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![Page 1: Drug Metabolism and Pharmacogenetics Brendan Stamper University of Washington Dept. of Medicinal Chemistry.](https://reader036.fdocuments.in/reader036/viewer/2022062309/56649f255503460f94c3c643/html5/thumbnails/1.jpg)
Drug Metabolism and Pharmacogenetics
Brendan Stamper
University of Washington
Dept. of Medicinal Chemistry
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What is Medicinal Chemistry?
• Medicinal Chemistry is a scientific discipline involved with designing, synthesizing and developing pharmaceuticals suitable for therapeutic use
• Highly interdisciplinary science combining genetics, molecular biology, biochemistry, organic chemistry, pharmacology, toxicology
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Outline
• Background– Drug Metabolism– Pharmacogenetics
• Examples– CYP2D6
• Codeine• DDI Scenario (fluoxetine)
– ALDH2• Ethanol• DDI Scenario (acetaminophen)
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Basic Vocabulary
• Lipophilicity vs Hydrophilicity– Lipophile: “Fat-lover”– Hydrophile: “Water-lover”
• Xenobiotic: a foreign chemical substance
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More Basic Vocabulary
• Metabolism: chemical reactions that occur in living organisms
• Enzyme: a biomolecule that catalyzes a chemical reaction
Xenobiotic MetaboliteEnzyme
Inducer
Inhibitor
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Today’s Focus
• We will focus on the enzymatic conversion of lipophilic xenobiotics to more water soluble metabolites . . .
. . . and how these processes are influenced by genetic predisposition
WHY DO WE CARE?
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• Lipophilic xenobiotics can be potentially dangerous because they can easily permeate lipid cell membranes and accumulate within cells
• By converting lipophilic xenobiotics to hydrophilic metabolites we can facilitate elimination
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Today’s Focus
• We will focus on the enzymatic conversion of lipophilic xenobiotics to more water soluble metabolites . . .
. . . and how these processes are influenced by genetic predisposition
(i.e. Can we expect xenobiotic metabolism to be consistent from person-to-person?)
NO
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Variability in Dose-Response “If it were not for the
great variability among individuals, medicine might as well be a science and not an art”
William Osler1849-1919
What factors are responsible for this variability?
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DrugResponse
Age
Gender
Race
DietOccupational
Exposure
Genetics
DiseaseStress
Variability in Dose-Response
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Pharmacogenetics
• Definition: The study of genetic variation that gives rise to variability in drug response (Optimize efficacy and limit toxicity)
DrugResponse
Age
Gender
Race
DietOccupational
Exposure
Genetics
DiseaseStress
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How do we predict optimal dose for most efficacious response
• Step 1: Understand the mechanism of drug action at the molecular level
• Step 2: Understand how genetic variations affect drug action
• Step 3: Rational choice of drug and dosage
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DNA Is Like a Language
• DNA• ATGC• Codon• Gene• Chromosome• Genome
• English• Abcdef . . .• Word• Sentence• Chapter• Book
Like language, DNA changes over time
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Polymorphism• Polymorphism: Change in DNA sequence that occurs in more
than 1% of the population• Allele: An alternative form of a gene (i.e. site of sequence
variation)• SNP (Single Nucleotide Polymorphism)
Gene: ATG-GGA-TGC-TAA met-gly-cys-STOPSNP: ATG-GCA-TGC-TAA met-ala-cys-STOP
• Impact of new allele– Alter protein function– Alter protein structure or stability– No consequence
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CYP2D6 and Codeine
Example #1
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Codeine• Analgesic• Prodrug• CYP2D6-mediated bioactivation critical for
analgesic effect– 200mg codeine is equivalent to 30mg morphine (~10%)
CYP2D6
More Lipophilic More Hydrophilic
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CYP2D6
• Drug metabolizing enzyme
• Member of the P450 family (Cytochrome P450 2D6)
• Common substrates– Beta-blockers (Metoprolol)
– SSRIs (Fluoxetine)
– Opiods (Codeine)
– SERMs (Tamoxifen)
• Highly polymorphic enzyme– Over 100 reported
Rowland et al, JBC (2006) 281:7614-7622
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Allele Kinetic Data
Kinetic plot of product formation versus substrate concentration for metabolic turnover of codeine catalyzed by highly purified recombinant CYP2D6 isoforms in vitro.
Yu et al, JPET (2002) 303:1291-1300
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CYP2D6 Genotypes
1. Ultra Metabolizers
2. Extensive Metabolizers
3. Intermediate Metabolizers
4. Poor Metabolizers
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Poor vs Extensive Metabolizers
Individual plasma concentration of codeine and morphine in 14 extensive (filled) and 14 poor (open) metabolizers after an oral dose of codeine.
Poulsen et al, Eur J Clin Pharmacol (1996) 51:289-295
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How can we sort the population into the different CYP2D6
metabolizing groups?
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Urinary Metabolic Ratio of CYP2D6 Substrate
• Dose patients with CYP2D6 substrate (codeine)
• Collect urine sample that contains substrate and metabolite
• Calculate ratio of substrate over metabolite
Substrate (codeine)
Metabolite (morphine)= High (poor metabolizer)
Low (extensitve metabolizer)
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Roden et al, Ann Intern Med 2006; 145:749-757
Urinary Metabolic Ratio of CYP2D6 Substrate
IntermediateMetabolizers
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Outcomes of CYP2D6 Allelic Variations
Zanger et al, Naunyn-Schiedeberg’s Arch Pharmacol (2004) 369: 23-37
No analgesic effect
Pain relief
‘Overdose’ effect
Slight analgesic effect
Null allele
Decreased function allele
Fully functional allele
Expected plasma concentration-time curve with therepeutic window indicated by the boxed area
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Codeine Pharmacogenetics
Green: Intermediate and Extensive MetabolizersPurple: Ultra MetabolizersOrange: Poor Metabolizers
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Who are most affected by CYP2D6 polymorphisms?
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Ethnic Variation in CYP2D6 Mutation Frequencies
Variant Phenotype Caucasian Asian AfricanEthiopian/
Saudi
CYP2D6*2xN UM 1-5% 0-2% 2% 10-16%
CYP2D6*4 PM 12-21% 1% 2% 1-4%
CYP2D6*10 IM 1-2% 51% 6% 3-9%
CYP2D6*17 IM 0% ND 34% 3-9%
CYP450 allele nomenclature committee database: http://www.imm.ki.se/cypalleles
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DDI Scenario:Codeine and Fluoxetine
+
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Drug-Drug Interactions:Codeine + Fluoxetine
CodeineCYP2D6
Morphine
Fluoxetine(inhibitor)
X
Zanger et al, Naunyn-Schiedeberg’s Arch Pharmacol (2004) 369: 23-37
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Summary: CYP2D6 & Codeine• Codeine is a prodrug (requires metabolism)• CYP2D6 metabolizes codeine to morphine• CYP2D6 is a highly polymorphic enzyme• Populations can be separated into different metabolic
sub-groups– UMs: ‘Overdose’ analgesic effect– EMs/IMs: Predicted analgesic effect– PMs: No analgesic effect
• Urinary sampling can enable the pre-sorting of different metabolizers
• Co-treatment with fluoxetine: EMs to PMs
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ALDH2 and Ethanol
Example #2
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Ethanol
• Low dose: Muscle relaxant, euphoria impaired judgment
• High dose: CNS depressant, impaired sensory/motor function
• Toxic when BAC > 400mg/dL (0.4%)
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Ethanol Metabolism
• Alcohol to aldehyde to carboxylic acid• Ethanol: CNS depressant• Acetaldehyde: Vasodilator
– Flushing– Hangover effects
• Acetic Acid: Relatively harmless
ADH ALDH
More Lipophilic More Hydrophilic
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ALDH2
• Aldehyde dehydrogenase 2• Mitochondrial enzyme• Homotetramer• Substrates: aldehydes• Cofactor: NAD+
• Catalyzes the oxidation of aldehydes
• Polymorphic enzyme
Larson et al, JBC (2005) 280:30550-30556
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ALDH2 Genotypes
• ALDH2*1/*1 Wild-type Homozygous
• ALDH2*1/*2 Heterozygous
• ALDH2*2/*2 Mutant Homozygous
• *2 allele = E487K mutation
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ALDH Crystal
Structure
Violet & Blue: NAD+-bound ALDH2*1Red: NAD+-bound ALDH2*2
Larson et al, JBC (2005) 280:30550-30556
*2 Mutation: E487K
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Kitagawa et al, FEBS Letters (2000) 476:306-311
ALDH2 Activity Among Differing Genotypes
Comparison of substrate specific activities of human liver ALDH2 derived from three ALDH genotypes
MALD
AALD
BALD
PALD
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ALDH2 Influence on AALD Blood Levels Following Ethanol Ingestion
Ginsberg et al, Reg Toxicol Pharmacol (2002) 36, 297-309
ADH ALDH2*1/*1
No FlushingNo Hangover Effects
Some FlushingSome Hangover Effects
FlushingHangover Effects
ALDH2*1/*2ALDH2*2/*2
X
X
X
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Who is Affected?
Ginsberg et al, Reg Toxicol Pharmacol (2002) 36, 297-309
ALDH2 polymorphism by ethnic group
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How do you treat an acetaldehyde overdose?
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DDI Scenario:(Ethanol and Acetaminophen)
+
Analgesic/AntpyreticCNS Depressant
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Drug-Drug Interaction:Ethanol and Acetaminophen
CYP2E1
Glutathione adducts(Detoxification)
Protein adducts(Toxicity)Ethanol
(inducer)
X
Cell Death
Liver Damage
NAPQI
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Toxic Scenario1. Chronic alcohol abuser induces CYP2E1
2. ‘Activated’ CYP2E1 forms more toxic metabolite (NAPQI)
3. Increased levels of NAPQI can lead to glutathione depletion
4. Increased protein adduct formation leading to cell death and liver damage
If a you are a chronic alcohol abuser, use ibuprofen instead of acetaminophen to treat your hangover.
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Summary: ALDH2 & Ethanol
• Ethanol metabolism occurs in two steps– ADH: Ethanol to acetaldehyde (toxic metabolite)– ALDH2: Acetaldehyde to acetic acid (detoxification step)
• Three common ALDH2 genotypes– ALDH2*1/*1: No flushing or hangover effects– ALDH2*1/*2: Some flushing and hangover effects– ALDH2*2/*2: Flushing and hangover effects
• ALDH2*2 most prevalent in Asian populations• Chronic alcohol abusers should not take
acetaminophen to treat their hangovers
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Things to Think About• Drug metabolizing enzymes tend to metabolize lipophilic compounds
into hydrophilic compounds (absorption to excretion)• Your genotype impacts how you metabolize drugs• Pharmacogenetics can be used to optimize therapy• Science is interdisciplinary
Genetics - Molecular Biology - Biochemistry - Organic Chemistry - Pharmacology - Toxicology
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Thank you!