explosion in pharmacogenomics-the research dealing with the interactions of an individual's genotype and the outcome of a drug therapy. Pharmacogenomics will undoubtedly be used to improve future health care and clinical research in different ways. Whereas treatment allocation has been based mainly on phenotype, genetic characterization will help researchers to identify suitable subjects for clinical trials, to facilitate interpretation of the results of clinical trials, and to identify novel targets for future drugs or new markets for current products. As interindividual variability in drug response is a substantial clinical problem, the second major objective of pharmacogenomic research is to decrease adverse responses to therapy through determination of adequate therapeutic targets and genetic polymorphisms that alter drug specificity and toxicity. Ultimately, genetic information will be used to select the most effective therapeutic agent and the optimal dosage to elicit the expected drug response for a given individual. Implementation of genetic criteria for stratification of patient populations and individual assessment of treatment risks and benefits emerges as a major challenge to the pharmaceutical industry.

CONCLUSIONS

In the future, technologies such as gene chip array will enhance genetic medicine and provide novel insights into a patient's susceptibility to disease, enabling a better assessment of prognostic risk factors, quicker diagnosis, and accurate prediction of individual responsiveness to drugs. The predictable consequences of such an approach on the prevention and treatment of diseases could revolutionize medicine.