PHAR 737 Midterm 2 Flashcards
Describe CYP P450s (structure, functions, importance)
Heme-containing superfamily of enzymes. Metabolize drugs, hormones, cholesterol and arachadonic acid. Regulate blood homestasis.
At least 80 percent are involved in phase 1 metabolism.
These are important targets for pharmacogenetics and pharmacogenomics.
Describe CYP2Cs
Most abundantly expressed enzyme in the human liver and responsible for metabolism of 15-20% of prescribed OTCs
Highly variant enzyme, and metabolizes drugs such as warfarin, tramadol, and codeine.
What is the importance of CYP2C9/2* and /3* defective variants?
Defective alleles associated with reduced S-warfarin hydroxylation, making these patients prone to bleeding events
The estimated variance in antidepressant response due to genetic variants is around _____
50 percent
Describe CYP2D6
Most polymorphic P450 with over 75 different alleles with variation in metabolism rates (5-10% whites and higher percentage of Asians are poor metabolizers)
Located in cells of instestinal wall, endothelium, liver, etc. and is missing in 7% of caucasians and 2% of non-caucasians (hyperactive in 30% of East Africans)
Deletion occurs in 3-5% worldwide, with duplications resulting in 2 pseudogenes and more than 80 possible polymorphisms in coding or promoter regions.
Describe CYP3A4
Most abundant P450 in human liver, metabolizing over 120 drugs.
Common substrates include: >Acetaminophen >Codeine >Erythromycin >Warfarin >Lovastatin
Describe UGTs
Uridine Diphosphoglucuronosyltransferases (catalyze the glucuronidation of polar aglycones)
Active on a diverse range of drugs and xenobiotics. UGT1, UGT2 and 130 structurally and functionally different variants
Describe SULTs
Sulfotransferases catalyze the transfer of the sulfonyl group from 3’-phosphoadenosine 5’-phosphosulfate (PAPS) to various compounds to make them readily excreted in urine.
There are membrane bound SULTS in golgi for sulfonation of proteins, lipids and glycosaminoglycans.
Cytosolic SULTs for sulfonation of drugs, xenobiotics, and endogenous substrates (bile, acids, steroids, neurotransmitters)
Describe NATs
Utilize the acetyl CoA to acetylate drugs and xenobiotics that contain amino and hydrazine substitutes to the corresponding amides and hydrides respectively.
NAT1 is broadly expressed
NAT2 is expressed in liver, small intestine and colon
Large allele variation globally
For 27 drugs frequently cited in adverse drug reaction studies, ____ are metabolized by at least one enzyme with a variant allele associated with decreased drug metabolism
59%
____ to _____ % of randomly selected drugs are metabolized by enzymes known to exhibit functional genetic polymorphisms
7-20
During which phase of clinical trials are genomic analyses common?
3rd (FDA recommends collection of DNA samples from all, but PK and PD outliers at the least)
How long should DNA in clinical trials be retained for postmarket analysis?
15 years at least
What main reactions make up Phase 1 metabolism? Phase 2?
Oxidation, reduction, hydrolysis
Acetylation, glucuronidation, sulfation, methylation
A SNP in CYP3A5 creates a non-functional enzyme by introduction of a _____
early stop-codon
Describe regulation of CYP3A4
Can give a drug (from cell or xenobiotic) to initiate CYP3A4 production by causing PXR and RXR together to form heterodimer which promotes production of CYP3A4, which can metabolize warfarin, doxorubicin, atorvastatin and many other drugs.
Describe GSTs
Glutathione-S-transferases
7 cytosolic families (A, M, T, P, S, O and Z) that participate in xenobiotic biotransformation
Mitochondrion (K family)
Play a role in detoxification of highly reactive drug metabolites
Describe drug transporters in the human body
Membrane proteins throughout body working in a coordinated fashion for drug disposition, therapeutic efficacy, adverse drug reactions, and drug-drug interactions.
SLCs (passive and active that rely on gradients) and ABCs (are ATP dependent)_
What are biomarkers?
Can be a gene, protein, or other change that indicates a biochemical phenotype before that phenotype is clinically apparent.
Important for diagnosing disease or determining risk of disease, establishing and/or predicting drug response and toxicity
Describe the difference between bimodal and unimodal distribution of drug-related polymorphisms
Biomodal represents mutations that eliminate activity of drug-clearing enzymes, while unimodal represents polymorphisms that cause small (basically no) variation in drug-clearing enzyme activity
Ideal Marker for Diagnosis
Sensitivity, specificity, accuracy, prognostic or outcome and treatment
Describe the ideal biomarker for screening
Highly specific (minimize false positives and negatives), able to clearly reflect the different stages of the disease, easily detected without complicated medical procedures, and cost effective method for screening
Describe Warfarin
Most commonly prescribed anticoagulant (2M people start taking every year in US) and is the 2nd most common drug implicated in emergency room visits for ADRs next to insulin.
Synthetic derivative of coumarin, originally developed as rat poison, and belongs to a class of Vitamin K antagonists
Common indications include: atrial fibrillations, deep venous thrombosis, pulmonary embolism, etc.
Warfarin is metabolized primarily by ________ and inhibits _____________________________
CYP2C9
Vitamin K epoxide reductase complex subunit 1 (VKORC1)
What test is available to determine the main mutation in CYP2C9 or VKORC1?
TherapID
Which warfarin isomer is most potent?
S is five times more potent than R
Up to ____ percent of the population inherits a form of the CYP2C9 gene which result in deficiency of the enzyme
35%
Which CYP2C9 variants require a lower warfarin maintenance dose?
CYP2C9*2 and *3
*3 being the more pronounced form (higher deficiency)
How does warfarin work?
Inhibits formation of clotting factors by inhibiting vitamin K epoxide reductase complex subunit 1 (VKORC1)
Polymorphisms in VKORC1 gene explain _____ of all dose variation between patients, and about _____ of all variance in warfarin dose can be attributed to VKORC1 and CYP2C9 combined
30%
40%
Which ethnicity is most affected by CYP2C9 variance? VKORC1 variance?
Whites (8-18% have *2 variant and 5-13% have *3 variant)
Asians (90-95% VKORC1)
What is clopidogrel? Why is it significant?
Antiplatelet drug for stent associated thrombosis
Up to 30% of patients do not display adequate antiplatelet response to clopidogrel
Describe clopidogrel metabolism
Absorbed in intestines - 85% converted to inactive carboxylic acid metabolite by esterases, 15% converted to active thiol metabolite.
Metabolized by: CYP3A4/A5, CYP2C19, CYP2C9, CYP1A2, CYP2B6 (all of these CYPs have many other substrates that can induce/inhibit them)
Which enzymes are the key players in clopidogrel metabolism for platelet aggregation
CYP3A4/A5 - you need at least one of them to be “free” and able to metabolize clopidogrel for platelet aggregation not to occur. When they are both “busy,” you will get aggregation.
Define Statins
Used to reduce the risk of cardiovascular even ts by 20-30% through the reduction of LDL cholesterol
What is the major metabolizer of Statins?
CYP3A4
Describe Alzeimer’s disease
Deficit in cholinergic neurotransmission
ApoE4 in chromosome 19 is associated with late onset of Alzeimer’s. Other susceptibility could include locus on 12 and 9
Describe a polymorphism important to ApoE4 carriers
Glutathione S-transferase polymorphism in gene regulating the rate of cognitive decline
Describe G6PD deficiency
African-American soldiers taking antimalarial drugs primaquine developed hemolytic anemia and were found to have decreased G6PD activity in affected RBCs.
Gene is X linked
G6PD catalyzes process leading to NADPH source for RBCs, a process that reduces oxidative damage
200-400 million people have variants that increase risk of hemolysis, with over 70 mutations being reported.
NAT2 polymorphism leading to slow acetylation will mostly impact which drugs?
Anti-TB drug isoniazid (INH), caffeine and sulfamethoxazole
What are some risks of NAT2 polymorphisms?
Cancer of lung, bladder, colon - resulting from acetlyation of aromatic amines found in tobacco smoke and cooked foods
Describe the Isoniazid pathway to get to Diacetyl Hydrazine
Isoniazid –> Acetyl isoniazid (via NAT2) —> Monoacetly hydrazine —> Diacetyl hydrazine (non-toxic)
Excretion of isoniazid from the body occurs via
hydrolysis
Which age group is most at risk of developing hepatitis?
50-64, followed by 35-47, 20-34 and under 20
INH (isoniazid hydrazine) for how many months reduces risks of active TB in persons with positive TB skin test?
6-12
How prevelant is deveoping irreversible hepatic failure from NAT polymorphism
1/10000
Describe somatic mutations
Occur in nongermline tissues, are nonheritable, and acquired alterations common for all cancers
Dihydropyrimidin mutation causing aberrant splicing and myelosuprression impacts which drug?
5-fluorouracil dehydrogenase (possible neurotoxicity)
Thiopurin methyltransferase SNP leading to instability affects which drug?
Mercaptopurine (may lead to myelosuppression or secondary tumors)
Glucuronosyl transferase SMP varying number of TA repeats in promoter impacts which drug?
Irinotecan (increasing risk of diarrhoea and myelosupression)
Describe PSA
Prostate Cancer Biomarker
Familial Adenomatous Polyposis (FAP) represents ____ percent of all colon cancers
1
Treatment options for Colon Cancer include
5-flurouracil (5FU) and Capecitabine
Irinotecan
Describe HNPCC (Colon Cancer)
Hereditary Non-polyposis Colon Cancer - represents 4-13% of all colon cancers
Describe Malignant conversion in Colon Cancer
Over 50 percent of tumors greater than 1cm have RAS mutation
Over 75 percent of tumors have p53 mutation with DCC mutations in up to 80%
What are the Amsterdam Criteria for determining if HNPCC
Three or more relatives with colon cancer, two generations and one or more diagnosed cases before the age of 50
What are fluoro-pyrimidines?
Developed in the late 50’s, 3rd most commonly prescribed chemo agent and used for single-agent activity against colorecatal carcinoma. Used in combination for breast, head/neck and other adult solid tumors. Belongs to class of chemo agents known as anti-metabolites
Describe the metabolism of 5-flurouracil (5FU)
metabolized (80%) in liver by dihydropyrimidine dehydrogenase. Remaining binds to thymidylate synthase to inhibit DNA synthesis
What happens when a patient has low hepatic DPD activity?
Cannot efficiently metabolize 5-FU and its accumulation will cause toxicity
In DPD, what substitution in exon 14 causes synthesis of non-functional protein?
G to A
Three tandem repeats of TS gene causes…
Over-expression of TS, leading to poor antitumour response to 5-FU
Two tandem repeats of TS gene causes…
Under-expression of TS causing good antitumour respsonse to 5-FU