Indwiani Astuti

Dept. of Pharmacology & Toxicology

Fac. of Medicine
Universitas Gadjah Mada

Prescribed drugs based on facts and

Only 30-60% of drugs are effective f

The rest of the population experienc

*no effect or
*raise their changes of adverse drug
wrong prescription.

???

Genetics
Age
Gender
Disease
Drugs

GENETIC
POLYMORPHISMS

Pharmacokinetic

Pharmacodynamic

Transporters
Plasma protein binding
Metabolism

Receptors
Ion channels
Enzymes
Immune molecules

Efficacy & Safety

History of
Pharmacogenetics
The first report of an inherited difference in response to a

chemically the inability to taste phenylthiourea-was reported

in the early 1930s (Snyder 1932).
In the late 1950s, Motulsky reported that certain adverse
reactions to drugs are due to genetically determined
variations in enzymatic activity (Motulsky 1957).
Pseudocholinesterasev ariants were associated with
suxamethonium sensitivity, and inherited abnormalities in
red cell glutathione metabolism were identified as causes of
primaquine sensitivity.
At about the same time, genetic differences in the
acetylation Of isoniazid were discovered (Evans et al. 1960).

Vogel first proposed the term pharmacogenetics

(Yogel 1959), and in 1962, Kalow wrote the first

monograph on the topic (Kalow 1962).

The field of pharmacogenetics was stimulated in

the 1970s when Vesell and colleagues

demonstrated that plasma half-lives of many drugs
are less divergent among monozygotic twin pairs
than among dizygotic twin pairs (for a review, see
Vesel 1990).
The implication was that multifactorial inheritance,
or multiple genes, may determine individual drug
metabolism (multigenic inheritance

Pharmacogenomics
pharmacology and
genetics.
Pharmacogenomics: use of genomics

(microarray technology, for example) to identify

one or more genes with altered expression or
activation as a result of exposure to a given drug

Pharmacogenetics: study of how variation in a

single gene or limited subset of genes leads to

variation in action, absorption, or distribution of
drugs (drugs response)

A gene codes for a protein

DNA

CCTGAGCCAACTATTGATGAA

transcription

mRNA

CCUGAGCCAACUAUUGAUGAA

translation

Protein

PEPTIDE

The central dogma of molecular

biology
The flow of the expression of genetic

information in cells is almost exclusively one

way: DNA RNA Protein

Modified Central
Dogma
Genome (Genomics)
Transcriptome (Transcriptomics)
Proteosome (Proteomics)
Metabalome (Metabolomics)

Drugs Metabolism
Phase I metabolism (functionalisation

reactions) Cytochrome P450 enzymes

(CYP450)
Polymorphisms resulting in poor (PM),

intermediate (IM), normal (EM) or rapid

metabolizers (UM)
isoenzymes CYP2D6 and 2C19.

Phase I
Slow metabolisers

have mutations which

inactivate members of
the CYP450 family,
normal metabolisers
carry 2 normal copies
of the CYP450 gene,
fast metabolisers carry
more than 2 genes
(gene duplication)
causing high levels of
CYP450 expression
Pharmacogenomic Frontiers in Medicine and Race
Tony Tu, 2006

Phase II metabolism (conjugation

reactions) (Daly, J Mol Med (1995) 73: 539-553)
Uridine diphosphate glucuronyl-transferases

(UGTs),
Sulfonyl transferases (SULTs),
Thiopurine methyltransferases (TPMTs).
N-acetyltransferase genes, NAT1 and NAT2.
There are at least 3 major slow acetylator
NAT2 alleles, 2 of which are common in
Caucasians and one in Mongoloids.

Genetic polymorphisms
in drug metabolizing
enzymes

From: Evans WE, Relling MV. Pharmacogenomics: Translating functional genomics into rational
therapeutics. Science 286:487-491, 1999.

Genetic polymorphisms in drug

metabolizing enzymes
Dehydropyrimidine dehydrogenase (DPD) is the

initial rate limiting enzyme in the catabolism of 5

fluorouracil (5FU)

located on chromosome 1p22 as a single copy and consists

of 23 exons for a total lenght of 950 kb

1 splice-site mutation, 2 deletions and 4 missense
mutations.

Thiopurine S-methyltransferase (TPMT) is a

cytosolic enzyme that preferentially catalyzes the Smethylation of mercaptopurine (6MP), azothioprine
and thioguanine hematopoietic toxicity
(leucopenia, anaemia, pancytopenia)
located to human chromosome 6 and several mutant alleles

have been isolated from TPMT-deficient patients.

Genetic polymorphisms in drug

metabolizing enzymes
Glutathione S--transferases catalyze the

conjugation of electrophilic compounds to

cellular glutathione
absence of GSTm 1 in children with acute

lymphoblastic leukemia is associated with a

82% remission versus only 52% in children
positive for GSTm .
Busulfan is an alkylating agent

Genetic polymorphisms in drug

metabolizing enzymes
N-acetyltransferases exist as two isoforms

respectively termed NAT1 and NAT2 and have been

initially described as the enzymes responsible for
the acetylation of isoniazid and caffeine
(conversion of 1-methylxanthine into 5acetylamino 6-amino 3-methyl uracil).
NAT2 is located on human chromosome 8q11.

Amonafide (NSC308847) fast acetylators

defined by their caffeine phenotype of NAT2 have

significantly greater leukopenia than slow
acetylators, as well as higher bone marrow toxicity
at the standard dose of 300mg/m2 daily for 5 days.

Pharmacodynamics
Study of the biochemical and physiologic

processes underlying drug action

Mechanism of drug action
Drug-receptor interaction
Efficacy
Safety profile

Effect of Disease on PD
Up regulation of receptors
Down regulation of receptors
Decreased number of drug receptors

Altered endogenous production of a

substance may affect the receptors

Drug Actions
Most drugs bind to cellular receptors
Initiate biochemical reactions
Pharmacological effect is due to the alteration
of an intrinsic physiologic process and not the
creation of a new process

Drug Receptors
Agonist
Drugs which alter the physiology of a cell by

binding to plasma membrane or intracellular

receptors

Partial agonist
A drug which does not produce maximal effect
even when all of the receptors are occupied

Drug Receptors
Antagonists
Inhibit or block responses caused by agonists

Competitive antagonist
Competes with an agonist for receptors
High doses of an agonist can generally
overcome antagonist

Drug Receptors
Noncompetitive antagonist
Binds to a site other than the agonist-binding
domain
Induces a conformation change in the receptor
such that the agonist no longer recognizes
the agonist binding site.
High doses of an agonist do not overcome the
antagonist in this situation

Drug Receptors
Irreversible Antagonist
Bind permanently to the receptor binding site
therefore they can not be overcome with
agonist

Drug Target
Pharmacogenomics
Direct protein target of drug
Receptor
Enzyme

Proteins involved in pharmacologic response

Signal transduction proteins or downstream proteins

Polymorphisms associated with

disease risk
Disease-modifying polymorphisms
Treatment-modifying polymorphisms

POLYGENIC

Evans WE. NEJM 2003; 348:538-48

Role of Mu Opioid Receptor and Related

Endorphin
Systems in Normal Physiological Functions*
Neuroendocrine Functions
Stress responsive systems including

hypothalamic-pituitary-adrenal axis
Reproductive function including
hypothalamic-pituitary-gonadal axis

Response to Pain
Immunological Function
Gastrointestinal Function
Cardiovascular Function
Pulmonary Function
? Mood, Affect; Cognition
* All disrupted by chronic abuse of the short acting opiate, heroin
Kreek, 2000

SNP a single nucleotide polymorphism, that

is, one nucleotide or base of any base pair

that is different from the usual, prototypic,
(or first identified and recorded base)

Coding region that part of a gene which

codes for a peptide (protein)

Allelic Frequency:

<1% low or rare

15%intermediate
>5% high or frequent
M.J. Kreek, 2000

Variant
Exon
(nucleotide position) location

Protein
domain

Corresponding
amino acid change

Allele
frequency

A118G

N-terminus

Asn 4 Asp (N40D)

10.5%
(26 heterozygous;
3 homozygous)

C17T

N-terminus

Ala 6 Val (A6V)

6.6%
(14 heterozygous;
3 homozygous)

G24A

N-terminus

Synonymous
mutation

2%
(6 heterozygous)

G779A

CL3

Arg 260 His (R260H) <1%

(1 heterozygous)

G942A

EL3

Synonymous
mutation

<1%
(1 heterozygous)

* Nucleotide position 1 is first base of the start codon.

Bond et al., 1998

New drugs design (for

exz.)
Receptor with intrinsic Tyrosine Kinase Activity
Large group of receptors for growth factors
(insulin, EGF, PDGF, hepatocyte GF etc)
Extracellular domain contains regions bind GF,
Intracellular domain contains a kinase activity
capable of phosphorylating proteins on tyrosine
residues

Indications
Gefitinib & Erlotinib:
Monotherapy in advanced stage of NSCLC

Cetuximab
Metastatic colorectal cancer with/without Irinotecan

Dose
Gefitinib 250 mg O.D. oral
Erlotinib 150 mg O.D. oral
Cetuximab 400 mg/ m2 i.v. 200 mg / m2 i.v. wkly

BLOCK EGFR
Tyrosine kinase
inhibitors

Signal cascades are useful:

1. At each step of the cascade, the signal is amplified
2. The information that arrived at the plasma membrane in the form of a
signal is communicated to the nucleus
3. The multitude of steps enables a signal to have different effects in
different cells (because they have different target proteins)

The objectives of research in

pharmacogenetics
the identification of genetically controlled

variations in responses to drugs,

the study of the molecular mechanisms causing
these variations,
the evaluation of their clinical significance, and
the development of simple methods to identify
individuals who may be susceptible to variable
responses before drugs are administered.
As a consequence, many of these conditions can
now be diagnosed by analyzing samples of
genomic DNA

Result:
Pharmacogenomics
is the study of how an individuals genome

influences his or her response to a specific drug.

is hoped to boost drug efficacy by guiding
physicians to the best drugs and optimal
prescriptions for different patients (Vascar et al.,
2002)
identify patients at high risk for adverse drug
responses and optimize therapy for each patient
by tailoring medicine

Pharmacotherapy

&

Pharmacogenomic
a near 100% effectiveness
in attacking a patient's disease
Pharmacogenomics
The Future
The Vision
The right drug, at the right
dose for every patient.

In the Drug World, One Size Should Not Fit All

Conclusion
Understanding the mechanisms of genetic

variation in drug effects is the key to applying

pharmacogenetic principles to produce
greater efficacy and fewer adverse reactions
of numerous drugs.
When the molecular mechanism of a genetic
variation is known, simple analyses of
genomic DNA can frequenly : identify
subpopulations of patients that may be at risk.