1

Rx + =

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????
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2
Rx + =

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Differences in genetic
constitution
Rx + =

3
PHARMACOGENETICS
The study of genetically
controlled variations in drug
response
4
I. Key Concepts and Terms
Monogenic: due to allelic variation at a single
gene

Polygenic: due to variations at two or more
genes

Polymorphic: frequently occurring monogenic
variants occurring at a frequency
>1%
5
Normal Distribution
F
r
e
q
u
e
n
c
y

Activity
6
Polymorphic Distribution
From Pratt WB,Taylor P. Fig 7-5b
7
GENETIC
POLYMORPHISMS
Pharmacokinetic Pharmacodynamic
Transporters
Plasma protein binding
Metabolism

Receptors
Ion channels
Enzymes
Immune molecules
8
From: Evans
WE, Relling MV.
Pharmacogenom
ics: Translating
functional
genomics into
rational
therapeutics.
Science 286:487-
491, 1999.

9
From: Evans WE, Relling MV. Pharmacogenomics: Translating functional genomics
into rational therapeutics. Science 286:487-491, 1999.
II. Genetic polymorphisms in drug
metabolizing enzymes
10
A. Atypical Plasma Cholinesterase
a rapid acting, rapid recovery muscle relaxant - 1951
usual paralysis lasted 2 to 6 min in patients
occasional pt exhibited paralysis lasting hrs
cause identified as an atypical plasma cholinesterase
Hydrolysis by pseudocholinesterase
choline
succinylmonocholine
O C CH
2
CH
2
O
(H
3
C)
3
NH
2
CH
2
C C
O
O CH
2
CH
2
N(CH
3
)
3
+ +
SUCCINYLCHOLINE
11
Atypical plasma cholinesterase has 1/100 the
affinity for succinylcholine as normal enzyme
occurs in 1:2500 individuals
tested clinically via the abilityof dibucaine to inhibit
esterase hydrolysis of benzoylcholine
0
20
40
60
80
100
-6 -4
log molar dibucaine conc.
%

I
n
h
i
b
i
t
i
o
n
Typical Atypical
Adapted from: Pharmac Ther 47:35-60, 1990.
normal enzyme inhibited > 70%
abnormal inhibited < 30%
12
Atypical plasma cholinesterase has 1/100 the
affinity for succinylcholine as normal enzyme
occurs in 1:2500 individuals
tested clinically via the abilityof dibucaine to inhibit
esterase hydrolysis of benzoylcholine
Family studies indicate variability in plasma
cholinesterase activity consistent with 2 allelic,
autosomal, codominant genes
other variant forms exist as well
13
B. Glucose-6-phosphate dehydrogenase activity
Effects >100 million worldwide
R-
NH
2

CYP
MPO
PGH Synthase
R-NOH
ERYTHROCYTE
R-NOH
O
2

HgbFe
+2

R-NO HgbFe
+3

Reactive
Oxygen
NADH
NAD+
MetHgb
Reductase
NADPH
or GSH(?)
NADP+ or
GSSG(?)
HMP Shunt
G-6-PD
Dependent
SOD
Catalase
GSH Peroxidase
Detoxification
Splenic
Sequestration
Hemolytic
Anemia
GSH
Semi-mercaptal
sulfinamide
R-
NH
2

14
Drugs and Chemicals Unequivocally
Demonstrated to Precipitate Hemolytic Anemia
in Subjects with G6PD Deficiency
Acetanilide Nitrofurantoin Primaquine
Methylene Blue Sulfacetamide Nalidixic Acid
Naphthalene Sulfanilamide Sulfapyridine
Sulfamethoxazole
15
INCIDENCE OF G6PD DEFICIENCY IN
DIFFERENT ETHNIC POPULATIONS
Ethnic Group Incidence(%)
Ashkenazic Jews 0.4
Sephardic Jews
Kurds 53
Iraq 24
Persia 15
Cochin 10
Yemen 5
North Africa <4

Iranians 8
Greeks 0.7-3
16
INCIDENCE OF G6PD DEFICIENCY IN
DIFFERENT ETHNIC POPULATIONS
Ethnic Group Incidence(%)
Asiatics
Chinese 2
Filipinos 13
Indians-Parsees 16
Javanese 13
Micronesians <1
17
C. N-ACETYLTRANSFERASE ACTIVITY
Distribution of plasma isoniazid concentration in 483 subjects
after and oral dose. Reproduced from Evans DAP. Br Med J 2:485, 1960.
18
NAT1*4 NAT2*4 NAT2*5A NAT2*6A NAT2*7A
PABA
PAS
SMX
PA
DDS
SMZ
AF
Modified from Grant DM. Pharmacogenetics 3:45-52, 1993
19
ETHNIC DIFFERENCES IN THE DISTRIBUTION OF
ACETYLATOR PHENOTYPE
Population % Slow % Hetero Fast % Homo Fast
South Indians 59 35.6 5.4
Caucasians 58.6 35.9 5.5
Blacks 54.6 38.6 6.8
Eskimos 10.5 43.8 45.7
Japanese 12 45.3 42.7
Chinese 22 49.8 28.2
From: Kalo W. Clin Pharmacokinet 7:373-4000, 1982.
20
XENOBIOTICS SUBJECT TO
POLYMORPHIC ACETYLATION IN MAN
Hydrazines
isoniazid
hydralazine
phenylzine
acetylhydrazine
hydrazine
Arylamines
dapsone
procainamide
sulfamethazine
sulfapyridine
aminoglutethimide
Carcinogenic
Arylamines
benzidine
-naphthylamine
4-aminobiphenyl
Drugs metabolized to amines
sulfasalazine nitrazepam
clonazepam caffeine
21
ADVERSE EFFECTS TO
SULFASALAZINE IN PATIENTS WITH
INFLAMMATORY BOWEL DISEASE
N N
COOH
OH S
O
O
H
N
N
SULFASALAZINE
NH
2
S
O
O
H
N
N
H
2
N
COOH
OH
SULFAPYRIDINE
5-AMINOSALICYLIC ACID
22
ADVERSE EFFECTS TO
SULFASALAZINE IN PATIENTS WITH
INFLAMMATORY BOWEL DISEASE
Data from: Das et al. N Engl J Med 289:491-495, 1973.
Side Effect
cyanosis
hemolysis
transient reticulocytosis
Frequency of side effect
Slow Acetylators Fast Acetylators
9 1
5 0
6 0
23
0
20
40
60
80
100
120
0 20 40 60 80 100
Duration of Therapy (months)
%

o
f

p
t
s

w
i
t
h

l
u
p
u
s

Slow Acetylators
Fast Acetylators
Relationship Between Onset of Lupus Syndrome in
Fast and Slow Acetylators Receiving Procainamide. Data
from: Woosley RL, et al. N Engl J Med 298:1157-1159, 1978.

24
NH
2
C
O
(H
3
CH
2
C)
2
NH
2
CH
2
CHN
PROCAINAMIDE
NH C
O
(H
3
CH
2
C)
2
NH
2
CH
2
CHN CCH
3
O
NHOH C
O
(H
3
CH
2
C)
2
NH
2
CH
2
CHN
NAT
CYP450
PROCAINAMIDE HYDROXYLAMINE
N-ACETYLPROCAINAMIDE
25
0
20
40
60
80
100
SLOW FAST
P
e
r
c
e
n
t
a
g
e

o
f

S
u
b
j
e
c
t
s
Control
HS
Distribution of acetylator phenotype in control
subjects and those experiencing a sulfonamide
hypersensitivity reaction.
Rieder et al. Clin Pharmacol Ther 49:13-17, 1991.
26
NAT1
N-acetyl-SMX
UDPGT
SMX-glucuronide
CYP2C9
MPO
PGH SYNTHASE
SMX hydroxylamine
Nitroso Detox
Covalent binding to
cellular macromolecules/
cytotoxicity
Hypersensitivity/
Adverse Reaction
O-acetylation
Acetoxy ester
NAT1
Hydroxamic
acid
N,O-AT
Detoxified metabolite
Sulfamethoxazole
(SMX)
N
O
NH
2
S
O
O
H
N
CH
3
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D. CYP2D6 ACTIVITY
N C NH
NH
2
N C NH
NH
2
CYP2D6
OH
DEBRISOQUINE
4-HYDROXYDEBRISOQUINE
H
N CH
3
OCH
3
H
N CH
3
OH
DEXTROMETHORPHAN
DEXTRORPHAN
CYP2D6
28
29
DRUGS WHOSE METABOLISM CO-
SEGREGATES WITH DEBRISOQUINE
alprenolol amitriptyline bufuralol clomipramine
codeine desipramine encainide ethylmorphine
flecainide fluoxetine guanoxan imipramine
metoprolol nortriptyline paroxetine phenformin
propafenone propranolol
30
Plasma metoprolol concentrations in poor () and extensive ()
metabolizers of debrisoquine after 200 mg of metoprolol tartrate
administered orally. Redrawn from Lennard MS, et al. NEJM 307:1558-1560, 1982.

31
Dose requirements for nortriptyline in patients with different CYP2D6
Phenotypes. From: Meyer U. Lancet 356:1667, 2000.
32
O-demethylation
morphine
N-demethylation
norcodeine
6-glucuronidation
codeine-6-glucuronide
M-6-G
M-3-G
normorphine
norcodeine-
6-glucuronide
CYP2D6
H
3
CO
NCH
3
HO
O
CODEINE
33
Effect of Quinidine on the Analgesic Response
to Codeine in Extensive Metabolizers of
CYP2D6 (Phenotyped with Dextromethorphan)
Data from: Desmeules J, et al. Eur J Clin Pharmacol 41:23:26, 1991
0
5
10
15
20
M
o
r
p
h
i
n
e

C
o
n
c

(
n
M
)
0 1 1.5 2 2.5
Time (hr)
EM
EM + Q
0
2
4
6
8
10
P
a
i
n

T
h
r
e
s
h
o
l
d

(
m
A
)
0 1 2
Time (hr)
EM
EM + Q
34
What is the cause of hypermetabolizers?
35
Debrisoquine phenotype in subjects
with different CYP2D6 genotypes

Genotype # of
Subjects
Metabolic
Ratio
CYP2D6wt/(CYP2D6L)
2
9 0.33
CYP2D6wt/CYP2D6wt 12 1.50
CYP2D6wt/CYP2D6(A or B) 9 2.14
CYP2D6B/CYP2D6B 6 48.84


(CYP2D6L)
2
- gene duplication; CYP2D6A - single base deletion
CYP2D6B - multiple point mutations
Data from: Agundez JG et al. Clin Pharmacol Ther 57:265, 1995.
36
From: Dalen P, et al. Clin Pharmacol Ther 63:444-452, 1998.
37
E. CYP2C9 ACTIVITY
Prescribed Daily Warfarin Dose and CYP2C9 Genotype
Warfarin Dose* Genotype
5.63 (2.56) *1/*1
4.88 (2.57) *1/*2
3.32 (0.94) *1/*3
4.07 (1.48) *2/*2
2.34 (0.35) *2/*3
1.60 (0.81) *3/*3
*Data presented as mean (SD) daily dose in mg
From: Higashi MK, et al. Association between CYP2C9 genetic variants and
anticoagulation-related outcomes during warfarin therapy. J AMA 287:1690-1698, 2002.
38
F. THIOPURINE METHYLTRANSFERASE (TPMT)
N
N
N
H
N
SH
N
N
N
H
N
SCH
3
TPMT
SAM
SAH
6-mercaptopurine 6-methylmercaptopurine
39
TPMT Activity
F
r
e
q
u
e
n
c
y

Distribution of Thiopurine Methyl-transferase Activity.
Reproduced from: Weinshelboum RM, Sladek SL. Am J Hum Genet 32:651-662, 1980.
40
41
G. GENETIC POLYMORPHISMS, MATERNAL
SMOKING AND LOW BIRTH WEIGHT (LBW)
65% of all infant deaths occur among LBW
infants, while LBW infants account for 7.6% of
all live births
Reduction in birth wgt among smoking women

Genotype Weight Reduction
CYP1A1 AA 252 g
CYP1A1 Aa/aa 520 g

GST1 AA/Aa 285 g
GST1 aa 642 g
Data from: Wang X, et al. J AMA 287:195-2002, 2002.
42
From: Esteller M, et al. Inactivation of the DNA-repair gene MGMT and the clinical response of
gliomas to alkylating agents. NEJ M 243:1350-1354, 2000.
Why are some gliomas
resistant to nitrosourea
alkylating agents?

Evidence suggests this may be
the result of an epigenetic
phenomenon one that does
not involve a change in DNA
sequence.

MGMT methylguanine-DNA
methyltransferase
Methylation of the promoter
region of MGMT may silence
the gene
43
From: Esteller M, et al. Inactivation of the DNA-repair gene MGMT and the clinical response of
gliomas to alkylating agents. NEJ M 243:1350-1354, 2000.
44
From: Esteller M, et al. Inactivation of the DNA-repair gene MGMT and the clinical response of
gliomas to alkylating agents. NEJ M 243:1350-1354, 2000.
45
46
Future Role of SNPs and Pharmacogenetics
SNP - Single Nucleotide Polymorphisms
. G G T A A C T G
. G G C A A C T G ...
AS of February 2001, 1.42 million SNPs had
been identified in the human genome.
47
Patients with efficacy
in clinical trials
Patients without efficacy
in clinical trials
Predictive of efficacy
Predictive of no efficacy