Oncogenes

1. Explain the biochemical mechanism of CML and how the Philadelphia chromosome was
formed. How would you explain the over production of leucocytes in patients with CML?
Chronic myeloid leukaemia is a rare type of cancer affecting approximately 700 people (mostly adults) in
the UK each year.
Leukaemia is a cancer of the white blood cells. Normally, white blood cells grow and divide in an orderly
and controlled way, but in leukaemia the process gets out of control and the cells divide too quickly, and
do not mature. In CML, too many myeloid cells (one of the main types of white blood cells) are
produced. The myeloid cells are released into the blood when they are immature and unable to work
properly. These immature white blood cells are known as blasts.
The immature cells fill up the bone marrow and prevent it from making blood cells properly. As the
leukaemia cells do not mature, they can't do the work of normal white blood cells, which leads to an
increased risk of infection. Because the bone marrow is overcrowded with immature white cells it also
can't make enough healthy red cells and platelets.
CML usually develops very slowly, which is why it is called chronic myeloid leukaemia.
Chronic myeloid leukaemia can occur at any age, but it more commonly affects middle-aged and older
people. It is rare in children.
Philadelphia chromosome is formed by chromosomal rearrangement or translocation in which c-abl is
translocated from chromosome 9 to chromosome 22, inserting in the bcr gene produces a bcr-abl hybrid
gene. The fusion promotes growth of luekemia cells in CML.
2. What is the cause of the anemia and bleeding tendencies?
As CML develops it is more likely to cause symptoms. In the accelerated phase there may be no more
symptoms than in the chronic phase, however, the number of healthy blood cells in the blood may be
lower. This may not cause any noticeable symptoms. Some people may develop high temperatures (fever)
and night sweats.
In the more advanced stages of CML (blast phase) the symptoms are likely to be more pronounced. The
symptoms are caused by the increased number of abnormal white blood cells in the bone marrow and the
low number of normal blood cells. Symptoms include:
having various infections one after another, caused by a lack of healthy white blood
cells
looking pale, due to a lack of red blood cells (anaemia)
unusual bleeding, caused by a low number of platelets in the blood. This may include
bruising (bruises appear without apparent injury), heavy periods in women, bleeding
gums, and frequent nose bleeds. Some people may notice a particular type of bruising
that consists of small blood-like spots, usually seen on the legs or in the mouth. This
is called petechiae.
swollen lymph nodes
small nodules in the skin, caused by the spread of leukaemia cells
generalised itching.

Xenobiotics
1. What is paracetamol? Mechanism of action? Compare with aspirin.
Paracetamol is usually classified along with nonsteroidal antiinflammatory drugs (NSAID), but is not
considered one. Like all drugs of this class, its main mechanism of action is the inhibition of
cyclooxygenase (COX), an enzyme responsible for the production of prostaglandins, which are important
mediators of inflammation, pain and fever. Therefore, all NSAIDs are said to possess anti-inflammatory,
analgesic (anti-pain), and antipyretic (anti-fever) properties. The specific actions of each NSAID drug
depends upon their pharmacological properties, distribution and metabolism.

The production of prostaglandins is part of the body's inflammatory response to injury, and inhibition
of prostaglandin production around the body by blocking the cyclooxygenase enzymes known as COX-1
and COX-2 has long been known to be the mechanism of action of aspirin and other non-steroidal antiinflammatory drugs (NSAIDs) such as ibuprofen. However, their action in blocking COX-1 is known to
be responsible for also causing the unwanted gastrointestinal side effects associated with these drugs.

Paracetamol has no significant action on COX-1 and COX-2, which left its mode of action a mystery
but did explain its lack of anti-inflammatory action and also, more importantly, its freedom from
gastrointestinal side effects typical of NSAIDs.
Early work (1) had suggested that the fever reducing action of paracetamol was due to activity in the
brain while its lack of any clinically useful anti-inflammatory action was consistent with a lack of
prostaglandin inhibition peripherally in the body.

Now, recent research (2) has shown the presence of a new, previously unknown cyclooxygenase
enzyme COX-3, found in the brain and spinal cord, which is selectively inhibited by paracetamol, and is
distinct from the two already known cyclooxygenase enzymes COX-1 and COX-2. It is now believed that
this selective inhibition of the enzyme COX-3 in the brain and spinal cord explains the effectiveness of
paracetamol in relieving pain and reducing fever without having unwanted gastrointestinal side effects.

2. Metabolism of Paracetamol
Paracetamol is metabolized primarily in the liver, where most of it (60-90% of a therapeutic dose)
is converted to inactive compounds by conjugation with sulfate and glucuronide, and then excreted by the
kidneys. the toxic effects of paracetamol are due to a minor alkylating metabolite (N-acetyl-p-benzoquinone imine, abbreviated as NAPQI) that is produced through this enzyme, not paracetamol itself or
any of the major metabolites. The metabolism of paracetamol is an excellent example of toxication,
because the metabolite NAPQI is primarily responsible for toxicity rather than paracetamol itself.

At usual doses, the toxic metabolite NAPQI is quickly detoxified by combining irreversibly with
the sulfhydryl groups of glutathione to produce a non-toxic conjugate that is eventually excreted by the
kidneys.

3. Paracetamol as substance for suicide attempts

Paracetamol as Poison
Because paracetamol is a potent drug that is available without prescription, it is often used in suicide
attempts, and in this respect it is potentially more dangerous than other over-the-counter drugs such as
aspirin. This is because paracetamol overdoses often cause liver failure, and there have been many cases
where attempted suicides have awakened from an overdose and changed their minds, yet still died a few
days later from liver damage.
The reasons for this poisoning are to do with the process by which paracetamol is eliminated from the
body. It is first metabolised to a quinone imine:

This compound is extremely toxic, and like other such compounds is eliminated in the liver by reaction
with a tripeptide, glutathione. If insufficient glutathione is available, the toxic quinone will not be
eliminated and begins to react with cellular proteins and nucleic acids in the liver, eventually causing
irreparable damage.

However, two compounds, methionine and N-acetylcysteine can boost levels of the vital glutathione in
the liver, and so can be used as antidotes for paracetamol poisoning if the overdose is discovered in time.
A new formulation of paracetamol is now being marketed in the UK which incorporates methianine, such
that the drug carries its own antidote with it!
As discussed above in the section regarding metabolism, paracetamol is mostly converted to inactive
compounds via Phase II metabolism by conjugation with sulfate and glucuronide, with a small portion
being oxidized via the cytochrome P450 enzyme system. Cytochrome P450 2E1 (CYP2E1) converts
paracetamol to a highly reactive intermediary metabolite, N-acetyl-p-benzo-quinone imine (NAPQI). In
cases of paracetamol toxicity, the sulfate and glucuronide pathways become saturated, and more
paracetamol is shunted to the cytochrome P450 system to produce NAPQI.
4. Risk factors that can increase toxicity of paracetamol
Chronic excessive ethanol (alcohol) consumption can induce CYP2E1, thus increasing the
potential
toxicity
of
paracetamol.
5. Unintentional overdose of Paracetamol in children
The toxic dose of paracetamol is highly variable.
In children acute doses above 200 mg/kg could potentially cause toxicity. This higher threshold is largely
due to children having relatively larger kidneys and livers than adults and hence being more tolerant of
paracetamol overdose than adults. Acute paracetamol overdose in children rarely causes illness or death
with chronic supratherapeutic doses being the major cause of toxicity in children.
Since paracetamol is often included in combination with other drugs, it is important to include all sources
of paracetamol when checking a person's dose for toxicity. In addition to being sold by itself, paracetamol
may be included in the formulations of various analgesics and cold/flu remedies as a way to increase the

pain-relieving properties of the medication. To prevent overdoses, one should read medication labels
carefully for the presence of paracetamol and check with a pharmacist before using over-the-counter
medications.