H Schneider - Why are therapeutic drugs ineffective in some people and toxic in others?

Why are therapeutic drugs ineffective in

some people and toxic in others?
Hans G Schneider

Clinical Professor of Medicine & Immunology

Director of Pathology & Head of Biochemistry
Alfred Pathology Service

Therapeutic Drugs
• Therapeutics- treatment and care of a
patient for the purpose of both
preventing and combating disease or
alleviating pain or injury. The term
comes from the Greek therapeutikos,
which means “inclined to serve.”

Principles of clinical Pharmacology

• interindividual variability in the response to pharmacologic agents
• plasma drug levels can vary more than 1000-fold when the same drug
dose is administered to two individuals having approximately the same
weight (Eur J Pharmacol. 2000;410:121)
• Contributors
– patient related factors- sex, age, disease state (ie, renal and hepatic function)
and pregnancy
– drug-food interactions, drug-drug interactions
– genetic factors
• Chain of events between administration of a drug and production of the
effect can be divided in 2 phases
• Both contribute to variability of effect
• 1. delivery and removal of drug from target- relationship between drug
concentration and time
• 2. processes that determine variability of effect with the same delivery to
effector sites
Harrison’s Principles of Internal Medicine 2012, Uptodate 2015

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H Schneider - Why are therapeutic drugs ineffective in some people and toxic in others?

Premise The pharmacologic response correlates with the

concentration of the drug at the site of action.

Therapeutic Ratio

Pharmacokinetics
from pharmakon "drug" and kinetikos "moving
• what the “body does to a drug”
• refers to the movement of drug into,
through, and out of the body—the time
course of its absorption, bioavailability,
distribution, metabolism, and excretion.
• depends on patient-related factors
• Depends on chemical properties of the
drug
http://www.msdmanuals.com/en-au/professional/clinical-
pharmacology/pharmacokinetics/overview-of-pharmacokinetics and wikipedia

Pharmacodynamics
• relationship between drug concentration at the site of
action and the resulting effect
• Modification of activity by
– Local blood flow
– Receptor concentration
– Post receptor signalling
– Other gene translation affecting sensitivity
– Protein production in the target cell
• This causes variability to drug effect from one
individual to another, for example it might cause
increased effectiveness or tolerance to drug effects

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H Schneider - Why are therapeutic drugs ineffective in some people and toxic in others?

Why are therapeutic drugs ineffective

in some people?
• Adherence- “the extent to which a person’s behaviour –
taking medications, following diet and/or executing lifestyle
changes – corresponds with agreed recommendations from a
health care provider” (WHO 2004)
• adherence to long-term therapy for chronic illness in
developed countries averages 50% (lower in developing
countries)
• Inadequate adherence leads to
– poor patient outcomes
– increased health care costs
• diminishes the effectiveness of improvements in and access to
medications

Wilczynski N et al. Interventions for enhancing medication adherence

(Review) Cochrane Review 2014

• RCTs of interventions to improve adherence with prescribed medications, measuring both

medication adherence and clinical outcome, > 80% follow-up of each group studied and, for
long-term treatments, > 6 months follow-up for studies with positive findings at earlier time
points.
• studies differed widely - qualitative analysis with focus on the RCTs with lowest risk of bias
• heterogeneous for patients, medical problems, treatment regimens, adherence
interventions, and adherence and clinical outcome measurements (most had high risk of
bias)
• Of 182 RCTs, 17 had the lowest risk of bias (six old)
• generally involved complex interventions with multiple components, means of tailored
ongoing support from allied health professionals such as pharmacists, who often delivered
intense education, counseling (including motivational interviewing or cognitive behavioral
therapy by professionals) or daily treatment support (or both), and sometimes additional
support from family or peers.
• Only five of these RCTs reported improvements in both adherence and clinical outcomes,
and no common intervention characteristics were apparent.
• Even the most effective interventions did not lead to large improvements in adherence or
clinical outcomes. Effects were inconsistent from study to study.
• Current methods mostly complex and not very effective,

Ratain MJ, Plunkett WK Jr. Principles of Pharmacokinetics. In: Kufe DW, Pollock RE,
Weichselbaum RR, et al., editors. Holland-Frei Cancer Medicine. 6th edition.
Hamilton (ON): BC Decker; 2003. Available from:
http://www.ncbi.nlm.nih.gov/books/NBK12815/ Courtesy of George Howell III, Ph.D

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H Schneider - Why are therapeutic drugs ineffective in some people and toxic in others?

Volume of Distribution
• amount of blood, per Kg
body weight, necessary to
contain all of the body
burden of drug
• A complex concept as it can
be very much larger than
actual body volume
• C0= D0 x f/Vd
– C0 blood concentration
– f bioavailability
– D0 amount given If kd = 0, Vd = 0.07 L/Kg (lower limit)
In very lipophilic drugs, Vd upto  100 L/Kg
• Vd = D0 x f/ C0

Compartment Models

Absorption
• Bioavailability • Gastric pH, pKa
(AUCoral/AUCiv) • Lipid solubility
• dissociation • GI motility
• dissolution in gastric j. • GI vascularity
• diffusion across • First pass metabolism
membranes • Rate of absorption
– generally first order
– newer sustained release
formulations

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H Schneider - Why are therapeutic drugs ineffective in some people and toxic in others?

Azol Drug Monitoring

• antifungal prophylaxis in • the azoles that are
the heavily available for systemic use
immunesuppressed can be classified into two
patient- HLTx, BMTx, groups: the
Neutropenic after high • triazoles
dose chemotherapy – Fluconazole
– Itraconazole
– Voriconazole
– posaconazole
• imidazoles
– ketoconazole

Antifungal Drugs
triazole family includes fluconazole, itraconazole, voriconazole, posaconazole, and isavuconazole

Voriconazol Posaconazol
• oral bioavailability >90% • Absorption increases with
• reduced by approximately meal (esp high fat)
30% with a high fat meal • impaired in GI tract disruption
(eg, GVHD)
• take fasting
• delayed-release tablets better
• intravenous preparation is better absorption with more
limited to patients who frequent administration (four
have CrCl >50 mL/min. daily dose versus two--serum
• large VD(4.6 L/kg) and ability concentration higher)
to penetrate into the CSF • Absorption saturates (800
mg/day)

Distribution
• After entering vascular • Plasma protein binding-
compartment free and protein bound
• binding to circulating drug
blood components • acidic drugs- albumin
• binding to fixed • basic drugs- globulins (a1-
receptors acid glycoprotein AAG)
• passage through • relative affinity of binding,
membrane barriers competition
• ability to dissolve in • fatty acids, pH, uremia
structural or storage
• decreased albumin
lipids

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H Schneider - Why are therapeutic drugs ineffective in some people and toxic in others?

Liver
(clearance and biotransformation)
• selective uptake- concentration- metabolism- excretion

• majority of drugs absorbed are lipophilic and water-insoluble

• rendered water-soluble via hepatic metabolism
• excreted in the bile or renally filtered

• hepatically metabolized predominantly through two

mechanisms
– phase I- oxidation, reduction, hydrolysis
– phase II reactions - conjugation to increase water solubility
(glucuronidation, acetylation, sulfation, glutathionidation etc.)
– phase III reactions (excretory transporters on either the canalicular or
sinusoidal membranes)

Phenytoin Metabolism

Principles of Pharmacology. 3rd Ed. LWW

Courtesy of George Howell III, Ph.D

Physiology
• Hepatic blood flow
– CHF, cirrhosis, hypotension, large blood loss
– food intake
• Enzyme activity
– enzyme inhibitors, liver disease, drug concentration
high, interaction
– induction
• Fraction unbound
– elevated protein, hypoproteinemia
– drug displacement from protein

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H Schneider - Why are therapeutic drugs ineffective in some people and toxic in others?

Cytochrom P450 enzymes (CYP)

• about 60 genes coding for CYP proteins
• Mainly cytoplasmic side of the membrane of the endoplasmic
reticulum (microsomal-type)
• P450 3A4 (CYP3A4)
– 3 = number of the enzyme family
– A = letter of the subfamily
– 4 = specifies specific enzyme
• Drug metabolism in liver by CYP1, CYP2, and CYP3 families,
small contribution CYP4
• CYP3A4
– ~50% of all therapeutic drugs metabolized by CYP3A4
– induced or inhibited by a variety of compounds
– significant drug interactions

Zanger UM, Schwab M. Cytochrome P450 enzymes in drug metabolism: Regulation of gene expression,
enzyme activities, and impact of genetic variation. Pharmacology & Therapeutics 138 (1) 103–141 (2013)

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H Schneider - Why are therapeutic drugs ineffective in some people and toxic in others?

HYDROXYLATION POLYMORPHISMS
• Debrisoquine (old
antihypertensive) –
CYP2D6
– 5-10% most
populations are poor
metabolizers (1-2%
Chinese, Japanese)
– Approximately 15
variants of CYP2D6
– Multiple gene copies
• Lundqvist E, et al. 1999 Gene 226, 327–338.
• Voronov P, Przybylo HJ, Jagannathan N. 2007 A
pnea in a child after oral codeine: a genetic
variant—an ultrarapid metabolizer. Paediatr.
Anaesth. 17, 684–687

Pharmacogenomics
• Majority of drug-metabolizing enzymes polymorphic
causing important interindividual differences in drug
and metabolite exposure and
• Several databases containing pharmacogenetic
information on web (see Genomics Proteomics
Bioinformatics. 2015 Feb; 13(1): 51–54)
• gene copy number variation (gene amplification,
deletion, small insertions and deletions, SNPs)
• Many GWA studies show importance, but not currently
included in management plans
• Specific genetic studies sometimes included in
management plans

SC Sim, M Kacevska and M Ingelman-Sundberg. The Pharmacogenomics Journal (2013), 1 – 11

SC Sim, M Kacevska and M Ingelman-Sundberg. The Pharmacogenomics Journal (2013), 1 – 11

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H Schneider - Why are therapeutic drugs ineffective in some people and toxic in others?

TPMT, thiopurine S-methyltransferase; HPRT, hypoxanthine-guanine phosphoribosyltransferase.

Peter Karran & Natalie Attard Nature Reviews Cancer 8, 24-36 (January 2008)

• Enzyme activity distribution population dependent

• 89-94% of individuals high activity
• 6-11% intermediate activity
• Approx. 0.3% low activity.
• Causes marked toxicity (myelosuppression)

TPMT
• ? Optimal way of testing
• Alfred Pathology- Start with Phenotype (WA)
• Evaluate abnormal phenotype with genotype
• 6-thioguanin (6-TG) and 6- mercaptomethylpurine
(6-MMP) predictive of myelotoxicity versus liver
toxicity
• Alfred Data in Inflammatory Bowel Disease control
encouraging
• Uptodate recommendations undecided
Sparrow MP et al Aliment Pharmacol Ther 2005; 22:441, Sparrow MP et al Clin Gastroenterol
Hepatol 2007; 5:209, Rahhal RM, Bishop WPInflamm Bowel Dis 2008; 14:1678, Haines ML et al.
Inflamm Bowel Dis. 2011;17(6):1301.

Excretion Kidney(Renal Clearance)

• Renal plasma flow (GFR)

– pregnancy, excess fluid intake
– renal disease, dehydration, shock, CCF
• Secretion carrier activity
– renal disease, competition for carrier
• Urine pH
– alkalisation, drugs or systemic alkalosis
– acidifying agents (NH4Cl, Salicylates)
• Urine Flow

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H Schneider - Why are therapeutic drugs ineffective in some people and toxic in others?

The Steady State

Peak
Plasma drug concentration

Therapeutic range

Trough

dose d d d d d d
Time

Digoxin

Digoxin
• Main indications • 2 compartment model
– Heart failure • High Vd 4-7 l/kg, distribution
– Atrial Fibrillation phase about 8-12 hours - Heart,
• Narrow therapeutic window kidneys, skeletal muscles
• Variability in patients with same – Acute iv 0.25-0.5 mg every 6 hours
dose – After iv loading effect within 15-30
min, peak 1-5 hours
• Absorption 70-80%
• Half-life 36-48 hrs
• 20 to 30% bound to albumin
• dependant on renal function
• Bacterial metabolism 40%
– Ethnic differences
• 25 -28% eliminated via nonrenal
routes
– Effect of antibiotics
• Drug interactions
– Inhibitors of P-glycoprotein efflux
transporters (eg, amiodarone and
others) can increase
– Inducers of P-glycoprotein (eg,
dexamethasone, and others)

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H Schneider - Why are therapeutic drugs ineffective in some people and toxic in others?

Cyclosporin
• Hepatic Metabolism
(cP450): > 30 metabolites
• Major Metabolites – AM1
(major active), AM9,
AM4N, AM19
• Significant Intra & Inter
individual variation in
Drug/ Metabs ratio
• Metabolism inhibited by
drugs such as
ketoconazole,
voriconazole, diltiazem,
erthromycin

Slide courtesy M Black

MRM- Multiple Reaction Monitoring

Static : Multiple Reaction Monitoring

Signal Response

Signal Response

Collision Cell
MS1 (Collision Gas, MS2
(STATIC RF & DC) Collision energy & RF) (STATIC RF & DC)

m/z 821.5 Tacrolimus

Span m/z 768.5
Spanproduct ion
x y x y

NB: These graphs represent Quad transmission only and do not

represent the scans visible on the software!
32
Waters Corporation

Everolimus- Alfred Patient Correlation

2009

LCMSMS = 0.4775 FPIA + 1.125, R2 = 0.79 n = 67

Alfred Everolimus Correlation
(n = 67)
Linear fit (1.125 +0.4775x)

95% CI
20

95% Prediction interval

15
LCMSMS (ug/L)

10

0
0 5 10 15 20

Abbott TDx (ug/L)

33

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H Schneider - Why are therapeutic drugs ineffective in some people and toxic in others?

Paracetamol
(Acetaminophen, N-acetyl-p-aminophenol, APAP)

• widely used over-the-counter pain medication

• to reduce fever, for headaches (good evidence,
combination with caffeine), other minor aches
and pains, in many cold medications
• combination with opioid analgesics in the
management of more severe pain
• not classified as an NSAID
• WHO Model List of Essential Medicines (list of the
most important medications needed in a basic health system)
• poisoning is among the most common causes of
medication-related poisoning and death

Paracetamol (US Acetaminophen)

Sood S et al. J Gastroenterol Hepatol. 2013 Aug;28(8):1356-60.

• 14,662 hospital admissions for

paracetamol overdose (2000-
2007, mean 2095 cases/year)
• Accidental overdoses 15% (n =
2149) of cases
• overdoses in women (71%),
• 15 and 50 years 78% of all
• 26 deaths directly attributable to
paracetamol
Mechanism of Injury
• With normal doses mainly
glucuronidation and sulfation
• N-acetyl-p-benzoquinoneimine
(NAPQI)
• Phenobarbital, Phenytoin effect on
UGT, INH, ETOH on CYP2E1
https://en.wikipedia.org/wiki/Paracetamol

Paracetamol Mechanism of Injury

• Saturation of sulfation and glucuronidation with higher doses
• NAPQI conjugated with hepatic glutathione to cysteine and mercaptate
compounds
• once hepatic glutathione stores depleted by 70 to 80%
• NAPQI binds mitochondrial proteins and ion channels, loss of energy production,
ion misbalance → cell death
• initial manifestations of acetaminophen poisoning are often mild and nonspecific,
and do not reliably predict subsequent hepatotoxicity
• Laboratory: acute in onset, marked elevation of plasma aminotransferases (>3000
IU/L), associated coagulopathy
• DD: alcoholic hepatitis, other drug- or toxin-induced hepatitis, viral hepatitis,
hepatobiliary disease, Reye's syndrome, and ischemic hepatitis ("shock liver")
• Early measurement of paracetamol level (nomogram) and initiation oif
detoxification
• N-acetylcysteine for all patients at significant risk for hepatotoxicity
• Serious hepatotoxicity is uncommon and death extremely rare if N-acetylcysteine
is administered within eight hours following overdose

Modified from Uptodate

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