Christian Albrechts University Kiel

University Hospital Schleswig-Holstein Institute of Experimental and Clinical Pharmacology

Pharmakogenetik/-genomik als Grundlage individualisierter

Therapieentscheidungen

Ingolf Cascorbi

36. Interdisziplinäres Forum der Bundesärztekammer

Berlin, 04.02.2012

Anwendung genomischer und molekularer Information

zur

• zielgerichteten Gesundheitsversorgung

• Erleichterung der Entdeckung und der klinischen Testung

neuer Produkte

• Hilfe die Prädisposition einer Person für eine bestimmte

Erkrankung oder Eigenschaft zu bestimmen"

Personalized Medicine

Personalized Med. 6(5) 479-480 (2009).

„Classic“ concept of pharmacogenetics

The observation on the polymorphic character of

CYP2D6 launched numerous studies in the field of

Antidepressants

Neuroleptics

Selected betablockers (metoprolol, carvedilol)

Selected opioids (codeine, tramadol, oxycodon)

Most studies aimed to determine effects on

pharmacokinetics rather on the clinical outcome

Meyer UA. Nature Rev Genet 2004;5:669-676

„Classic“ concept of pharmacogenetics

0

50

100

150

200

Adap

tion a

ccord

ing t

o s

tandard

dose (

%)

Ultra rapid

Fast

Intermediate

Slow

Kirchheiner et al., Mol Psychiatry 2004

CYP2D6 genotype based dose adaption of

antidepressents and antipsychotics

0

0,5

1

1,5

2

2,5

CGI Side effects (%)

PM ODV/V <= 0.3

EM ODV/V 1-5.2

UM ODV/V >= 5.2

Clinical outcome of venlafaxine

considering CYP2D6

Shams et al. J Clin Pharm Ther 2006, 31:493-502

4 64 6 4 64 6

CGI =

Clinical global impression score

CYP2D6 poor metabolizers

have more frequent side effects

Laika et al. Pharmacogenomics J 2009

ADR or lack of efficay

TDM

Deviating plasma levels Expected plasma levels

Pharmacodynamic explanation?

Genetics?

Pharmacokinetic interaction?

yes no

EM

Dose adaptation or exchange

PM or UM

Pharmacogenetic test

Dose adaptation or exchange Compliance or other factors

2001: Hype of Hope?

…once researchers find the genes or molecules

involved in diseases, they can work on developing

medicines that target those molecules and treat

the cause of the disease, not just its symptoms.

WHO Definition of Genomics

Genomics in health examines the molecular mechanisms

and the interplay of this molecular information and health

interventions and environmental factors in disease.

0

200

400

600

800

1000

1960 1965 1970 1975 1980 1985 1990 1995 2000 2005 2010

Pu

blic

ati

on

s p

er

ye

ar

Year

Pharmacogenomics Pharmacogenetics

Invention

of PCR DNA

sequencing

(Sanger)

Phenotyping

Genotyping/

sequencing/

expression

analyses

The rise of pharmacogenetics/-genomics

2007: First HapMap completed

Intrinsic system Extrinsic system

Surface contact Tissue damage

XII XIIa

XI XIa

IX IXa

X VIII Ca2+

Xa X

VII VIIa

Tissue

thromboplastin (III)

Ca2+

Ca2+ V Va

Phospholipo-

proteins

Phospholipids

Prothrombin (II)

XIII

XIIIa

Thrombin (IIa)

Fibrinogen

Fibrin (instab.)

Fibrin (stab.)

Fibrinopeptides

Plasminogen Plasmin

Blood and tissue activators

Vitamin K dependent

coagulation factors

Blood coagulation

Prospective study on CYP2C9-genotype

directed warfarin dosage

Caraco et al, Clin Pharmacol Ther 2007

Re-labelling of Coumadin by FDA in 2007

FOR IMMEDIATE RELEASE

August 16, 2007

Media Inquiries:

Karen Riley, 301-827-6242

Consumer Inquiries:

888-INFO-FDA

FDA Approves Updated Warfarin (Coumadin) Prescribing Information

New Genetic Information May Help Providers Improve Initial Dosing Estimates of the Anticoagulant for

Individual Patients The U.S. Food and Drug Administration announced today the approval of updated labeling for the widely used blood-thinning drug, Coumadin, to explain that people's genetic

makeup may influence how they respond to the drug.

Manufacturers of warfarin, the generic version of Coumadin, are to add similar

information to their products' labeling, FDA said.

The labeling change highlights the opportunity for healthcare providers to use

genetic tests to improve their initial estimate of what is a reasonable warfarin

dose for individual patients. Testing may help optimize the use of warfarin

and lower the risk of bleeding complications from the drug.

These labeling updates are based on an analysis of recent studies that found

people respond to the drug differently based, in part, on whether they have

variations of certain genes.

The International Warfarin Pharmacogenetics Consortium. N Engl J Med 2009;360:753-764

Comparisons of Warfarin Doses Predicted According to

the Clinical Algorithm and the Pharmacogenetic Algorithm

• The patient’s CYP2C9 and VKORC1 genotype information,

when available, can assist in selection of the starting dose.

• In all patients, subsequent dosage adjustments must be made

based on the results of PT/INR determinations.

Re-labelling of Coumadin by FDA in 2010

Consequences of pharmacogenomics-adapted dosing

Pharmacogenetics-based maintenance dose. Individualized PGx-based 3-day initiation dose regimen

followed by a PGx-based maintenance dose.

Avery et al. Clin Pharm Ther 2011;90:701-706

Thrombozytenaggregationshemmung

Clopidogrel ist eine Prodrug

Clopidogrel-mediated inhibition of platelet

aggregation is influenced by CYP2C19

Kim et al. Clin Pharmacol Ther 2008; 84, 236–242

CYP2C19 and clopidogrel response

Mega et al. NEJM 2009;360:354-362

PPI

Clopidogrel + PPI

Clopidogrel

none

Omeprazol inhibits formation

of the active metabolite of clopidogrel A

nte

il T

od

od

er

reku

rren

tes A

CS

Ho et al. JAMA 2009;301:937-944

Consequences?

Harmsze et al. Pharmacogenet Genom 2012 (epub ahead of print)

Rate of TIMI major bleedings

Cytochrom P450 2C19 (CYP2C19) Pharmakogenetik: Bei Patienten, die

langsame CYP2C19-Metabolisierer sind, wird bei empfohlener

Clopidogrel-Dosierung weniger aktiver Metabolit von Clopidogrel

gebildet, was einen verminderten Effekt auf die Thrombozyten-funktion

zur Folge hat. Es sind Tests verfügbar, mit denen der CYP2C19-

Genotyp des Patienten bestimmt werden kann.

Da Clopidogrel teilweise durch CYP2C19 zu seinem aktiven Metaboliten

verstoffwechselt wird, ist zu erwarten, dass der Gebrauch von

Arzneimitteln, die die Aktivität dieses Enzyms hemmen, zu einem

erniedrigten Spiegel des aktiven Metaboliten von Clopidogrel führt. Die

klinische Relevanz dieser Wechselwirkung ist ungewiss. Als

Vorsichtsmaßnahme sollte vom gleichzeitigen Gebrauch starker oder

mäßig starker CYP2C19-Inhibitoren abgeraten werden …

Safety Announcement

[03-12-2010] The U.S. Food and Drug Administration (FDA) has added a Boxed Warning to

the label for Plavix, the anti-blood clotting medication. The Boxed Warning is about patients

who do not effectively metabolize the drug (i.e. "poor metabolizers") and therefore may not

receive the full benefits of the drug.

The Boxed Warning in the drug label will include information to:

Warn about reduced effectiveness in patients who are poor metabolizers of Plavix. Poor

metabolizers do not effectively convert Plavix to its active form in the body.

Inform healthcare professionals that tests are available to identify genetic differences in

CYP2C19 function.

Advise healthcare professionals to consider use of other anti-platelet medications or

alternative dosing strategies for Plavix in patients identified as poor metabolizers.

Die FDA empfiehlt andere Thrombozytenaggregationshemmer

oder alternative Dosierungen in CYP2C19-Poor-Metabolisierern

Information on Clopidogrel Bisulfate (marketed as Plavix)

[10-27-2010]

The U.S. Food and Drug Administration (FDA) is reminding the public that it continues to

warn against the concomitant use of Plavix (clopidogrel) and omeprazole because

the co-administration can result in significant reductions in clopidogrel's active metabolite

levels and antiplatelet activity…

With regard to the proton pump inhibitor (PPI) drug class, this recommendation applies

only to omeprazole and not to all PPIs. Not all PPIs have the same inhibitory effect on the

enzyme (CYP 2C19) that is crucial for conversion of Plavix into its active form.

Pantoprazole (Protonix) may be an alternative PPI for consideration. It is a weak inhibitor

of CYP2C19 and has less effect on the pharmacological activity of Plavix than omeprazole.

Die FDA empfiehlt Pantoprazol statt Omeprazol

bei gleichzeitiger Einnahme mit Clopidogrel

Holmes et al. JAMA 2011;306:2704-2714

Anwendung Pharmakogenetischer Diagnostik

in der Onkologie

• Überexpression bestimmter Gene im Tumor

• Chromosomale Abberationen

• Genetische Varianten des Tumorgenoms

• Genetische Varianten des Gesamtgenoms

Anwendung Pharmakogenetischer Diagnostik

in der Onkologie

• Überexpression bestimmter Gene im Tumor

• Chromosomale Abberationen

• Genetische Varianten des Tumorgenoms

• Genetische Varianten des Gesamtgenoms

Dezentje, V. O. et al. Clin Cancer Res 2009;15:15-21

Metabolic activation of tamoxifen

Punglia et al. J. Natl. Cancer Inst. 2008;100:642-648

Model results for disease-free survival in the unselected population and in each genotypic subgroup

Tamoxifen

CYP2D6 wt/wt

Tamoxifen

CYP2D6 *4/*4

Tamoxifen

CYP2D6 wt/*4

Tamoxifen

(unselected)

Aromatase

(unselected)

Schroth et al. JAMA 2009;302:1429-1436

Evans and Relling, Science 1999, 286:487-491

Drug metabolizing enzymes of the liver : Phase II

Drug-revelant polymorphic

enzymes:

• Arylamine N-acetyltransferase 2

• Thiopurine S-methyltransferase

• UDP-glucuronosyltransferases

Irinotecan

pathway

www.pharmgkb.org

adapted from Parodi 2005

Frequency of neuropenia dependent on UGT1A1 genotype

Likelihood of neutropenia under irinotecan treatment

UGT1A1*28/*28 UGT1A1*1/*1 and 1/*28

Hoskins et al, J Natl Cancer Inst. 2007;99:1290-5

Costs of per million

basepairs of sequening

At the current rate of technological progress, DNA

sequencing is soon likely to become a commodity,

and the generation of cheap, high quality sequence

data will cease to be an issue.

Craig Venter, Nature 2010;464:674

The generation of genomic data will have little value

without corresponding phenotypic information about

individuals’ observable characteristics, and

computational tools for linking the two.

The challenges facing researchers today are at least as

daunting as those my colleagues and I faced a decade

ago.

Craig Venter, Nature 2010;464:674

The value of phenotypic information

The rise of omics…

…or the search for biomarkers

Diagnostische Biomarker

• Hohe Spezifität – Detektion von spezifischen Erkrankungen

Prognostische Biomarker

• Differentielle Expression – Korrelation mit Verlauf der Erkrankung

• Stratifizierung von Hoch- und Niedrig-Risiko-Patienten

• Orientierungshilfe für Patienteninformation und Monitoring

Prädiktive Biomarker

• Differentielle Expression – Korrelation mit Ansprechen der Therapie

• Stratifizierung von Respondern und Non-Respondern

• Orientierungshilfe zur Selektion des therapeutischen Regimes

What have we learned from

GWAS analyses in drug response?

Confirmation of known SNPs important in warfarin PK/PD variation

The SEARCH Collaborative Group. N Engl J Med 2008;10.1056/NEJMoa0801936

Results of Tests for a Trend in the Association between Myopathy and Each SNP Measured in the Genomewide Association Study

GWAS of statin-associated rhabdomyopathy

OATP1B1 521 T>C

Confirmation of known SNP important in statin PK variation

Association of OATP1B1 genotype

to statin-induced rhabdomyolysis

CYP3A4

Metabolite

Statin

OATP1B1

Time

Concentr

ation

OATP1B1 521TT

Metabolite

Statin

Time

Concentr

ation

OATP1B1 521CC

CYP3A4

OATP1B1

Association of OATP1B1 genotype

to statin-induced rhabdomyolysis

Carbamazepine-Induced

Hypersensitivity Syndrome

McCormack M et al. N Engl J Med 2011;364:1134-1143. Postgrad Med J 1999;75:680-681

HLA-A*3101 carriers at 9-fold risk

HLA-B*5701 is associated to Abacavir hypersensitivity

Hypersensitivity: 5% of HIV patients

Association to HLA-B* 5701: 48-61%

Only 0-4% are HLA–B* 5701 negative

HLA-B*5701 exhibits a broad interethnic

variability

Abacavir nucleoside analog reverse transcriptase inhibitor

51 DILI-cases vs. 282 population controls

HLA-B *5701

p = 8.7 * 10-33

Daly et al. Nature Genetics 2009;41:816-821

Flucloxacillin induced liver toxicity

Confirmation of known SNP important in flucloxacillin-related DILI

Flucloxacillin induced liver toxicity

Daly et al. Nature Genetics 2009;41:816-821

Funds from the Netherlands ATLA

— Alternatives to Laboratory Animals

to set up a DILIGEN study

University of Utrecht

Dept. Pharmacy

Dr. Antje-Hilse Maitland van der Zee

University of Kiel

Dept. Pharmacology

Prof. Ingolf Cascorbi

Dr. Anneke Werk

AKdÄ Berlin

Prof. Ursula Gundert-Remy

Dr. Thomas Stammschulte

Medical Practices

DILI GENE Genetische Ursachen Arzneistoff-induzierter Lebertoxizität

Ziel

• Identifikation genetischer Risikofaktoren, die die Variabilität

in der Reaktion auf die Arzneistoffe erklären helfen

• Identifikation von Biomarkern, die die Diagnose

arzneimittel-induzierter Lebertoxizität verbessern

• Langfristig Verbesserung der Arzneimittelsicherheit

• Verordnung von Arzneimitteln entsprechend den

individuellen Risikofaktoren

DILI GENE Genetische Ursachen Arzneistoff-induzierter Lebertoxizität

Definition der DILIGENE-Studie

(SAE consortium)

• klinisch auffälliger Ikterus oder Bilirubin >40 µmol/l

• AST > 5x ULN

• AP > 2x ULN + Bilirubin > ULN

Daly et al., 2009 Nature Genetics 200941:816-819

DILI GENE Genetische Ursachen Arzneistoff-induzierter Lebertoxizität

iSAEC’s “Clinical Registry” Technology

Integrated study management, EDC, ePRO, and CDMS for late phase

observational studies & registries

iSAEC Phase 2 Objectives (2010-2012 )

Balanced Investment Mix to Enable Research Goals

Academic networks

iDILIC – Liver Injury

ITCH – Hypersensitivity

GWAS

Common risk factors

Resequencing

Rare risk factors

Mechanistic studies

Pathways and context

“Developing new SAE research opportunities”

Discovery Research

Case Recruitment

New channels

EMR-based

Integrated healthcare systems

Existing collections

Pharmacos

Partners

58

Drugs with Tests Required

Abacavir:

Before initiating treatment with abacavir, screening for carriage of the HLA-B*5701 allele should be performed in any HIV-infected patient, irrespective of racial origin. Abacavir should not be used in patients known to carry the HLA-B*5701 allele, unless no other therapeutic option is available in these patients, based on the treatment history and resistance testing (see section 4.4 and 4.8).

Carbamazepine: “Before deciding to initiate treatment, patients of Han Chinese and Thai origin should whenever possible be screened for HLA-B*1502 as this allele strongly predicts the risk of severe carbamazepine-associated SJS (see section 4.4)”

Individualized therapy: now fact or still fiction?

Drugs with pharmacogenetic tests recommended by FDA

Cumadin (Warfarin):

The patient’s CYP2C9 and VKORC1 genotype information, when available, can assist in selection of the starting dose

In all patients, subsequent dosage adjustments must be made based on the result of PT/INR determinations.

Camptosar (Irinotecan):

Individuals who are homozygous for the UGT1A1*28 allele are at increased risk for neutropenia following initiation of CAMPTOSAR treatment. A reduced initial dose should be considered for patients known to be homozygous for the UGT1A1*28 allele.

Heterozygous patients may be at increased risk for neutropenia.

Imuran (Azathioprine):

It is recommended that consideration be given to either genotype or phenotype patients for TPMT.

TPMT testing cannot substitute for complete blood count (CBC) monitoring in patients receiving IMURAN

Gleevec (imatinib) for c-kit+ GIST [and for Ph+ CML]

Tasigna (nisotinib) for imatinib-resistant Ph+ CML

Sprycel (dasatinib) for imatinib-resistant Ph+ CML

Trisenox (arsenic trioxide) for PML/RARα gene+ [or t(15;17) translocation]

acute promyelocytic leukemia

Herceptin (HER2/neu over expression necessary for patients appropriate for

therapy)

Erbitux (cetuximab) for EGFR+ metastatic CRC after failure ofirinotecan; KRAS

wild-type metastatic CRC

Tarceva (erlotinib) for advanced NSCLC (« no clinically relevanteffects

demonstrated for patients with EGFR– tumours, i.e. ≤ 10% cells »)

Vectibix (panitumumab) for EGFR+, non-mutated KRAS, metastatic, previously

treated CRC –conditional MA

Tyverb (lapatinib) in combination with capecitabine for Her2+ BC after failure of

taxanes and trastuzumab –conditional MA

Iressa (gefitinib), for the treatment of adult patients with locally advanced or

metastatic non-small cell lung cancer with activating mutations of EGFR-TK

Drugs with pharmacogenetic tests required

Patient

Physician A

Physician C Physician B

Clinical

Pharmacologists

Human Genetists

Pathologists

Clinical Chemists

Biometrician

Microbiologists

System Biologists

Radiologists

Notwendigkeit von Biomarkern für die individualisierte Behandlung

Diagnostische Biomarker

• Hohe Spezifität – Detektion von spezifischen Erkrankungen

Prognostische Biomarker

• Differentielle Expression – Korrelation mit Verlauf der Erkrankung

• Stratifizierung von Hoch- und Niedrig-Risiko-Patienten

• Orientierungshilfe für Patienteninformation und Monitoring

Prädiktive Biomarker

• Differentielle Expression – Korrelation mit Ansprechen der Therapie

• Stratifizierung von Respondern und Non-Respondern

• Orientierungshilfe zur Selektion des therapeutischen Regimes

Vielen Dank für Ihre Aufmersamkeit