Impaired hepatic drug and steroid metabolism in congenital adrenal hyperplasia due to P450 oxidoreductase deficiency

Objective: Patients with congenital adrenal hyperplasia due to P450 oxidoreductase (POR) deficiency(ORD) present with disordered sex development and glucocorticoid deficiency. This is due to disruption of electron transfer from mutant POR to microsomal cytochrome P450 (CYP) enzymes that play a key role in glucocorticoid and sex steroid synthesis. POR also transfers electrons to all major drugmetabolizing CYP enzymes, including CYP3A4 that inactivates glucocorticoid and oestrogens. However, whether ORD results in impairment of in vivo drug metabolism has never been studied. Design:We studied an adult patient with ORD due to homozygous POR A287P, the most frequent POR mutation in Caucasians, and her clinically unaffected, heterozygous mother. The patient had received standard dose oestrogen replacement from 17 until 37 years of age when it was stopped after she developed breast cancer. Methods: Both subjects underwent in vivo cocktail phenotyping comprising the oral administration of caffeine, tolbutamide, omeprazole, dextromethorphan hydrobromide and midazolam to assess the five major drug-metabolizing CYP enzymes. We also performed genotyping for variant CYP alleles known to affect drug metabolism. Results: Though CYP enzyme genotyping predicted normal or high enzymatic activities in both subjects, in vivo assessment showed subnormal activities of CYP1A2, CYP2C9, CYP2D6 and CYP3A4 in the patient and of CYP1A2 and CYP2C9 in her mother. Conclusions: Our results provide in vivo evidence for an important role of POR in regulating drug metabolism and detoxification. In patients with ORD, in vivo assessment of drug-metabolizing activities with subsequent tailoring of drug therapy and steroid replacement should be considered

Drug monitoring in child and adolescent psychiatry for improved efficacy and safety of psychopharmacotherapy

Most psychotropic drugs used in the treatment of children and adolescents are applied "off label" with a direct risk of under- or overdosing and a delayed risk of long-term side effects. The selection of doses in paediatric psychiatric patients requires a consideration of pharmacokinetic parameters and the development of central nervous system, and warrants specific studies in children and adolescents. Because these are lacking for most of the psychotropic drugs applied in the Child and Adolescent and Psychiatry, therapeutic drug monitoring (TDM) is a valid tool to optimise pharmacotherapy and to enable to adjust the dosage of drugs according to the characteristics of the individual patient. Multi-centre TDM studies enable the identification of age- and development-dependent therapeutic ranges of blood concentrations and facilitate a highly qualified standardized documentation in the child and adolescent health care system. In addition, they will provide data for future research on psychopharmacological treatment in children and adolescents, as a baseline for example for clinically relevant interactions with various co-medications. Therefore, a German-Austrian-Swiss "Competence Network on Therapeutic Drug Monitoring in Child and Adolescent Psychiatry" was founded [1] introducing a comprehensive internet data base for the collection of demographic, safety and efficacy data as well as blood concentrations of psychotropic drugs in children and adolescents

Translating Pharmacogenomics: Challenges on the Road to the Clinic

Pharmacogenomics is one of the first clinical applications of the postgenomic era. It promises personalized medicine rather than the established “one size fits all” approach to drugs and dosages. The expected reduction in trial and error should ultimately lead to more efficient and safer drug therapy. In recent years, commercially available pharmacogenomic tests have been approved by the Food and Drug Administration (FDA), but their application in patient care remains very limited. More generally, the implementation of pharmacogenomics in routine clinical practice presents significant challenges. This article presents specific clinical examples of such challenges and discusses how obstacles to implementation of pharmacogenomic testing can be addressed

Arzneitherapieempfehlungen auf pharmakogenetischer Basis

Genetische Polymorphismen in den Enzymen CYP2D6, CYP2C19 und CYP2C9 beeinflussen die Pharmakokinetik medizinisch bedeutsamer Arzneimittel wie Antidepressiva, oraler Antidiabetika und nichtsteroidaler Antiphlogistika in erheblichem Ausmaß. In der Zukunft kann die Bestimmung genetischer Varianten bei Patienten zur Verbesserung der Arzneitherapie genutzt werden, jedoch nur dann, wenn klinische Konsequenzen wie konkrete Therapieempfehlungen aus den genetischen Daten abgeleitet werden können. An gesunden Probanden wurde die die Bedeutung der beiden Aminosäurevarianten des Enzyms CYP2C9, Arg144Cys (CYP2C9*2) und Leu359Ile (CYP2C9*3) für die Pharmakokinetik von Tolbutamid, Glibenclamid, Nateglinid, Diclofenac, Ibuprofen, Celecoxib und Fluvastatin untersucht. Die Analyse der pharmakokinetischen Parameter ergab eine erheblich erniedrigte Clearance für diese Substrate bei homozygoten Trägern der Allelvariante CYP2C9*3, wie sie etwa 1% in der Bevölkerung tragen. Um bioäquivalente Konzentrationsverläufe zu erreichen, müssten diese Patienten deutlich niedrigere Dosierungen (unter 50%) der meisten der untersuchten CYP2C9-Substrate erhalten. Hingegen zeigte die CYP2C9*2-Variante nur einen geringen Einfluss auf die Pharmakokinetik der untersuchten Medikamente. Für den Bereich der Therapie mit Antidepressiva und Antipsychotika sollte untersucht werden, inwieweit umfassende pharmakogenetisch begründete Therapieempfehlungen gegeben werden können. Eine systematische Analyse aller bisher publizierten Daten zum Einfluss von Polymorphismen von CYP2D6, CYP2C19 und CYP2C9 ergab, dass für die meisten gängigen Antidepressiva bereits Studien zur Bedeutung von Cytochrom-P450-Polymorphismen durchgeführt wurden. Für die beiden in Deutschland sehr häufig verwendeten Trizyklika Trimipramin und Doxepin dagegen lagen keine ausreichenden Daten vor. Beide Medikamente wurden deshalb bei Probanden getestet, die jeweils Träger eines oder zweier Allele mit defizienter oder herabgesetzter Enzymaktivität von CYP2D6, CYP2C19 oder CYP2C9 waren. Es ergab sich ein deutlicher Einfluss des CYP2D6-Genotyps, ein schwächerer von CYP2C19 und des Genotyps CYP2C9*3/*3. Eine Dosisreduktion für Langsam-Metabolisierer von CYP2D6 und etwas moderater für Langsam-Metabolisierer von CYP2C19, sowie für Träger des Genotyps CYP2C9*3/* erscheint für diese beiden Antidepressiva sinnvoll. Die eigenen Daten und die Daten für andere Antidepressiva aus der Literatur wurden dazu verwendet, eine Methode zur Ableitung von pharmakogenetisch basierten Dosierungsempfehlungen zu entwickeln. Auf dem Prinzip der Bioäquivalenz basierend wurden Dosierungsanpassungen für unterschiedliche Genotypen je nach Unterschieden in der Clearance von Substanzen errechnet. Durch diese Dosierungsanpassungen können zumindest theoretisch die durch herabgesetzte Enzymaktivität verursachten Unterschiede in den Plasmakonzentrationsverläufen von Medikamenten ausgeglichen werden. Dabei wurden aktive an der Arzneimittelwirkung teilhabende Metaboliten mit berücksichtigt. Auf Seiten der Pharmakodynamik wurden die vielen Studien zu genetischen Polymorphismen in Serotonin-, Dopaminrezeptoren und Transportern und auch zu anderen Kandidatengenen für die Antidepressiva-, und Antipsychotikawirkung analysiert. Jedoch lassen sich aus den teilweise geringen Einflüssen einzelner Genotypen auf die Arzneimittelwirkung derzeit noch keine pharmakodynamisch begründeten Therapieempfehlungen ableiten. Zusammenfassend lassen sich also bereits heute pharmakogenetisch basierte Dosierungsempfehlungen für viele Medikamente berechnen. Derartige Empfehlungen müssen prospektiv überprüft, validiert und angepasst werden. Auf Seiten der Zielmoleküle der Arzneimittelwirkung ist eine Ableitung genetisch basierter Therapieempfehlungen schwieriger. Das Ziel, konkrete Therapieempfehlungen aus genetischen Daten abzuleiten, ist eine notwendige Bedingung, um Pharmakogenetik in die klinische Praxis der Arzneitherapie einzuführen.Genetic polymorphisms of the cytochrome P450 enzymes CYP2D6, CYP2C19 and CYP2C9 largely influence pharmacokinetics of clinically important drugs such as antidepressants, oral antidiabetics and nonsteroidal antiphlogistic drugs. Pharmacogenetic diagnostics is ready to be used for optimization of drug treatment in the future if concise recommendations for clinical decisions can be derived from the genetic data. Panel studies in healthy volunteers served to characterize the impact of the amino acid variants Arg144Cys (CYP2C9*2) and Leu359Ile (CYP2C9*3) in cytochrome P450 2C9 on pharmacokinetics of the oral antidiabetics tolbutamide, glyburide and nateglinide, of the nonsteroidal analgetic drugs diclofenac, ibuprofen, celecoxib, and of fluvastatin. Analysis of pharmacokinetic parameters revealed largely reduced oral clearances in homozygous carriers of the CYP2C9*3 allele for most of the substrates studied. About 1% in the general population are carriers of this genotype and patients should get about 50% lower doses of most of the CYP2C9 substrates in order to achieve similar plasma concentration versus time courses. In contrast, the CYP2C9*2 variant had little influence on pharmacokinetics of the CYP2C9 substrates. For antidepressant and antipsychotic drug therapy, the aim was to derive detailed dose recommendations from the large amount of data existing. Thus, a systematic analysis of all published data on the clinical influence of genetic polymorphisms in CYP2D6, CYP2C19 and CYP2C9 was performed and dose recommendations were given for many antidepressants. For two substances, the tricyclics doxepin and trimipramine, no pharmacogenetic data have been found, and therefore own clinical studies were performed. Healthy volunteers who were heterozygous and homozygous carriers of alleles with deficient activity of CYP2D6, CYP2C19 or CYP2C9 were tested for differences in metabolism and elimination of doxepin and trimipramine and compared to carriers of the wildtype. A significant influence of the CYP2D6 genotype was detected whereas CYP2C19 and the genotype CYP2C9*3/*3 had smaller influences. A significant dose reduction for CYP2D6 poor metabolizers and a smaller reduction for CYP2C19 poor metabolizers would be predicted from these data. According the principles of bioequivalence, calculation methods for pharmacogenetic based dose recommendations from clearance or drug concentration data were developed. Using all published data and the own study results, we developed dose adjustments for each genotype. These dose adjustments would allow to compensate for lower drug clearance caused by genetic variants. Active metabolites which contribute to overall drug effects were considered as well. With regard to target molecules of antidepressant and antipsychotic drug action, many studies have been performed on genetic polymorphisms in serotonin-, and dopamine receptors and in transporter molecules but as well in other candidate genes. However, it is not yet possible to derive therapeutic consequences based on these data. In conclusion, on the pharmacokinetic side of drug action, we are already able to give pharmacogenetic based therapeutic recommendations by adjusting the doses according to genotype. However, the benefit of pharmacogenetic dose adjustments has to be studied prospectively. With regard to the pharmacodynamic side of drug action, the situation is much more complex and we are not yet ready to give pharmacogenetics based therapeutic guidelines. However, this has to be a major goal in order to introduce pharmacogenetic diagnostic into clinical practice

Baseline Brain Perfusion and the Serotonin Transporter Promoter Polymorphism

[Background] The serotonin transporter length repeat polymorphism (5-HTTLPR) in the promoter region of the serotonin transporter gene (SLC6A4) has been associated in healthy subjects with changes in basal perfusion levels in the limbic system and ventral prefrontal areas, regions involved in the pathophysiology of depression and anxiety, suggesting the existence of a neurobiological trait predisposing to these disorders. We reassess the findings of an increased baseline perfusion in the amygdala and ventral prefrontal areas in healthy carriers of the risk genotype in a much larger sample than in previous studies.[Methods] A cohort of 183 healthy European individuals underwent perfusion imaging with continuous arterial spin-labeling (CASL) while resting quietly in the scanner for 8 minutes. Participants were genotyped to assess the occurrence of the short allele and the Lg and La variants of the long repeat.[Results] No association between the 5-HTTLPR polymorphism and baseline brain perfusion was detected in the regions of interest or elsewhere in the brain. In the amygdala, variability in baseline perfusion was explained in large part by global cerebral flow levels (between 50% and 55%), in minor part by sex (between 4% and 5%), but not by genotype (less than .5%). Power analyses showed that the study was of sufficient size to be informative.[Conclusions] The findings did not confirm the existence of a biological marker of the effect of 5-HTTLPR polymorphism in the amygdala or in the orbitofrontal cortex. © 2010 Society of Biological Psychiatry.Peer Reviewe

Relative potency of proton-pump inhibitors—comparison of effects on intragastric pH

International audienc