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Polasek TM. Pharmacogenomics - a minor rather than major force in clinical medicine. Expert Rev Clin Pharmacol 2024; 17:203-212. [PMID: 38307498 DOI: 10.1080/17512433.2024.2314726] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2023] [Accepted: 02/01/2024] [Indexed: 02/04/2024]
Abstract
INTRODUCTION Pharmacogenomics (PGx) is touted as essential for the future of precision medicine. But the opportunity cost of PGx from the prescribers' perspective is rarely considered. The aim of this article is to critique PGx-guided prescribing using clinical pharmacology principles so that important cases for PGx testing are not missed by doctors responsible for therapeutic decision making. AREAS COVERED Three categories of PGx and their limitations are outlined - exposure PGx, response PGx, and immune-mediated safety PGx. Clinical pharmacology reasons are given for the narrow scope of PGx-guided prescribing apart from a few medical specialties. Clinical problems for doctors that may arise from PGx are then explained, including mismatch between patients' expectations of PGx testing and the benefits or answers it provides. EXPERT OPINION Contrary to popular opinion, PGx is unlikely to become the cornerstone of precision medicine. Sound clinical pharmacology reasons explain why PGx-guided prescribing is unnecessary for most drugs. Pharmacogenomics is important for niche areas of prescribing but has limited clinical utility more broadly. The opportunity cost of PGx-guided prescribing is currently too great for most doctors.
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Affiliation(s)
- Thomas M Polasek
- Centre for Medicine Use and Safety, Monash University, Melbourne, Australia
- CMAX Clinical Research, Adelaide, Australia
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Coombs S, Pittet LF, Tang K, Gwee A. Incidence and predisposing factors for flucloxacillin-related hepatotoxicity in children. J Antimicrob Chemother 2023; 78:2667-2671. [PMID: 37699070 DOI: 10.1093/jac/dkad279] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2023] [Accepted: 08/21/2023] [Indexed: 09/14/2023] Open
Abstract
BACKGROUND Flucloxacillin-induced hepatotoxicity is well established in adults. However, there are few paediatric studies of flucloxacillin-induced hepatotoxicity despite this drug being among the most commonly prescribed in children. We aimed to determine the incidence of flucloxacillin-induced hepatotoxicity in children receiving IV therapy as well as identify risk factors for this adverse drug reaction. METHODS We undertook a 2 year retrospective audit of children aged 0-18 years admitted to the Royal Children's Hospital (March 2019 to March 2021) who had liver function tests determined before and after receiving IV flucloxacillin for at least 24 hours duration. Causality was assessed using the Roussel Uclaf Causality Assessment Method and Naranjo criteria. RESULTS Overall, the incidence of hepatotoxicity was 66/393 (17%). The median age of children with hepatotoxicity was 1.1 years (IQR 0.3-11.9), 43 (65%) received two or more concomitant hepatotoxic medications and 23 (35%) were receiving total parenteral nutrition. The median timing of onset of hepatotoxicity after commencement of flucloxacillin was 4 days (range 2-7). Severe hepatotoxicity (Common Terminology Criteria for Adverse Events grade 3 or above) occurred in 9/66 (14%) for bilirubin, 13/66 (20%) for ALT and 10/66 (15%) for GGT. Predisposing factors for hepatotoxicity were increasing age (OR 1.06 per additional year, 95% CI 1.01-1.10, P = 0.02), with adolescents aged 12-18 years having the highest risk (OR 5.10, 95% CI 2.02-12.85, P = 0.001), and two or more concomitant hepatotoxic medications (OR 2.51, 95% CI 1.02-6.18, P = 0.05). The median time to resolution of hepatotoxicity after cessation of flucloxacillin was 5 days (range 2-10). CONCLUSIONS In children, older patients and those receiving two or more concomitant hepatotoxic medications are at greater risk of flucloxacillin-induced hepatotoxicity.
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Affiliation(s)
- Stefan Coombs
- Department of Pharmacy and General Medicine, The Royal Children's Hospital Melbourne, 50 Flemington Road Parkville, Victoria 3052, Australia
| | - Laure F Pittet
- Infectious Diseases Unit, Department of Paediatrics, Gynaecology and Obstetrics, Faculty of Medicine, University of Geneva and University Hospitals of Geneva, Geneva, Switzerland
- Antimicrobials Group, Murdoch Children's Research Institute, Royal Children's Hospital Melbourne, 50 Flemington Road Parkville, Victoria 3052, Australia
- Department of Paediatrics, University of Melbourne, Reception Level 2, West Building, Royal Children's Hospital Melbourne, 50 Flemington Road Parkville, Victoria 3052, Australia
| | - Kailey Tang
- Department of Paediatrics, University of Melbourne, Reception Level 2, West Building, Royal Children's Hospital Melbourne, 50 Flemington Road Parkville, Victoria 3052, Australia
| | - Amanda Gwee
- Department of Pharmacy and General Medicine, The Royal Children's Hospital Melbourne, 50 Flemington Road Parkville, Victoria 3052, Australia
- Antimicrobials Group, Murdoch Children's Research Institute, Royal Children's Hospital Melbourne, 50 Flemington Road Parkville, Victoria 3052, Australia
- Department of Paediatrics, University of Melbourne, Reception Level 2, West Building, Royal Children's Hospital Melbourne, 50 Flemington Road Parkville, Victoria 3052, Australia
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Alshabeeb M, Alomar FA, Khan A. Impact of SLCO1B1*5 on Flucloxacillin and Co-Amoxiclav-Related Liver Injury. Front Pharmacol 2022; 13:882962. [PMID: 35754504 PMCID: PMC9214039 DOI: 10.3389/fphar.2022.882962] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2022] [Accepted: 04/28/2022] [Indexed: 11/13/2022] Open
Abstract
Background: Idiosyncratic drug-induced liver injury (DILI) is a serious uncommon disease that may develop as a result of the intake of certain drugs such as the antimicrobials flucloxacillin and co-amoxiclav. The reported cases showed significant associations between DILI and various human leukocyte (HLA) markers. The solute carrier organic anion transporter 1B1 (SLCO1B1), a non-HLA candidate gene, was previously reported as a risk factor for liver injury induced by rifampin and methimazole. This study presumed that SLCO1B1 may play a general role in the DILI susceptibility and therefore investigated the association of rs4149056 (SLCO1B1*5, T521C) polymorphism with flucloxacillin- and co-amoxiclav-induced liver injury. Methodology: We recruited 155 and 165 DILI cases of white ancestral origin from various European countries but mainly from the United Kingdom owing to flucloxacillin and co-amoxiclav, respectively. Only adult patients (≥18 years) who were diagnosed with liver injury and who showed i) clinical jaundice or bilirubin >2x the upper limit of normal (ULN), ii) alanine aminotransferase (ALT) >5x ULN or iii) alkaline phosphatase (ALP) >2x ULN and bilirubin > ULN were selected. The population reference sample (POPRES), a European control group (n = 282), was used in comparison with the investigated cases. TaqMan SNP genotyping custom assay designed by Applied Biosystems was used to genotype both DILI cohorts for SLCO1B1 polymorphism (rs4149056). Allelic discrimination analysis was performed using a step one real-time PCR machine. Genotype differences between cases and controls were examined using Fisher's exact test. GraphPad Prism version 5.0 was used to determine the p-value, odds ratio, and 95% confidence interval. Compliance of the control group with Hardy-Weinberg equilibrium was proven using a web-based calculator available at https://wpcalc.com/en/equilibrium-hardy-weinberg/. Results: A small number of cases failed genotyping in each cohort. Thus, only 149 flucloxacillin and 162 co-amoxiclav DILI cases were analyzed. Genotyping of both DILI cohorts did not show evidence of association with the variant rs4149056 (T521C) (OR = 0.71, 95% CI = 0.46-1.12; p = 0.17 for flucloxacillin cases and OR = 0.87, 95% CI = 0.56-1.33; p = 0.58 for co-amoxiclav), although slightly lower frequency (22.8%) of positive flucloxacillin cases was noticed than that of POPRES controls (29.4%). Conclusion: Carriage of the examined allele SLCO1B1*5 is not considered a risk factor for flucloxacillin DILI or co-amoxiclav DILI as presumed. Testing a different allele (SLCO1B1*1B) and another family member gene (SLCO1B3) may still be needed to provide a clearer role of SLCO1B drug transporters in DILI development-related to the chosen antimicrobials.
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Affiliation(s)
- Mohammad Alshabeeb
- King Abdullah International Medical Research Center (KAIMRC), Riyadh, Saudi Arabia.,King Saud bin Abdulaziz University for Health Sciences (KSAU-HS), Riyadh, Saudi Arabia
| | - Fadhel A Alomar
- Department of Pharmacology and Toxicology, College of Clinical Pharmacy, Imam Abdulrahman Bin Faisal University, Dammam, Saudi Arabia
| | - Amjad Khan
- Department of Biological Sciences (Zoology), Faculty of Science, University of Lakki Marwat, Lakki Marwat, Pakistan
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Leegwater E, Westgeest AC, Schippers EF, Wilms EB, Nieuwkoop C, Visser LE. Hypokalemia in patients treated with intravenous flucloxacillin: incidence and risk factors. Br J Clin Pharmacol 2022; 88:2938-2945. [DOI: 10.1111/bcp.15236] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2021] [Revised: 01/10/2022] [Accepted: 01/11/2022] [Indexed: 11/26/2022] Open
Affiliation(s)
- Emiel Leegwater
- Department of Hospital Pharmacy Haga Teaching Hospital AA The Hague The Netherlands
- The Hague Hospital Pharmacy, Charlotte Jacobslaan 70 AB The Hague The Netherlands
| | - Annette C. Westgeest
- Department of Internal Medicine Haga Teaching Hospital AA The Hague The Netherlands
- Department of Infectious Diseases Leiden University Medical Center ZA Leiden The Netherlands
| | - Emile F. Schippers
- Department of Internal Medicine Haga Teaching Hospital AA The Hague The Netherlands
- Department of Infectious Diseases Leiden University Medical Center ZA Leiden The Netherlands
| | - Erik B. Wilms
- Department of Hospital Pharmacy Haga Teaching Hospital AA The Hague The Netherlands
- The Hague Hospital Pharmacy, Charlotte Jacobslaan 70 AB The Hague The Netherlands
| | - Cees Nieuwkoop
- Department of Internal Medicine Haga Teaching Hospital AA The Hague The Netherlands
| | - Loes E. Visser
- Department of Hospital Pharmacy Haga Teaching Hospital AA The Hague The Netherlands
- Department of Epidemiology, Erasmus MC GD Rotterdam The Netherlands
- Department of Hospital Pharmacy Erasmus MC GD Rotterdam The Netherlands
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Predictive Model for Drug-Induced Liver Injury Using Deep Neural Networks Based on Substructure Space. Molecules 2021; 26:molecules26247548. [PMID: 34946636 PMCID: PMC8707960 DOI: 10.3390/molecules26247548] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2021] [Revised: 12/09/2021] [Accepted: 12/09/2021] [Indexed: 01/22/2023] Open
Abstract
Drug-induced liver injury (DILI) is a major concern for drug developers, regulators, and clinicians. However, there is no adequate model system to assess drug-associated DILI risk in humans. In the big data era, computational models are expected to play a revolutionary role in this field. This study aimed to develop a deep neural network (DNN)-based model using extended connectivity fingerprints of diameter 4 (ECFP4) to predict DILI risk. Each data set for the predictive model was retrieved and curated from DILIrank, LiverTox, and other literature. The best model was constructed through ten iterations of stratified 10-fold cross-validation, and the applicability domain was defined based on integer ECFP4 bits of the training set which represented substructures. For the robustness test, we employed the concept of the endurance level. The best model showed an accuracy of 0.731, a sensitivity of 0.714, and a specificity of 0.750 on the validation data set in the complete applicability domain. The model was further evaluated with four external data sets and attained an accuracy of 0.867 on 15 drugs with DILI cases reported since 2019. Overall, the results suggested that the ECFP4-based DNN model represents a new tool to identify DILI risk for the evaluation of drug safety.
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Abstract
Flucloxacillin is a penicillin antibiotic used as first-line treatment for soft tissue infections caused by Staphylococcus aureus It is used frequently in the elderly and is an established cause of cholestatic liver injury. Risk factors for cholestasis include prolonged duration of treatment, female sex and older age. Elderly patients are also more likely to suffer from comorbidities and polypharmacy, which increases the incidence of drug-induced liver injury and hospitalisation, which in turn can lead to irreversible deterioration in functional baseline. Our case report aims to raise awareness of flucloxacillin-induced liver injury in elderly patients and to encourage the use of alternative treatments and/or limited duration. We advocate for further research into individualised treatments and new diagnostic techniques in patients with painless jaundice based on their genotype.
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Affiliation(s)
- Roberta Angheleanu
- Medicine for the Care of Older People, Whittington Health NHS Trust, London, UK
| | - Johnny N Swart
- Medicine for the Care of Older People, Whittington Health NHS Trust, London, UK
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Susukida T, Aoki S, Shirayanagi T, Yamada Y, Kuwahara S, Ito K. HLA transgenic mice: application in reproducing idiosyncratic drug toxicity. Drug Metab Rev 2020; 52:540-567. [PMID: 32847422 DOI: 10.1080/03602532.2020.1800725] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Various types of transgenic mice carrying either class I or II human leukocyte antigen (HLA) molecules are readily available, and reports describing their use in a variety of studies have been published for more than 30 years. Examples of their use include the discovery of HLA-specific antigens against viral infection as well as the reproduction of HLA-mediated autoimmune diseases for the development of therapeutic strategies. Recently, HLA transgenic mice have been used to reproduce HLA-mediated idiosyncratic drug toxicity (IDT), a rare and unpredictable adverse drug reaction that can result in death. For example, abacavir-induced IDT has successfully been reproduced in HLA-B*57:01 transgenic mice. Several reports using HLA transgenic mice for IDT have proven the utility of this concept for the evaluation of IDT using various HLA allele combinations and drugs. It has become apparent that such models may be a valuable tool to investigate the mechanisms underlying HLA-mediated IDT. This review summarizes the latest findings in the area of HLA transgenic mouse models and discusses the current challenges that must be overcome to maximize the potential of this unique animal model.
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Affiliation(s)
- Takeshi Susukida
- Laboratory of Biopharmaceutics, Graduate School of Pharmaceutical Sciences, Chiba University, Chiba, Japan.,Laboratory of Cancer Biology and Immunology, Section of Host Defenses, Institute of Natural Medicine, University of Toyama, Toyama, Japan
| | - Shigeki Aoki
- Laboratory of Biopharmaceutics, Graduate School of Pharmaceutical Sciences, Chiba University, Chiba, Japan
| | - Tomohiro Shirayanagi
- Laboratory of Biopharmaceutics, Graduate School of Pharmaceutical Sciences, Chiba University, Chiba, Japan
| | - Yushiro Yamada
- Laboratory of Biopharmaceutics, Graduate School of Pharmaceutical Sciences, Chiba University, Chiba, Japan
| | - Saki Kuwahara
- Laboratory of Biopharmaceutics, Graduate School of Pharmaceutical Sciences, Chiba University, Chiba, Japan
| | - Kousei Ito
- Laboratory of Biopharmaceutics, Graduate School of Pharmaceutical Sciences, Chiba University, Chiba, Japan
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