Mol Diag Ther 2007; 11 (2): 97-104

RESPIRATORY DISORDERS 1177-1062/07/0002-0097/$44.95/0

© 2007 Adis Data Information BV. All rights reserved.

Treatment Heterogeneity in Asthma

Genetics of Response to Leukotriene Modifiers
John J. Lima
Nemours Children’s Clinic, Centers for Clinical Pediatric Pharmacology & Pharmacogenetics, Jacksonville, Florida, USA

Contents

Abstract . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 97
1. Asthma Burden . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 98
2. Pharmacogenetics and Response Variability . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 98
3. Pharmacotherapy of Leukotriene (LT) Modifiers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 98
3.1 LT Modifiers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 98
3.2 LT Modifier Use in Asthma . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 99
4. Genetic Basis for Treatment Heterogeneity to LT Modifers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 99
4.1 Consequences of Genetic Variation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 99
4.2 Pharmacodynamic Consequences of Genetic Variants in LT Pathway . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 100
4.3 Pharmacokinetic Consequences of Genetic Variation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 101
5. Future Studies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 102

Abstract Despite advances in treatment, asthma continues to be a significant health and economic burden. Although
asthma cannot be cured, several drugs, including β2 agonists, corticosteroids, and leukotriene (LT) modifiers,
are well tolerated and effective in minimizing symptoms, improving lung function, and preventing exacerba-
tions. However, inter-patient variability in response to asthma drugs limits their effectiveness. It has been
estimated that 60–80% of this inter-patient variability may be attributable to genetic variation. LT modifiers, in
particular, have been associated with heterogeneity in response. These drugs exert their action by inhibiting the
activity of cysteinyl leukotrienes (CysLTs), which are potent bronchoconstrictors and pro-inflammatory agents.
Two classes of LT modifiers are 5-lipoxygenase (ALOX5) inhibitors (zileuton) and leukotriene receptor
antagonists (LTRAs) [montelukast, pranlukast, and zarfirlukast]. LT modifiers can be used as alternatives to
low-dose inhaled corticosteroids (ICS) in mild persistent asthma, as add-on therapy to low- to medium-dose ICS
in moderate persistent asthma, and as add-on to high-dose ICS and a long-acting β2 agonist in severe persistent
asthma. At least six genes encode key proteins in the LT pathway: arachidonate 5-lipoxygenase (ALOX5),
ALOX5 activating protein (ALOX5AP [FLAP]), leukotriene A4 hydrolase (LTA4H), LTC4 synthase (LTC4S),
the ATP-binding cassette family member ABCC1 (multidrug resistance protein 1 [MRP1]), and cysteinyl
leukotriene receptor 1 (CYSLTR1). Studies have reported that genetic variation in ALOX5, LTA4H, LTC4S, and
ABCC1 influences response to LT modifiers. Plasma concentrations of LTRAs vary considerably among
patients. Physio-chemical characteristics make it likely that membrane efflux and uptake transporters mediate
the absorption of LTRAs into the systemic circulation following oral administration. Genes that encode efflux
and uptake transport proteins harbor many variants that could influence the pharmacokinetics, and particularly
the bioavailability, of LTRAs, and could contribute to heterogeneity in response. In the future, large, well
designed clinical trials studying the pharmacogenetics of LT modifiers in diverse populations are warranted to
determine whether a genetic signature can be developed that will accurately predict which patients will respond.
98
1. Asthma Burden
Asthma affects an estimated 20 million people in the US and
300 million people worldwide. Asthma rates and rates of hospitali-
zation, healthcare utilization, and mortality are increasing world-
wide, and the number of individuals with asthma in the US is
expected to rise to 29 million by 2020. Although mortality is
decreasing in this country, which is consistent with better asthma
management, about 4000 individuals die each year from asthma.[1]
In 1998, an estimated $US12–14 billion was spent on the diagno-
sis and management of asthma. Asthma is the most common
childhood disease, with an estimated 4 million children aged <18
years having had an asthma attack in the past 12 months, and many
others with ‘hidden’ or undiagnosed asthma. Asthma is also the
most common cause of school absenteeism as a result of chronic
disease. Among children and young adults, African Americans are
three to four times more likely than Whites to be hospitalized for
asthma, and four to six times more likely to die from asthma. In
2003, an estimated 11 million Americans (4 million aged <18
years) had an asthma attack. Attack prevalence rates were higher
among adult women, children aged <18 years, and African Ameri-
cans. The asthma prevalence rates among Hispanics were lower
compared with non-Hispanic Blacks and non-Hispanic Whites.
The total economic burden of asthma in the US for 2004, including
direct costs such as hospital care, physicians’ services, and pre-
scription drugs, and indirect costs (morbidity and mortality) ex-
ceeded $US16 billion.[2]
2. Pharmacogenetics and Response Variability
There is no cure for asthma. Fortunately, there are a number of
drug classes and drugs that are generally well tolerated and effec-
tive in controlling asthma and asthma symptoms. However, signif-
icant inter-patient variability in response associated with asthma
drugs limits their usefulness. It has been suggested that as much as
60–80% of the inter-patient variability in response to asthma drugs
can be attributed to genetic variation.[3] Asthma is a common,
complex disease with important genetic components that contrib-
ute to asthma phenotypes, including response to drugs. Unlike
diseases involving single gene defects, the genetic contributions to
asthma may be viewed as susceptibility loci that influence but do
not determine the overall disease risk. Therefore, asthma, as with
other common complex diseases (e.g. cardiovascular diseases,
obesity, and diabetes mellitus), conforms to the common disease -
common variant model.[4] As such, asthma and response to asthma
drugs are thought to involve single or multiple variants on single
or multiple genes, with each variant contributing modestly to
phenotypes.
© 2007 Adis Data Information BV. All rights reserved.
Lima
The study of the contribution of genetic variation to heteroge-
neity in drug response defines pharmacogenetics (pharmacoge-
nomics).[5] Drug response can be simply categorized as adequate
(therapeutic), inadequate (poor or no response), or toxic (adverse
reactions). Association studies between drug response and single
or multiple variants (polymorphisms) on single or multiple candi-
date genes distinguish pharmacogenetics from pharmacoge-
nomics, which explores associations between drug response and
genomic (whole genome) variants. The long-range goal of
pharmacogenetics (or pharmacogenomics) is to use genetic infor-
mation to individualize drug treatment, which is expected to lessen
the asthma burden. Although numerous pharmacogenetic studies
of different asthma drugs have been published (see reviews),[6-9]
we are not currently using genetic information to personalize
asthma treatment, because we do not have enough genetic infor-
mation to accurately predict response to any of the asthma drugs.
Large, genome-wide association (pharmacogenomic) studies are
expected to greatly improve our ability to personalize asthma drug
treatment.
Three major drug classes used in the treatment of asthma are β2
agonists, corticosteroids, and leukotriene (LT) modifiers. The
objectives of treatment are to minimize symptoms, maximize lung
function, prevent exacerbations, and minimize adverse drug
events.[10] Although drugs in these classes achieve these objectives
to a greater or lesser extent, all drugs are characterized by signifi-
cant inter-patient variability in response, although none more than
the LT modifiers. Herein, the genetic basis for the heterogeneity in
response to the LT modifiers will be reviewed.
3. Pharmacotherapy of Leukotriene (LT) Modifiers
3.1 LT Modifiers
The LT modifiers are a class of drugs that inhibit the action of
cysteinyl leukotrienes (CysLT). Currently, two subclasses of
agents are available to treat asthma: inhibitors of 5-lipoxygenase
(5-LO) and leukotriene receptor antagonists (LTRA). Zileuton is
the only example of a 5-LO inhibitor that is commercially availa-
ble, whereas several LTRAs are used (table I). LTs are a family of
lipid mediators synthesized in leukocytes and mast cells from
arachidonic acid located in membrane-phospholipids, through the
Table I. Leukotriene modifier drugs use in the treatment of asthma
Class Drug
Inhibitors of 5-Lipoxygenase Zileuton
Leukotriene receptor antagonists Montelukast
Pranlukast
Zafirlukast
Mol Diag Ther 2007; 11 (2)
Treatment Heterogeneity in Asthma
LTA4H LTB4
Arachadonic FLAP
acid
5-HPETE LTA4
5-LO
LTC4S
LTC4
Cell
MRP1 membrane
LTC4
Inflammation & CYLTR1 LTD4
asthma symptoms
LTE4
Fig. 1. Simplified scheme of the leukotriene pathway showing the forma-
tion and action of the cysteinyl leukotrienes (LTC4, LTD4, and LTE4) and
proteins (5-lipoxygenase [5-LO], 5-LO-activating protein [FLAP], leuko-
triene A4 hydrolase [LTA4H], LTC4 synthase [LTC4S], multidrug resistance
protein 1 [MRP1], and the cysteinyl leukotriene 1 receptor [CYLTR1]).
action of phospholipase A (PLA2) in response to stimulation. LTs
are classified into two classes: LTB4 and the CysLTs. LTB4 is a
potent chemoattractant; CysLTs are potent bronchocontrictors and
mediators of asthma inflammation.[11-13] Figure 1 depicts the syn-
thesis of CysLT through the LT pathway. Arachidonic acid is
converted to LTA4 by membrane-bound 5-lipoxygenase (ALOX5)
and 5-LO-activating protein (FLAP; encoded by the gene
ALOX5P). In human mast cells, basophils, eosinophils, and mac-
rophages, LTA4 is converted to LTB4 by LTA4 hydrolase
(LTA4H) or conjugated with reduced glutathione by LTC4
synthase (LTC4S) to form LTC4. LTC4 is transported to the
extracellular space mainly by the multidrug resistance protein 1
(MRP1; encoded by the gene ABCC1) and converted to LTD4 and
LTE4 by γ-glutamyltransferase and dipeptidase. Collectively,
LTC4, LTD4, and LTE4 (formerly known as slow-reacting sub-
stance of anaphylaxis) comprise the CysLTs, and their actions are
mediated by at least two G-protein coupled receptors: CysLT1 and
CysLT2. Zileuton and the LTRAs inhibit the action of CysLTs by
competitively inhibiting 5-LO and CysLT1 receptor, respectively.
It is also possible that LTRAs inhibit 5-LO, which may contribute
to the beneficial effects exerted by these agents.[14]
3.2 LT Modifier Use in Asthma
Guidelines[15,16] recommend that LT modifiers can be used as
alternatives to low-dose inhaled corticosteroids (ICS) in mild
persistent asthma, as add-on therapy to low- to medium-dose ICS
in moderate persistent asthma, and as add-on to high-dose ICS and
a long-acting β2 agonist in severe persistent asthma. Long-term,
placebo-controlled clinical trials with LT modifiers have estab-
lished their efficacy in asthma.[17-20] However, their use has been
associated with a significant degree of inter-patient variability in
© 2007 Adis Data Information BV. All rights reserved.
99
response. For example, in a study of standard doses of zileuton,
<50% of patients with asthma had a <10% increase in forced
expiratory volume in 1 second (FEV1) over baseline.[21] In large
clinical trials comparing the effects of ICS and montelukast
monotherapy on changes in FEV1, 42–44% of patients receiving
montelukast could be classified as good responders, whereas 34%
could be classified as non-responders.[22,23] In a clinical trial com-
paring response rates of ICS and montelukast monotherapy in
children with asthma, 23% were classified as responders to
montelukast.[24]
There is little question that LT modifiers are an important
addition to asthma controller therapy, owing to their unique mech-
anism of action, tolerability, efficacy, convenient once-daily (for
LTRAs) administration, and the convenience of oral formulations.
However, the marked heterogeneity in response to LT modifiers,
which is greater than that observed with ICS,[22,24] seriously de-
tracts from their advantages such that they are used only as an
alternative to ICS monotherapy in mild persistent asthma. A
possible exception is the use of LT modifiers in LT-dependent
asthma phenotypes such as aspirin-intolerant asthma.[25-27]
Results of several studies support the use of LT modifiers as
add-on therapy to ICS,[11] however, recent meta-analyses have
questioned the efficacy of anti-LTs in this scenario.[28,29] Recently,
a large, placebo-controlled clinical trial compared the addition of
once-daily, low-dose theophylline or montelukast for 6 months
with existing treatment in poorly controlled adults with asthma.
Compared with placebo, neither drug lowered the event rate of
poor asthma control, reduced asthma symptoms, or improved
quality of life, despite improved lung function,[30] which raises the
question of whether LT modifiers added to existing therapy in
poorly controlled asthma are beneficial. However, we demonstrat-
ed in a pharmacogenetic study that was ancillary to this clinical
trial that individuals with certain genotypes were responsive to
montelukast treatment[31] (see section 4.2). These data support the
idea that treatment of asthma with LT modifiers may be personal-
ized based on genetic information about the individual patient.
4. Genetic Basis for Treatment Heterogeneity to
LT Modifers
4.1 Consequences of Genetic Variation
Genetic variation can have several consequences, including
pharmacokinetic, pharmacodynamic, or both.[32] Genetic variants
that influence the activity (affinity and capacity) of phase I drug-
metabolizing enzymes (cytochrome P450 [CYP] enzymes) or
phase II enzymes (conjugation reactions: acetylation and sulfa-
tion) and transporters expressed in the gut and/or liver can affect a
Mol Diag Ther 2007; 11 (2)
100
Table II. Encoded proteins and chromosomal locations of major leuko-
triene (LT) pathway candidate genes
Candidate gene Encoded protein Chromosomal
location
ALOX5 5-Lipoxygenase 10q11.21
ALOX5AP 5-Lipoxygenase activating 13q12-13
protein
LTA4H Leukotriene A4 hydrolase 12q21
LTC4S Leukotriene C4 synthase 5q35
ABCC1 Multidrug resistance protein 1 16p13.12
CYSLTR1 Cysteinyl leukotriene 1 receptor Xq21.1
drug’s pharmacokinetics, including bioavailability. Polymorph-
isms that influence a drug’s binding to plasma and tissue proteins
will also affect a drug’s pharmacokinetics. The consequences of a
drug’s altered pharmacokinetic profile caused by genetic variants
can often be mediated by changes in dose rate (i.e. daily dose).
Polymorphisms that influence drug targets (receptors, enzymes,
and transporters) will alter the drug’s pharmacodynamics, which
usually cannot be mediated by changes in dose rate. There are
numerous studies of the pharmacodynamic consequences of genet-
ic variation in response to inhaled β agonists and ICS.[6-9] Howev-
er, there are virtually no studies of the pharmacokinetic conse-
quences of genetic variation on these drugs, in part because they
are inhaled and evoke their effects locally rather than systemically.
Therefore, it is expected that the pharmacokinetic consequence of
genetic variants would have only a minor influence on the thera-
peutic benefits of inhaled asthma drugs. Because LT modifiers are
administered systemically (oral and parenteral), genetic variants
could alter their pharmacokinetics and pharmacodyamics.
4.2 Pharmacodynamic Consequences of Genetic
Variants in LT Pathway
The underlying rationale for pharmacodynamic consequences
associated with LT pathway polymorphisms is that carriers of
polymorphisms that increase the activity of CysLT respond better
to LT modifiers compared with carriers of variants that have no
effect or that downregulate activity. At least six genes encode
proteins in the pathway that are responsible for the production of
the LTs: ALOX5, ALOX5AP, LTA4H, LTC4S, ABCC1, and
CYSLTR1 (figure 1; table II). The results of early, single-variant
studies suggest that polymorphisms in ALOX5 and LTC4S influ-
ence response to LT modifiers. Addition and deletion variants in
the core promoter of the ALOX5 gene were associated with dimin-
ished promoter-reporter activity in tissue culture.[33] Drazen et
al.[3] hypothesized that there would be decreased 5-LO production
and diminished response to LT modifiers because of diminished
© 2007 Adis Data Information BV. All rights reserved.
Lima
gene transcript association with addition/deletion variants. They
tested this hypothesis in a placebo-controlled trial of ABT-761, a
5-LO inhibitor similar to zileuton, in asthma. On days 8 and 84,
individuals carrying wild-type ALOX5 (five repeats on both al-
leles) and heterozygotes had a significantly greater response com-
pared with individuals who were homozygous for the mutant allele
(five repeats on both alleles) [figure 2]. This was one of the first
clear examples of a pharmacogenetic response in asthma treat-
ment. However, individuals with the homozygous mutant geno-
type comprised only 3% of the population, suggesting that this
genotype contributes in a minor way to the heterogeneity in
response to LT modifiers.
In relatively small studies, we and others have reported that
individuals with the C allele of the LTC4S gene promoter (–444A/
C) polymorphism responded better to zafirlukast,[34] pranlukast,[35]
and montelukast[36] compared with the A allele, although negative
associations between this single nucleotide polymorphism (SNP)
and LTRA response have been reported.[37,38]
In a recent pharmacogenetic study[31] that was ancillary to the
large, placebo-controlled clinical trial of add-on low-dose theo-
phylline or montelukast,[30] we adopted a candidate gene approach
and explored associations between response to montelukast (both
change in FEV1 and the risk of an asthma exacerbation) and 28
SNPs in the ALOX5, LTA4H, LTC4S, ABCC1, and CYSLTR1
genes, and the addition/deletion repeat polymorphism in the
ALOX5 promoter in 61 self-identified Caucasians taking
montelukast (African Americans were not studied owing to the
small number of participants). The risk of having an exacerbation
was reduced 73% in individuals carrying a variant number (n = 2,
3, 4, 6, 7) of repeats in the ALOX5 promoter on one allele
compared with homozygotes for the five repeat (wild-type) allele
25 p < 0.0001
FEV1 change from baseline (%)
20
p = 0.026
15 p = 0.004 Wild type:
p = 0.039
ABT-761
10
Wild type:
placebo
5
Mutant:
0 ABT-761
–5
–10 Day 8 Day 84
Fig. 2. Percentage change in forced expiratory volume in 1 second (FEV1)
from pretreatment baseline stratified by genotype of the 5-lipoxygenase
(ALOX5) core promoter polymorphism following treatment with ABT-761 or
placebo. Responsiveness in patients with the wild-type genotype (5 re-
peats on each allele) is compared with patients with no wild-type alleles at
this locus. Data are shown after the first week and on the final day of active
treatment. Standard errors of the mean are indicated by the bars (repro-
duced from Drazen et al.,[3] with permission).
Mol Diag Ther 2007; 11 (2)
Treatment Heterogeneity in Asthma
(p = 0.045). The risk of an asthma exacerbation was reduced 80%
in carriers of the LTC4S –444C variant allele compared with AA
homozygotes (p < 0.0001). These data support previous studies
that the ALOX5 repeat promoter polymorphisms and LTC4S –444
A/C SNP are important pharmacogenetic loci.
In addition, three novel SNPs were associated with either
changes in FEV1 from baseline or the risk of an asthma exacerba-
tion while on montelukast treatment. For the ALOX5 rs2115819
(intron 2) and the ABCC1 rs119774 (intron 1) SNPs (shown in
figure 3), changes in FEV1 over baseline during 6 months of
montelukast treatment were compared. For the LTA4H rs2660845
SNP, the risk of an asthma exacerbation while on montelukast was
4.5-fold higher in carriers of the G allele compared with AA
homozygotes (p < 0.001). The mechanisms underlying this associ-
ation are unknown. Interestingly, the G allele of this SNP com-
prised a 5-SNP haplotype (termed HapK), which was associated
with the risk of myocardial infarction in Icelanders and European
Americans, and increased production of LTB4, formed from the
catalysis of LTA4 by LTA4H.[39] If the G allele of the LTA4H
rs2660845 SNP favors increased production of LTB4, it is possi-
ble that that substrate is shunted away from the alternative LTC4
pathway, which would lead to decreased production of CysLT and
a reduced response to LT modifiers.
Thus, adopting a candidate gene approach to explore associa-
tions between LT variants and response to montelukast resulted in
replication of previous studies and the identification of novel
variants that may represent important pharmacogenetic loci. How-
ever, the results of this study require replication in a larger, more
diverse population possibly using haplotype tagging SNPs
(htSNPs). In addition, the results of our study suggest that there
may be other, functional SNPs that are in linkage disequilibrium
ALOX5;
rs2115819
40
Change in predicted FEV1 (%)
p = 0.017
30
20
10
0
GG GA AA
Genotype
Fig. 3. Influence of genotype on percent change in % predicted forced
expiratory volume in 1 second (FEV1) from baseline in individuals taking
montelukast 10mg daily for 6 months. Changes in % predicted FEV1 over
baseline were compared by genotypes of ABCC1 marker rs119774 and
5-lipoxygenase (ALOX5) marker rs2115819 (reproduced from Lima et
al.,[31] with permission).
© 2007 Adis Data Information BV. All rights reserved.
101
(LD) with the polymorphisms we studied, which may improve our
ability to predict responsiveness to LTRAs and possibly 5-LO
inhibitors.
4.3 Pharmacokinetic Consequences of Genetic Variation
There are no published studies that explore associations be-
tween plasma concentrations or response and polymorphisms that
could affect the disposition of LT modifiers. Zileuton is marketed
as a racemate, and its R(+) and S(–) enantiomers are extensively
metabolized in the liver by CYP1A2, CYP2C9, and CYP3A4.[40,41]
The drug is 93% bound to plasma proteins.[42] Following oral
administration of a 14C-labeled dose, 95% of the radioactivity was
recovered in the urine, indicating that the drug is well ab-
sorbed.[13,43] Its oral bioavailability and hepatic clearance are un-
known but are estimated to be 75% and 375 mL/min, respectively.
Genetic variants are known to alter the activity of the CYP1A2,
CYP2C9, and CYP3A4 enzymes,[44] which could contribute to
variability in plasma concentrations of, and therefore response to,
zileuton.
The LTRAs share structural, physical, and chemical character-
istics that are different from most other drugs.[45-49] LTRAs gener-
ally have high molecular weights (≈500 or higher), high partition
coefficients, and are amphipathic. According to empirical rules
that allow prediction of a drug’s solubility and permeability,[50]
these physio-chemical properties suggest that LTRAs may not be
passively absorbed into the systemic circulation following oral
administration (as are most drugs), but rather may require the
participation of one or more membrane transporters. In addition,
LTRAs are highly bound to plasma albumin (>99%), extensively
metabolized by hepatic drug-metabolizing enzymes, and excreted
mainly in bile.[45-49]
MRP1 Owing to these characteristics, it is possible that LTRAs are
rs119774
substrates for drug transporters expressed on the apical (lumen)
p = 0.004 and basolaterol brush border membranes that transport them from
lumen to circulation to hepatocyte, where they are metabolized
and then excreted into the bile.[51] Membrane transporters can be
broadly divided into efflux transporters, which belong to three
different gene subfamilies within the super family of ATP-binding
cassette (ABC) transporters (the multidrug resistance-association
proteins [MRPs] and the multidrug resistance transporter
CC CT [MDR1]), and the uptake transporters, which comprise solute
carrier uptake transporters (SLC) and include organic anion and
cation transporters.[51-53] Acting alone or in concert with CYP450
enzymes, membrane transporters can influence the pharmacoki-
netics and pharmacodyamics of numerous drugs.[52,54-58] Variation
in genes that encode membrane transporters influence the
pharmacokinetics of many drugs and thus can contribute to hetero-
Mol Diag Ther 2007; 11 (2)
102
geneity in response.[53,59] Although there are no published data
demonstrating that LTRAs are substrates for membrane transport-
ers, there is evidence that montelukast is a substrate for membrane
transporters, and thus, genetic heterogeneity could contribute to
variability in pharmacokinetics and response.
Montelukast is cleared mainly by the liver by CYP3A4,
CYP2C9,[60] and possibly CYP3A5, has an absolute bioavailabili-
ty of 64%, is highly bound to plasma albumin (>99%), and is
excreted mainly into bile.[61-64] The molecular weight of
montelukast is 585 G/mol, the log of the octanol to water partition
coefficient is high (about 8.9), and the drug’s pKa is 5.7.[65] Based
on these characteristics it is possible that montelukast is transport-
ed from the intestinal lumen by uptake transporters expressed on
the apical side into enterocytes, followed by transport into the
systemic circulation by efflux transporters expressed on the baso-
lateral membrane. It is speculated that montelukast is transported
from blood into hepatocytes by uptake transporters and undergoes
hepatic transformation (CYP) to metabolites, which are transport-
ed into the bile by efflux transporters. In support of this, Letschert
et al.[66] reported that montelukast and MK571 (a racemic mixture
of the precursor of montelukast of which the S-enantiomer is
verlukast)[45] are potent inhibitors of hepatic solute carrier organic
anion transporter (SLCO) family members SLCO1B3, SLCO2B1,
and SLCO1B1 expressed in specific cell lines.[66] SLCO2B1 is
also expressed in the apical membrane of the intestinal epitheli-
um[67] and may aid in the absorption of montelukast from the
intestinal lumen. In addition, SLCO transporters prefer
amphipathic organic anions that are highly bound to serum pro-
teins.[58] These data support the idea that montelukast may be a
substrate for one or more SLC transport proteins. That
montelukast is metabolized in the liver and excreted in the bile
implicates the participation of one or more ABC transporters.
MK571 is a competitive inhibitor of ABCC1-mediated LTD4
transport in selective cell systems[68,69] and has been reported to
inhibit other members of the ABCC subfamily of ABC transport-
ers.
Genes that encode efflux (ABC genes) and uptake (SLC genes)
transport proteins harbor many variants that could influence
pharmacokinetics, particularly the bioavailability of montelukast,
and could contribute to variability in response. Figure 4 demon-
strates variability in plasma levels of montelukast in two normal
subjects who received a 10mg tablet of Singulair® 1 (montelukast)
and an encapsulated formulation containing a split 10mg tablet of
Singulair® (Lima JJ, unpublished data). The areas under the
plasma concentration time curve (AUC) differed by more than 10-
fold between the two subjects on both occasions, yet the half-lives
1 The use of trade names is for product identification purposes only and does not imply endorsement.
© 2007 Adis Data Information BV. All rights reserved.
Lima
were similar, suggesting that the variability in AUC was the result
of differences in bioavailability. Six subjects volunteered for this
study to determine whether splitting and encapsulating Singulair®
influenced the bioavailability. The bioavailability of encapsulated
montelukast was 97% compared with Singulair®. It is possible
that this inter-patient variability in montelukast pharmacokinetics
may be related to variants in genes that encode efflux and/or
uptake proteins that transport montelukast and potentially other
LTRAs.
5. Future Studies
It is clear that the LT modifiers are important additions to the
growing list of drugs used to treat asthma and possibly other
inflammatory diseases.[70] It is equally clear that inter-patient
variability in response to LT modifiers, particularly LTRAs, limits
their usefulness as a controller for asthma. This review focused on
the genetic basis for this variability in response. It is clear that
more studies are required to identify genetic variants that influence
both the pharmacodynamics and pharmacokinetics of LT modifi-
ers. Marked heterogeneity in response is common for most asthma
drugs, and LT modifiers are probably associated with the greatest
degree of heterogeneity, yet are the least studied class of common
asthma drugs from a pharmacogenetic view. Large, well designed
clinical trials studying the pharmacogenetics of LT modifiers in
diverse populations are warranted to determine whether a genetic
signature can be developed that will accurately predict which
patients will respond. We should also be mindful that genetic
variation, although substantial, is not the only source of response
heterogeneity to LT modifiers. Other sources of variability include
250 Montelukast-encapsulated form
Singulair®
Concentrations (ng/mL)
200
150
100
50
0
0.00 1.22 1.68 3.42 6.77 10.02 13.45 16.70
Time (hours)
Fig. 4. Variability in montelukast plasma concentrations. Shown are plas-
ma concentrations vs time curves in two individuals who took montelukast
10mg (Singulair®) and the encapsulated formulation (10mg) on two differ-
ent occasions separated by at least 1 week. Area under the plasma con-
centration-time curve (AUC) values on both dosing occasions were similar
for both formulations. The AUC between subjects differed by more than
10-fold on both occasions.
Mol Diag Ther 2007; 11 (2)
Treatment Heterogeneity in Asthma
ethnicity (possibly genetic), asthma severity, and asthma pheno-
type.
Acknowledgments
This work was supported by the American Lung Association Asthma
Clinical Research Centers, the Nemours Research Foundation, and the Nation-
al Institutes of Health (grants R01 HL 071394 and R01 HL 074755). JJL does
not have a financial relationship with a commercial entity that has an interest
in the subject of this manuscript.
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Correspondence: Dr John J. Lima, Centers for Clinical Pediatric Pharmacolo-
gy & Pharmacogenetics, Nemours Children’s Clinic, 807 Children’s Way,
Jacksonville, FL 32207, USA.
E-mail: Jlima@nemours.org
Mol Diag Ther 2007; 11 (2)