Farmakogenetika v klinični farmakokinetiki

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1 Variabilnost v farmakokinetiki Farmakogenetika v klinični farmakokinetiki Igor Locatelli genetski polimorfizem telesna masa bolezenska stanja starost interakcije Interindividualna variabilnost v FK in/ali FD parametrih + zko terapevtsko okno v povezavi s klinično pomembnimi neželenimi učinki Različen klinični izid farmakoterapije pri bolnikih Katedra za biofarmacijo in farmakokinetiko Fakulteta za farmacijo Univerza v Ljubljani Individualizacija režima odmerjanja takega zdravila 2 Farmakogenetika Proučuje vpliv genetskih dejavnikov na variabilnost v kliničnem učinku po aplikaciji določenega zdravila. Genetski dejavniki: variante genskem zapisu (genotip) spremenjena aktivnost proteinov (fenotip) Farmakogenetika Genetski polimorfizem (wt, mt) v farmakogenetiki pojavljanje dveh ali več variant v določenem genskem lokusu z znano frekvenco v populaciji (vsaj 1%) in vpliv na FK/FD lastnosti učinkovin. SP (single-nucleotide polymorphism) Alel posamezen gen iz para genov (ali izmed več genov) na istem lokusu v homolognih kromosomih Homozigoti (enaka alela) in heterozigoti (različna alela) Haplotip 3 4 1

2 Vpliv genetskega polimorfizma na FK/FD FARMAKKIETIKA Absorpcija, porazdelitev, ekskrecija Transportni proteini (npr. P-glikoprotein, MDR1, ABCB1) Metabolizem (Δ očistka) Metabolni encimi 1. in 2. faze FARMAKDIAMIKA Genetski polimorfizem v genih, ki kodirajo tarčne receptorje ali encime. Citokromi P450 CYP PREDZDRAVILA! UDP-glukuronozil-transferaze UGT Enterohepatični cikel! 5 6 Klinično pomembni genetski polimorfizmi Evans WE and Relling MV. Science 286 (1999)

3 Klinično pomembni genetski polimorfizmi Klinično pomembni genetski polimorfizmi 9 Regulativa Klinično pomembni genetski polimorfizmi povezani z farmakokinetiko učinkovin Genomics at FDA: Pharmacogenetics/default.htm Pharmacogenetics/ucm htm 11 CYP encimi iz družine citokromov P450 DPD dihidropirimidin-dehidrogenaza AT -acetil-transferaza TPMT tiopurin metil-transferaza UGT UDP glukuronizil-transferaza 12 3

4 Pomen encimov CYP Delež učinkovin, ki ga encim metabolizira Količina (%) encima v jetrih ADH; alkohol dehidrogenaza, ALDH; aldehid dehidrogenaza, CYP; citokromi P450, DPD; dihidropirimidin dehidrogenaza, Q1, ADPH; oksidoreduktaze. CMT; katehol -metil trasferaza; GST; glutation S-transferaza HMT; histamin metil-trasferaza; AT; -acetil-transferaza; STs; sulfotransferaze; TPMT; tiopurin metil-transferaze. UGTs; uridin-3-fosfat glukuronizil-transferaze omenklatura CYP

5 Kirchheiner et al. at Rev Drug Discov Aug;4(8): Tomalik-Scharte D et al. Pharmacogenomics J Feb;8(1): Vpliv genetskega polimorfizma CYP2D6 na metabolizem učinkovin Fenotip CYP2D

6 dnos med fenotipom in genotipom CYP2D6 dmerjanje glede na genotip CYP2D6 PM slabi presnavljalci, IM srednje dobri presnavljalci, EM dobri presnavljalci, UM ultrahitri presnavljalci PM IM EM! UM Določanje genetskega polimorfizma v klinični praksi AmpliChip CYP450 (CYP2D6 in CYP2C19) TaqMan Genotyping assay (real time PCR)

7 Vpliv genetskega polimorfizna na farmakokinetiko učinkovine/metabolita Risperidon Atipičen antipsihotik Titracija odmerka 9-hidroksirisperidon glavni metabolit, aktiven, kiralni center na mestu 9. Predsistemski metabolizem; obseg aborpcije ~ 66%. RISP 9-H-RISP H CH 3 CYP2D6, CYP3A4 CH 3 F F Razvoj modela FK risperidona First-pass metabolizem učinek prvega prehoda Dose K a Razpon plazemskih koncentracij RISP: ng/ml (+)-9-H-RISP: ng/ml (-)-9-H-RISP: ng/ml K a Fp r Dose K a (1-Fp) K a Fp (1-r) f = f(+) + f(-) Fp = 1 F 2(1 F) Θ f + f f RISP f(+) /V f(-) /V K a f(+) Hitrostna konstantna absorpcije (fiksirana 2.34 h -1 ) Tvorni očistek za (+)-9-H-RISP RISP f(+) /V f(-) /V r = f(+) /f (+)-9-H-RISP m /V (-)-9-H-RISP m /V f(-) m V Tvorni očistek za (-)-9-H-RISP Eliminacijski očistek 9-H-RISP Volumen porazdelitve (enak za vse) (+)-9-H-RISP m /V (-)-9-H-RISP m /V Fp FP f(+) f

8 Genotip CYP2D6 Končni model Genotip CYP2D6 (n) *4/*4 (2), *3/*4 *4/*41 (3), */*41, *3/*41, *4/* *1/*4 (9), *1/* (3), *1/*41 (6) *1 /*1xn or *2xn (2) *1/*1 (21) Skupina (fenotip) 0/0 (PM) 0/x (IM) 0/1 (EM) 1/x (EM) X (UM) 1/1 (EM) Št. bolnikov f ( + ) f ( ) m 0/0 0/ x 0/1 1/ x X [ L / h] = [ L / h] = [ L / h] = % interval zaupanja 0/0 0/ x 0/1 1/ x X x PM IM f(+) f(-) CYP2D6 0 1 Testirani aleli CYP2D6: *2, *3, *4, *5, *6; *8, *9, *, *11, *12,*14, *15, and *41 1 x X Ratio 30 Vpliv genotipa CYP2D6 na plazemske koncentracije aktivne oblike v stacionarnem stanju Vpliv genotipa CYP2D6 na plazemske koncentracije risperidona in aktivne oblike P=0.014 IM PM Koncentracija aktivna oblike Mediana 24.6 ng/ml Razpon ng/ml Plasma concentration [ng/ml] RISP Risperidon 0/0-PM 0/1-IM Plasma concentration [ng/ml] "Active moiety" Aktivna oblika 0/0-PM 0/1-IM 1/1-EM 0 1/1-EM Time [days] Time [days] 31 Simulacija plazemskih koncentracij za tipičnega bolnika težkega 70 kg, z normalno ledvično funkcijo, pri terapiji 2 mg risperidona dvakrat dnevno. 32 8

9 Vpliv genotipa CYP2D6 na plazemske koncentracije 9-H-RISP enantiomerov Povezava FK risperidona s pojavnostjo ekstrapiramidnih motenj gibanja 15 (+)-9-H-RISP (+)-9-H-RISP 15 (-)-9-H-RISP Parkinsonizem (n=29) (mean SAS 0.4 ali več) Distonia (n=6) (AIMS at least moderate in 1 or mild in 2 of the 7 body areas) 1/1-EM Plasma concentration [ng/ml] 5 0/0-PM Plasma concentration [ng/ml] 5 1/1-EM 0/0-PM Time [days] Time [days] p=0,037 Mann-Whitney p=0,016 Mann-Whitney Simulacija plazemskih koncentracij za tipičnega bolnika težkega 70 kg, z normalno ledvično funkcijo, pri terapiji 2 mg risperidona dvakrat dnevno Sklep Vprašanja Genotip CYP2D6 je pomemben dejavnik, ki vpliva na plazemske koncentracije risperidona in njegove aktivne oblike. Bolniki, ki jih glede na genotip CYP2D6 lahko razvrstimo med slabe ali srednje presnavljalce substratov za CYP2D6, imajo zaradi višjih plazemskih koncentracij aktivne oblike risperidona povečano tveganje za pojav EPS. Klinično pomembna vloga genotipizacije CYP2D6 pri individualizaciji odmerjanja risperidona. Zakaj je koncentracija aktivne oblike risperidona odvisna od genotipa CYP2D6? Zakaj genotip CYP2D6 ne vpliva na plazemske koncentracije metabolitov RISP v stacionarnem stanju? Kdaj se vzpostavi stacionarno stanje in od česa je to odvisno? Kakšen odstotek odmerka risperidona bi morali prejeti PM v relaciji do EM? Če so bolniki bili titrirani, zakaj smo potem v študiji opazili značilen vpliv genotipa CYP2D6 na plazemske koncentracije aktivne oblike?

10 Varfarin S in R-varfarin ajbolj pogosto uporabljeno antikoagulacijsko zdravilo. Velika variabilnost dnevnih odmerkov za vzdrževanje enakega učinka (0,5 50 mg/dan); individualno prilagajanje odmerka. Zaradi ozke terapevtske širine je potrebno spremljanje bolnika in merjenje protrombinskega časa (IR) zlasti v uvajalnem obdobju (vnos hrane bogate z vitaminom K, interakcije z drugimi zdravili), pogoste kontrole. S-VARFARI 6 2C9 7 8 H 4 1 * 9 H 4' 2C8 2C18 2C19 3A4 R-VARFARI 3A4 Variabilnost je v znatni meri posledica kompleksne farmakokinetike. 37 1A1 1A2 2C19 1A1 1A2 2C H 4 1 1A1 1A2 2C19 * 9 H 4' 2C9 2C18 3A4 38 Encim Predstavlja 15 % celokupnih jetrnih P450 Presnavlja >0 zdravil ekateri klinično pomembni substrati: S - varfarin, fenitoin, diklofenak, ibuprofen, S- naproksen, fluoksentin, losartan Inhibitorji: flukonazol, izoniacid, lovastatin, trimetoprim Induktorji: rifampin, fenobarbital Polimorfizem encimska frekvenca aleli polimorfizem aktivnost (belci) * normalna 86 90% *2 R144C zmanjšana 8-14% *3 I359L zmanjšana 7-% 39 40

11 Preiskovanci in potek raziskave 204 bolniki na dolgotrajnem zdravljenju z varfarinom in urejenim antikoagulacijskim statusom (UKC Ljubljana, bolnišnica Murska Sobota). Indikacije: atrijska fibrilacija (84%), globoka venska tromboza (6%), umetne srčne zaklopke (2%), ostale srčnožilne bolezni (8%). Povprečni dnevni vzdrževalni odmerek: 0,75 15 mg. Vzorčenje: ur po zadnjem odmerku. Genotip so določili na Inštitutu za Biokemijo, Medicinska fakulteta, Univerza v Ljubljani. Farmakokinetična analiza Izračun plazemskega očistka S- in R-varfarina: D D2 C = τ = F = 1, C = C F ss, av ssav, ss Css τ Statistični model za napoved očistka. - multipla linearna regresija Dejavniki vključeni v statistični model Vpliv genotipa na očistek S-varfarina normaliziranega na telesno težo brez maščob Spol, starost, telesna teža brez maščob. Genotip *2 ali *3 Sočasno jemanje zdravil, ki so: induktorji citokromov P450 (karbamazepin, primidon), močni inhibitorji citokromov P450, ki so vpleteni v metabolizem varfarina (amiodaron, fenofibrat, fluvastatin, gemfibrozil, losartan). šibki inhibitorji citokromov P450, ki so vpleteni v metabolizem varfarina (atorvastatin, irbesartan, nifedipin, sertralin, simvastatin, propranolol). Plazemska koncentracija albuminov

12 Vpliv polimorfizma na presnovo varfarina Vpliv polimorfizma na dnevni odmerek varfarina Plazemska koncentracija čistek *1/*1 *1/*x *x/*x èistek S-varfarina (ml/min/kg) Plazemska koncentracija S-varfarina (mg/l) S-varfarin *1/*1 (118) *1/*x (59) *x/*x (11) *1/*1 (118) *1/*x (59) *x/*x (11) èistek R-varfarina (ml/min/kg) Plazemska koncentracija R-varfarina (mg/l) R-varfarin *1/*1 (118) *1/*x (59) *x/*x (11) *1/*1 (118) *1/*x (59) *x/*x (11) 45 *1/*1 *1/*x *x/*x Dnevni odmerek varfarina (mg/dan) *1/*1 (118) *1/*x (59) *x/*x (11) 46 Povezava med plazemskim očistkom S- varfarina in dnevnim odmerkom varfarina Association of warfarin dose with genes involved in its action and metabolism Polimorfizem VKRC!

13 Vpliv Vpliv VKRC Perspektiva Ali je genotipizacija in VKRC1 izvedljiva v klinični praksi? Vpliv starosti Ali se zmanjša število zapletov zaradi nezadostne in prekomerne antikoagulacije? Ali se skrajša čas uvajalnega obdobja do stabilnega IR v terapevtskem območju? Predicted IR response during the induction phase following administration of warfarin at the same dose to typical individuals with different combinations of age,, and VKRC1 genotype. The top left figure shows six typical individuals with the same age (50 years) and VKRC1 genotype (GG), but with different genotypes, the top right figure shows three typical individuals with the same age (50 years) and genotype (*1/*1), (GG) but with different VKRC1 genotypes, and the bottom left figure shows three typical individuals with the same (*1/*1) and VKRC1 genotype (GG), but different ages. The bottom right figure shows three typical individuals with the same age (50 years), but with different combinations of and VKRC1 genotypes that demonstrate similar early IR response, but divergent steady-state effects. The forth individual, with wild-type alleles for both CYPC9 and VKRC1, is included only as a reference. 49 Farmakoekonomska upravičenost? 50 13

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