Dott. Davide SeripaBiologo Dirigente di Ricerca

Laboratorio di Gerontologia-Geriatria

ISTITUTO DI RICOVERO E CURA A CARATTERE SCIENTIFICO

Ospedale “Casa Sollievo della Sofferenza”

Opera di San Pio da PietrelcinaSan Giovanni Rotondo (FG)

http://www.operapadrepio.it

Farmacogenetica e farmacogenomicanell’anziano

In VI century B.C. Pythagoras reported that the adverse reaction to the ingestion of fava beans was attributable to a inter-individual differences!

Ad personam optimization of drug treatments

1866: Mendel establishes rules of heredity.

1959: Vogel coins the term pharmacogenetics (how genetics may influence drug response).

1962: Kalow publishes the first monograph on pharmacogenetics.

1987: First nomenclature of Cytochrome P450 (CYP) gene superfamily.

1988: Gonzalez and Meyer collaborate to clone CYP2D6 and characterize the genetic defect of the debrisoquine/sparteine polymorphism.

1997: The term pharmacogenomics first appears in the literature.

2003: The human genome sequence was completed.

(Meyer, Nature Rev Genet 2004;5:669-676)

Future prospects for pharmacogenetics in the quest of personalized medicine

(Howland, J Psychosoc Nurs Ment Health Serv 2012;50:13-16)

The potential role of genome and its mechanism of maintenance, interactions and modifications in

pharmacogenetics and adverse drug reactions is immense… but immense is complexity than assessing

the role of a SNP.

Pharmacogenomics: challenges and opportunities(Roden, Ann Internal Med 2006;145:749-757)

Small effect

Large effect

Single gene Whole genomeSmall numberof genes

Great numberof genes

Pharmacogenetics

Pharmacogenomics

We are here!

Evolution of the Cytochrome P450 (CYP)gene superfamily

La vitaconquista

l’ambiente terrestre

Gli animalidiventano erbivori,

assumono tossine vegetali,e muoiono.

Innescodella pressione selettiva

Duplicazione dei 3 geniCYP ancestrali

CYP3A3CYP3A4CYP3A5CYP3A5P1CYP3A5P2

Chromosome 7

CYP2C8CYP2C9CYP2C18CYP2C19

Chromosome 10 Chromosome 22

CYP2D6CYP2D7PCYP2D8P

Evidence for the evolution of CYP gene superfamilyby gene duplications

CYP3A420 allele families / 41 alleles

CYP2D673 allele families / 120 alleles

CYP2C934 allele families / 41 alleles.

CYP2C1926 allele families / 32 alleles.

Variability of the CYP gene superfamily

(*) Human Cytochrome P450 (CYP) Allele Nomenclature Committee (http://www.imm.ki.se/CYPalleles/)

Nomenclatura per gli alleli (isoenzimi) del Citocromo P450 (CYP)secondo il Comitato Internazionale per la Nomenclatura degli alleli del Citocromo 450 (*)

Maggiori famiglie geniche del CYP

Famiglia CYP1: CYP1A1; CYP1A2; CYP1B1

Famiglia CYP2: CYP2A6; CYP2A13; CYP2B6; CYP2C8; CYP2C9; CYP2C19; CYP2D6; CYP2E1;

CYP2F1; CYP2J2; CYP2R1; CYP2S1

Famiglia CYP3: CYP3A4; CYP3A5; CYP3A7; CYP3A43

Famiglia CYP4: CYP4A11; CYP4A22; CYP4B1

Nomenclature of the CYP gene superfamily

CYP Citocromo P450 (superfamiglia genica)

2 Questo numero identifica la famiglia del gene

D Questa lettera identifica la sottofamiglia del gene

6 Questo numero identifica il gene specifico (l’isoenzima proteico)

* Tutto quello dopo l’asterisco riguarda l’identificazione dell’allele

4 Questo numero identifica la famiglia allelica

A Questa lettera identifica l’allele specifico

Is not a chance if most of drugs currently used in clinical practice are lipofilic compound derived from plant metabolites, and if about 80% of

these drugs are metabolized by the CYP system.

Substrates of the CYP gene system

0 1 2 3 4

Association between CYP2C9 genetic variants and warfarin-related outcomes

1.40

2.39

1.8

CYP2C9*3 (I359L)(Lindh, Clin Pharm Ther 2005)

2.2

CYP2C9*2 (R144C)(Higashi, JAMA 2002)

CYP2C9 *1/*1 wild type

2.57CYP2C9*2 or *3 (R144C or I359L)(Margaglione, Thromb Haemost 2000)

CYP2C9*3 (I359L)(Higashi, JAMA 2002)

CYP2C9*2 (R144C)(Lindh, Clin Pharm Ther 2005)

Severebleedin

g

Risk ofbleedin

g

Nobleedin

g

Vitamin K Oxide Reductase Complex 1 (VKORC1) polymorphisms and warfarin dose

(Rieder, NEJM 2005;352: 2285-93)

A = low-dose haplotype group B = high-dose haplotype group

A genome-wide association study confirms VKORC1, CYP2C9 and CYP4F2 as

principal genetic determinants of warfarin dose

The first genome-wide association study (GWAS) on 1053 Swedish subjetcts (325.997 SNPs). The results were confirmed in 588

additional swedish patients (p < 0.0029)(Takeuchi, PLos Genet 2009;5:e1000433)

CYP2C9 and VKORC1

genotypes explain about 30-40% of the

total variation in the final warfarin

dose

The International Warfarin Pharmagenetics Consortium

Estimation of the warfarin dose with clinical and pharmacogenetic data

(New Engl J Med 2009;361:753-764)

Derivation cohort = 4043 subjectsValidation cohort = 1009 subjects

Warfarin genotyping reduces hospitalization rates(Epstein, J Am Coll Cardiol 2010;55:2804-2812)

~ 900 patients with information on CYP2C9

and VKORC1 available to prescribing physicians

versus historical control group

6 months after the initiation of warfarin

therapy, hospitalizations for hemorrhage were

28% less common in the intervention than in

control group

Association of Cytochrome P4502C19 genotype with the antiplatelet effect and clinical efficacy of Clopidogrel

(Shuldiner, JAMA 2009;302:849-858)

rs12777823 polymorphism CYP2C19*2 variant in 227 patients undergoing percutaneous coronary intervention treated for 1-year with clopidogrel

p=0.02 p=0.02; HR=2.42,95%CI 1.18-4.99

0.2 1 2 3 4

Reduced-function CYP2C19 genotype and risk of adverse outcomes in patients treated with clopidogrel

(Mega, JAMA 2010;304:1821-1830)

1.55

Meta-analysis of 9 studies evaluating 9685 patients (91.3% with PIC and 54.5% with acute coronary syndrome)

1.76

2.67

3.97

Risk of stent

thrombosisCYP2C19*2/*2

CYP2C19*1/*2

CYP2C19*2/*2

CYP2C19*1/*2 Risk of CV, MI or

stroke

February 2010The FDA revised the label on Warfarin providing

genotype-specific ranges of doses and suggesting that genotypes be taken into consideration

when the drug is prescribed.

The FDA added a boxed warning to prescribing information for clopidogrel:

“persons with a CYP2C19 variant encoding a form of the enzyme associated with a low rate of

metabolism might require dose adjustment or the use of a different drug”

FDA Drug Safety Communication(Available at URL http://www.fda.gov/)

I FANS e l’emorragia gastroduodenale

CYP2C9 genotyping may identify subgroups of persons who potentially are at increased risk of gastroduodenal bleeding when treated with NSAIDs

metabolized by CYP2C9.

Reclutati(n = 78)

Bleeding(n = 26)

No bleeding(n = 52)

Allele SNP-ID DNA change

Protein change

Enzyme activity

CYP2C9*2 rs1799853 C430T Arg144Cys Decreased

CYP2C9*3 rs1057910 A1075C Ile359Leu Decreased

p = 0.034OR = 4.2 (1.1 - 16.2)

Reference

p < 0.001OR = 15.8 (1.1 - 16.2)

I FANS e l’emorragia gastroduodenale

1) Lo SNP rs1080985 nel gene CYP2D6 può influenzare l’efficacia clinica del donepezil in pazienti con malattia di Alzheimer di grado lieve/moderato.

2) L’analisi dei genotipi del CYP2D6 può essere utile per identificare sottogruppi di pazienti con differente risposta terapeutica.

Il donepezil nel trattamento dell’Alzheimer

• Mantenimento o miglioramento dello stato cognitivo (valutato tramite ADAS-Cog e MMSE)

• Miglioramento dello stato funzionale (valutato tramite ADL o IADL)

http://medicine.iupui.edu/clinpharm/ddis/table.asp

Inibitori del CYP2D6Fenocopia

(rispetto EM)Induttoridel CYP2D6

Fenocopia(rispetto EM)Forti Moderati Deboli

Bupropion Duloxetine Amiodarone PM Dexamethasone UM

Fluoxetine Sertraline Cimetidine PM Rifampin UM

Paroxetine Terbinafine PM

Quinideine PM

FenocopiaUn fenotipo che somiglia ad un fenotipo genetico ma che ha cause ambientali.

Le fenocopie

Multicenter, 415 AD patients, donepezil 10mg/day, 6 months follow-up

Responders = 172; Non-responders = 243-----

Multivariate analysis corrected for age, gender, MMSE at baseline, APOE-ε4 status.

Results confirm the association between rs1080985 and response to donepezil after 6

months of treatment

p < 0.05; OR 1.74, 95% CI 1.01-3.00

Replication study confirm the role of CYP2D6 polymorphism rs1080985 on donepezil efficacy in Alzheimer’s disease patients

(Albani, J Alzheimers Dis 2012;30:745-749)

Il donepezil nel trattamento dell’Alzheimer

Da 552 pazienti arruolati nello studiosono stati selezionati 37 responders e 19 non-respondersp = 0.005; OR = 6.286 (1.828 - 21.667). Potenza dell’analisi = 84.87%.

Pharmacogenomic protocols in CNS disorders and dementia(Cacabelos, Neurodegenerative Dis 2010;7:167-169)

These data clearly indicate that the incorporation of pharmacogenomic protocols to dementia reserach

and clinical trials can foster therapeutics optimization by helping to develop cost-effective pharmaceuticals and improve drug eccicacy and

safety

About 25% of the 100 most prescribed drugs in USA and western countries are psychotropic drugs currently used in dementia.

A trigenic cluster integrating CYP2D6+CYP2C19+CYP2C9 polymorphic variants yealds 82 different genetic profiles in wich

only 26% are normal (EM).

Pharmacogenetics of risperidone and haloperidolCYP2D6 genotype and plasma concentration of psychotropic drugs

RISPERIDONE(Scordo, Psychopharmacology 1999;147:300-305)

p<0.01

HALOPERIDOL(Bertilsson, Br J Clin Pharmacol 2002;53:111-122)

Defining the opportunity for pharmacogenetic intervention in primary care

(Grice, Pharmacogenomics 2006;7:61-65)

607 patients in primary care (USA), 16 drugs cause ADRs

28.6% took > 1 of pharmacogenetic ADR-associated drugsRisk factors for ADRs: - Old age (p<0.001); Chronic disease (p<0.001); Number of drugs (p<0.001)

Farmacogenetica dell’analgesia post-operatoria- protocolli terapeutici -

LieveL1

L2

ModeratoM1

M2

Grave G

Dol

ore

post

-ope

rato

rio

  Protocollo terapeutico  L1 L2 M1 M2 GArtrosilene X X X X XZantac X X X X XContramal X X X X XPlasil X X X X XFentanest - - - A volte -Morfina - - - - X

40 pazienti consecutivi interapia antidolorifica post-operatoria

Farmacogenetica dell’analgesia post-operatoria- protocolli terapeutici, farmaci e citocromi -

EM versus IM: p = 0.015 – EM versus PM: p = 0.024 – IM vs PM: p < 0.001

Farmacogenetica dell’analgesia post-operatoria- risposta terapeutica e fenotipo metabolico -

Farmacogenetica dell’analgesia post-operatoria- considerazioni -

1. La sovrapposizione di substrati suggerisce che, probabilmente, in questi protocolli terapeutici non si ottiene una piena azione dei diversi farmaci (come se venissero usati singolarmente!).

2. La concomitante presenza di un azione inibitoria dei substrati verso l’enzima suggerisce un ulteriore diminuzione dell’azione dei diversi farmaci.

3. Visto che i protocolli terapeutici differiscono solo per il dosaggio dei diversi farmaci, come è possibile valutare con accuratezza l’effetto terapeutico dei diversi protocolli?

4. Queste considerazione suggeriscono con forza:

a) L’impiego di un farmaco principale che non abbia una concomitante azione inibitoria per l’enzima;

b) L’impiego di farmaci secondari che non presentino una sovrapposizione dei substrati con il farmaco principale.

5. In questo caso si otterrebbe:

a) Una piena azione farmacologica;

b) La possibilità di identificare e studiare in maniera inequivocabile la risposta al trattamento terapeutico, incluse le reazioni avverse.

0.2 1 3 5 7

Erythromycin1.79

1.48

5.35

CYP3A4 INHIBITORS(nitroimidazole antifungal agents, diltiazem, verapamil, troleandomycin)

Amoxicillin

Erythromycin + CYP3A4 inhibitors

? ?

?

I

II

1 2

1

CYP2D6*1/*XN

2

Although CYP2D6 metabolizes paracetamol into NAPQI (N-acetyl-p-benzoquinone imine) to a lesser extent than other P450 enzymes, its activity may contribute to paracetamol toxicity in extensive and ultrarapid metabolizers.

Pharmacogenetics of acetaminophen

Challenges and measures in PGx development(Gurwitz, Public Health Genomics 2009; 12: 134-41)

Public Health Genomics

Pharmacogenetics in Europe: Barriers and OpportunitiesEuropean Commission Joint Research Center

Current Drug Metabolism 2011:12;621-634

Pharmacogenetics in Geriatric Medicine: Challenges and Opportunities for Clinical Practice

Alberto Pilotto, Francesco Panza, and Davide Seripa

In clinical practice several factors may explain the variable response to drug treatments, including functional and cognitive disabilities, malnutrition, organ-specific failures, concomitant diseases, and concomitant therapies. This may seriously limiting the pharmacogenetic approach to drug prescription.Geriatric patients need a multidimensional approach to optimize their clinical care including treatments. The introduction in clinical practice of pharmacogenetics may be useful to improve the “clinical decision making” in drug treatments.

PHARMACOGENETICS AS A “DOMAIN” OF THE MULTIDIMENSIONAL ASSESSMENT

La farmacogenetica nella clinica geriatrica- prospettive future-

Davide Seripa(dseripa@operapadrepio.it)

Laboratorio di Gerontologia-GeriatriaSig.ra Carolina Gravina

Sig.ra Maria UrbanoDott.ssa Giulia Paroni

Dott.ssa Grazia D’OnofrioDott. Alberto Pilotto

U.O.C. di GeriatriaDott. Antonio Greco

Laboratorio Analisi ClinicheDott. Lazzaro Di Mauro

Sig.ra Antonietta P. Gallo

Rianimazione 1Dott.ssa Paola Latina

U.O.C. NeurologiaPoliclinico Universitario “A. Gemelli”

Prof. Carlo MasulloDott. Antonio Daniele

Istituto di Gerontologia e GeriatriaUniversità degli Studi di Perugia

Prof.ssa Patrizia Mecocci