Pharmacogenomics:

designer drugs

Paula Gregory, Ph.D.

Dept. of Genetics
“If it were not for the great variability among
individuals, medicine might as well be a
science and not an art.” Sir William Osler
Did you know?
 Over 2 million people are hospitalized each
year for adverse reactions to prescription
drugs.

 Every year more than 100,000 people die

from those reactions, making it the sixth
leading cause of death!
Pharmacogenomics

Will allow:
 individualized medication use
based on genetically determined
variation in effects and side
effects
 use of medications otherwise
rejected because of side effects
 new medications for specific
genotypic disease subtypes
 How Pharmacogenomics works
 Identifying gene sequence
variations (SNPs) that affect drug
response

 Identifying disease susceptibility

genes which represent potential
new
drug targets

 Identifying gene sequence

variations that can cause adverse
drug reactions
Challenges to drug design
Drug responses are genetic!
 Drug metabolism/response can be
monogenic
• alteration of the key metabolizing enzyme can
alter drug’s effect
 Drug responses are polymorphic
• Drugs trigger downstream events that can vary
among patients
Drug response curve
Variation in drug response can be
hereditary

 Variations in absorption rates

 Variations in drug metabolism
 Variations in drug
inactivation/elimination
 Variation in target receptors
How genes alter drug responses:

 Hereditary metabolic disorders that

alter drug metabolism

 Genetic variants of drug metabolizing

enzymes

 Genetic variants of drug receptors

 Examples of genetic variation
in drug metabolism
 Variants of plasma pseudocholinesterase
• experience prolonged apnea when treated with
the muscle relaxant succinylcholin
 Variants of Acetyltransferase
• Slow metabolizers experience toxic neuritis,
lupus and bladder cancer when treated with
anti-arrhythmic drug (procainamide)
• Rapid metabolizers can experience colon cancer
Hereditary metabolic disorders
that alter drug metabolism
 G-6-PD deficiency - can cause hemolysis
when exposed to anti-malaria drugs
 Factor V Leiden allele - increases risk of
venous thrombosis (don’t use oral
contraceptives in these women)
 Lesch-Nyhan Syndrome - chemo and gout
treatments are ineffective (the drugs are not
metabolized to their active form)
Genetic Variation & Polymorphism
influence metabolism

 Alcohol dehydrogenase - three loci; variant

of ADH2 much more common in Japanese
(90%) than Europeans (15%)

 Lactose activity – two major alleles; low

activity allele more common in Africans
and Asians
 Drug Metabolism

Gene X

Enzyme X

Drug A Substance A
 Variants of drug metabolism
Variant of Gene X

Enzyme X No Product

Drug A Substance A
Genetic variants that decrease levels of
drug metabolizing enzymes

Variant of Gene X

Enzyme X

Drug A Substance A
Genetic variants that result in over
production of metabolizing enzyme

Variant of Gene X

Enzyme X

Drug A Substance A
 Genetic Variants in Drug
Receptors
Gene X

Receptor X

Drug A Cascade of

cellular events
Genetic variants in drug receptors

Variant of Gene X

Aberrant Receptor X

Drug A Cascade of

cellular events
 Over (or under) expression of
receptors can alter drug response
Mutant receptors may not bind the drug;
therefore, altering drug response
(may look like drug “resistance”)
 Genetic variation in drug
receptors
 Steroid-induced glaucoma (dexamethasone)
 Malignant hyperthermia (general anesthesia)
 Anticoagulant resistance (Coumarin,
warfarin) requires 7-20X more drug to get a
response
 Retinoic Acid suppression of leukemia
 Vasopressin resistance
 Warfarin = coumadin

Warfarin inhibits vitamin

K reductase, which is the
enzyme responsible for
recycling oxidated
vitamin K back into the
system. For this reason,
drugs in this class are
also referred to as
vitamin K antagonists.
 Warfarin

 Discovered 60 years ago and one

of the most widely prescribed drugs in the world
 Intended to prevent and treat thromboembolisms
• Afib, recurrent stroke, DVT, pulmonary embolism, heart
valve prosthesis
 Multi-source anticoagulant
• 1, 2, 2.5, 3, 4, 5, 6, 7.5 and 10 mg tablet strengths
 Significant increase in Rx’s over past 10 years
especially in the elderly
Trends in Warfarin Use: 1.5-fold
Increase (45%) in Last 6 Years

Prescriptions Dispensed in the U.S. for

Warfarin Tablets and Vials
30
Dispensed Rx

25
(millions)

20

15

10
1998 1999 2000 2001 2002 2003 2004 YTD
9/2005
Year
Source: IMS Health National Prescription Audit Plus TM Data Extracted 11/2005
 Safety of Warfarin
•Major risk is bleeding: frequent
and severe
•1.2 – 7 major bleeding episodes
per 100 patients
•Responsible for 1 in 10 hospital
admissions
•Relative risk of fatal extracranial
bleeds 0 - 4.8%
Schulman, N Engl J Med 349:675-683, 2003
Pirmohamed, British Med J 329:15-19, 2004
DaSilva, Seminars Vasc Surg 15:256-267, 2002
Eikelboom, Med J Australia 180:549-551, 2004
Purple-toe syndrome & skin necrosis:
rare adverse reactions to warfarin
 Dosing of Warfarin is Complex
 Narrow therapeutic index
• Small separation between dose-response curves
for preventing emboli and excess coagulation
 Nonlinear dose-response (INR)
• Small changes in dose may cause large changes
in INR with a time lag
 Wide range (50x) of doses (2-112 mg/week)
to achieve target INR of 2-3
• Patient intrinsic and extrinsic factors
 DNA testing for
Warfarin sensitivity
The FDA Clinical Pharmacology
Subcommittee of the Advisory Committee
for Pharmaceutical Sciences has
recommended testing for variations in the
CYP2C9 and VKORC1 in patients
requiring warfarin therapy. The drug label
will reflect this recommendation soon.
Article on this test
 Warfarin Metabolism

 Two polymorphic genes, CYP2C9 and

VKORC1, affect warfarin metabolism and
response. Allelic frequencies of these two genes
are usually associated with ethnicity. Here are
the concerns with prescribing warfarin to
patients with CYP2C9 or VKORC1
polymorphisms:
 Overdose can result in bleeding which can be
fatal.
 Under dose can result in thrombosis which can
be fatal
 VKORC1 Variants

VKORC1 polymorphisms may explain up to

25% of patient variability in response to
warfarin. Patients with VKORC1
polymorphisms are at risk for exaggerated
anticoagulant response.
 CYP2C9 Variants

CYP2C9 variants take more time to achieve

stable dosing, and are associated with
increased risk of bleeding events. Low
CYP2C9 activity results in higher plasma
levels of warfarin so the patient is at risk for
bleeding
 Warfarin Sensitivity
The Warfarin Sensitivity DNA Test
determines the presence of specific
variations in the CYP2C9 and VKORC1
genes that confer sensitivity to warfarin
and thus significantly reduce the
required maintenance dose. CYP2C9 is
involved in warfarin metabolism and
VKORC1 influences warfarin's
anticoagulation effect through vitamin K.
 Mechanistic Basis of Dosing
Problem

Large interindividual variability related to S-

warfarin metabolism by CYP2C9 (genetics)
• *1 (wild type), *2 and *3 (variant alleles)
Genotype Prevalence % Enzyme S/R Weekly Clearance/L
(N = 188) Activity Warfarin Doses BW
(mg/L) (mg) (ml/min/kg)
2C9 *1/*1 63% 100% 0.45 34.1 0.065 (0.025)
(0.11) (19.5)
2C9 *1/*X 31% 50-70% 0.69 19.0 0.041 (0.021)
(0.28) (10.8)
2C9 *X/*X 6% 10% 1.43 11.5 0.020 (0.011)
(0.63) (7.2)

Herman et al, The Pharmacogenomics J 4:1-10. 2005

 Dosing Adjustments Based on
Genotype-Specific S-Warfarin
Clearance

Equivalent Warfarin Doses in Common Genotypes

100%

80%

PDR Recommended Dose,

60%

%
40%

20%

0%
Wild Type *1/*2 *1/*3 *2/*2 *3/*3

Stefanovic and Samardzija, Clin Chem & Lab Med, 42(1) 2004
Iressa: cancer “miracle” drug

Epidermal growth factor

receptor-tyrosine kinase inhibitor

Used as a single treatment agent for

non-small cell lung cancer

Seems to work best on patients

with lung cancer who never smoked

It works by blocking tyrosine kinases found on the surface of normal &

cancer cells

Works on metastatic tumors as well.

 Genetic variants in drug
metabolism
 Fluorouracil (5-FU) Toxicity
• 5-FU is a very common chemo agent for solid tumors
• dihydropyrimidine dehydrogenase deficiency (DPD)
increases the half life of 5-FU from 13 min to 160
min (prolonged exposure to the drug)
• Incidence of this variant is 1-3% of cancer patients
• The prolonged exposure to all tissues results in
toxicity, primarily BM and GI (neuro occassionally)
 Genetic variants in drug
metabolism
 Thiopurine methyltransferase “null variants”
• incidence of about 1 in 300
• Pts. Cannot metabolize chemo drugs used to
treat leukemia(6-mercaptopurine, 6-thioguanine
& azathioprine) into their inactive methylated
forms
• Pts. Can be treated with 10-15 times less chemo
than commonly prescribed
• Genotyping or functional enzyme assay is now
the STANDARD PRACTICE in cancer centers
 Genetic variants in drug
metabolism
 “Slow acetylator phenotype” results in
peripheral neuropathy in pts treated with anti-
TB drug (isoniazid)
 Causes slow clearance of the drug and
associated toxicity
 This phenotype is found in 40 -60% of
Caucasians, 80% of Middle Eastern pop but
only 20% of Japanese pop.
 Variants of Cytochrome P450

 Cytochrome P450 enzymes are responsible

for the MAJOR portion of drug metabolism
 CYP2D6 null alleles result in poor
metabolizers and adverse reactions to cardio
and psyc medications
 CYP2C9 mutations result in 5X decline in
metabolism of drugs (ibuprofen,
naproxen,etc)
Genetic variations in the rate of drug
metabolism can be specific for certain
ethnic groups
 Genetics for new
drug design

 Genomics is making it
 possible to identify new drug targets
• Protease inhibitors targeting HIV
• Tamoxifen (estrogen analog)for
treatment/prevention of breast cancer
• Herceptin is a monoclonal Ab against the
HER2 receptor
 Gleevec:
pharmacogenetics in action!
 Used to treat CML
 4,500 middle-aged Americans diagnosed with
CML each year
 Designed to block the activity of the BCR-ABL
protein
 BCR-ABL is a fusion protein produced by the
9;22 translocation associated with this leukemia
 Gleevec

 New England Jou Med report (April 2001)

reports that normal blood counts restored in
53/54 patients with chemotherapy resistant
CML

 Fast-tracked by the FDA due to good

response and low side effects
SNPs = Single Nucleotide
Polymorphisms
Occur throughout the genome

Occur about every 1,000 bases

May be “linked” to
polymorphisms in drug response

Under intense study by

pharmaceutical companies.
SNPs are throughout the genome
 SNPs
Characterization of SNPs
may help in identifying
subsets of individuals at
risk for specific
diseases
SNPs may predict drug
responses/adverse
reactions
Gene Expression Analysis using
Microarrays
 Transcript Profiling Approach for
Understanding Novel Drug
Mechanisms

Bumol, T. F. et al. JAMA 2001;285:551-555.

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Cluster analysis of 118 anticancer drugs against highly correlated genes
Pharmacogenomics

“therapy with the

right drug at the
right dose in the
right patient”