PHARMACOGENETICS

Dr. Frans D. Suyatna

Background
Garrod (1909) :
Defective genes : deficiency of enzymes in
inborn error of metabolism
Gene difference : variability in drug response

Ecogenetics : genetic traits affecting

metabolism of environmental chemicals eg.
G6PD deficiency
Pharmacogenetics : combines techniques of
pharmacology, biochemistry, genetics,
molecular biology to understand genetic
basis of response to drugs and xenobiotics

Objectives of
pharmacogenetic research

Identification of genetically-controlled
variation in drug metabolism and response
The study of the molecular mechanism
causing these variations
Evaluation of the clinical implications and
relevance of these variations
The development of methods to identify
susceptible individuals in order to
prospective avoid undesirable drug
responses

Pathway Marker
drugs

Enzyme

Acetylation

INH
NAT2
Caffeine

Oxidation

DebriCyP2D6
soquine
Sparteine
Dextromethorphan
Mephenytoin

CyP2C19

Drugs

Incidence of deficiency (%)

Caucasians Asians

Sulfonamides
50-70
Hydralazines
Dapsone
Procainamide
Antidepressants 5-10
Opioids
blockers
Antiarrhythmics

10-15

Mephobarbital
Diazepam
Omeprazole
Proquanil

15-20

3-5

Genetic
variation
pharmacogenetics
Transport (absorption, plasma protein
binding)
Transducer mechanisms (receptors,
enzyme induction/inhibition
Biotransformation
Excretory mechanisms (renal & biliary)

in

Methods of
Pharmacogenetics
Clinical observations
Family or twin studies
Protein polymorphisms
Animal models
DNA polymorphisms

Mode of Inheritance
Monogenic
dominant : hepatic porfirias
autosomal
Mendelian
fashion

recessive : slow acetylation

of INH
dominant

sex-linked
recessive

Polygenic unimodal

Clinical implication :
variation of responses to
drugs

Classification of human
pharmacogenetic
disorder
Less enzyme or defective protein
- Succinylcholine apnea
- Acetylation polymorphism
* Isoniazid-induced neurotoxicity
* Drug-isoniazid lupus erythematosus
* Phenytoin-induced hepatitis
* Arylamine-induced bladder cancer

- Increased susceptibility to drug-induced

hemolysis
* Glucose-6-phosphate dehydrogenase
deficiency
* Other defects in glutathione formation or use
* Hemoglobinopathies

- Hereditary methemoglobinemia
- Hypoxanthine-guanine phosphoribosyltransferase (HPRT-deficient gout)

- P450 monooxygenase polymorphisms

* Debrisoquine 4-hydroxylase deficiency
* Vitamin D-dependent rickets type I
* C21-hydroxylase polymorphism

- Enzymes of methyl conjugation

- Hyperbilirubinemia
* Crigler-Najjar syndrome type II
* Gilberts disases

- Fish-Odor syndrome

Increased resistance to drugs

- Inability to taste phenylthiourea
- Coumarin resistance
- Possibility of (or proven) defective receptor
* Steroid hormone resistance
* Cystic fibrosis
* Trisomy 21
* Dysautonomia
* Leprechaunism

- Defective absorption
* Juvenile pernicious anemia
* Folate absorption-conversion

- Increased metabolism
* Succinylcholine resistance
* Atypical liver alcohol dehydrogenase
* Atypical aldehyde dehydrogenase

Change in drug response due to enzyme

induction
- The porphyrias
- The Ah locus

Abnormal drug distribution

- Thyroxine (hyperthyroidism of hypothyroidism)
- Iron (hemochromatosis)
- Copper (Wilsons disease)

Disorder of unknown etiology

- Corticosteroid-induced glaucoma
- Malignant hyperthermia associated with
general anesthesia
- Halothane-induced hepatitis
- Chloramphenicol-induced aplastic anemia
- Phenytoin-induced gingival hyperplasia
- Thromboembolic complications caused by
anovulatory agents

Less enzymes or defective

protein
1. Succinylcholine apnea
Neuromuscular blocking agent
Catabolism : serum cholinesterase
Enzyme defect : prolonged apnea

BChE

Butyrylcholinesterase
Synthesized: liver
Mw: 342.136
Tetramer, 4 identical subunit
Each subunit: 574 amino acids
Chromosome 3 region 3q21-25
Succinylcholine: neuromuscular junction
blocker
BChE
Succinylcholine
succinylmonocholine + choline

UU: 3-6 min apnea

UA: 5-12 min
AA: 50-65 min
DNA sequences, codon 70
UU: normal
UA/AA: 70 asp gly nt 209
(GAT GGT)

Less enzymes
protein

or

defective

2. Acetylation polymorphism
Liver metabolism by N-acetyl transferase
Conjugation in biotransformation
Bimodal, autosomal, recessive
Slow metabolizer : neuropathy, SLE,
hepatitis (+ rifampicin), bladder cancer
Rapid metabolizer : colon cancer
Also : hydralazine, procainamide

Slow Isoniazid
Inactivation
Testing a Genetic Hypothesis

1. Evans et al (Brit. Med. J. 2: 485, 1960)

found 152 out of 291 unrelated persons
were slow INH inactivators. They
proposed the hypothesis that slow
inactivators ( ) are homozygous for a
recessive slow inactivator gene (r)
Thus the proportion of inactivators (rr)
is
152
= 0.523
291

According to the Hardy-Weinberg law, this

is also r2 so that the frequency of the slow
gene, r = 0.52 = 0.72 and the frequency of
the rapid gene, R = 1-r = 0.28
Thus :
MOTHER
r

RR =
0.080

Rr = 0.20

Rr =
0.20

rr = 0.20

FATHER

2. The test: to predict the relative frequencies of

slow ( ) and rapid (
) metabolizers among
the children of matings between
parents
of
each of the possible phenotypes, and to
compare these frequencies with the
observed frequencies (see table)
A mating of
x
should give only
children
A mating of
x
may give both and
and of
x
children
The freq. of the phenotype = 0.2+0.2+0.077 =
0.477
The fraction of
which is Rr = 0.400/0.477 = 0.84

For an x
mating :
The expected fraction of rr children =
0.400/0.477 x 0.400/0.477 x = 0.176
The expected no. of rr children (among 38 see
table) = 38 x 0.176 = 6.68
For an x
mating :
The fraction of rr children =
0.400/0.477 x 1 x = 0.419
The expected no. of rr children (among 67 see
table) = 70 x 0.42 = 28.1

Less enzymes or defective

protein

3. Increased susceptibility to drug-induced hemolysis

G6PD deficiency :
G P-gluconate
G6PD
G6P

NADPH
NADP+

GSSG

Red blood cell

GSH
GSH
Hemolysis

Drug
Metabolite

Drug induced hemolytic

anemia in G6PD
deficiency

Acetanilide Primaquine
Methylene blue
Sulfacetamide
Nalidixic acid Sulfamethoxazole
Naphthalene Sulfanilamide
Niridazole
Sulfapyridine
NitrofurantoinThiazolesulfone
Pamaquine Toluidine blue
Pentaquine Trinitrotoluene
Phenylhydrazine

P450 Monooxygenase
Polymorphisms
Debrisoquin : adrenergic blocking agent for
hypertension
Deficiency of debrisoquin 4 hydroxylase
Deficiency of this enzyme poor
metabolizer
Extensive metabolizer
cancer of liver
and GI, bronchogenic Ca for smokers
Slow metabolizer
Parkinson

Increased drug resistance

due to defective receptor
Steroid hormone resistance
Cystic fibrosis
Abnormal reaction to -adrenergic,
-adrenergic and cholinergic agents
Downs sydnrome
Increased sensitivity to atropin and
-adrenergic

Enzyme induction
Drug
heme synthesis
Alcohol P450 heme genetic defect
Steroid
Porfiria

Abnormal drug
distribution
Thyroxine bound to : - albumin
- prealbumin
- thyroxin-bindingglobulin (also T3)
Hemochromatosis

Disorders of unknown
etiology
Halothane induced hepatitis :
- dose dependent
- dose independent genetic
Halothane
P450 II
Metabolite

Corticosteroid induced glaucoma

Chloramphenicol induced aplastic anemia
Malignant hyperthermia in general anesthesia