Present and Future of Pharmacogenomics (slideshow)

Present and Future of Pharmacogenomics
with Pharmacoproteomic and Molecular Imaging
Biomarkers enablingg Personalized Medicine
Towards Personalized Justice?
S
Steven
H
H. Y.
Y W
Wong, Ph
Ph.D.,
D DABCC (TC)
(TC), FACB
Prof. Pathology, Psychiatry and Behavioral Medicine
Co-Dir. Clin. Chem./Tox, TDM, PGx & Proteomics, Med. Coll. WI
Sci. Dir., Tox. Dept., Milwaukee Co. Med. Examiner’s Off.
E il [email protected]
Email:
h
@
d
11th Duzen Klinik Biyokimya Gunerli
Ankara Turkey
Ankara,
October 21, 2007
Acknowledgement
g
Postdoctoral fellows
D R
Dr.
Run Shi
Shi, D
Dr. R
Randy
d S
Schneider,
h id D
Dr.
Ming Jin, Dr. Paul Jannetto,
Dr. Elvan Laleli-Sahin,
Dr. Michael Wagner and Dr.
Dr
Dr
Nazihid Nuwayhid
Colleagues
MCW and MCMEO – Mr. Schur,
Dr. Jentzen, Ms.Gock,
k Dr.
Risinger and Ms. Thompson
Outline
1. History of genetics and Personalized Medicine
– Pharmacogenomics, Molecular Imaging,
Proteomics
Personalized Justice (Wong,
10.07)
2. PGx and MI – OCD, opioids addiction/abuse
(methadone) and toxicology
3. Personalized Justice?
Landmarks in
Pharmacogenetics
Proteomics
New
GeneBased
Drugs
g
Personalized Medication
P
Personalized
li d
Justice? (Wong
10.07)
1865
1925
1955
1985
Discovery of
genetic variation
in liver enzymes
y
2015
?
Proteomics,
Pharmacoproteomics,
Nutritional Genomics
and Proteomics
Proteomics,
Systems Biology
Early Genetics
I
Inception
ti off Modern
M d
Pharmacogenetics
Ph
ti
Pharmacogenomics Emerges, Personalized Justice
Proteomics, Systems Biology
Modified : Weber
SOFT 2002
Mendal’ss birthplace
Mendal
Wed. 5:10 PM, Oct. 3, 2007
St. Thomas Abbey
Overview of Personalized Medicine
• Genomic research & new molecular assays
• Global
Gl b l - New
N regulatory
l
guidelines
id li
andd the
h
recognition of pharmacogenomic and other
bi
biomarkers
k
• Clinical Applications
pp
with ppossible benefit
of enhanced patient safety
• Complementary to TDM,
TDM proteomic and
other biomarkers
Source: Collins
Personalized Medicine with 5Rs
Personalized Laboratory Medicine
Right patient/target, Right Diagnosis
(including Genomics and Proteomics Biomarkers)
Biomarkers),
Right treatment, Right drug/target,
Right dose,
dose Right time*
Genomics and PharmacoProteomics Biomarkers
Pharmacokinetics and Pharmacodynamics
y
Complementary to TDM/Toxicology
*FDA Acting Commissioner
PM Notables
AACC
CC jo
joint Personalized
e so
ed Medicine
ed c e Co
Coalition,
o , 2006
006
AACC PMAG (Chair – Valdes) – Working definition
“ PM is the integration and application of an individual’s
unique healthcare information to predict, prevent, diagnose
and treat disease as differentiated from traditional medical
practice supported by population-based information.
From the
F
th perspective
ti off the
th practice
ti off lab
l b med,
d PM is
i the
th
application of high-resolution analytical tools to obtain
biochemical information that is characteristically unique to
an individual and the interpretation of laboratory data into
patient-specific actionable information for use by clinicians
and other healthcare providers. “
Other Personalized Medicine Notables
93002 Integrating Laboratory Diagnostics and Diagnostic
Imaging in an IT
IT-Driven
Driven Environment: Experts Assess the
Potential Impact on Laboratories, Patients and Physicians
Closing plenary lecture PGx and PM
Siemens/Bayer Diagnostics -Early diagnosis and prevention
Genomics and Personalized Medicine Act (Senators – Obama
and Burr, March 23, 2007)
Genomics and Personalized Medicine Act
March 23,
23 2007
Sponsored
p
by
y Senator Barack Obama
( D- IL)
Co-sponsored by Senator Richard Burr
(R NC)
(R-NC)
provides a comprehensive, well-reasoned approach
to improve access to and establish appropriate
utilization of molecular genetic tests.
Pharmacogenomics and
P
Proteomics
i
Enabling the Practice of Personalized Medicine
A il 2006
April,
AACC Press
Pharmacogenomics
Scientific
S
i ifi andd clinical
li i l discipline
di i li uses
genetic information to predict the
efficacy and toxicity of a drug, and to
identify responders and non-responders
Pharmacology Paradigm
Pharmacogenetics, PG
Source: Linder et al
.
Pharmacogenomics PG, Proteomics PR ~ Drug Efficacy & Behavior
Allpatients
Patients with
samediagnosis
diagnosis
All
withthe
same
PG, PR
1 Remove
non-responders
and toxic responders
PG ,PR
2
Treat
Responders and Patients
Not Predisposed
p
to Toxicity
y
PG, PR
3 Car accidents/deaths
PG PR Drug Induced/related
PG,
Evans and McLeod, modified by Wong
ADME
~PG
~PG
~PG
Polygenic Determinants of Drug Response
E
Evans
& McLeod,
M L d PG – Drug
D
Di
Disposition,
iti D
Drug T
Targets
t and
d Sid
Side Eff
Effects.
t NEJM
NEJM, 2003
2003;38(6):538-49.
38(6) 538 49
Human CYP450s
Note: 75% of all drugs metabolized by two enzymes CYP3A4 + CYP2D6
REF: Merck Sharp and Dohme, Watt AP. Neuroscience Research Centre
Am J PG
Mutant CYP2D6 alleles
PG of CYP 2D6
Weinshilboum R. Inheritance and Drug Response. NEJM;2003;348(6):529-537
Top
p 10 PGx tests CLN 2005, May
1.
2.
3.
4.
5
5.
6.
7.
8.
9.
10
10.
11.
CYP 2D6
TPMT
CYP 2C9
CYP 2C19
NAT
CYP 3A5
UGT1A1
MDR1
CYP 2B6
MTHFR
VKORC1* - Warfarin dosing
HUPO
Cardiovascular
Disease
Functional
Glycoproteomics
Liver
Microbial
Neuroproteomics
Plasma
Protein microarray, nanotechnology and bioinformatics
Proteomics
(Wilkins, 94)
The study of the Proteome - the protein
complement of the genome of an organism,
tissue, cell , organelle or biological fluid
Scope
11.
2.
3
3.
4.
Sequence and
S
d structural
t t l proteomics
t
i
Expression proteomics
Interaction proteomics
Functional proteomics
Sources : Hortin and Twyman
Pharmacoproteomics
• Definition: “Study of the role and function of proteins
(primarily enzymes) in the pharmacokinetics and
pharmacodynamics of therapeutics”
• It can be useful to assess protein (enzyme)
– Expression proteomics: Has the gene been expressed as protein?
– Functional proteomics:
• Activity: e.g. Dihydropyrimidine dehydrogenase (DPD) activity for 5p
fluorouracil treatment of cancer patients
• Modifications: Presence of various forms and isoforms with differences in
their Vmax
Source: Jortani
Metabolites !?
1. Metabolites p
profiling
g-p
pharmaceuticals
2. Metabolomics - Quantitative measurement
of the time multiparameters metabolic
response of multicellular systems to
pathophysiological stimuli as part of
systems biology, 3000 to 10,000
compounds?!!
3. Metabonomics – environment, ecology
4. Metabolomics = metabonomics?
Molecular Imaging
g g Definitions
MICoE & SNM
Visualization, characterization, and
measurement of biological processes at
the molecular and cellular levels --2- or 3-D imaging, radiotracer
imaging/nuclear med., MRI, MR spect
((metabolomics?).,
) , optical
p
imaging,
g g, ultrasound and others (PET, SPET)
Mankoff DA, J Nucl Med. 2007;48:18-21N.
Molecular Imaging
g g
1. Reveals disease clinical biology
1
2. Drug discovery and development
3 Personalizes
3.
P
li patient
ti t care approaches
h
• Cardiovascular diseases --transplant rejection -p p
,
• Cancer ((tumor properties,
processes)
tumors
• Neurological diseases – tumors.,
dementias., movement, seizure and
psychiatric
hi t i disorders
di d
.
Mankoff DA, J Nucl Med. 2007;48:18-21N
Figure 1. The increasingly divergent path from genes to behavior. Imaging genetics allows
for the estimation of genetic effects at the level of brain information processing, which
represents a more proximate biological link to genes as well as an obligatory intermediate of
behavior.
behavior
Conclusions
Hariri
etBiol.
al. Psych.
Biol.2006;59:888-97.
Psych. 2006;59:888-97.
Hariri etla.
5 gene signatures
i t
- NSCLC
•
•
•
•
Current staging – inadequate
185 ffrozen samples
l – microarray/RTPCR
i
/RTPCR
Gene expression
p
of 125 randomlyy selected
patients ~ survival
5 gene biomarkers ( DUSP6,
5-gene
DUSP6 MMD
MMD, STAT1
STAT1,
ER BB3 , LCK) ~ an independent predictor
off relapse-free
l
f andd overall
ll survival
i l
Development of Personalized
Drug for Lung Cancer, from
Identification of Genomic
Signatures (Biomarkers) to
Prospective Trials of
Personalized Therapy
(Personalized Medicine)
Personalized Laboratory Medicine Now!!
PGx and Pharmacoproteomic Biomarkers
•
•
•
•
•
Renal transplant
All
Cr Cholesterol
Cr,
TDM
CsA, FK 506, Rapa
PGx
CYP 3A4/5, MDR1
Pharmacoproteomics
3 proteomic biomarkers?
Nucl. Med. Imaging
Renal function
Part 2 - PGx and MI for Psychiatry
y
y
1. Obsessive compulsive disorder (OCD)
2. Opioids Addiction - Methadone studies –
pharmacology update
g of Pharmacogenomics
g
of
• Preliminaryy findings
Methadone for opioid addiction
• Findings of an earlier methadone death study
• Multi-center study preliminary findings
3. Antidepressants and Antipsychotics (refer to Steimer in CC,
& Kirchheiner, Acta Pscyh. Scand. & Mol. Psych.)
1
1.
PGx for Neurology
Protocol
Sertraline (9) and desipramine (7) effect on
OCD w
OC
with
t major
ajo depression
dep ess o
SPEC scans att 0 andd 12 weeks
k
Results
Sertraline patients – reduced rCBF in right
prefrontal and temporal region
Desipramine
D
i
i patients
i
– more diffused
diff d lleft
f
prefrontal and temporal region
11 responders and 5 non
non-responders
responders (YBOCS)
Responders,
R
d
before
b f
treatment, higher
hi h cCBF
CBF in
i
left prefrontal and in cingulate and basal
ganglia
li bilaterally
bil
ll
Sertraline
Se
a e
((n=9))
• Average age: 38.5(22-65)years, 2 male,
8 white
hi andd 1 African
Af i
American.
A
i
• Average
g dailyy dose of 194 (150-200)
(
) mgg
• Mean sertraline blood levels - 99.3 (26211) μg/L at Week 12.
12
• Responses mean scores
YBOCS
HAM-D
Before
25 1 (20-28)
25.1
(20 28) 26.8
26 8 (19(19 34)
After
13.9 (2- 29) 10.7 (1-24)
Desipramine
es p a
e ((n=7))
•
•
•
•
Average age was 40.2
40 2 (25-50)years,
(25 50)years 4 male,
male
6 were white and 1 East Asian.
Average daily dose - 228.5 (150-300) mg
Mean desipramine blood level - 322 (108 –
545) μg/L at Week 12.
R
Responses
mean scores
Before
YBOCS
24.0 (22-26)
HAM-D
23.6 (19- 27)
After
9 6 (19.6
(1 20)
7 9 (3-17)
7.9
(3 17)
Conclusion
“ Finally, in our study, patients took clinically adequate
doses; however, drug plasma levels varied considerably
at the end of the study, ranging from low to excessively
high. In most studies plasma drug levels have not been
reported and variation in drug levels may account for
some variations in the results. Therefore, in future
studies plasma levels of the medications need to be
controlled. ”
~~~~~~~~~~~~~
Gene dose recommendations (Kirchheiner)
Desipramine - CYP 2D6 PM 30%
S
Sertraline
li None
N
Increases in Heroin/Morphine-Related
Deaths in
i Five
i CEWG
C
G Areas
A
(DAWN
WN ED,, 1996-1H-1999)
996
999)
Area
1995
1996
1997
1998
Atlanta
16
18
30
46
Detroit
107
158
224
232
Mi i
Miami
24
30
38
50
New Orleans
26
38
45
62
Washington D.C.
91
93
107
117
1999
2000
~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~
Milwaukee
5
2
14
12
21
The 1999 ADAM ddata show
Th
h relatively
l i l hi
high
h percentages off adult
d l males
l and
d
females testing positive for opiates, based on the EMIT
Increased use of Heroin - Why?
Higher purity ~~ the user
– Ability to snort
•N
No risk
i k off AIDS
• 4 hour “High” @ $10 - $20 for each dose
• Not
N an A
Aggressive
i “Hi
“High”
h”
– Ability to smoke
Methadone – Chiral pharmacology
• Methadone activity is almost solely to the
drug itself rather than the metabolites
• Half
H lf lif
life is
i variable
i bl 15-55
15 55 hhrs
• R Methadone active form is 25-50 times
more active than S
• However – CYP 2B6 poor metabolizer and
S-methadone
cardiotoxicity
Methadone Metabolism (2003-4)
2B6
**
3A4/5
2C9
2C19
2D6
2D6
UGT
*Asymmetric
y
carbon
Moody.SOFT WS 2003
Winecker, Clin For Tox News(AACC), June 2003
Bimodal distribution
Hypothesis
yp
- altered methadone p
pharmacokinetics,,
partly due to varied metabolic disposition of
methadone determined mainly by patients’
patients
genotype of CYP450 subfamilies
Shi, Risinger, -- Wong
1 Convergence of pharmacogenomics and TDM of
1.
Methadone addiction therapy - enantiomeric levels
2 Pharmacogenetics and TDM can improve clinical practice of
2.
methadone therapy for drug addiction - Personalized methadone
py - Pendingg
therapy
Procedure
• IRB approval
• Subject Selection –
– n = 42, an inner city
– Consented
– Mean age 37 (range 17-59), Caucasian (90.5%)
– Average dose of 106 mg (range 27-200, medium
105) for 20 month .
– Moderately depressed - 16.5 on the Beck
Depression Inventory
In entor
– Opiate Dosage Adequacy Scale (ODAS)
evaluation
P
Procedure,
d
cont.
t
– SS Methadone maintenance treatment
– 2 blood trough samples for plasma drug enantiomer
levels and genotyping (CYP450 CYP 2C9,
2C9 2C19,2D6
2C19 2D6 andd 3A4/5)
– Drug conc. of R- and S-methadone and their
corresponding
di metabolites
b li RR andd S-EDDP
S EDDP using
i
LC-MS/MS at Provincial Health Laboratory
(
(Regina,
i SK, Canada),
d ) using a Chiral-AGP column
– Participant
p demographics
g p
& Hx
CYP450 Alleles and Adjusted Methadone Enantiomer Concentrations
0.9
T/MDN
R-MDN
Adjustted Metha
adone En
nantiome
er
Conce
entrations
s
0.8
S-MDN
0.7
R-EDDP
0.6
S-EDDP
0.5
0.4
0.3
0.2
0.1
0
CYP2D6 xN
All WT
CYP2D6 *2HM CYP2D6 *4HM CYP3A5 *3HT
-0.1
CYP450 Allelels
Pharmacogenomics
as Molecular Autopsy for
Forensic Pathology /Toxicology
Molecular Autopsy
p y - Genomic Markers
SCN5A for SIDS( Ackerman et al. Postmortem
molecular analysis
y of SCN5A defects in sudden
infant death syndrome. JAMA 2001; 2264-9.)
Pharmacogenomics for Forensic Toxicology
Certification – Genotyping CYP 450 - Wong et al
al.
JAT, JFS etc.
Hypothesis
Methadone fatalities as ADRs attributable in
Part to CYP P450 allelic variant resulting in
impaired metabolism
Case 2
• 41, female, pregnant, history of heart
m rm r arthritis,
murmur,
arthritis avid
a id drug
dr g and alcohol
abuser, alive at 2030, found by husband not
breathing the following morning at 1130
• Med. - methadone, synthroid, fluoxetine
h d
hydroxyzine,
i amitriptyline
i i li andd albuterol
lb
l
Case 2
C
Case
2
• Autopsy
A
– Rheumatic heart disease
– Dilated left ventricle
– No internal trauma
• Molecular Autopsy - Pharmacogenetics
– CYP2D6*3 and *5 - WT
– CYP2D6*4 - HM,, deficient enzyme
y activity,
y,
poor metabolizer
Methadone Metabolism
**
CYP 2D6
Ì
CYP450 : 3A4, 2D6 (→ p-hydroxylation), 1A2
* Asymmetric
A
t i carbon
b
Amitriptyline metabolism
FMO
CYP 2D6
2C19&3A4
CYP 2D6
Case 2
• Death certifications
– Cause of death : MDO - Amitriptyline,
methadone and diazepam
p
• OSC - drug and alcohol abuse, rheumatic heart
disease
– Manner of death: Accident
A converging
g g continuum for
CYP 2D6 Wt prevalence ?
Evidence
id
off gene dose
d
effect?
ff ?
Drug
ug therapy
t e apy
Control
85%
PG? Addiction 74.6%
Pain management
78.3%
PG?
T i i
Toxicity
Pain – OD ?%
Addiction – OD
?%
PG?
Forensic
Pathology/
Toxicology
Drugs/Wt
Antidepressants-73%
Oxycodone-73%
y
Methadone-71%
Pharmacogenomics as Molecular
Autopsy - Adjunct for Forensic
Pathology/Toxicology
Methadone-related deaths
St t
States
St d years
Study
% IIncrease
Florida
Maine
Maryland
N. Carolina
1998-2001
1997-2002*
1997-2001
1997
2001
1997-2001
1850
450
1000
800
*First
First half of 2002
Winecker Clin For Tox News(AACC),
Winecker,
News(AACC) June 2003
Group Members
(August, ‘04)
Methadone Case Load 2002-3
British Columbia
Cuyahoga
Milwaukee
N H
New
Hampshire
hi
North Carolina
Suffolk
Washington, D.C.
Washington
y Detroit
Wayne
Total
88
32
24
9*
400+
50
41
246
71
~1100
1100
CYP 2D6 Prevalence
20.00%
15.00%
Methadone
10.00%
Caucasian
5 00%
5.00%
Paired t-test NS
0.00%
N = 570
*3
*4
*5
*6
*7
*8
Prevalence
CYP 2C9
CYP 2C19
14.00%
14.00%
12.00%
12.00%
10.00%
10.00%
8.00%
8.00%
Methadone
6.00%
%
6.00%
Caucasian
4.00%
4.00%
2.00%
2.00%
0 00%
0.00%
0 00%
0.00%
*2
*3
*2
*3
*4
Paired t-test NS
“ Combined ’’ Phenotypes
Ultra Poor 21.1%**
Poor 5.3%
Extensive 42.1%
Intermediate 31.5%
3 combination (2D6*4*4/2C9*2/C19*2, & 2D6*4/2C9*3/2C19*2)
Kid’ss cold medicines pulled
Kid
AP, Washington Post - Oct. 12, 2007
Drug makers (95%) – pulled 14 cold medicine
Am Acad Ped. - petition cough and cold med pose
health risks for babies and preschoolers
Parent often use OTC med
FDA scientific advisors meet this week
Possible PGx interpretation – dextromethorphan
metabolized CYP 2D6, accummulation in PM
Part 3. Personalized Justice
A pproposed
p
definition – In criminal and forensic
proceedings, molecular analysis – genomic and
pproteomic,, is included in the deliberation for ppossible
genetic and proteomic contributions to adverse
behavior/outcome
Pharmacogenomics as a biomarker for assessing
ppossible drugg toxicity
y in driving
g –under-the-influence of
drugs - a proposed multi-center study in the near future
Pharmacogenomics as a biomarker for assessing
possible drug toxicity in driving –under-theinfluence of drugs (DUID)
yp
– Genetic disposition
p
affects drug
g
Hypothesis
metabolism and therefore driving behavior
A multi-centers
lti
t study
t d (n
( = 9) ffor 500 DUID cases andd
100 Roadside 1. DUID – 4 drugs zolpidem, oxycodone,
methadone and dextromethorphan,
p , alcohol
exclusion
2 DUID postmortem
2.
t
t
3. Roadside – blood and oral fluids ((PGx and Tox))
Pharmacogenomics PG, Proteomics PR ~ Drug Efficacy & Behavior
Allpatients
Patients with
samediagnosis
diagnosis
All
withthe
same
PG, PR
1 Remove
non-responders
and toxic responders
PG ,PR
2
Treat
Responders and Patients
Not Predisposed
p
to Toxicity
y
PG, PR
3 Car accidents/deaths
PG PR Drug Induced/related
PG,
Evans and McLeod, modified by Wong
PGx biomarkers for
Personalized Medicine and Personalized Justice
• PGx is not a genetic but a functional test?
• Clinician
Cli i i education
d
i and
d acceptance
• Time and opportunity
pp
y for co-development
p
–
pharma/sponsor, biotech and diagnostics
• Role of FDA (enriching/classifying patients in
adaptive clinical trials, GDS) and
harmonization with other agencies
• AACC,, CLSI,, CAP and others
• Proficiency
y surveyy program
p g
– e.g.
g CAP PGx
survey for 2007, CDC - QA
• Reimbursements?
• IP issue for co-development
• Genetic counseling?
• But majority of lab NOT ready
readyopportunity!!??
• Personalized Medicine and Personalized
Justice (Wong, 10.07 in Beijing)
Beijing, China to Ankara, Turkey
Global Personalized Medicine
Personalized Justice?