Factors Affecting

Drug Metabolism H H
H
O N NH 2 O N N O

N N

Prof. Patrick Davis

Basic Med Chem Principles
PHR 143M Fall-08

Factor Affecting Drug Metabolism

The Big Picture

Factor Affecting Drug Metabolism

The Simple View
• Consider: Route(s) of metabolism (Phase-1
& Phase 2) depend on enzymes.
• What happens if metabolism decreased (i.e.,
if enzyme levels or activity go down)?
• What happens if metabolism increased (i.e.,
if enzyme levels or activity go up)?
• Generally changes are quantitative rather
than qualitative.

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Factor Affecting Drug Metabolism

Metabolite A
Enz A Inactive

Metabolite B
Enz B
Active
Drug
Enz C Metabolite C
Toxic
Enz D Metabolite D
Undetectable

Factor Affecting Drug Metabolism

Metabolite A
Enz A Inactive

Metabolite B
Enz B
Active
Drug
Enz C Metabolite C
Toxic
Enz D Metabolite D
Undetectable

Factor Affecting Drug Metabolism

Metabolite A
Enz A Inactive

Metabolite B
Enz B
Active
Drug
Enz C Metabolite C
Toxic
Enz D Metabolite D
Detectable

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 Cytochrome P-450 Multiplicity
• Devlin, “Textbook of Biochemistry With Clinical
Correlation”, 5th Ed. (2002); Chap 11, The
Cytochromes P-450’s.
• Lewis, “Guide to Cytochrome P-450: Structure
and Function (2001).
• Foye, “Principles of Medicinal Chemistry” 6th Ed.
(2007); Chap 10, Drug Metabolism.
• D.R. Nelson’s P-450 site::
http://drnelson.utmem.edu/CytochromeP450.html

Cytochrome P-450 Multiplicity

• Superfamily: Current estimates >1000 genes.
• Some of these “pseudogenes”.
• Humans: Current estimates:
~57 distinct P-450’s in 17 “families”.
• Initially simple P-450’s cholesterol & FA’s
form membranes) Millions of years; evolved
Endogenous -> Endogenous + Exogenous

Cytochrome P-450 Multiplicity

Fe Heme Center

P-450
Enzyme
Active
Site

Substrate Binding Site

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 Cytochrome P-450 Multiplicity

Cytochrome P-450
Superfamily Nomenclature

CYP2D6
Cyt P-450
Family (>40% homology)
Sub-Family (>55% homology)
Individual Form

Human P-450 Multiplicity

CYP1 CYP2 CYP3 CYP4 CYP11 CYP17 CYP19 CYP21
1A1 2A6 3A3 4A9 11A1 21A2
1A2 2A7 3A4 4A11 11B1
2B6 3A5 4B1 11B2
2C8 3A7 4F2
2C9 4F3
2C10
2C18
2C19
2D6
2E1

From Foye

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 Human P-450 Multiplicity
CYP1 CYP2 CYP3 CYP4 CYP11 CYP17 CYP19 CYP21

Drugs Endobiotics
Xenobiotics
PAH’s Fatty Acids
Aryl Amines Arach Acid
Drugs Endogenous Steroids, Bile Acids
Steroids
Drugs

Human P-450 Multiplicity

CYP1 CYP2 CYP3 CYP4 CYP11 CYP17 CYP19 CYP21

1A1 2A6 3A3 4A9 11A1 21A2

1A2 2A7 3A4 4A11 11B1
2B6 3A5
4B1 11B2
2C8 3A7 4F2
2C9 4F3
2C10
2C18
2C19 2D6 = See Table 8.9 (Foye)
2D6 2E1 = See Table 8.10 (Foye)
2E1 Ethanol, Acetaminophen
3A4/3A5 = See Table 8.12 (Foye)

Factor Affecting Drug Metabolism

• Age • Drug Dose
• Disease • Enzyme Induction
• Species Differences • Enzyme Inhibition
• Gender • Diet
• Pregnancy • Heredity/Genetics
• Environmental =>Pharmacogenetics
=>Pharmacogenomics

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Factor Affecting Drug Metabolism
• Age: Very Young
– Not fully ‘metabolically competent.’
– Chloramphenicol toxicity in newborns
(Gray Baby Syndrome) due to poor
glucuronidation (virtually no Phase-2
enzymes).
– Fetus: CYP3A Sub-family only
(poor metabolism overall).
– FDA questions re fetus/infants….

Factor Affecting Drug Metabolism

• Age: Elderly
– Diminished metabolism and excretion.
– Diminished enzyme induction.
– Multiple drugs: average 10 drugs/patient
(health care facilities)
– Dose using escalation strategy.
– Beer’s List

Factor Affecting Drug Metabolism

• Disease
– Hepatitis, hepatic cancer, nephritis, etc.
– General decrease with acute or chronic
liver disease (assess).
– Is drug cleared by liver??
Overdose danger!

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 Factor Affecting Drug Metabolism
• Species Differences
– Inter- and intraspecies variation.
– Cats form sulfates (lack UDP-GT) but
Pigs form glucuronides (lack of
sulfotransferase enzymes).
– Animal models for predicting metabolism.
• Humans have ONE CYP2D isoform
(CYP2D6).
• Rats have SIX CYP2D isoforms.

Factor Affecting Drug Metabolism

• Species Differences
COOH
Rabbits
Guinea Pigs
O
Humans

NH2

Rats
NH2
HO

Factor Affecting Drug Metabolism

• Gender
– Humans few examples
(contraceptives?).
– Differences probably hormonally based
(menstrual cycle can affect PKin).
– N-Demethylation of erythromycin F>M.
– Propranolol oxidation M>F.
– Significance not well understood.

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 Factor Affecting Drug Metabolism
• Pregnancy
– Pregnancy = Concern for fetus (Age)
– Placenta high in CYP1A family if smoker.
Consequences to fetus or neonate:
teratogenicity, carcinogenicity, hepatotoxicity
– Can have profound induction in pregnancy.
e.g., may have to increase anticonvulsants.

Factor Affecting Drug Metabolism

• Environmental Factors
• Example: Cigarette smoke
– Cigarette Smoke -> PAH’s
– PAH’s -> Induce CYP1A2
– CYP1A2 metabolizes PAH to carcinogens.
– Carcinogens -> lung & colon cancer.
– Difficult to correlate (carcinogenesis complex
and takes a long time)

Factor Affecting Drug Metabolism

• Drug Dose
– Classic: Acetaminophen
– Try graphing Dose/Toxicity curve!

Acetaminophen
UDP-GT Glucuronide
Sulfo-
Acetaminophen
Acetaminophen Transferase
Sulfate

CYP2E1 p-quinoneimine
Toxic

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 Factor Affecting Drug Metabolism
• Enzyme Induction => More Enzyme!
• “Adaptive” process based on exposure.
• Transcriptional (classic derepression):
“inducer” + receptor protein =>
binds “repressor” upstream of regulatory
gene resulting in derepression (expression).
• Post-Transcriptional: Stabilize mRNA.

Factor Affecting Drug Metabolism

• Enzyme Induction: Example

Oral CYP3A4
Contraceptive Inactive, Excreted
Steroids
Induction
Rifampin

Consequences??

Factor Affecting Drug Metabolism

• Enzyme Induction: Example

CYP2E1 p-Quinone Imine

Acetaminophen (TOXIC!)
Induction
Ethanol

Consequences??

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 Factor Affecting Drug Metabolism
• Enzyme Induction: Example
CYP3A1
CYP2B2 OH-Warfarins
Warfarin (inactive)
Induction
Phenobarbital

Consequences?? Consequences??
=> Levetiracetam (Keppra®)

Factor Affecting Drug Metabolism

• Enz Induction: Drug/Herbal Interaction

CYP3A4
Cyclosporin Metabolites
(Immunosuppressive) (inactive)

Factor Affecting Drug Metabolism

• Enz Induction: Drug/Herbal Interaction

CYP3A4

Cyclosporin Metabolites
(Immunosuppressive)
Induction (inactive)
St. John’s Wort (hyperforin)
Consequences: Liver transplant rejection!
[Transplantation, 71:239 (2001)]
Huge number of interactions coming to light!

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Factor Affecting Drug Metabolism
• Enzyme Induction: Additional Points
– Especially P-450 Isozymes:
– 3A4 Inducible (See Table 8-11)
(large number of drugs affected; Table 8-12).
– 2D6 Not Inducible.
– 2E1 Inducible
(large number of drugs and solvents affected;
Table 8-10).

Factor Affecting Drug Metabolism

• Enzyme Inhibition: Example
CYP3A1
CYP2B2 OH-Warfarins
Warfarin (inactive)
Inhibition
Chloramphenicol (AB)
Miconazole (AF)

Consequences??

Factor Affecting Drug Metabolism

• Enzyme Inhibition: Example
CYP3A4
Terfenadine Active
(Seldane®) Antihistamine
Inhibition
Erythromycin
Ketoconazole
Many drugs
Consequences?? => Arrhythmias
Consequences?? => Fexofenadine

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 Factor Affecting Drug Metabolism
• Enzyme Inhibition: Example

CYP2D6
Many Inactive
Drugs Metabolites
Inhibition
Quinidine

Consequences??

Factor Affecting Drug Metabolism

• Enzyme Inhibition: Example

Many
Many P-450’s Inactive
Drugs Metabolites
Inhibition S
S

HN N NH Cimetidine O NH

N C CH3 O2 N CH3
NH CH3 N
N H
CH3

Consequences?? => Ranitidine

Factor Affecting Drug Metabolism

• Enzyme Inhibition: Additional Points
– Virtually any enzyme involved in
metabolism.
– 3A4 Inhibition (See Table 8-11)
(large number of drugs affected; Table 8-12).
– 2D6 Inhibition (See Table 8-11)
(large number of drugs affected; Table 8-9).

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Factor Affecting Drug Metabolism
• Diet: Example Grapefruit Juice

CYP3A4
Terfenadine Active
(Seldane®) Antihistamine
Inhibition
Grapefruit Juice
(Bioflavinoids, e.g. naringin)
Consequences??
Critically assess Austin Statesman Article

Factor Affecting Drug Metabolism

• Heredity/Genetics
– Genetic Polymorphism = demonstrably
different forms or levels of enzyme(s) in
distinct population
– Defined by >1% incidence in population.
– e.g. lower levels or non-functional P450’s
-> “poor metabolizers” -> toxicity.
– e.g. higher P450 levels.
-> “fast metabolizers” -> therapeutic failure.
– Inter-individual or interracial differences.

Pharmacogenomics
“Influence of DNA-sequence variation
on drug response”
• A. Var. in drug metabolizing enzymes
• B. Var. in drug transport (abs, dist, excr)
• C. Var. in drug targets (receptors, enzymes)

=> adverse effects

=> therapeutic failures
=> drug interactions

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 Pharmacogenomics
Drug results are ‘polygenic’:

• A. Enzymes  = 
• B. Transport  = 
• C. Receptors  = 

Pharmacogenomics
Drug results are ‘polygenic’:

• A. Enzymes  = 
• B. Transport  = 
• C. Receptors  = 
• D. Other Factors (environment, induction,
inhibition, foods) => Complex

Factor Affecting Drug Metabolism

• A Clear Example: CYP2D6!
– Genetic Polymorphism: 80 different alleles*
– SNP’s = Single Nucleotide Polymorphisms.
– Also gene duplication (1-13 copies)
– => Many possibilities
• Normal enzyme (fully functional), normal amts.
• Normal enzyme in diminished amounts.
• Poorly active or inactive enzyme.
• Massive amounts of enzyme.
* http://www.imm.ki.se/cypalleles

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 Factor Affecting Drug Metabolism
• A Clear Example: CYP2D6!
– CYP2D6 normal enzyme
– CYP2D6*4 = defective splicing => inactive
– CYP2D6*2xn = gene duplicate => 2X active
– CYP2D6*5 = gene deletion => no enzyme
– CYP2D6*17 = 3 bases => dec substrate affin

• Note nomenclature; it’s important!

http://www.imm.ki.se/cypalleles

Factor Affecting Drug Metabolism

• A Clear Example: CYP2D6!
– => Four 2D6 phenotypic sub-populations
• Poor metabolizers (PM)
• Intermediate metabolizers (IM)
• Extensive metabolizers (EM)
• Ultrarapid metabolizers (UM)

http://www.imm.ki.se/cypalleles

Factor Affecting Drug Metabolism

• Heredity/Genetics: Example CYP2D6
– Marker Probe: Debrisoquine
NH

N NH2

NH

N NH2

OH

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 Factor Affecting Drug Metabolism
• A Clear Example: CYP2D6!
– Inter-racial Differences
• 5-10% Caucasians (European) => PM’s
• 1-2% SE-Asian (descent) => PM’s
– => Potential consequences?
• PM’s toxicity
• UM’s failure
• Prodrugs? (e.g. consider codeine to morphine
bioconversion for each group)

Factor Affecting Drug Metabolism

• A Clear Example: CYP2D6!
– Racial (geographic) differences in gene duplication.
– 104-fold variation in rates.
– Arose 3-5,000 years ago (alkaloid metabolism)

Factor Affecting Drug Metabolism

• Azathioprine (Antileukemia Drug)
CH3
N

N CH3
S SH S

NO2 N N N
N N TPMT N

N N N N N N
H H H

• Autosomal codominant inheritance [TPMTH/TPMTH]

• If homozygous recessive (1% Caucasians
[TPMTL/TPMTL]) no activity.
=> low TPMT => fatal myelosuppression.

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 Factor Affecting Drug Metabolism
• Azathioprine (Antileukemia Drug)

Factor Affecting Drug Metabolism

• Azathioprine (Antileukemia Drug)
CH3
N

N CH3
S SH S

NO2 N N N
N N TPMT N

N N N N N N
H H H
• RBC test for TPMT deficiency (first PGenomic)
• Serious liability issues.

Factor Affecting Drug Metabolism

• Heredity/Genetics: Example INH
– N-Acetyltransferase NAT-2): Isoniazid
H H H
O N NH 2 O N N O

N N

– "Slow Acetylators" (50% Caucasians and African-

Americans; only 5% Asian-Amer)
– "Fast Acetylators" (Eskimos & Asian-Amer)
– Applies to INH, phenelzine, procainamide.

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 Factor Affecting Drug Metabolism
• Heredity/Genetics: Example INH
– N-Acetyltransferase: Isoniazid

Factor Affecting Drug Metabolism

• Heredity/Genetics: Excellent Pharmacogenetics &
Pharmacogenomics Reviews on Website
– “Pharmacogenomics: Translating Functional
Genomics into Rational Therapeutics”, W.E. Evans
and M.V. Relling, Science, 286:487 (1999).
– “Inheritance and Drug Response”, R. Weinshilboum,
New Eng. J. Medicine, 348:529 (2003).
– “Pharmacogenomics - Drug Disposition, Drug
Targets, and Side Effects”, W.E. Evans, H.L. McLeod,
New Eng. J. Medicine, 348:538 (2003).
– “Cytochromes P450, Drugs and Disease”, F.P. Guengerich,
Molecular Interventions, 3:194 (2003).

Factor Affecting Drug Metabolism

•

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 Factor Affecting Drug Metabolism
Age Drug
Dose
Disease Enzyme
Induction
Species Differences Enzyme Inhibition
Gender Diet
Pregnancy Heredity/Genetics
Environmental =>Pharmacogenetics
=>Pharmacogenomics
• May look complex, but it's usually COMMON
SENSE -and-
PREDICTABLE!

Factors Affecting
Drug Metabolism
H H H
O N NH 2 O N N O

N N

Prof. Patrick Davis

Basic Med Chem Principles
PHR 143M Fall-08

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