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Bastaki K, Velayutham D, Irfan A, Adnan M, Mohammed S, Mbarek H, Qoronfleh MW, Jithesh PV. Forging the path to precision medicine in Qatar: a public health perspective on pharmacogenomics initiatives. Front Public Health 2024; 12:1364221. [PMID: 38550311 PMCID: PMC10977610 DOI: 10.3389/fpubh.2024.1364221] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/01/2024] [Accepted: 02/20/2024] [Indexed: 04/02/2024] Open
Abstract
Pharmacogenomics (PGx) is an important component of precision medicine that promises tailored treatment approaches based on an individual's genetic information. Exploring the initiatives in research that help to integrate PGx test into clinical setting, identifying the potential barriers and challenges as well as planning the future directions, are all important for fruitful PGx implementation in any population. Qatar serves as an exemplar case study for the Middle East, having a small native population compared to a diverse immigrant population, advanced healthcare system, national genome program, and several educational initiatives on PGx and precision medicine. This paper attempts to outline the current state of PGx research and implementation in Qatar within the global context, emphasizing ongoing initiatives and educational efforts. The inclusion of PGx in university curricula and healthcare provider training, alongside precision medicine conferences, showcase Qatar's commitment to advancing this field. However, challenges persist, including the requirement for population specific implementation strategies, complex genetic data interpretation, lack of standardization, and limited awareness. The review suggests policy development for future directions in continued research investment, conducting clinical trials for the feasibility of PGx implementation, ethical considerations, technological advancements, and global collaborations to overcome these barriers.
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Affiliation(s)
- Kholoud Bastaki
- Clinical and Pharmacy Practice Department, College of Pharmacy, QU Health, Qatar University, Doha, Qatar
| | - Dinesh Velayutham
- College of Health & Life Sciences, Hamad Bin Khalifa University, Education City, Doha, Qatar
| | - Areeba Irfan
- College of Health & Life Sciences, Hamad Bin Khalifa University, Education City, Doha, Qatar
| | - Mohd Adnan
- College of Health & Life Sciences, Hamad Bin Khalifa University, Education City, Doha, Qatar
| | - Sawsan Mohammed
- College of Medicine, Pre-Clinical Education Department, QU Health, Qatar University, Doha, Qatar
| | | | - M. Waild Qoronfleh
- Q3 Research Institute (QRI), Research & Policy Division, Ann Arbor, MI, United States
| | - Puthen Veettil Jithesh
- College of Health & Life Sciences, Hamad Bin Khalifa University, Education City, Doha, Qatar
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Ndong Sima CAA, Othman H, Möller M. Advancing pharmacogenetics research in Africa: the "Project Africa GRADIENT" initiative. Drug Discov Today 2024; 29:103939. [PMID: 38430965 DOI: 10.1016/j.drudis.2024.103939] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2023] [Revised: 02/20/2024] [Accepted: 02/27/2024] [Indexed: 03/05/2024]
Affiliation(s)
- Carene Anne Alene Ndong Sima
- DSI-NRF Centre of Excellence for Biomedical Tuberculosis Research, South African Medical Research Council Centre for Tuberculosis Research, Division of Molecular Biology and Human Genetics, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
| | - Houcemeddine Othman
- Sydney Brenner Institute for Molecular Bioscience, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Marlo Möller
- DSI-NRF Centre of Excellence for Biomedical Tuberculosis Research, South African Medical Research Council Centre for Tuberculosis Research, Division of Molecular Biology and Human Genetics, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa; Centre of Bioinformatics and Computational Biology, Stellenbosch University, Stellenbosch, South Africa.
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Hurrell T, Naidoo J, Masimirembwa C, Scholefield J. The Case for Pre-Emptive Pharmacogenetic Screening in South Africa. J Pers Med 2024; 14:114. [PMID: 38276236 PMCID: PMC10817273 DOI: 10.3390/jpm14010114] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2023] [Revised: 01/12/2024] [Accepted: 01/15/2024] [Indexed: 01/27/2024] Open
Abstract
Lack of equitable representation of global genetic diversity has hampered the implementation of genomic medicine in under-represented populations, including those on the African continent. Data from the multi-national Pre-emptive Pharmacogenomic Testing for Preventing Adverse Drug Reactions (PREPARE) study suggest that genotype guidance for prescriptions reduced the incidence of clinically relevant adverse drug reactions (ADRs) by 30%. In this study, hospital dispensary trends from a tertiary South African (SA) hospital (Steve Biko Academic Hospital; SBAH) were compared with the drugs monitored in the PREPARE study. Dispensary data on 29 drugs from the PREPARE study accounted for ~10% of total prescriptions and ~9% of the total expenditure at SBAH. VigiLyze data from the South African Health Products Regulatory Authority were interrogated for local ADRs related to these drugs; 27 were listed as being suspected, concomitant, or interacting in ADR reports. Furthermore, a comparison of pharmacogene allele frequencies between African and European populations was used to frame the potential impact of pre-emptive pharmacogenetic screening in SA. Enumerating the benefit of pre-emptive pharmacogenetic screening in SA will only be possible once we initiate its full application. However, regional genomic diversity, disease burden, and first-line treatment options could be harnessed to target stratified PGx today.
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Affiliation(s)
- Tracey Hurrell
- Bioengineering and Integrated Genomics Group, Future Production Chemicals Cluster, Council for Scientific and Industrial Research, Pretoria 0001, South Africa; (T.H.); (J.N.)
| | - Jerolen Naidoo
- Bioengineering and Integrated Genomics Group, Future Production Chemicals Cluster, Council for Scientific and Industrial Research, Pretoria 0001, South Africa; (T.H.); (J.N.)
| | - Collen Masimirembwa
- African Institute of Biomedical Science and Technology, Harare 00263, Zimbabwe;
- Sydney Brenner Institute for Molecular Biology, Division of Human Genetics, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg 2193, South Africa
| | - Janine Scholefield
- Bioengineering and Integrated Genomics Group, Future Production Chemicals Cluster, Council for Scientific and Industrial Research, Pretoria 0001, South Africa; (T.H.); (J.N.)
- Department of Human Biology, Faculty of Health Sciences, University of Cape Town, Cape Town 7925, South Africa
- Division of Human Genetics, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg 2193, South Africa
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Leung JG. Ethnopsychopharmacology: Clinical and scientific writing pearls. Ment Health Clin 2023; 13:276-288. [PMID: 38058595 PMCID: PMC10696167 DOI: 10.9740/mhc.2023.12.276] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2023] [Accepted: 09/26/2023] [Indexed: 12/08/2023] Open
Abstract
The concept of ethnopsychopharmacology aims to predict or explain the pharmacologic response to psychiatric medications based on the influence of biologic and nonbiologic factors. Interactions involving these factors are complex and influence patient outcomes in health care. Pharmacists and other clinicians working in patient care environments, research, or medical education should engage in lifelong learning to enhance ethnopsychopharmacologic knowledge gaps, which ultimately may improve and individualize care across diverse populations. Through two cases, this paper provides pearls on how biogeographical ancestry and cytochrome P450 status may influence pharmacotherapy selection, dosing, or response. A third scenario highlights a publication, like many other published works, with deficiencies in how data on ancestry, race, and ethnicity are collected or reported. Current recommendations on the use of inclusive language in scientific writing are reviewed, with attention to specific examples.
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Lusiki Z, Blom D, Soko ND, Malema S, Jones E, Rayner B, Blackburn J, Sinxadi P, Dandara MT, Dandara C. Major Genetic Drivers of Statin Treatment Response in African Populations and Pharmacogenetics of Dyslipidemia Through a One Health Lens. OMICS 2023. [PMID: 37956269 DOI: 10.1089/omi.2023.0122] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/15/2023]
Abstract
A One Health lens is increasingly significant to address the intertwined challenges in planetary health concerned with the health of humans, nonhuman animals, plants, and ecosystems. A One Health approach can benefit the public health systems in Africa that are overburdened by noncommunicable, infectious, and environmental diseases. Notably, the COVID-19 pandemic revealed the previously overlooked two-fold importance of pharmacogenetics (PGx), for individually tailored treatment of noncommunicable diseases and environmental pathogens. For example, dyslipidemia, a common cardiometabolic risk factor, has been identified as an independent COVID-19 severity risk factor. Observational data suggest that patients with COVID-19 infection receiving lipid-lowering therapy may have better outcomes. However, among African patients, the response to these drugs varies from patient to patient, pointing to the possible contribution of genetic variation in important pharmacogenes. The PGx of lipid-lowering therapies may underlie differences in treatment responses observed among dyslipidemia patients as well as patients comorbid with COVID-19 and dyslipidemia. Genetic variations in APOE, ABCB1, CETP, CYP2C9, CYP3A4, CYP3A5, HMGCR, LDLR, NPC1L1, and SLCO1B1 genes affect the pharmacogenomics of statins, and they have individually been linked to differential responses to dyslipidemia and COVID-19 treatment. African populations are underrepresented in PGx research. This leads to poor accounting of additional diverse genetic variants that could be important in understanding interindividual and between-population variations in therapeutic responses to dyslipidemia and COVID-19. This expert review examines and synthesizes the salient and priority PGx variations, as seen through a One Health lens in Africa, to improve and inform personalized medicine in both dyslipidemia and COVID-19.
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Affiliation(s)
- Zizo Lusiki
- Division of Human Genetics, Department of Pathology, Institute of Infectious Diseases and Molecular Medicine (IDM), University of Cape Town, Cape Town, South Africa
- Platform for Pharmacogenomics Research and Translation (PREMED) Unit, South African Medical Research Council (SAMRC), Cape Town, South Africa
| | - Dirk Blom
- Platform for Pharmacogenomics Research and Translation (PREMED) Unit, South African Medical Research Council (SAMRC), Cape Town, South Africa
- Division of Lipidology and Cape Heart Institute, Department of Medicine, University of Cape Town, Cape Town, South Africa
| | - Nyarai D Soko
- Division of Human Genetics, Department of Pathology, Institute of Infectious Diseases and Molecular Medicine (IDM), University of Cape Town, Cape Town, South Africa
- Platform for Pharmacogenomics Research and Translation (PREMED) Unit, South African Medical Research Council (SAMRC), Cape Town, South Africa
| | - Smangele Malema
- Platform for Pharmacogenomics Research and Translation (PREMED) Unit, South African Medical Research Council (SAMRC), Cape Town, South Africa
| | - Erika Jones
- Platform for Pharmacogenomics Research and Translation (PREMED) Unit, South African Medical Research Council (SAMRC), Cape Town, South Africa
- Division of Nephrology and Hypertension, Department of Medicine, University of Cape Town, Cape Town, South Africa
| | - Brian Rayner
- Platform for Pharmacogenomics Research and Translation (PREMED) Unit, South African Medical Research Council (SAMRC), Cape Town, South Africa
- Division of Nephrology and Hypertension, Department of Medicine, University of Cape Town, Cape Town, South Africa
| | - Jonathan Blackburn
- Division of Chemical and Systems Biology, Department of Integrative Biomedical Sciences, University of Cape Town, Cape Town, South Africa
| | - Phumla Sinxadi
- Platform for Pharmacogenomics Research and Translation (PREMED) Unit, South African Medical Research Council (SAMRC), Cape Town, South Africa
- Division of Clinical Pharmacology, Department of Medicine, University of Cape Town, Cape Town, South Africa
| | - Michelle T Dandara
- Platform for Pharmacogenomics Research and Translation (PREMED) Unit, South African Medical Research Council (SAMRC), Cape Town, South Africa
| | - Collet Dandara
- Division of Human Genetics, Department of Pathology, Institute of Infectious Diseases and Molecular Medicine (IDM), University of Cape Town, Cape Town, South Africa
- Platform for Pharmacogenomics Research and Translation (PREMED) Unit, South African Medical Research Council (SAMRC), Cape Town, South Africa
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Nabukenya S, Waitt C, Senyonga R, Castelnuovo B, Munabi IG, Kyaddondo D, Mwaka ES. Research Participants' Preferences for Individual Results of Pharmacogenomics Research: A Case of a Ugandan HIV Research Institute. J Empir Res Hum Res Ethics 2023; 18:218-232. [PMID: 37448227 PMCID: PMC10648306 DOI: 10.1177/15562646231187434] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/15/2023]
Abstract
Little is known about whether people living with HIV would like to receive their results from pharmacogenomics research. This study explored the factors influencing participants' preferences and the reasons for their desire to receive individual results from pharmacogenomics research. We employed a convergent parallel mixed methods study design comprising a survey of 225 research participants and 5 deliberative focus group discussions with 30 purposively selected research participants. Almost all (98%) participants wanted to receive individual pharmacogenomics research results. Reasons for the desire to receive results were reciprocity for valuable time and effort, preparing for future eventualities, and the right to information about their health. Overall, participants desire to receive feedback from pharmacogenomics research, particularly if results are well established and clinically actionable.
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Affiliation(s)
- Sylvia Nabukenya
- Makerere University College of Health Sciences, Kampala, Uganda
- Infectious Diseases Institute, Kampala, Uganda
| | - Catriona Waitt
- Infectious Diseases Institute, Kampala, Uganda
- University of Liverpool, Liverpool, UK
| | - Ronald Senyonga
- Makerere University College of Health Sciences, Kampala, Uganda
| | | | | | - David Kyaddondo
- Makerere University College of Health Sciences, Kampala, Uganda
| | - Erisa S. Mwaka
- Makerere University College of Health Sciences, Kampala, Uganda
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Veale CGL, Edkins AL, Winks S, Njoroge M, Chibale K. Including African data in drug discovery and development. Nat Rev Drug Discov 2023; 22:521-522. [PMID: 37264173 DOI: 10.1038/d41573-023-00088-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/03/2023]
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Katsukunya JN, Soko ND, Naidoo J, Rayner B, Blom D, Sinxadi P, Chimusa ER, Dandara M, Dzobo K, Jones E, Dandara C. Pharmacogenomics of Hypertension in Africa: Paving the Way for a Pharmacogenetic-Based Approach for the Treatment of Hypertension in Africans. Int J Hypertens 2023; 2023:9919677. [PMID: 38633331 PMCID: PMC11022520 DOI: 10.1155/2023/9919677] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2023] [Revised: 04/21/2023] [Accepted: 05/22/2023] [Indexed: 04/19/2024] Open
Abstract
In Africa, the burden of hypertension has been rising at an alarming rate for the last two decades and is a major cause for cardiovascular disease (CVD) mortality and morbidity. Hypertension is characterised by elevated blood pressure (BP) ≥ 140/90 mmHg. Current hypertension guidelines recommend the use of antihypertensives belonging to the following classes: calcium channel blockers (CCB), angiotensin converting inhibitors (ACEI), angiotensin receptor blockers (ARB), diuretics, β-blockers, and mineralocorticoid receptor antagonists (MRAs), to manage hypertension. Still, a considerable number of hypertensives in Africa have their BP uncontrolled due to poor drug response and remain at the risk of CVD events. Genetic factors are a major contributing factor, accounting for 20% to 80% of individual variability in therapy and poor response. Poor response to antihypertensive drug therapy is characterised by elevated BPs and occurrence of adverse drug reactions (ADRs). As a result, there have been numerous studies which have examined the role of genetic variation and its influence on antihypertensive drug response. These studies are predominantly carried out in non-African populations, including Europeans and Asians, with few or no Africans participating. It is important to note that the greatest genetic diversity is observed in African populations as well as the highest prevalence of hypertension. As a result, this warrants a need to focus on how genetic variation affects response to therapeutic interventions used to manage hypertension in African populations. In this paper, we discuss the implications of genetic diversity in CYP11B2, GRK4, NEDD4L, NPPA, SCNN1B, UMOD, CYP411, WNK, CYP3A4/5, ACE, ADBR1/2, GNB3, NOS3, B2, BEST3, SLC25A31, LRRC15 genes, and chromosome 12q loci on hypertension susceptibility and response to antihypertensive therapy. We show that African populations are poorly explored genetically, and for the few characterised genes, they exhibit qualitative and quantitative differences in the profile of pharmacogene variants when compared to other ethnic groups. We conclude by proposing prioritization of pharmacogenetics research in Africa and possible adoption of pharmacogenetic-guided therapies for hypertension in African patients. Finally, we outline the implications, challenges, and opportunities these studies present for populations of non-European descent.
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Affiliation(s)
- Jonathan N. Katsukunya
- Division of Human Genetics, Department of Pathology and Institute of Infectious Disease and Molecular Medicine (IDM), Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa
- UCT/South African Medical Research Council (SAMRC) Platform for Pharmacogenomics Research and Translation Unit, University of Cape Town, Cape Town, South Africa
| | - Nyarai D. Soko
- Division of Human Genetics, Department of Pathology and Institute of Infectious Disease and Molecular Medicine (IDM), Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa
- UCT/South African Medical Research Council (SAMRC) Platform for Pharmacogenomics Research and Translation Unit, University of Cape Town, Cape Town, South Africa
| | - Jashira Naidoo
- Department of Medicine, Division of Nephrology and Hypertension, Groote Schuur Hospital and Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa
| | - Brian Rayner
- UCT/South African Medical Research Council (SAMRC) Platform for Pharmacogenomics Research and Translation Unit, University of Cape Town, Cape Town, South Africa
- Department of Medicine, Division of Nephrology and Hypertension, Groote Schuur Hospital and Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa
| | - Dirk Blom
- UCT/South African Medical Research Council (SAMRC) Platform for Pharmacogenomics Research and Translation Unit, University of Cape Town, Cape Town, South Africa
- Department of Medicine, Division of Lipidology and Cape Heart Institute, Groote Schuur Hospital and Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa
| | - Phumla Sinxadi
- UCT/South African Medical Research Council (SAMRC) Platform for Pharmacogenomics Research and Translation Unit, University of Cape Town, Cape Town, South Africa
- Department of Medicine, Division of Clinical Pharmacology, Groote Schuur Hospital and Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa
| | - Emile R. Chimusa
- Department of Applied Sciences, Faculty of Health and Life Sciences, Northumbria University, Newcastle, Tyne and Wear NE1 8ST, UK
| | - Michelle Dandara
- UCT/South African Medical Research Council (SAMRC) Platform for Pharmacogenomics Research and Translation Unit, University of Cape Town, Cape Town, South Africa
| | - Kevin Dzobo
- Medical Research Council-SA Wound Healing Unit, Hair and Skin Research Laboratory, Division of Dermatology, Department of Medicine, Groote Schuur Hospital, Faculty of Health Sciences University of Cape Town, Anzio Road Observatory, Cape Town 7925, South Africa
| | - Erika Jones
- UCT/South African Medical Research Council (SAMRC) Platform for Pharmacogenomics Research and Translation Unit, University of Cape Town, Cape Town, South Africa
- Department of Medicine, Division of Nephrology and Hypertension, Groote Schuur Hospital and Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa
| | - Collet Dandara
- Division of Human Genetics, Department of Pathology and Institute of Infectious Disease and Molecular Medicine (IDM), Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa
- UCT/South African Medical Research Council (SAMRC) Platform for Pharmacogenomics Research and Translation Unit, University of Cape Town, Cape Town, South Africa
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Marwa KJ, Kapesa A, Kamugisha E, Swedberg G. The Influence of Cytochrome P450 Polymorphisms on Pharmacokinetic Profiles and Treatment Outcomes Among Malaria Patients in Sub-Saharan Africa: A Systematic Review. Pharmgenomics Pers Med 2023; 16:449-461. [PMID: 37223718 PMCID: PMC10202199 DOI: 10.2147/pgpm.s379945] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2022] [Accepted: 04/24/2023] [Indexed: 05/25/2023] Open
Abstract
Background Sub-Saharan Africa (SSA) population is genetically diverse and heterogenous thus variability in drug response among individuals is predicted to be high. Cytochrome P450 (CYP450) polymorphisms is a major source of variability in drug response. This systematic review presents the influence of CYP450 single nucleotide polymorphisms (SNPs), particularly CYP3A4*1B, CYP2B6*6 and CYP3A5*3 on antimalarial drug plasma concentrations, efficacy and safety in SSA populations. Methods Searching for relevant studies was done through Google Scholar, Cochrane Central Register of controlled trials (CENTRAL), PubMed, Medline, LILACS, and EMBASE online data bases. The Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines were used. Two independent reviewers extracted data from the studies. Results Thirteen studies reporting the influence of CYP450 SNPs on plasma concentrations, efficacy and safety were included in the final data synthesis. CYP3A4*1B, CYP3A5*5, CYP2B6*6 and CYP2C8*2 did not affect antimalarial drug plasma concentration significantly. There was no difference in treatment outcomes between malaria patients with variant alleles and those with wild type alleles. Conclusion This review reports lack of influence of CYP3A4*1B, CYP3A5*3, CYP2C8*3 and CYP2B6*6 SNPs on PK profiles, efficacy and safety in SSA among P. falciparum malaria patients.
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Affiliation(s)
- Karol J Marwa
- Department of Pharmacology, Catholic University of Health and Allied Sciences, Mwanza, Tanzania
| | - Anthony Kapesa
- Department of Community Medicine, Catholic University of Health and Allied Sciences, Mwanza, Tanzania
| | - Erasmus Kamugisha
- Department of Biochemistry, Catholic University of Health and Allied Sciences, Mwanza, Tanzania
| | - Göte Swedberg
- Department of Medical Biochemistry and Microbiology, Uppsala University, Uppsala, Sweden
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Kabbani D, Akika R, Wahid A, Daly AK, Cascorbi I, Zgheib NK. Pharmacogenomics in practice: a review and implementation guide. Front Pharmacol 2023; 14:1189976. [PMID: 37274118 PMCID: PMC10233068 DOI: 10.3389/fphar.2023.1189976] [Citation(s) in RCA: 10] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2023] [Accepted: 05/03/2023] [Indexed: 06/06/2023] Open
Abstract
Considerable efforts have been exerted to implement Pharmacogenomics (PGx), the study of interindividual variations in DNA sequence related to drug response, into routine clinical practice. In this article, we first briefly describe PGx and its role in improving treatment outcomes. We then propose an approach to initiate clinical PGx in the hospital setting. One should first evaluate the available PGx evidence, review the most relevant drugs, and narrow down to the most actionable drug-gene pairs and related variant alleles. This is done based on data curated and evaluated by experts such as the pharmacogenomics knowledge implementation (PharmGKB) and the Clinical Pharmacogenetics Implementation Consortium (CPIC), as well as drug regulatory authorities such as the US Food and Drug Administration (FDA) and European Medicinal Agency (EMA). The next step is to differentiate reactive point of care from preemptive testing and decide on the genotyping strategy being a candidate or panel testing, each of which has its pros and cons, then work out the best way to interpret and report PGx test results with the option of integration into electronic health records and clinical decision support systems. After test authorization or testing requirements by the government or drug regulators, putting the plan into action involves several stakeholders, with the hospital leadership supporting the process and communicating with payers, the pharmacy and therapeutics committee leading the process in collaboration with the hospital laboratory and information technology department, and healthcare providers (HCPs) ordering the test, understanding the results, making the appropriate therapeutic decisions, and explaining them to the patient. We conclude by recommending some strategies to further advance the implementation of PGx in practice, such as the need to educate HCPs and patients, and to push for more tests' reimbursement. We also guide the reader to available PGx resources and examples of PGx implementation programs and initiatives.
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Affiliation(s)
- Danya Kabbani
- Department of Pharmacology and Toxicology, Faculty of Medicine, American University of Beirut, Beirut, Lebanon
| | - Reem Akika
- Department of Pharmacology and Toxicology, Faculty of Medicine, American University of Beirut, Beirut, Lebanon
| | - Ahmed Wahid
- Department of Pharmaceutical Biochemistry, Faculty of Pharmacy, Alexandria University, Alexandria, Egypt
| | - Ann K. Daly
- Department of Pharmacology and Toxicology, Faculty of Medicine, American University of Beirut, Beirut, Lebanon
| | - Ingolf Cascorbi
- Department of Pharmacology and Toxicology, Faculty of Medicine, American University of Beirut, Beirut, Lebanon
| | - Nathalie Khoueiry Zgheib
- Department of Pharmacology and Toxicology, Faculty of Medicine, American University of Beirut, Beirut, Lebanon
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Sitabule BR, Othman H, Choudhury A, Twesigomwe D, Hanchard NA. Promoting Pharmacogenomics in Africa: Perspectives From Variation in G6PD and Other Pharmacogenes. Clin Pharmacol Ther 2023; 113:476-479. [PMID: 36576133 DOI: 10.1002/cpt.2816] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2022] [Accepted: 12/08/2022] [Indexed: 12/29/2022]
Affiliation(s)
- Blessing R Sitabule
- Sydney Brenner Institute for Molecular Bioscience, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa.,Division of Human Genetics, National Health Laboratory Service and School of Pathology, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Houcemeddine Othman
- Sydney Brenner Institute for Molecular Bioscience, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Ananyo Choudhury
- Sydney Brenner Institute for Molecular Bioscience, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - David Twesigomwe
- Sydney Brenner Institute for Molecular Bioscience, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa.,Division of Human Genetics, National Health Laboratory Service and School of Pathology, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Neil A Hanchard
- Childhood Complex Disease Genomics Section, Center for Precision Health Research, National Human Genome Research Institute, National Institutes of Health, Bethesda, Maryland, USA
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Barry A, Kabatende J, Telele NF, Mnkugwe RH, Mugisha M, Ntirenganya L, Bienvenu E, Aklillu E. Effect of pharmacogenetic variations on praziquantel plasma concentration and safety outcomes among school children in Rwanda. Sci Rep 2023; 13:1446. [PMID: 36702944 PMCID: PMC9879930 DOI: 10.1038/s41598-023-28641-w] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2022] [Accepted: 01/23/2023] [Indexed: 01/27/2023] Open
Abstract
School-based mass drug administration (MDA) of Praziquantel (PZQ) is the global intervention strategy for elimination of schistosomiasis. Genetic variations in drug metabolizing enzymes and transporter proteins influences drug exposure and treatment outcomes, but data on PZQ pharmacokinetics and safety outcomes are scarce. We investigated the effect of pharmacogenetics variations on PZQ plasma concentrations and safety outcomes among 462 Rwandan schoolchildren who received single dose PZQ and albendazole in MDA. Genotyping for common functional variant alleles CYP3A4*1B, CYP3A5 (*3, *6, *7), CYP2C19 (*2, *3, *17), CYP2C9 (*2, *3) and CYP2J2*7 were done. Plasma concentration of PZQ, cis-4-OH-PZQ and trans-4-OH-PZQ were measured using LC/MS/MS. Active safety monitoring was done on days 1, 2, and 7 post-MDA. CYP2C9 and CYP2C19 genotypes were significantly associated with PZQ plasma concentrations and its cis- and trans-4-OH-PZQ/PZQ metabolic ratios (MR). CYP2C9*2 and CYP2C9*3 carriers had significantly higher PZQ concentration (p = 0.02), lower trans-4-OH-PZQ/PZQ (p < 0.001), and cis-4-OH-PZQ/PZQ (p = 0.02) MR. CYP2C19 (*2, *3) carriers had significantly higher plasma PZQ concentration than CYP2C19 *1/*1 and CYP2C19 *17 carriers (*1/*17 or *17/*17) (p < 0.001). CYP3A4 was significantly associated with cis-4-OH-PZQ MR (p = 0.04). Lower cis-4-OH-PZQ/PZQ MR (p < 0.0001) was a predictor of MDA-associated adverse events, but no significant association with genotypes were found. In conclusion, CYP2C9 and CYP2C19 genotypes significantly influence the plasma PZQ concentration and its MR. Lower cis-4-OH-PZQ/PZQ MR is significant predictor of adverse events following MDA.
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Affiliation(s)
- Abbie Barry
- Division of Clinical Pharmacology, Department of Laboratory Medicine, Karolinska Institutet at Karolinska University Hospital, Huddinge, Stockholm, Sweden
| | - Joseph Kabatende
- Division of Clinical Pharmacology, Department of Laboratory Medicine, Karolinska Institutet at Karolinska University Hospital, Huddinge, Stockholm, Sweden.,Rwanda Food and Drugs Authority, Nyarutarama Plaza, KG 9 Avenue, Kigali, Rwanda
| | - Nigus Fikrie Telele
- Division of Clinical Pharmacology, Department of Laboratory Medicine, Karolinska Institutet at Karolinska University Hospital, Huddinge, Stockholm, Sweden
| | - Rajabu Hussein Mnkugwe
- Department of Clinical Pharmacology, School of Medicine, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania
| | - Michael Mugisha
- College of Medicine and Health Sciences, University of Rwanda, KK 737, Kigali, Rwanda
| | - Lazare Ntirenganya
- Rwanda Food and Drugs Authority, Nyarutarama Plaza, KG 9 Avenue, Kigali, Rwanda
| | - Emile Bienvenu
- Rwanda Food and Drugs Authority, Nyarutarama Plaza, KG 9 Avenue, Kigali, Rwanda.,College of Medicine and Health Sciences, University of Rwanda, KK 737, Kigali, Rwanda
| | - Eleni Aklillu
- Division of Clinical Pharmacology, Department of Laboratory Medicine, Karolinska Institutet at Karolinska University Hospital, Huddinge, Stockholm, Sweden.
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Kuguyo O, Chambwe N, Nhachi CFB, Tsikai N, Dandara C, Matimba A. A cervical cancer biorepository for pharmacogenomics research in Zimbabwe. BMC Cancer 2022; 22:1320. [PMID: 36526993 PMCID: PMC9756582 DOI: 10.1186/s12885-022-10413-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2022] [Accepted: 12/06/2022] [Indexed: 12/23/2022] Open
Abstract
BACKGROUND Research infrastructures such as biorepositories are essential to facilitate genomics and its growing applications in health research and translational medicine in Africa. Using a cervical cancer cohort, this study describes the establishment of a biorepository consisting of biospecimens and matched phenotype data for use in genomic association analysis and pharmacogenomics research. METHOD Women aged > 18 years with a recent histologically confirmed cervical cancer diagnosis were recruited. A workflow pipeline was developed to collect, store, and analyse biospecimens comprising donor recruitment and informed consent, followed by data and biospecimen collection, nucleic acid extraction, storage of genomic DNA, genetic characterization, data integration, data analysis and data interpretation. The biospecimen and data storage infrastructure included shared -20 °C to -80 °C freezers, lockable cupboards, secured access-controlled laptop, password protected online data storage on OneDrive software. The biospecimen or data storage, transfer and sharing were compliant with the local and international biospecimen and data protection laws and policies, to ensure donor privacy, trust, and benefits for the wider community. RESULTS This initial establishment of the biorepository recruited 410 women with cervical cancer. The mean (± SD) age of the donors was 52 (± 12) years, comprising stage I (15%), stage II (44%), stage III (47%) and stage IV (6%) disease. The biorepository includes whole blood and corresponding genomic DNA from 311 (75.9%) donors, and tumour biospecimens and corresponding tumour DNA from 258 (62.9%) donors. Datasets included information on sociodemographic characteristics, lifestyle, family history, clinical information, and HPV genotype. Treatment response was followed up for 12 months, namely, treatment-induced toxicities, survival vs. mortality, and disease status, that is disease-free survival, progression or relapse, 12 months after therapy commencement. CONCLUSION The current work highlights a framework for developing a cancer genomics cohort-based biorepository on a limited budget. Such a resource plays a central role in advancing genomics research towards the implementation of personalised management of cancer.
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Affiliation(s)
- Oppah Kuguyo
- grid.13001.330000 0004 0572 0760Clinical Pharmacology Department, University of Zimbabwe College of Health Sciences, Avondale, Mazowe Street, Harare, Zimbabwe
| | - Nyasha Chambwe
- grid.416477.70000 0001 2168 3646Institute of Molecular Medicine, Feinstein Institutes for Medical Research, Northwell Health, Manhasset, NY USA
| | - Charles F. B. Nhachi
- grid.13001.330000 0004 0572 0760Clinical Pharmacology Department, University of Zimbabwe College of Health Sciences, Avondale, Mazowe Street, Harare, Zimbabwe
| | - Nomsa Tsikai
- grid.13001.330000 0004 0572 0760Department of Oncology, University of Zimbabwe College of Health Sciences, Harare, Zimbabwe
| | - Collet Dandara
- grid.7836.a0000 0004 1937 1151Pharmacogenomics and Drug Metabolism Research Group, Division of Human Genetics, Department of Pathology & Institute of Infectious Diseases and Molecular Medicine, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa
| | - Alice Matimba
- grid.13001.330000 0004 0572 0760Clinical Pharmacology Department, University of Zimbabwe College of Health Sciences, Avondale, Mazowe Street, Harare, Zimbabwe
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14
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Mbavha BT, Kanji CR, Stadler N, Stingl J, Stanglmair A, Scholl C, Wekwete W, Masimirembwa C. Population genetic polymorphisms of pharmacogenes in Zimbabwe, a potential guide for the safe and efficacious use of medicines in people of African ancestry. Pharmacogenet Genomics 2022; 32:173-182. [PMID: 35190514 DOI: 10.1097/fpc.0000000000000467] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE Pharmacogenomics (PGx) is a clinically significant factor in the safe and efficacious use of medicines. While PGx knowledge is abundant for other populations, there are scarce PGx data on African populations and is little knowledge on drug-gene interactions for medicines used to treat diseases common in Africa. The aim of this study was to use a custom-designed open array to genotype clinically actionable variants in a Zimbabwean population. This study also identified some of the commonly used drugs in Zimbabwe and the associated genes involved in their metabolism. METHODS A custom-designed open array that covers 120 genetic variants was used to genotype 522 black Zimbabwean healthy volunteers using TaqMan-based single nucleotide polymorphism genotyping. Data were also accessed from Essential Drugs' List in Zimbabwe (EDLIZ), and the medicines were grouped into the associated biomarker groups based on their metabolism. We also estimated the national drug procurement levels for medicines that could benefit from PGx-guided use based on the data obtained from the national authorities in Zimbabwe. RESULTS The results demonstrate the applicability of an open-array chip in simultaneously determining multiple genetic variants in an individual, thus significantly reducing cost and time to generate PGx data. There were significantly high frequencies of African-specific variants, such as the CYP2D6*17 and *29 variants and the CYP2B6*18 variant. The data obtained showed that the Zimbabwean population exhibits PGx variations in genes important for the safe and efficacious use of drugs approved by the EDLIZ and are procured at significantly large amounts annually. The study has established a cohort of genotyped healthy volunteers that can be accessed and used in the conduct of clinical pharmacogenetic studies for drugs entering a market of people of predominantly African ancestry. CONCLUSION Our study demonstrated the potential benefit of integrating PGx in Zimbabwe for the safe and efficacious use of drugs that are commonly used.
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Affiliation(s)
- Bianza T Mbavha
- Department of Genomic Medicine, African Institute of Biomedical Science and Technology (AiBST), Harare, Zimbabwe
| | - Comfort R Kanji
- Department of Genomic Medicine, African Institute of Biomedical Science and Technology (AiBST), Harare, Zimbabwe
| | - Nadina Stadler
- Research Division, Federal Institute for Drugs and Medical Devices (BfArM), Bonn
| | - Julia Stingl
- Institute of Clinical Pharmacology, University Hospital RWTH Aachen, Aachen, Germany
| | - Andrea Stanglmair
- Research Division, Federal Institute for Drugs and Medical Devices (BfArM), Bonn
| | - Catharina Scholl
- Research Division, Federal Institute for Drugs and Medical Devices (BfArM), Bonn
| | - William Wekwete
- Evaluations and Registration Division, Medicines Control Authority of Zimbabwe (MCAZ), Harare, Zimbabwe
| | - Collen Masimirembwa
- Department of Genomic Medicine, African Institute of Biomedical Science and Technology (AiBST), Harare, Zimbabwe
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15
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Abstract
To embrace the prospects of accurately diagnosing thousands of monogenic conditions, predicting disease risks for complex traits or diseases, tailoring treatment to individuals' pharmacogenetic profiles, and potentially curing some diseases, research into African genomic variation is a scientific imperative. African genomes harbor millions of uncaptured variants accumulated over 300,000 years of modern humans' evolutionary history, with successive waves of admixture, migration, and natural selection combining with extensive ecological diversity to create a broad and exceptional genomic complexity. Harnessing African genomic complexity, therefore, will require sustained commitment and equitable collaboration from the scientific community and funding agencies. African governments must support academic public research and industrial partnerships that build the necessary genetic medicine workforce, utilize the emerging genomic big data to develop expertise in computer science and bioinformatics, and evolve national and global governance frameworks that recognize the ethical implications of data-driven genomic research and empower its application in African social, cultural, economic, and religious contexts. Expected final online publication date for the Annual Review of Genomics and Human Genetics, Volume 23 is October 2022. Please see http://www.annualreviews.org/page/journal/pubdates for revised estimates.
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Affiliation(s)
- Ambroise Wonkam
- Division of Human Genetics, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa; , , .,Current affiliation: McKusick-Nathans Institute of Genetic Medicine and Department of Genetic Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA;
| | - Nchangwi S Munung
- Division of Human Genetics, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa; , ,
| | - Collet Dandara
- Division of Human Genetics, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa; , ,
| | - Kevin K Esoh
- Division of Human Genetics, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa; , ,
| | - Neil A Hanchard
- Center for Precision Health Research, National Human Genome Research Institute, National Institutes of Health, Bethesda, Maryland, USA;
| | - Guida Landoure
- Faculty of Medicine and Odontostomatology, University of Sciences, Techniques, and Technology of Bamako, Bamako, Mali;
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Maseng MJ, Tawe L, Thami PK, Moyo S, Kasvosve I, Novitsky V, Essex M, Russo G, Gaseitsiwe S, Paganotti GM. The role of CYP2B6 516G>T polymorphism on efavirenz/nevirapine toxicity. Implications on treatment outcomes: Lessons from Botswana. Medicine (Baltimore) 2022; 101:e29066. [PMID: 35512066 PMCID: PMC9276322 DOI: 10.1097/md.0000000000029066] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/26/2022] [Accepted: 02/25/2022] [Indexed: 01/04/2023] Open
Abstract
The two non-nucleoside reverse transcriptase inhibitors (NNRTIs), efavirenz (EFV) and nevirapine (NVP), are currently the core antiretroviral drugs for treatment of HIV in sub-Saharan Africa including Botswana. The drugs are metabolized by Cytochrome P450 2B6 (CYP2B6) liver enzyme. The CYP2B6 gene that encodes for metabolism of these drugs is known to be highly polymorphic. One of the polymorphism in the CYP2B6 gene, 516G>T, particularly the 516T allele, is known to confer poor metabolism of EFV and NVP. This may lead to high levels of plasma drug concentrations and development of treatment toxicities, like central nervous system toxicities, and cutaneous and hepatic toxicities, for EFV and NVP, respectively. The CYP2B6 516G allele on the other hand is associated with an extensive metabolism of the two NNRTIs drugs. We sought to establish association between possible developments of NNRTIs toxicities with CYP2B6 516G>T variation in Botswana.A total of 316 peripheral blood mononuclear cells samples were used in a retrospective view. All the samples were from participants on EFV/NVP-containing regimen with known toxicity output. TaqMan Real-Time PCR approach was applied for assessing CYP2B6 516 allele variation in cases with treatment toxicity and those without. Analysis was performed by chi-square statistics and logistic regression analysis.The rate of poor metabolizers among participants with toxicity and those without toxicity was 18.4% and 15.1%, respectively. The CYP2B6 516 genotype distribution comparisons between the participants with toxicity and those without were not statistically different (chi-square = .326; P = .568).CYP2B6 516 variation was not associated with NNRTI toxicity. No other factors were associated with toxicity when considering age, baseline body mass index, baseline CD4, baseline HIV viral load and adherence. The results were discussed in the context of all the studies done in Botswana to date.
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Affiliation(s)
- Monkgomotsi J. Maseng
- School of Allied Health Professions, Faculty of Health Sciences, University of Botswana, UB Campus, Block 246, Gaborone, Botswana
- Botswana-Harvard AIDS Institute Partnership, Plot 1836 North Ring Road, Gaborone, Botswana
| | - Leabaneng Tawe
- School of Allied Health Professions, Faculty of Health Sciences, University of Botswana, UB Campus, Block 246, Gaborone, Botswana
- Botswana-Harvard AIDS Institute Partnership, Plot 1836 North Ring Road, Gaborone, Botswana
- Botswana-University of Pennsylvania Partnership, UB Campus, Block 244G, Gaborone, Botswana
| | - Prisca K. Thami
- Botswana-Harvard AIDS Institute Partnership, Plot 1836 North Ring Road, Gaborone, Botswana
- Division of Human Genetics, Department of Pathology, Faculty of Health Sciences, University of Cape Town, Anzio Road Observatory, Cape Town, South Africa
| | - Sikhulile Moyo
- Botswana-Harvard AIDS Institute Partnership, Plot 1836 North Ring Road, Gaborone, Botswana
- Department of Immunology and Infectious Diseases, Harvard School of Public Health, 677 Hungtinton Avenue, Boston, MA
| | - Ishmael Kasvosve
- School of Allied Health Professions, Faculty of Health Sciences, University of Botswana, UB Campus, Block 246, Gaborone, Botswana
| | - Vladimir Novitsky
- Botswana-Harvard AIDS Institute Partnership, Plot 1836 North Ring Road, Gaborone, Botswana
- Department of Immunology and Infectious Diseases, Harvard School of Public Health, 677 Hungtinton Avenue, Boston, MA
| | - Max Essex
- Botswana-Harvard AIDS Institute Partnership, Plot 1836 North Ring Road, Gaborone, Botswana
- Department of Immunology and Infectious Diseases, Harvard School of Public Health, 677 Hungtinton Avenue, Boston, MA
| | - Gianluca Russo
- Department of Public Health and Infectious Disease, Faculty of Medicine, Sapienza University of Rome, Piazzale Aldo Moro 5, Rome, Italy
| | - Simani Gaseitsiwe
- Botswana-Harvard AIDS Institute Partnership, Plot 1836 North Ring Road, Gaborone, Botswana
- Department of Immunology and Infectious Diseases, Harvard School of Public Health, 677 Hungtinton Avenue, Boston, MA
| | - Giacomo M. Paganotti
- Botswana-University of Pennsylvania Partnership, UB Campus, Block 244G, Gaborone, Botswana
- Division of Infectious Diseases, Perelman School of Medicine, University of Pennsylvania, 3120-2740 Hamilton Walk, Philadelphia, PA
- Department of Biomedical Sciences, Faculty of Medicine, University of Botswana, UB Campus, Block 246, Gaborone, Botswana
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Hurrell T, Naidoo J, Scholefield J. Hepatic Models in Precision Medicine: An African Perspective on Pharmacovigilance. Front Genet 2022; 13:864725. [PMID: 35495161 PMCID: PMC9046844 DOI: 10.3389/fgene.2022.864725] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2022] [Accepted: 03/29/2022] [Indexed: 01/02/2023] Open
Abstract
Pharmaceuticals are indispensable to healthcare as the burgeoning global population is challenged by diseases. The African continent harbors unparalleled genetic diversity, yet remains largely underrepresented in pharmaceutical research and development, which has serious implications for pharmaceuticals approved for use within the African population. Adverse drug reactions (ADRs) are often underpinned by unique variations in genes encoding the enzymes responsible for their uptake, metabolism, and clearance. As an example, individuals of African descent (14–34%) harbor an exclusive genetic variant in the gene encoding a liver metabolizing enzyme (CYP2D6) which reduces the efficacy of the breast cancer chemotherapeutic Tamoxifen. However, CYP2D6 genotyping is not required prior to dispensing Tamoxifen in sub-Saharan Africa. Pharmacogenomics is fundamental to precision medicine and the absence of its implementation suggests that Africa has, to date, been largely excluded from the global narrative around stratified healthcare. Models which could address this need, include primary human hepatocytes, immortalized hepatic cell lines, and induced pluripotent stem cell (iPSC) derived hepatocyte-like cells. Of these, iPSCs, are promising as a functional in vitro model for the empirical evaluation of drug metabolism. The scale with which pharmaceutically relevant African genetic variants can be stratified, the expediency with which these platforms can be established, and their subsequent sustainability suggest that they will have an important role to play in the democratization of stratified healthcare in Africa. Here we discuss the requirement for African hepatic models, and their implications for the future of pharmacovigilance on the African continent.
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Affiliation(s)
- Tracey Hurrell
- Bioengineering and Integrated Genomics Group, Next Generation Health Cluster, Council for Scientific and Industrial Research, Pretoria, South Africa
| | - Jerolen Naidoo
- Bioengineering and Integrated Genomics Group, Next Generation Health Cluster, Council for Scientific and Industrial Research, Pretoria, South Africa
| | - Janine Scholefield
- Bioengineering and Integrated Genomics Group, Next Generation Health Cluster, Council for Scientific and Industrial Research, Pretoria, South Africa
- Department of Human Biology, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa
- *Correspondence: Janine Scholefield,
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Ebenezer TE, Muigai AWT, Nouala S, Badaoui B, Blaxter M, Buddie AG, Jarvis ED, Korlach J, Kuja JO, Lewin HA, Majewska R, Mapholi N, Maslamoney S, Mbo'o-Tchouawou M, Osuji JO, Seehausen O, Shorinola O, Tiambo CK, Mulder N, Ziyomo C, Djikeng A. Africa: sequence 100,000 species to safeguard biodiversity. Nature 2022; 603:388-92. [PMID: 35292740 DOI: 10.1038/d41586-022-00712-4] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
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19
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Mnkugwe RH, Minzi O, Kinung'hi S, Kamuhabwa A, Aklillu E. Effect of Pharmacogenetics Variations on Praziquantel Plasma Concentrations and Schistosomiasis Treatment Outcomes Among Infected School-Aged Children in Tanzania. Front Pharmacol 2021; 12:712084. [PMID: 34531744 PMCID: PMC8438567 DOI: 10.3389/fphar.2021.712084] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2021] [Accepted: 07/29/2021] [Indexed: 11/13/2022] Open
Abstract
Studies on pharmacogenetics of praziquantel (PZQ) and its relevance on plasma drug concentrations and schistosomiasis treatment outcomes are lacking. We investigated the effect of pharmacogenetics variations of PZQ on plasma drug levels and schistosomiasis treatment outcomes among infected Tanzanian school-aged children. A total of 340 Schistosoma mansoni infected children were enrolled and treated with single-dose PZQ. Stool samples analysis was done by thick smear Kato-Katz technique, and treatment efficacy was assessed at 3-weeks post-treatment. Safety was assessed within 4 h after PZQ intake. Plasma samples were collected at 4 h post-dose, and PZQ and trans-4-OH-PZQ concentrations were quantified using UPLCMS/MS. Genotyping for CYP3A4*1B, CYP3A5 (*3, *6, *7), CYP2C19 (*2, *3, *17), and CYP2C9 (*2, *3) were done by Real-Time PCR. The median age (range) of the study participants was 12 years (7-17). There was a significant association of CYP2C19 genotypes with PZQ concentrations and its metabolic ratio (trans-4-OH-PZQ/PZQ). PZQ concentration was significantly higher among CYP2C19 (*2, *3) carriers than CYP2C19 *1/*1 and CYP2C19 *17 carriers (ultra-rapid metabolizers) (p = 0.04). The metabolic ratio was significantly higher among CYP2C19*17 carriers than CYP2C19 (*2, *3) carriers (p = 0.01). No significant effect of CYP3A4, CYP3A5, CYP2C19, and CYP2C9 genotypes on treatment efficacy or adverse events were observed. Baseline infection intensity and CYP3A5 genotype were significant predictors of treatment associated-adverse events. In conclusion, CYP2C19 genotype significantly affects plasma PZQ concentration and its metabolic ratio. For the first time, we report the importance of pharmacogenetic variation for the treatment of schistosomiasis, a neglected tropical disease.
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Affiliation(s)
- Rajabu Hussein Mnkugwe
- Department of Clinical Pharmacology, School of Medicine, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania.,Division of Clinical Pharmacology, Department of Laboratory Medicine, Karolinska University Hospital-Huddinge, Karolinska Institutet, Stockholm, Sweden
| | - Omary Minzi
- Department of Clinical Pharmacy and Pharmacology, School of Pharmacy, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania
| | - Safari Kinung'hi
- National Institute for Medical Research (NIMR), Mwanza Research Centre, Mwanza, Tanzania
| | - Appolinary Kamuhabwa
- Department of Clinical Pharmacy and Pharmacology, School of Pharmacy, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania
| | - Eleni Aklillu
- Division of Clinical Pharmacology, Department of Laboratory Medicine, Karolinska University Hospital-Huddinge, Karolinska Institutet, Stockholm, Sweden
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20
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Giacomini KM, Karnes JH, Crews KR, Monte AA, Murphy WA, Oni-Orisan A, Ramsey LB, Yang JJ, Whirl-Carrillo M. Advancing Precision Medicine Through the New Pharmacogenomics Global Research Network. Clin Pharmacol Ther 2021; 110:559-562. [PMID: 34318925 DOI: 10.1002/cpt.2340] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2021] [Accepted: 06/04/2021] [Indexed: 12/16/2022]
Affiliation(s)
- Kathleen M Giacomini
- Department of Bioengineering and Therapeutic Sciences, University of California San Francisco, San Francisco, California, USA
| | - Jason H Karnes
- Department of Pharmacy Practice and Science, University of Arizona College of Pharmacy, Tucson, Arizona, USA
| | - Kristine R Crews
- Department of Pharmacy and Pharmaceutical Sciences, St Jude Children's Research Hospital, Memphis, Tennessee, USA
| | - Andrew A Monte
- Department of Emergency Medicine, University of Colorado School of Medicine, Aurora, Colorado, USA
| | - William A Murphy
- Division of Pharmacotherapy and Experimental Therapeutics, University of North Carolina Eshelman School of Pharmacy, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Akinyemi Oni-Orisan
- Department of Clinical Pharmacy, University of California San Francisco, San Francisco, California, USA
| | - Laura B Ramsey
- Division of Clinical Pharmacology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA.,Division of Research in Patient Services, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA.,Department of Pediatrics, University of Cincinnati, Cincinnati, Ohio, USA
| | - Jun J Yang
- Department of Pharmacy and Pharmaceutical Sciences, St Jude Children's Research Hospital, Memphis, Tennessee, USA
| | - Michelle Whirl-Carrillo
- Department of Biomedical Data Science, Stanford University School of Medicine, Stanford, California, USA
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21
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Langmia IM, Just KS, Yamoune S, Brockmöller J, Masimirembwa C, Stingl JC. CYP2B6 Functional Variability in Drug Metabolism and Exposure Across Populations-Implication for Drug Safety, Dosing, and Individualized Therapy. Front Genet 2021; 12:692234. [PMID: 34322158 PMCID: PMC8313315 DOI: 10.3389/fgene.2021.692234] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2021] [Accepted: 06/14/2021] [Indexed: 12/11/2022] Open
Abstract
Adverse drug reactions (ADRs) are one of the major causes of morbidity and mortality worldwide. It is well-known that individual genetic make-up is one of the causative factors of ADRs. Approximately 14 million single nucleotide polymorphisms (SNPs) are distributed throughout the entire human genome and every patient has a distinct genetic make-up which influences their response to drug therapy. Cytochrome P450 2B6 (CYP2B6) is involved in the metabolism of antiretroviral, antimalarial, anticancer, and antidepressant drugs. These drug classes are commonly in use worldwide and face specific population variability in side effects and dosing. Parts of this variability may be caused by single nucleotide polymorphisms (SNPs) in the CYP2B6 gene that are associated with altered protein expression and catalytic function. Population variability in the CYP2B6 gene leads to changes in drug metabolism which may result in adverse drug reactions or therapeutic failure. So far more than 30 non-synonymous variants in CYP2B6 gene have been reported. The occurrence of these variants show intra and interpopulation variability, thus affecting drug efficacy at individual and population level. Differences in disease conditions and affordability of drug therapy further explain why some individuals or populations are more exposed to CYP2B6 pharmacogenomics associated ADRs than others. Variabilities in drug efficacy associated with the pharmacogenomics of CYP2B6 have been reported in various populations. The aim of this review is to highlight reports from various ethnicities that emphasize on the relationship between CYP2B6 pharmacogenomics variability and the occurrence of adverse drug reactions. In vitro and in vivo studies evaluating the catalytic activity of CYP2B6 variants using various substrates will also be discussed. While implementation of pharmacogenomic testing for personalized drug therapy has made big progress, less data on pharmacogenetics of drug safety has been gained in terms of CYP2B6 substrates. Therefore, reviewing the existing evidence on population variability in CYP2B6 and ADR risk profiles suggests that, in addition to other factors, the knowledge on pharmacogenomics of CYP2B6 in patient treatment may be useful for the development of personalized medicine with regards to genotype-based prescription.
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Affiliation(s)
- Immaculate M. Langmia
- Institute of Clinical Pharmacology, University Hospital of Rheinisch-Westfälische Technische Hochschule Aachen, Aachen, Germany
| | - Katja S. Just
- Institute of Clinical Pharmacology, University Hospital of Rheinisch-Westfälische Technische Hochschule Aachen, Aachen, Germany
| | - Sabrina Yamoune
- Institute of Clinical Pharmacology, University Hospital of Rheinisch-Westfälische Technische Hochschule Aachen, Aachen, Germany
| | - Jürgen Brockmöller
- Department of Clinical Pharmacology, University Medical Center Göttingen, Georg-August University, Göttingen, Germany
| | - Collen Masimirembwa
- African Institute of Biomedical Science and Technology (AiBST), Harare, Zimbabwe
| | - Julia C. Stingl
- Institute of Clinical Pharmacology, University Hospital of Rheinisch-Westfälische Technische Hochschule Aachen, Aachen, Germany
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22
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Morse GD. Strategies for Implementation Research to Investigate the Negative Pharmacokinetic Interaction Between Efavirenz and Dolutegravir. Clin Infect Dis 2021; 72:1823-1825. [PMID: 32667998 DOI: 10.1093/cid/ciaa982] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2020] [Accepted: 07/09/2020] [Indexed: 11/12/2022] Open
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23
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Zhou DT, Mudhluli TE, Madhombiro M, Nyamhunga A, Matekaire-Chirimo R, Mudzviti T, Manasa J, Ma Q, Maponga CC, Morse GD. Emerging role for pharmacogenomics in HIV research in Africa. Future Virol 2021. [DOI: 10.2217/fvl-2020-0388] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
Tweetable abstract Pharmacogenomics (Pgx); the study of how genes affect drug response may optimize treatment by improving effectiveness and safety of medications. To apply current guidelines for African HIV-infected patients Pgx research is key.
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Affiliation(s)
- Danai Tavonga Zhou
- University of Zimbabwe, Faculty of Medicine & Health Sciences, Department of Pharmacy & Pharmaceutical Sciences, Medical Laboratory Sciences Unit, Box A 178, Avondale, Harare, Zimbabwe
| | - Taona Emmah Mudhluli
- University of Zimbabwe, Faculty of Medicine & Health Sciences, Department of Laboratory Diagnostic and Investigative Sciences, Medical Laboratory Sciences Unit, Box A 178, Avondale, Harare, Zimbabwe
| | - Munyaradzi Madhombiro
- University of Zimbabwe, Faculty of Medicine & Health Sciences, Department of Primary Health Care, Psychiatry Unit, Box A 178, Avondale, Harare, Zimbabwe
| | - Albert Nyamhunga
- University of Zimbabwe, Faculty of Medicine & Health Sciences, Department of Oncology, Radiology Unit, Box A 178, Avondale, Harare, Zimbabwe
| | - Ratidzo Matekaire-Chirimo
- University of Zimbabwe, Faculty of Medicine & Health Sciences, Department of Primary Health Care, Paediatrics Unit, Box A 178, Avondale, Harare, Zimbabwe
| | - Tinashe Mudzviti
- University of Zimbabwe, Faculty of Medicine & Health Sciences, Department of Pharmacy & Pharmaceutical Sciences, Box A 178, Avondale, Harare, Zimbabwe
| | - Justen Manasa
- University of Zimbabwe, Faculty of Medicine & Health Sciences, Department of Laboratory Diagnostic and Investigative Sciences, Medical Microbiology Unit, Box A 178, Avondale, Harare, Zimbabwe
| | - Qing Ma
- University at Buffalo, School of Pharmacy and Pharmaceutical Sciences, Center for Integrated Global Biomedical Sciences, NYS Center of Excellence in Bioinformatics and Life Sciences, 701 Ellicott Street, Buffalo, NY 14203-1101, USA
| | - Charles Chiedza Maponga
- University of Zimbabwe, Faculty of Medicine & Health Sciences, Department of Pharmacy & Pharmaceutical Sciences, Box A 178, Avondale, Harare, Zimbabwe
- University at Buffalo, School of Pharmacy and Pharmaceutical Sciences, Center for Integrated Global Biomedical Sciences, NYS Center of Excellence in Bioinformatics and Life Sciences, 701 Ellicott Street, Buffalo, NY 14203-1101, USA
| | - Gene D Morse
- University at Buffalo, School of Pharmacy and Pharmaceutical Sciences, Center for Integrated Global Biomedical Sciences, NYS Center of Excellence in Bioinformatics and Life Sciences, 701 Ellicott Street, Buffalo, NY 14203-1101, USA
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24
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Wenning L, Pillai GC, Knepper TC, Ilic K, Ali AM, Hibma JE. Clinical Pharmacology Worldwide: A Global Health Perspective. Clin Pharmacol Ther 2021; 110:946-951. [PMID: 33893656 DOI: 10.1002/cpt.2274] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2021] [Accepted: 04/07/2021] [Indexed: 11/06/2022]
Abstract
Low- and middle-income countries (LMICs) have the highest rates of mortality and morbidity globally, but lag behind high-income countries in the number of clinical trials and trained researchers, as well as research data pertaining to their populations. Lack of local clinical pharmacology and pharmacometrics expertise, limited training opportunities, and lack of local genomic data may contribute to health inequalities and limit the application of precision medicine. Continuing to develop health care infrastructure, including well-designed clinical pharmacology training and data collection in LMICs, can help address these challenges. International collaboration aimed at improving training and infrastructure and encouraging locally driven research and clinical trials will be of benefit. This review describes several examples where clinical pharmacology expertise could be leveraged, including opportunities for pharmacogenomic expertise that could drive improved recommendations for clinical guidelines. Also described are clinical pharmacology and pharmacometrics training programs in Africa, and the personal experience of a Tanzanian researcher currently on a training sabbatical in the United States, as illustrative examples of how training in clinical pharmacology can be effectively implemented in LMICs. These training efforts will benefit from advocacy for employment opportunities and career development pathways for clinical pharmacologists that are gradually being recognized and developed in LMICs. Clinical pharmacologists have a key role to play in global health, and development of training and research infrastructure to advance this expertise in LMICs will be of tremendous benefit.
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Affiliation(s)
| | - Goonaseelan Colin Pillai
- Division of Clinical Pharmacology, University of Cape Town, Cape Town, South Africa.,Pharmacometrics Africa, Cape Town, South Africa.,CP+ Associates GmbH, Basel, Switzerland
| | | | - Katarina Ilic
- Shire, a Takeda Company, Lexington, Massachusetts, USA
| | - Ali Mohamed Ali
- Department of Bioengineering and Therapeutic Science, University of California, San Francisco, California, USA
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25
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da Rocha JEB, Lombard Z, Ramsay M. Potential Impact of DPYD Variation on Fluoropyrimidine Drug Response in sub-Saharan African Populations. Front Genet 2021; 12:626954. [PMID: 33767731 PMCID: PMC7985174 DOI: 10.3389/fgene.2021.626954] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2020] [Accepted: 01/25/2021] [Indexed: 11/13/2022] Open
Abstract
Cancer is a critical health burden in Africa, and mortality rates are rising rapidly. Treatments are expensive and often cause adverse drug reactions (ADRs). Fluoropyrimidine treatments can lead to severe toxicity events which have been linked to variants within the dihydropyrimidine dehydrogenase (DPYD) gene. There are clinical guidelines to improve safety outcomes of treatment, but these are primarily based on variants assessed in non-African populations. Whole genome sequencing data from the 1000 Genomes Project and the African Genome Variation Project were mined to assess variation in DPYD in eight sub-Saharan African populations. Variant functional annotation was performed with a series of bioinformatics tools to assess potential likelihood of deleterious impact. There were 29 DPYD coding variants identified in the datasets assessed, of which 25 are rare, and some of which are known to be deleterious. One African-specific variant (rs115232898-C), is common in sub-Saharan Africans (1-4%) and known to reduce the function of the dihydropyrimidine dehydrogenase enzyme (DPD), having been linked to cases of severe toxicity. This variant, once validated in clinical trials, should be considered for inclusion in clinical guidelines for use in sub-Saharan African populations. The rs2297595-C variant is less well-characterized in terms of effect, but shows significant allele frequency differences between sub-Saharan African populations (0.5-11.5%; p = 1.5 × 10-4), and is more common in East African populations. This study highlights the relevance of African-data informed guidelines for fluorouracil drug safety in sub-Saharan Africans, and the need for region-specific data to ensure that Africans may benefit optimally from a precision medicine approach.
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Affiliation(s)
- Jorge E B da Rocha
- Faculty of Health Sciences, Sydney Brenner Institute for Molecular Bioscience, University of the Witwatersrand, Johannesburg, South Africa.,Division of Human Genetics, National Health Laboratory Service and School of Pathology, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Zané Lombard
- Division of Human Genetics, National Health Laboratory Service and School of Pathology, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Michèle Ramsay
- Faculty of Health Sciences, Sydney Brenner Institute for Molecular Bioscience, University of the Witwatersrand, Johannesburg, South Africa.,Division of Human Genetics, National Health Laboratory Service and School of Pathology, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
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26
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B. Tata E, A. Ambele M, S. Pepper M. Barriers to Implementing Clinical Pharmacogenetics Testing in Sub-Saharan Africa. A Critical Review. Pharmaceutics 2020; 12:pharmaceutics12090809. [PMID: 32858798 PMCID: PMC7560181 DOI: 10.3390/pharmaceutics12090809] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2020] [Revised: 08/19/2020] [Accepted: 08/22/2020] [Indexed: 12/14/2022] Open
Abstract
Clinical research in high-income countries is increasingly demonstrating the cost- effectiveness of clinical pharmacogenetic (PGx) testing in reducing the incidence of adverse drug reactions and improving overall patient care. Medications are prescribed based on an individual’s genotype (pharmacogenes), which underlies a specific phenotypic drug response. The advent of cost-effective high-throughput genotyping techniques coupled with the existence of Clinical Pharmacogenetics Implementation Consortium (CPIC) dosing guidelines for pharmacogenetic “actionable variants” have increased the clinical applicability of PGx testing. The implementation of clinical PGx testing in sub-Saharan African (SSA) countries can significantly improve health care delivery, considering the high incidence of communicable diseases, the increasing incidence of non-communicable diseases, and the high degree of genetic diversity in these populations. However, the implementation of PGx testing has been sluggish in SSA, prompting this review, the aim of which is to document the existing barriers. These include under-resourced clinical care logistics, a paucity of pharmacogenetics clinical trials, scientific and technical barriers to genotyping pharmacogene variants, and socio-cultural as well as ethical issues regarding health-care stakeholders, among other barriers. Investing in large-scale SSA PGx research and governance, establishing biobanks/bio-databases coupled with clinical electronic health systems, and encouraging the uptake of PGx knowledge by health-care stakeholders, will ensure the successful implementation of pharmacogenetically guided treatment in SSA.
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Affiliation(s)
- Emiliene B. Tata
- Institute for Cellular and Molecular Medicine, Department of Immunology, and South African Medical Research Council Extramural Unit for Stem Cell Research & Therapy, Faculty of Health Sciences, University of Pretoria, Pretoria 0084, South Africa; (E.B.T.); (M.A.A.)
| | - Melvin A. Ambele
- Institute for Cellular and Molecular Medicine, Department of Immunology, and South African Medical Research Council Extramural Unit for Stem Cell Research & Therapy, Faculty of Health Sciences, University of Pretoria, Pretoria 0084, South Africa; (E.B.T.); (M.A.A.)
- Department of Oral Pathology and Oral Biology, Faculty of Health Sciences, School of Dentistry, University of Pretoria, PO BOX 1266, Pretoria 0001, South Africa
| | - Michael S. Pepper
- Institute for Cellular and Molecular Medicine, Department of Immunology, and South African Medical Research Council Extramural Unit for Stem Cell Research & Therapy, Faculty of Health Sciences, University of Pretoria, Pretoria 0084, South Africa; (E.B.T.); (M.A.A.)
- Correspondence: ; Tel.: +27-12-319-2190
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