Chapter 17

Pharmacokinetic
Pharmacogenomics
Safaa Mohammed M. Alsanosi, Craig Skiffington, and Sandosh Padmanabhan
BHF Glasgow Cardiovascular Research Centre, Institute of Cardiovascular and Medical Sciences,
University of Glasgow, UK

Chapter Outline
17.1 Overview 341 17.2.7 Zero- and First-Order
17.2  Principles of Pharmacokinetics 341 Kinetics349
17.2.1 Absorption 341 17.3 ADME: Pharmacogenomics 349
17.2.2 Distribution 342 17.3.1  CYP450 Enzymes 350
17.2.3 Metabolism 343 17.3.2  Non-CYP450 Enzymes 354
17.2.4 Excretion 346 17.3.3  Drug Transporters 357
17.2.5 Half-Life 348 17.4 Conclusions 360
17.2.6 Clearance 349 References361

17.1 OVERVIEW the basic principles of pharmacokinetics and summarize the

progress in the pharmacogenomics of key pharmacokinetic
The goal of therapeutics is to achieve a definite beneficial
systems.
effect with minimal adverse effect, and the approach to this
has been through combining the principles of pharmacoki­
netics and pharmacodynamics. Pharmacokinetics (PK) is 17.2  PRINCIPLES OF
the branch of pharmacology that deals with the absorption, PHARMACOKINETICS
distribution, and elimination of drugs, while pharmaco­
PK studies are usually based on measuring the drug levels
dynamics (PD) deals with the actions of drugs on the organ­
in blood and urine at different times following drug admin­
ism. PK governs the relationship between the drug dose and
istration in order to understand how rapidly and for how
its concentration whereas PD relates the concentration to
long the drug appears in the target organ [4]. This involves
the effect; together PK/PD clarify a drug’s dose–effect rela­
mathematical modeling of data obtained from these stud­
tionship. Since the 1950s there have been major advances
ies around four domains: drug absorption (A), distribution
in understanding the genetic basis of the interindividual
(D), metabolism (M), and excretion (E). Together these are
variability observed in the pharmacokinetics, efficacy, and
referred as ADME [4,5].
toxicity of various drugs. Recently, the European Medicines
Agency (EMA) published guidance on the use of pharmaco­
genetics to investigate PK properties of new medicines [1]
and PK pharmacogenetics feature in an increasing number
17.2.1 Absorption
of drug labels approved by the FDA [2]. Many pharmaceuti­ Drugs are normally administered through various routes:
cal companies investigate the associations between PK gene orally, subcutaneously, intramuscularly, intravenously,
variants and the observed interindividual pharmacokinetic rectally, or sublingually. Once a drug is administered, it is
and pharmacodynamic variability of drugs in early clinical absorbed and distributed to different cells and organs. Drug
development (phases I and II) [3]. In this chapter, we outline absorption is generally defined as the rate and extent to
Handbook of Pharmacogenomics and Stratified Medicine. http://dx.doi.org/10.1016/B978-0-12-386882-4.00017-7
© 2014 Elsevier Inc. All rights reserved. 341
342 PART | VI  Fundamental Pharmacogenomics

which the drug moves from its site of administration to its a typical IV dose of verapamil is 1–5 mg, compared to the
intended target (site) of action [6,7]. Absorption is a criti­ usual single oral dose of 40–120 mg.
cal component in drug PKs, and several barriers must be First-pass metabolism is a major reason for recogniz­
overcome for a drug to reach its effect site. The rate and able differences in drug bioavailability among individuals,
extent of absorption, as well as the time required to notice as even healthy people show considerable metabolizing
an observable effect, dictate the dose that should be admin­ differences in liver capacity. Moreover, in patients with
istered [8]. severe liver disease, first-pass metabolism may be sharply
Bioavailability indicates the proportion of the drug decreased, leading to greater bioavailability [6]. Marked
that passes into systemic circulation after administration, interindividual variations in terms of first-pass metabolism
taking into account both absorption and local metabolic lead to unpredictable consequences. Examples of drugs that
degradation [7]. Intravenous delivery provides 100% bio­ undergo significant “first-pass effect” are aspirin, morphine,
availability, while an orally ingested drug may be incom­ levodopa, verapamil, salbutamol, and lidocaine [7,11].
pletely absorbed by the GI tract before it reaches systemic
circulation (around 75% of an orally administered drug is 17.2.2 Distribution
absorbed in 1–3 hours). In addition, the gastrointestinal lin­
ing expresses several cytochrome P450 enzymes and drug- Once a drug has reached the bloodstream, it is distributed
efflux transporters (e.g., ATP-binding cassette, or ABC) that into the interstitial and intracellular compartments. As
can decrease bioavailability [6,9]. a general rule, the movement of lipophilic drugs is faster
Bioavailability depends on several factors, including than that of hydrophilic drugs, and small lipophilic mol­
the drug’s physicochemical properties and formulation, ecules distribute across cell membranes more easily than
first-pass metabolism, concomitant drug therapies, compli­ do large polar molecules [12–14]. Lipophobic drugs are
ance, and disease state. The area under the curve (AUC) primarily confined to plasma and interstitial fluids and gen­
calculated from time zero to infinity following drug admin­ erally do not go through the brain tissue after acute dos­
istration is an important PK parameter that measures the ing. Hydrophilic drugs, such as the aminoglycosides, are
patient’s “exposure” to a drug and depends on dose, bio­ mostly distributed into extracellular fluid, and their volume
availability, and clearance [6]. The patient’s plasma drug is affected by fluid retention or dehydration, both of which
concentration time profile can be developed by measuring can happen in a number of renal diseases.
the plasma drug concentration at many time points and then Passive diffusion, facilitated diffusion, and active trans­
estimating AUC, which is proportional to the absorbed frac­ port are the three mechanisms involved in drug distribution
tion only when clearance is constant and the concentration across cell membranes [15]. Solute carrier (SLC) and ATP-
is standardized. binding cassette (ABC) transporters play an important role
Following linear kinetics, AUC is directly proportional in active drug transport [16]. Cardiac output, regional blood
to drug dose and inversely proportional to drug clearance. flow, capillary permeability, lipid solubility, and plasma-
Therefore, the higher the clearance, the less time the drug protein binding determine the rate and amount of drug dis­
spends in the systemic circulation and the earlier the decline tributed into tissue [12].
in the concentration. As a result, the body’s exposure to the Sites with high blood flow primarily receive greater
drug and the AUC are smaller. Clearance is slightly depen­ amounts of a drug compared to sites with low or disturbed
dent on the shape of the concentration time profile and is blood flow. Consequently, drug concentrations increase
calculated by dividing the dose absorbed by the AUC [10]. faster in organs such as the brain, heart, and kidneys as
Orally administered drugs are absorbed from the GI sys­ compared with skin, muscle, and bone. The structure and
tem and transferred to the liver via the portal vein before permeability of capillaries varies depending on the organ,
entering systemic circulation. The drug-metabolizing and this affects how the drug is distributed. For example,
systems in the liver can thus exert a substantial effect on capillaries in the kidney and liver sinusoids show more
bioavailability; this is called first-pass metabolism or pre­ permeability as compared with the tight junctions between
systemic elimination. The larger the first-pass metabolism, endothelial cells that line the brain capillaries, creating a
the smaller the bioavailability of an orally administered relatively impermeable blood–brain barrier (BBB). The
drug. The liver drug metabolizing enzymes can be com­ BBB allows only selective transport of lipophilic molecules
pletely avoided by sublingual or buccal administrations or and prevents passive entry of lipophobic/ionized molecules
partially avoided by rectal administration [6]. Drugs that into the brain [12,13].
undergo extensive first-pass metabolism and cannot be
administered orally (e.g., nitroglycerin) require alterna­ 17.2.2.1  Plasma-Protein Binding
tive routes of administration, such as sublingual or intra­ In blood, many drugs are bound to plasma protein. This
venous. Drugs with extensive first-pass metabolisms can binding is reversible with bound and unbound drug frac­
still be administered orally with higher doses. For example, tions in dynamic equilibrium. Any change in unbound-drug
Chapter | 17 Pharmacokinetic Pharmacogenomics 343

concentration is directly followed by a change in bound- 17.2.2.2  Volume of Distribution

drug concentration. Only free (unbound) fractions are Volume of distribution (Vd), represents the apparent vol­
able to cross membranes or interact with drug targets and ume into which the drug is distributed to provide the same
are considered pharmacologically active. In general, the concentration as it currently is in blood plasma. It is calcu­
amount of a drug that is bound to protein depends on three lated by the amount of the drug in the body divided by the
main factors: free-drug concentration, binding site affinity, plasma concentration [19]. Thus, Vd reflects the extent to
and protein concentration [17,18]. which the drug is present in extravascular tissues but not in
The most significant plasma-protein binding is to plasma. Lipid solubility can affect Vd, as highly lipid-solu­
albumin, which is the major carrier of acidic drugs (e.g., ble drugs have good cell penetration, resulting in high Vd.
warfarin, sulfonamides). Other plasma proteins, such as Plasma-protein binding, particularly to albumin, reduces
α1-acid glycoprotein, bind basic drugs. In addition, certain the Vd, while tissue binding increases it [17].
drugs may bind to proteins that function as specific hor­ Vd can be used to determine the size of a loading dose
mone carrier proteins, such as the binding of estrogen or in order to quickly reach the required therapeutic plasma
testosterone to sex hormone–binding globulin or the bind­ concentration, assuming that successful therapy is directly
ing of thyroid hormone to thyroxin-binding globulin. For linked to the plasma concentration and that there are no
many drugs, more than 90% in the plasma is bound to a adverse effects if a quite large dose is rapidly administered.
protein (e.g., warfarin, diazepam), whereas other drugs may In addition, Vd is helpful in predicting the initial maximum
have less extensive protein binding (digoxin and gentami­ concentration for an IV bolus and can be used to predict the
cin). Because binding of drugs to plasma proteins such as effectiveness of dialysis in treating drug intoxication during
albumin is nonselective, and because the number of bind­ an emergency [18].
ing sites is relatively large (high-capacity), many drugs with
similar physicochemical characteristics can compete with
each other and with endogenous substances for these bind­ 17.2.3 Metabolism
ing sites, resulting in displacement of one drug by another Once drugs have been distributed throughout the body,
and leading to an increase in its pharmacological activity they are metabolized into more polar, inactive metabo­
or toxicity. lites in order to eliminate them from the body. The lipo­
Changes in plasma-protein concentrations can also lead philic characteristics of drugs that promote their passage
to variability in pharmacological effects of drugs, which through biological membranes and subsequent access to
are also affected by disease-related factors; for example, their site of action also serve to hinder their excretion
hypoalbuminemia secondary to nephrotic syndrome results from the body. Metabolism includes two main processes:
in decreased drug binding, which increases the drug’s one, the molecule is made more lipophobic in order to
unbound fraction of the drug. In addition, acute-phase reac­ reduce the possibility of reabsorption in the renal tubules;
tion responses (e.g., cancer, arthritis) can lead to high levels two, the molecule is conjugated to reduce its effect and
of α1-acid glycoprotein and can enhance basic drug bind­ increase its excretion. While for some drugs the metabo­
ing. Misinterpretation of plasma drug concentration mea­ lites have the actions of the parent drug (e.g., diazepam
surements is a common problem that results from drugs and its metabolite, nordiazepam), for others, the metab­
competing for plasma-protein binding sites, as most assays olite may result in toxicity (e.g., paracetamol). Also, a
do not differentiate unbound from bound drugs. number of drugs are “prodrugs” (i.e., inactive) but trans­
A number of drugs concentrate in body tissues at higher form into an active drug in the body. Prodrugs are often
levels than those in extracellular fluids and blood; for exam­ designed to improve oral bioavailability in cases where
ple, the concentration of an antimalarial agent (quinacrine) the intended drug is poorly absorbed through the gastro­
in the liver can be many thousand times higher than that intestinal tract; for example, enalapril is hydrolyzed to
in the blood if the drug is administered for long periods. the active compound enalaprilat [12].
Reversible tissue binding of drugs regularly happens with Metabolizing enzymes are distributed in many tissues
proteins and phospholipids. Fractions of a drug in the body in the human body, with the highest levels found in GI
may be bound in this way and can act as a reservoir that tract tissues (e.g., the liver and the small and large intes­
prolongs drug action in the same tissue or at a distant site. tines). The liver is the major metabolizing organ for both
Lipophilic drugs can accumulate in adipose tissue [12]. drugs and endogenous chemicals (e.g., cholesterol, fatty
Halothane can concentrate in fat during long operations, acids, and proteins). The small intestine also plays a vital
and its slow release can cause postoperative prolonged cen­ role in drug metabolism, as most orally administered drugs
tral nervous system (CNS) depression. Tissue binding and become inactivated metabolically in either the intestinal
drug accumulation may lead to local toxicity, as in the case epithelium or the liver before they reach systemic circula­
of aminoglycoside antibiotic (gentamicin) accumulation in tion [20]. Drug metabolism reactions are classified as either
the kidneys and vestibular system [12]. phase I or phase II.
344 PART | VI  Fundamental Pharmacogenomics

17.2.3.1  Phase I Reactions molecule and provides a site for phase II reactions. Phase I
Drugs metabolized by phase I reactions usually lose their metabolic reactions include oxidation, reduction, and hydro­
pharmacological activity, although there are some examples lysis [20] (see Table 17.1).
of enhanced or altered pharmacological activity. If not elim­ Oxidations are the most common type of reaction and
inated rapidly through urine, phase I reaction products can are catalyzed by the cytochrome P450 (CYP) system,
react with endogenous compounds to form a highly water- which is located in the smooth endoplasmic reticu­
soluble conjugate [12]. lum. Metabolizing enzymes responsible for oxida­
Phase I reactions “functionalize” the drug for phase II, as tion are mainly CYPs, alcohol dehydrogenase (ADH),
they introduce a functional group—such as –OH, –COOH, aldehyde dehydrogenase (ALDH), dihydropyrimidine
–SH, –O–, or NH—which increases the polarity of the drug dehydrogenase (DPD), monoamine oxidase (MAO),

TABLE 17.1 Phase I and Phase II Reactions, Enzymes, and Substrate Drugs

Reaction Enzymes Drugs

Phase I

Oxidation N-dealkylation Fentanyl, Buprenorphine, Morphine,

Imipramine, Diazepam Codeine,
­Erythromycin, Tamoxifen, Theophylline,
Caffeine, Methadone
O-dealkylation Codeine, Dextromethorphan,
­Indometacin,
Aliphatic hydroxylation Ibuprofen, Tolbutamide, Phenobarbital,
Meprobamate, Cyclosporine, Midazolam
Aromatic hydroxylation Phenytoin, Phenobarbital, Propranolol,
Ethinyl Estradiol, Amphetamine, Warfarin
N-oxidation Dapsone, Chlorpheniramine, Meperidine
S-oxidation Cimetidine, Chlorpromazine,
­Thioridazine, Omeprazole
Deamination Diazepam, Amphetamine
Hydrolysis Modafinil, Salvinorin A, ­Carbamazepine,
Procaine, Aspirin, Clofibrate
­Meperidine, Enalapril, Cocaine,
­Lidocaine, ­Procainamide, Indomethacin,
­Suxamethonium
Reduction Prednisone
Phase II
Glucuronidation UDP-glucuronosyl transferases (UGT) Morphine, Acetaminophen, Oxazepam,
Lorazepam, UDP-Glucuronic
Sulphation Sulfotransferases (SULT) Paracetamol, Steroids, Methyldopa
Methylation Methyltransferases (MT) L-Dopa, Methyldopa, Mercaptopurine,
Captopril
Acetylation N-acetyltransferases (NAT) Sulphonamides, Isoniazid, Dapsone,
Clonazepam
Amino acid conjugation Bile acid-coenzyme A:amino acid Glycine
N-acyltransferase (BAAT)
Glutathione conjugation Glutathione-S-transferases (GST) Paracetamol, Adriamycin, Fosfomycin,
Busulfan
Chapter | 17 Pharmacokinetic Pharmacogenomics 345

and ­flavin-containing monooxygenase (FMO) [20,21]. Glucuronidation, which is catalyzed by UGT enzymes, is
Oxidation via phase I enzymes adds or exposes a func­ considered an essential metabolic pathway for hepatic bile
tional group, allowing phase I metabolites to act as acids [20,22].
substrates for the phase II conjugating enzyme [20].
The oxidation of a drug by the CYP system requires a
P450 enzyme, molecular oxygen, nicotinamide adenine 17.2.3.3  Non-CYP450 Enzymes
dinucleotide phosphate (NADPH), and a flavoprotein Non-CYP450 enzymes play a vital role in both the metab­
(NADPH-P450 reductase). olism and the elimination of several drugs; for example,
Hydrolysis is not limited to the liver but also takes place UGT, SULT, thiopurine S-methyltransferase (TPMT),
in various tissues. The main metabolic enzymes involved DPD, NAT, and GST have been indentified for their clinical
in drug hydrolysis are epoxide hydrolases (EH), ester­ significance [23].
ases, and amidases [21]. Inactive prodrugs are converted UGTs are membrane-bound enzymes found in the
rapidly to active metabolites mostly through an ester or hepatic endoplasmic reticulum and various other extra­
amide linkage hydrolysis; for example, enalapril, the hepatic tissues [21]. They involve a superfamily of vital
angiotensin-converting enzyme inhibitor, is quite inactive proteins that catalyze the glucuronidation reaction on a wide
until it is transformed by esterase into its diacid metabo­ range of structurally different endogenous and exogenous
lite (enalaprilat) [12]. Examples of drugs that undergo compounds. UGTs catalyze the transfer of the glucuronic
hydrolysis include carbamazepine, aspirin, meperidine, acid group of uridine diphosphoglucuronic acid to the func­
lidocaine, procainamide, and indomethacin [20]. tional group (e.g., hydroxyl, carboxyl, amino, sulfur) of a
Reduction reactions are much less common than oxi­ specific substrate [24].
dation reactions. The main metabolic enzyme involved SULTs are localized in the cytosol and catalyze the
in reduction is NADPH-CYP reductase [21]. A few transfer of the sulfonyl group from the cofactor PAPS to the
drugs undergo reduction reactions, and some reductive nucleophilic sites of a range of substrates, including hor­
reactions are important; for example, warfarin is inacti­ mones and drugs. In humans, 11 SULT isoforms have been
vated by conversion of a ketone to a hydroxyl group by recognized and have been classified into four main groups
the CYP2A6 enzyme. based on evolutionary projections (SULT 1, 2, 3, and 4)
CYPs, FMO, and EH, in addition to some phase II [20,21]. They play a significant role in human homeostasis.
conjugating enzymes, particularly Uridine 5′-diphospho- For instance, SULT1B1, which is mostly expressed in the
glucuronosyltransferase (UDP-glucuronosyltransferase, or skin and brain, is responsible for cholesterol and thyroid
UGT), are located mainly in the endoplasmic reticulum, hormone catalysis [20].
while phase II enzymes are mostly cytosolic [20]. TPMT is recognized for its important role in the metab­
olism of thiopurine drugs (e.g., 6-mercaptopurine (6-MP),
azathiopurine (AZA), and 6-thioguanine) and is catalyzed
17.2.3.2  Phase II Reactions through the s-methylation of aromatic and heterocyclic
Whereas various phase I reactions inactivate a drug bio­ sulfhydryl [21]. AZA and 6-MP are used to treat inflamma­
logically, phase II enzymes enable drug elimination by tory bowel disease and autoimmune disorders such as sys­
significantly increasing water solubility, abolishing phar­ temic lupus erythematosus and rheumatoid arthritis. 6-MP
macological activity, and increasing molecular weight. is also used for the treatment of childhood acute lympho­
Phase II reactions are generally biosynthetic (conjugation) blastic leukemia (ALL). 6-thioguanine is used to treat acute
reactions, such as glucuronidation, sulphation, acetylation, myeloid leukemia (AML), and since TPMT is responsible
methylation, and glutathione conjugation [20]. These highly for the detoxification of 6-MP, any deficiency in it can result
polar conjugates in general are inactive and are eliminated in severe toxicities in patients taking those drugs [20,25].
rapidly through urine and feces. DPD is the rate-limiting enzyme in pyrimidine and 5-fluo­
Phase II enzymes comprise a number of conjugat­ rouracil (5-FU) degradation. 5-FU is commonly prescribed
ing enzyme superfamilies, including the glutathione- to treat GI malignancies, and DPD deficiency can increase
S-transferases (GST), UGT, sulfotransferases (SULT), concentrations of bioavailable 5-FU anabolic products,
N-acetyltransferases (NAT), and methyltransferases (MT). leading to 5-FU–related toxicity [26].
Phase II reactions as a whole depend on catalytic reactions GST catalyzes glutathione conjugation to a broad range
for cofactors such as UDP-glucuronic acid (UDP-GA) for of endogenous metabolites and drugs. Human GSTs are
UGT and 3-phosphoadenosine-5-phosphosulfate (PAPS) classified into three major families: cytosolic/nuclear, mito­
for SULT, which respond to the substrate functional groups. chondrial, and microsomal. They also have nonenzymatic
These functional groups are mainly formed via phase I functions, as they work as regulators of cell signaling and
CYPs. In cholestasis, toxic bile acids accumulate in hepatic the post-translational modification pathway in response to
cells, leading to their damage and functional impairment. stress, growth factors, DNA damage, cell proliferation, cell
346 PART | VI  Fundamental Pharmacogenomics

death, and other processes that eventually lead to tumor the inhibiting drug becomes high enough to compete with
growth and drug resistance. Because of their functionalities, the affected drug. Examples of enzyme-inhibiting agents
GSTs are seen as significant determinants of cancer suscep­ are cimetidine, erythromycin, ciprofloxacin, and isoniazid.
tibility, therapeutic response, and prognosis [20,21,27]. In certain cases, enzyme inhibition can cause potentially
NATs are responsible for the metabolism of both drugs serious adverse events; for example, ketoconazole reduces
and environmental compounds that contain an aromatic the metabolism of the CYP3A4 substrate (terfenadine),
amine or hydrazine group. NATs catalyze the transfer of an resulting in a prolonged QT interval and torsades de pointes.
acetyl group from acetyl coenzyme A to arylamines, arylhy­ As with enzyme induction, enzyme inhibition is not lim­
droxylamines, and arylhydrazines [20,21]. ited to drug interactions [30]; for example, grapefruit juice
(a CYP3A4 inhibitor) can cause clinically significant inter­
17.2.3.4  Enzyme Induction actions with many drugs, such as midazolam, simvastatin,
The pharmacological effect of a drug is dependent on its and terfenadine. Resulting in much higher plasma concentra­
concentration at its site of action, which is partly dependent tions of the inhibited drug than intended, enzyme inhibition
on its metabolism rate. Any changes in this enzyme activity can be a major safety issue, such as in co-administration of
can affect drug action. Enzyme induction can be defined as ketoconazole or ritonavir with midazolam, which increases
the increased synthesis (higher amount) or decreased degra­ midazolam plasma exposure (AUC) by 15–20 times—a
dation (increased activity) of enzymes that occurs as a result condition that should be avoided [8].
of the presence of an exogenous substance [20,28]. It is usu­
ally associated with a reduction in drug efficacy but may 17.2.4 Excretion
also change the toxicity of particular substances. CYP3A4
Drugs are eliminated from the body through two main
plays a role in the metabolism of about 50% of the drugs
mechanisms—liver metabolism and renal excretion. Some
that are currently prescribed. Induction of CYP3A4 by
drugs are excreted in insignificant amounts via other routes,
rifampicin can increase oestrogen metabolism, thus reduc­
such as sweat, saliva, and tears, and elimination through
ing the effectiveness of birth control pills.
these routes depends mostly on nonionized lipophilic diffu­
Certain drugs can increase the rate of synthesis of
sion through the epithelial cells of the glands and on urine
CYP450 enzymes; consequently, this enzyme induction
pH [12].
can enhance the clearance of other drugs. Generally, such
induction needs exposure to the inducing agent for more
than a week before effects can be observed [28]. Clinical 17.2.4.1  Renal Excretion
studies have shown that carbamazepine, phenytoin, and The kidney is the principal organ of excretion for a drug
rifampicin are the most potent enzyme inducers in clinical and its metabolites. Drugs that are water soluble are mostly
use as they produce many clinically significant drug inter­ excreted unchanged through the kidneys. Lipid-soluble
actions mainly associated with increases in the metabo­ drugs are not eliminated efficiently by the kidneys and first
lism of CYP2C9, CYP2C19, and CYP3A4 substrates (see need to be metabolized to more polar products. Renal dis­
Table 17.2). However, enzyme induction is not limited to ease influences the excretion of particular drugs. The extent
the administration of prescription drugs. St. John’s Wort, an to which excretion is impaired can be deduced by measur­
herbal medicine, can also induce metabolizing enzymes, as ing creatinine clearance. Drug and metabolite excretion in
can tobacco, which induces a CYP1A2 substrate, such as urine includes three different processes: glomerular filtra­
theophylline [29]. tion, active tubular secretion, and passive tubular reabsorp­
tion; changes in kidney function in general affect all three
17.2.3.5  Enzyme Inhibition processes to a similar degree [12].
Enzyme inhibition refers to a decrease in enzyme-related Glomerular filtration is the most common route of renal
processes, enzyme production, or enzyme activity. A num­ elimination. The amount of drug entering the tubular lumen
ber of clinically important interactions between drugs result through filtration depends on the glomerular filtration rate
from CYP450 inhibition. CYP450 inhibitors are different (GFR) and the level of plasma binding of the drug. Only
in their selectivity toward enzymes and are classified by unbound drugs are cleared by filtration; protein-bound
their mechanisms of action. Some drugs are potent com­ drugs remain in circulation, where some of them dissociate
petitive inhibitors and compete for the active site, but they to restore equilibrium. The size of the molecule is the only
are not a substrate for the enzyme (e.g., quinidine and limiting factor at this step. In relation to filtered drugs, it is
CYP2D6), while other drugs are noncompetitive inhibitors expected that great declines in renal function, as reflected
(e.g., ketoconazole and CYP3A4). Enzyme inhibition can by a decreased GFR, lead to drug accumulation, and there­
cause many adverse drug interactions that tend to happen fore renal patients may need dose adjustments. However,
more rapidly (within a couple of days) than those seen with for actively secreted drugs, GFR is less important than renal
enzyme induction, as they occur once the concentration of plasma flow [31].
Chapter | 17 Pharmacokinetic Pharmacogenomics 347

TABLE 17.2 Cytochrome P450 Enzymes, Substrates, Inducers, and Inhibitors

Enzymes Substrates Inducers Inhibitors

CYP2D6 Timolol, Metoprolol, Cimetidine, Quinidine, Halperidol,
Carvedilol, Fluoxetine, Bupropion, Fluoxetine, Paroxetine,
Paroxetine, Tricyclic antide- ­Perhexaline, Cinacalcet, Doxepin,
pressants, Propafenone, ­Duloxetine, Flecainide, Moclobemide,
Flecainide, Codeine, Phenfor- Quinine, Terbinafine, Sulphaphenazole,
min, Codeine, Debrisoquine Benzoflavone, Troleandomycin,
­Ritonavir, Chlorpromazine, ­Miconazole,
Diphenhydramine, Ketoconazole,
­Methadone, ­Nicardipine, Sertraline,
­Venlafaxine, ­Tricyclic antidepressants
CYP2C19 Omeprazole, Rifampicin, Phenobarbital, Omeprazole, Fluconazole, ­Fluvoxamine,
Mephenytoin, Phenytoin Lopinavir/Ritonavir, Ticlopidine, Clarithromycin, ­Fluoxetine,
St John’s wort Moclobemide, Moriconazole,
­Diethyldithiocarbamate, Cimetidine,
Ketoconazole
CYP1A2 Caffeine, Paracetamol, Ta- Phenytoin, Tobacco smoke, Cimetidine, Ranitidine, ­Ciprofloxacin,
crine, Theophylline Phenobarbital, Beta-Naphtho- Fluvoxamine, Ethinylestradiol,
flavone, Rifampin ­Interferon Alpha-2b, Methoxsalen,
­Sulphaphenazole, Benzoflavone,
­Troleandomycin, Furafylline
CYP2E1 Alcohol, Paracetamol Isoniazid, Phenobarbital, Tetrahydrofurane,
Rifampin Diethyldithiocarbamate, Disulfiram,
­Sulphaphenazole, Benzoflavone,
­Quinidine, Troleandomycin
CYP2C8 Paclitaxel, Repaglinide, Phenytoin, Rifampicin Sulphaphenazole,
Rosiglitazone, Pioglitazone, Benzoflavone, Quinidine,
Troglitazone, Amiodarone, ­Troleandomycin
Chloroquine, Amodiaquine,
Verapamil, Ibuprofen,
Ofluvastatin, Amitriptyline,
Perphenazine, Diclofenac,
Gallopamil, Omeprazole,
Carbamazepine
CYP2C9 Warfarin, Phenytoin, Rifampin Phenobarbital Fluconazole, Sulphaphenazole,
Glipizide, Losartan, Ibuprofen, ­Benzoflavone, Quinidine,
Tolbutamide ­Troleandomycin, Ketoconazole,
­Amiodarone, Phenytoin
CYP3A Calcium Channel Blockers, Bosentan, Rifampicin, Carba- Erythromycin, Clarithromycin,
Antiarrhythmics (Lidocaine, mazepine, Efavirenz, Pheno- ­Itraconazole, Ketoconazole, ­Lopinavir/
Quinidine, Mexiletine), HMG- barbital, Modafinil, Phenytoin, Ritonavir, Ritonavir, Saquinavir,
Coa Reductase Inhibitors, St John’s Wort, Clotrimazole, ­Saquinavir/Ritonavir, ­Voriconazole,
Cyclosporine, Tacrolimusin- Ritonavir, Sulfinpyrazone Grapefruit Juice, Fluconazole,
dinavir, Saquinavir, Ritonavir, ­Amiodarone Cimetidine, Fluvoxamine,
Nifedipine, Simvastatin Diltiazem, Cyclosporin, Imatinib,
­Verapamil, Atazanavir/ Ritonavir,
­Atazanavir, Aprepitant, ­Sulphaphenazole,
Benzoflavone, Quinidine,
­Troleandomycin, Diltiazem, Itraconazole
CYP2A6 Coumarin, Halothan, Meth­ Phenobarbital, Rifampin Methoxsalen, Diethyldithiocarbamate
oxyflurane, Valporic Acid,
Disulfiram, Losigamone,
Letrozole
CYP2B6 Cyclophosphamide, Phenobarbital, Rifampin, Ritonavir, Efavirenz, Nelfinavir
Methadone Clotrimazole, Ritonavir,
Sulfinpyrazone
348 PART | VI  Fundamental Pharmacogenomics

Passive reabsorption in the distal tubule occurs only 17.2.5 Half-Life

with unionized (lipid-soluble) drugs. Urine PH determines
whether weak acids and bases are reabsorbed, and this in The half-life (t1/2) is one of the simplest PK parameters to
turn determines the degree of ionization. If renal function calculate. It is the time taken for a drug concentration to fall
is impaired, for instance, by disease, the clearance of drugs to half of its original value, measured in hours. However, not
that usually undergo renal excretion is decreased. Tubular only does it determine the time needed for drug concentra­
reabsorption follows the role of passive nonionic diffusion tions to fall to immeasurably low levels following a single
and depends on both urinary pH and the drug’s pKa. A pH bolus; it is also the main determinant of the time required
that prefers the nonionized state of a drug increases both to achieve steady-state plasma concentrations (Css) after
its lipophilicity and passive reabsorption across the tubular any changes in dose. When a drug is administered chroni­
membrane. The extent of passive reabsorption also depends cally and its amount administered per unit time equals the
on urinary volume. The clinical relevance of renal tubular amount eliminated per unit time, this situation represents a
reabsorption relates generally to the disease effect on the steady state. While Css is stable in a continuous IV infusion,
process [31,32]. it varies during the dosing interval in chronic oral adminis­
Active secretion in the proximal tubule is predominant tration although the profile of time-concentration between
in that the proximal convoluted tubule can actively secrete dosing intervals is still stable.
some compounds—mostly weak acids and bases—into the The t1/2 is related to elimination rate constant, clearance,
lumen of the nephron. Actively secreted drugs accumu­ and Vd. The “initial” concentration achieved after a single
late in patients with reduced renal function, as renal blood IV bolus, then, decreases by a constant amount per unit time
flow and GFR generally also decrease. The SLC transport­ as the drug is eliminated from the body. The parameter that
ers, which include organic cation transporters (OCTs) and describes this rate of decline is the elimination rate constant
organic anion transporters (OATs), are involved in active (k), and it depends on both clearance and volume of distri­
transport of many endogenous substances and drugs [32]. bution. Clearance measures the ability of the body to elim­
Actively secreted drugs are subject to competition for trans­ inate a drug; therefore, as clearance decreases (e.g., with
port, so there are some concerns with particular clinical disease), t1/2 is expected to increase. However, this kind of
conditions in which co-administered drugs inhibit transport, relationship is applicable only when the disease does not
which can expose patients to high drug concentrations [31]. affect the Vd; for example, diazepam t1/2 increases with
As about 80% of a drug delivered to the kidney is subjected patient age, but it is the volume of distribution that changes,
to the carrier, tubular secretion is probably the most efficient not the clearance [12,18]. The t1/2 represents the time taken
mechanism of renal drug elimination. A number of organic to eliminate a drug and the time taken for the drug to accu­
acids are actively secreted (e.g., penicillins, probenecid), as mulate to a steady state with multiple dosing or during a
well as quite a few diuretics (e.g., furosemide, thiazides) constant-rate infusion. This takes about 4–5 t1/2 (when start­
and different conjugates (e.g., glucuronic acid, sulphate). ing from zero). Drug concentration data are generally plot­
Some organic cations are also secreted, such as morphine ted against time. A drug achieves 50% of its Css after one
and amiloride. t1/2, 75% after two t1/2, 88% after three t1/2, 94% after four
t1/2, and 97% after five t1/2.
t1/2 is an important determinant of dose frequency and
17.2.4.2  Biliary Excretion time required to achieve Css; however, it provides little
Liver cells transfer different substances, and bile excre­ information about differences in dose requirements asso­
tion is a main route of excretion for a small number of ciated with clinical conditions or diseases. For instance, a
drugs (e.g., cromoglycate) and a larger number of drug change in t1/2 might reflect a change in Vd or clearance or
metabolites (e.g., morphine glucuronide). Drug conju­ both. In the same way, if both clearance and volume change
gates are excreted into the bile and later released into in proportion, the t1/2 may be unaltered although average
the intestines, where they are reabsorbed into the body steady-state concentrations may change. Clearance and vol­
(enterohepatic circulation). Enterohepatic circulation ume should therefore be calculated individually whenever
has important clinical consequences, as it prolongs the possible [18,33].
drug effect and increases its plasma half-life (t1/2). While In a number of diseases, clearance and distribution vol­
some drugs are excreted mostly unchanged in bile (e.g., ume can be affected by changes in protein binding, result­
vecuronium), other drugs are excreted in bile after deacet­ ing in unpredictable t1/2 changes. For example, in patients
ylation, which retains their biological activity and stops with acute viral hepatitis, tolbutamide t1/2 exhibits enhanced
their reabsorption. Drugs pass from plasma to bile via clearance which is unexpected. This occurs because the dis­
transport systems similar to renal tubules, such as OCTs, ease changes both plasma and tissues protein binding, does
OATs, and P-glycoproteins. not affect volume of distribution, but increases clearance
Chapter | 17 Pharmacokinetic Pharmacogenomics 349

because free drugs are present in the bloodstream in higher other hand, a number of drug interactions and genetic vari­
concentrations. Although it can be a poor indicator of drug ants increase CYP expression, and therefore increased drug
elimination from the body, t1/2 does give a good indication dosage might be required to maintain a therapeutic effect
of the time required to reach a steady state whenever a drug [12].
regimen is initiated or changed, the time needed for a drug
to be cleared from the body, and a means to predict the
appropriate dosing interval [12,17]. 17.2.7  Zero- and First-Order Kinetics
The hallmark of first-order (linear) kinetics is the pro­
portionality between dose rate and Css. Most drugs show
17.2.6 Clearance
first-order kinetics, where a constant fraction of drug
Clearance (CL) is the most important concept to consider in the body is eliminated per unit time. Linear kinetics
when designing a rational regimen for long-term drug explains that the decrease in drug levels in the body is
administration. CL (expressed as volume/time) describes dependent on the plasma concentration (a concentration-
the volume of fluid that is completely cleared of drug per dependent process). The higher the drug concentration,
unit time, mainly through hepatic metabolism and renal the larger the absolute amount of drug eliminated per unit
excretion [12]. While elimination t1/2 determines the time time. Therefore, the rate of elimination is proportional to
required to achieve Css, the level of that steady state is the amount of drug in the body, while CL remains con­
determined through CL and dose alone. If the drug is given stant. Generally, for drugs with first-order kinetics, Vd,
for long enough, the amount of drug eliminated from the t1/2, k, and CL are all interrelated [12].
body during one dosage interval is equal to the amount of However, if the elimination mechanisms of a particular
drug that enters the systemic circulation during each dosage drug become saturated, the kinetics move toward zero-order
interval. This is known as a steady state. CL depends essen­ (nonlinear) kinetics, in which a constant amount of drug
tially on liver and/or kidney efficiency to eliminate a drug, is eliminated per unit of time. Various drugs follow zero-
and it varies in certain diseases that affect those organs or order kinetics at high or toxic concentrations. Metabolism
the blood supply to them. In a stable clinical situation, CL in general, which involves particular enzymes, is one of the
remains constant and is directly proportional to dose rate. most important elements contributing to a drug undergo­
The clinical importance of this is that, for most drugs, if the ing zero-order kinetics. When metabolism enzymes reach a
dose rate is doubled, the Cssaverage doubles, and, if the dose point of saturation, the rate of elimination does not increase
rate is halved, the Cssaverage is halved. in response to a concentration increase but rather becomes
The concept of CL is very useful in clinical PKs constant (a concentration-dependent process).
because its value for certain drugs is generally constant Common examples of drugs that follow nonlinear kinet­
over the clinically encountered concentration ranges. Drug ics are aspirin, phenytoin, alcohol, heparin, and ethanol.
elimination systems, such as metabolizing enzymes and The t1/2 is not constant for zero-order reactions, but rather
transporters, are usually not saturated; therefore, the abso­ depends on concentration. The higher the concentration, the
lute elimination rate is basically a linear function of the longer the t1/2. The clinical significance of nonlinear kinetics
drug’s concentration in plasma. To be precise, the elimi­ is that any small increase in dose can cause a large increase
nation of most drugs follows first-order kinetics, where a in concentration. This is mainly important when toxic side
constant fraction of drug in the body is eliminated per unit effects and concentration are strongly related, which is the
of time. If the elimination mechanisms of a particular drug situation with, for example, phenytoin [12].
become saturated, the kinetics move toward zero-order
kinetics, in which a constant amount of drug is eliminated
per unit of time. In such situations, CL changes with drug
concentration [12]. 17.3  ADME: PHARMACOGENOMICS
It is vital to understand that CL does not indicate how As discussed previously, there are many sources of varia­
much of a drug is being cleared; rather, it indicates the vol­ tion in enzyme activity; age, enzyme induction or inhibi­
ume of blood or plasma from which the drug would have to tion, and diseases (especially of the liver) are among them.
be totally removed to account for the CL. The CL by differ­ Variation in the DNA sequence of genes encoding enzymes
ent organs (GI tract, kidney, liver, and other organs) is addi­ can abolish, reduce, or increase the expression and activity
tive. Diseases, drug interactions, or even genetic variants of an enzyme, and this can manifest as the “metabolizer”
that decrease the activity of drug-metabolizing enzymes or phenotype in an individual. Individuals who are homozy­
mechanisms of execration may decrease CL; consequently, gous for the two alleles coding for “normal” enzyme func­
a dose adjustment to avoid drug toxicity is required. On the tion are termed extensive metabolizers (homozygous EM
350 PART | VI  Fundamental Pharmacogenomics

or “wild-type”); those who are homozygous with two vari­ result of inhibition of the enzyme by another drug or by
ant alleles resulting in inactive or absent enzymes are “poor itself (“autophenocopying”). This can result in a reduc­
metabolizers” (PM); those who are heterozygous manifest tion in a trait’s variation in a population. For example,
an intermediate metabolizer (IM) phenotype with reduced all patients chronically taking a drug are poor metabo­
function (heterozygous EM). Intermediate and extensive lizers either because of their genotype or because of
metabolizers are often collectively referred as extensive autophenocopying. Phenocopying sometimes explains
metabolizers, especially in studies in which metabolizer why differences between PMs and EMs are less at
status is assigned using phenotype. steady state than after single doses.
Gene duplication or multiplication, as, for example, seen
in CYP2D6, can result in “ultrarapid metabolizer” (UM)
phenotype. Standard drug doses achieve normal concentra­ 17.3.1  CYP450 Enzymes
tions and effect in homozygous EMs (which usually make
The major causes of interindividual and intraindividual
up the largest proportion of the population), but they may
variability in CYP activity are environmental factors
be toxic in PMs (possibly in heterozygous EMs or IMs)
(inducers and inhibitors), biological factors (gender, dis­
and ineffective in UMs, who may require a higher dose to
ease, and circadian rhythms), and genetic polymorphisms
achieve therapeutic effective drug concentrations [9,21,34].
in CYP450 genes and their regulators. There are large varia­
In general, the most important factor affecting drug
tions between individual CYP450 isoforms in terms of their
action is the AUC at the site of action, reflecting the
susceptibility to these mechanisms [35,36]. Overall, 57
“metabolizer” phenotype; AUC is the best pharmacokinetic
CYP450 genes and 58 pseudogenes have been identified,
end point for the assessment of pharmacogenetic effects.
42 of which play a role in the metabolism of both exoge­
However, even if there is a clear association between con­
nous xenobiotics and endogenous substances (e.g., steroids
centration and drug effect/toxicity, there are multiple fac­
tors that determine the clinical relevance of a functional and prostaglandins), and 15 of which are involved in the
polymorphism in a drug metabolizing gene [34]. These are metabolism of drugs in humans [35,36]. CYP450 genes are
summarized here: highly polymorphic and can exhibit clinically significant
genetic polymorphisms. In general, CYP3A4/5, CYP2D6,
CYP2C9, CYP2C19, CYP2A6, CYP2B6, and CYP2C8 are
l Clear association between concentration and drug
the most important and most studied metabolic enzymes.
effect/toxicity. Genetic variation that affects the func­
The variations in CYP450 genes—deletions, missense
tioning of the drug metabolizing gene can affect the
mutations, deleterious mutations (creating splicing defects
AUC and hence can predict drug effects.
or premature stop codons), and duplications—can result in
l The clinical significance of a genetic variant depends
abolished, reduced, normal, or enhanced enzyme activity
on the drug’s therapeutic index (the ratio between dose
[21,35,37,38].
effectiveness and safety). A high therapeutic index indi­
cating that a drug is safe over a wide range of concentra­
tions and variations due to genetics may be irrelevant, 17.3.1.1 CYP2D6
whereas a low therapeutic index indicates that minor CYP2D6 is a member of the cytochrome P450 superfamily
variations in drug concentration, such as from polymor­ involved in metabolizing and eliminating many prescribed
phisms, may be important. medications; it accounts for approximately 2% of total
l If the drug effect is mediated by multiple active moi­ hepatic CYP450 content. The CYP2D6 gene is highly poly­
eties, the relevance of genetic variation is diminished. morphic, with at least 100 genetic variants and 120 alleles
For example, if the product of the drug–enzyme reac­ identified. Additionally, its variants are the best character­
tion is an active metabolite with activity similar to that ized among all CYP450 variants, and the distributions of
of the parent molecule, an altered ratio of parent drug these alleles exhibit notable interethnic differences. (See
to metabolite (through polymorphism) may have little Chapter 16.) Approximately 7–10% of Caucasians and 1%
clinical effect. of Chinese, Japanese, and Koreans are PMs of CYP2D6
l If a drug is metabolized or eliminated by multiple path­ [34,39,40].
ways, total ablation of one pathway (as in a PM) may In Caucasians, CYP2D6*3, *4, and *5 produce
result in minimal alteration of overall drug concentra­ inactive enzymes or no protein products and are the
tions and hence have minimal effect. variants most commonly implicated in the PM pheno­
l Sometimes enantiomers have different pharmacological type. CYP2D6*4 is the most common variant allele in
activity and pathways of elimination. This is called ste­ Caucasians (allele frequency ∼21%), but it is virtually
reoselective metabolism. absent in Chinese, although overall CYP2D6 activity is
l Phenocopying is the conversion of a patient from a phe­ lower in Chinese than in Caucasians as a result of the high
notypic normal metabolizer into a slow metabolizer as a allele frequency of CYP2D6*10 (∼50%), which is largely
Chapter | 17 Pharmacokinetic Pharmacogenomics 351

absent in Caucasians. Gene duplication occurs in ∼1–7% nonresponse to codeine may be explained by PM status, it
of Caucasians and 29% of black Ethiopians; also, it is pre­ also may be due to other factors, including phenocopying
dictive of an UM phenotype [34]. This variant produces by a CYP2D6 inhibitor such as paroxetine [34].
an unstable enzyme with reduced (but not absent) ability The beta-1-selective metoprolol appears to have both
to metabolize substrate drugs. consistent gene–concentration and gene–effect relation­
CYP2D6 is responsible for the metabolism of almost ships in healthy volunteers, suggesting that dose reduc­
20–30% of drugs and is the most widely studied enzyme tion to ∼25% should occur in PMs or those phenocopied
in relation to polymorphisms. Examples include tricyclic by other drugs [34]. Metoprolol is administered as a race­
antidepressants, selective serotonin reuptake inhibitors mate, with S-metoprolol thought to produce most of the
(SSRIs), antiarrhythmics, beta-blockers, neuroleptics, opi­ β-blockade. The main metabolite, O-desmethylmetoprolol
oid analgesics, antiemetics, and anticancer drugs. CYP2D6 (essentially inactive), accounts for approximately two-
is not inducible, and therefore variations in the enzyme thirds of the metabolism and occurs via various path­
expression and activity are largely attributable to genetic ways, including CYP2D6 (mainly R-metoprolol); another
polymorphisms [21,41]. Powerful CYP2D6 inhibitors have pathway, to α-hydroxymetoprolol, accounts for ∼10% of
been shown to significantly decrease EM metabolic capac­ the dose in EMs and seems to be under CYP2D6 control
ity; therefore, EM subjects may seem to be PMs during the because very little is produced in PMs. AUCs of metoprolol
coexisting administration of potent inhibitors (e.g., fluox­ are 4- to 6-fold higher in PMs than in EMs after one dose
etine and paroxetine) [39]. and 3- to 4-fold higher after repeated dosing. UMs achieve
Recently, ADRs have been reported in UMs, mainly of metoprolol concentrations that are half those observed in
a 10- to 30-fold increase in drug metabolite concentrations. EMs. The strong CYP2D6 inhibitor, paroxetine, increases
For example, codeine is converted through CYP2D6 to mor­ the mean AUCs of S- and R-metoprolol by 5- and 8-fold,
phine, which is more pharmacologically active. UMs receiv­ respectively.
ing standard doses of codeine have been reported to display Enhanced or prolonged β-blockade has been observed in
symptoms of narcotic overdose significantly related to higher both PMs and EMs receiving CYP2D6 inhibitors [44,45].
morphine concentrations [39,42]. Perhexiline is an antiangi­ Three recent prospective studies failed to show a relation­
nal drug that is almost entirely metabolized by CYP2D6 to ship between CYP2D6 and adverse effects with metoprolol
hydroxyperhexiline (inactive). PMs have trough concentra­ [46–48]. The high therapeutic index of the drug and the fact
tions up to 6-fold higher than EMs after a single dose, with that the effects of excessive β-blockade are usually easy
evidence of saturable metabolism. The major toxicity of per­ to detect clinically (e.g., bradycardia) lessen the need for
hexiline is hepatotoxicity and peripheral neuropathy, which genotype testing. The long history of metoprolol use with­
are concentration-dependent. Therapeutic drug monitoring out genotyping or phenotyping suggests that these tests are
has assisted dosing, with a suggested range of 0.15–0.6 mg/l, unlikely to happen in practice.
supported by both concentration-dependent efficacy and tox­
icity [43]. This supports a case for prospective genotyping. 17.3.1.2 CYP2C9
In most individuals, only a small fraction (∼10%) of CYP2C9 is the most abundant of the CYP2C enzymes and
codeine is metabolized to morphine via CYP2D6, with accounts for about 30% of total hepatic CYPs. It plays an
most of that fraction glucuronidated to codeine-6-glucuro­ important role in the metabolism of about 10% of the drugs
nide and the remainder metabolized by CYP3A4 to nor­ available on the market, including nonsteroidal anti-inflam­
codeine. The AUC of codeine is similar in PMs and EMs, matories (e.g., ibuprofen), antiepileptics (e.g., phenytoin),
whereas morphine is virtually undetectable in PMs as well oral anticoagulants (e.g., warfarin), and antihypertensives
as EMs taking quinidine (phenocopying). Clinical studies in (e.g., losartan). The human CYP2C9 and CYP2C19 genes
volunteers generally support the lack of analgesia in PMs, are highly homologous at the nucleotide level [39,49], and
which is consistent with the belief that morphine is the key more than 30 variants of CYP2C9 have been identified.
metabolite responsible for codeine’s antinociceptive effects. Generally, CYP2C9 polymorphisms encode proteins with
Theoretically, UMs may convert codeine to morphine more a loss of catalytic function, with the extent this reduction
rapidly, resulting in increased opioid effects for a given often being substrate-dependent.
dose. However, studies to date have been with volunteers Many variants have been associated with reduced
and not the target population. enzyme activity (see http://www.cypalleles.ki.se), with
Overall there is a strong argument for a gene–concen­ CYP2C9*3 and, to a lesser extent, *2 having the most clin­
tration effect resulting from the failure of prodrug conver­ ical relevance. In vitro studies show that *3 is associated
sion to morphine in PMs and phenocopied EMs. As far as with a lower intrinsic clearance of substrate drugs than
the gene–effect relationship is concerned, there seems to is *2. The effects of CYP2C9*2 are more substrate spe­
be a predictable failure of analgesia in healthy volunteers cific (e.g., warfarin and phenytoin), whereas CYP2C9*3
but a less clear relationship with adverse effects. Although displays reduced catalytic activity toward the majority of
352 PART | VI  Fundamental Pharmacogenomics

CYP2C9 substrates. The clinical importance of CYP2C9 least one CYP2C9*2 or *3 allele is associated with one-
polymorphisms is demonstrated by the dose adjustment third lower mean dose requirements (199 versus 314 mg/
of an oral anticoagulant, warfarin, based on the CYP2C9 day, respectively). Furthermore, a “gene-dose” effect seems
genotype[4,39,49,50]. to exist, with dose requirements of 314, 193, 202, 217, and
At least one CYP2C9*2 or *3 allele is carried by ∼20% 150 mg/day for the CYP2C9*1/*1, *1/*2, *1/*3, *2/*2, and
and 12% of Caucasians, respectively, with ∼2.5% being *2/*3 genotypes, respectively [60].
homozygotes for *2 or *3, or for compound heterozygotes In a single-dose study in healthy volunteers 30% lower
for both alleles. The remaining two-thirds of the Caucasian concentrations were seen in wild-type individuals com­
population are wild types and have normal enzyme activity. pared with carriers of CYP2C9*2 or *3 alleles. CYP2C9*2
The small proportion of individuals (∼0.4% of Caucasians) and *3 were suggested as accounting for 31% of the varia­
homozygous for CYP2C9*3 have the lowest ability to metab­ tion in phenytoin concentrations taken 12 h after a single
olize substrate drugs. The CYP2C9*2/*2 and *2/*3 geno­ 300 mg dose [61]. As central nervous system toxicity (e.g.,
types may also cause important reductions in the metabolism
ataxia and nystagmus) is closely related to concentration, it
of some drugs (e.g., phenytoin). CYP2C9*2 and *3 are rare
is likely that individuals with CYP2C9 variants are predis­
in African American and Asian populations, with the wild
posed to these effects. There is some evidence for an asso­
type making up more than 95% of these populations [51].
ciation between CYP2C9*1 and *3 genotype and cutaneous
The three oral coumarin anticoagulants—warfarin,
acenocoumarol, and phenprocoumon—exist as S- and reactions [62]. A reasonable case for genotyping in relation
R-enantiomers. The S-enantiomers are CYP2C9 sub­ to phenytoin to guide the initial choice of a maintenance
strates and are responsible for most of the effects of war­ dose can be made on the basis of a strong gene-(dose) con­
farin and phenoprocoumon. In contrast, although S- and centration effect, a moderate gene-effect relationship, a
R-acenocoumarol have comparable activities, rapid elim­ strong concentration-effect relationship for both desired and
ination of the S-enantiomer means that R-acenocoumarol adverse effects, and a low therapeutic index. Points against
produces most of the anticoagulant effect. All three oral genotyping include the fact that an alternative pathway
anticoagulants have low therapeutic indices, and the dose (CYP2C19) exists for phenytoin metabolism. Therapeutic
required to produce a target prothrombin time is largely drug monitoring continues to be necessary, and clinicians
unpredictable [34] (see Chapter 24). CYP2C9 is impor­ have long experience with phenytoin.
tant for the metabolism of this class, with CYP2C9*3
(but not CYP2C9*2) being clearly implicated in impaired 17.3.1.3 CYP2C19
clearance of tolbutamide, glyburide, and glimepiride CYP2C19 accounts for about 3% of total hepatic CYPs.
[52–54]. The ability of individuals to metabolize S-mephenytoin has
Losartan is metabolized by CYP2C9 via an aldehyde enabled them to be classified as PMs or EMs. PM pheno­
intermediate (E-3179) to E-3174, the predominant active
types for CYP2C19 are common (20%) among Asians and
moiety. E-3174 is at least 10-fold more potent than losar­
rare (3–5%) in European-derived populations. CYP2C19
tan at the AT1 receptor. Furthermore, although only 14% of
catalyzes the metabolism of several drugs, including pro­
losartan is metabolized to E-3174, the AUC of the latter is
ton pump inhibitors (PPIs) (e.g., omeprazole, lansoprazole,
4-fold to 8-fold higher than that of the parent and is thought
to be responsible for most of the activity [55]. This find­ pantoprazole), antidepressants (e.g., citalopram and ami­
ing suggests that individuals with CYP2C9 variants might triptyline), antiplatelet drugs (e.g., clopidogrel), antifungals
exhibit a reduced losartan response. Only one of the three (e.g., voriconazole), and anticancer compounds (e.g., cyclo­
studies in healthy volunteers that included blood pressure phosphamide). Seven variants (*2–*8) in the CYP2C19
assessments reported a significant influence of CYP2C9; gene have now been associated with reduced enzyme activ­
they reported reduced response among those with the *1/*3 ity in vivo, largely due to production of inactive enzyme
genotype [56–58]. Studies on the impact of genotype on protein.
AUC have been inconclusive, and it seems unlikely that A novel CYP2C19 variant (CYP2C19*17) that may pro­
CYP2C9 variants significantly affect parent losartan con­ duce an ultrarapid metabolizer phenotype was recently iden­
centrations since production of E-3174 constitutes a quanti­ tified [63]. A splice site mutation, CYP2C19*2 (rs4244285,
tatively minor route of elimination [56–59]. 19154G >A), and a premature stop codon, CYP2C19*3
Phenytoin is a commonly used antiepileptic drug (rs4986893, 17948G >A) represent the two most predomi­
despite its complex nonlinear pharmacokinetics and low nant null alleles [4,39,64]. Genotyping for CYP2C19*2
therapeutic index. It is primarily (80–90%) eliminated via and *3 identifies most PMs in African American and
4′-hydroxylation to 5-(4p-hydroxyphenyl)-5-phenylhydan­ Chinese populations, while genotyping for CYP2C19*2
toin (HPPH), largely via CYP2C9, which preferentially identifies 70–85% of variant reduced-activity alleles and
produces the S-enantiomer of HPPH. The presence of at CYP2C19*2–*8 identifies more than 99% of PMs [65].
Chapter | 17 Pharmacokinetic Pharmacogenomics 353

CYP2C19 plays an important role in proton-pump A deletion of the CYP2A6 gene is common in the Asian
inhibitor (PPI) therapy for peptic ulcers and gastroesopha­ population and accounts for significant differences in PMs
geal reflux disease. In EMs, it is responsible for >80% of compared with the Caucasian population. Since CYP2A6
the metabolism of omeprazole, lansoprazole, and pantopra­ is the high-affinity metabolizer of both nicotine and its oxi­
zole [66], the remainder with CYP3A4 [39,64]. The metab­ dized metabolite, cotinine, CYP2A6 variants have mainly
olites produced are inactive. A fourth PPI, rabeprazole, been studied for treating tobacco abuse. Studies have
may be less reliant on CYP2C19 as it undergoes nonen­ revealed that the kinetics of nicotine metabolism are dif­
zymatic conversion to rabeprazole thioether. S-Omeprazole ferent in individuals carrying the variant CYP2A6 alleles.
(esomeprazole) was recently marketed as an individual For example, in three studies, smokers who carried the
entity to exploit its reduced variation in CYP2C19 geno­ CYP2A6 variants smoked fewer cigarettes and were more
type pharmacokinetics compared with the racemate or with likely to quit smoking. These results reflect the possibil­
R-omeprazole [67]. ity of increased nicotine concentrations and, subsequently,
The AUCs of both omeprazole and lansoprazole are 4- to increased nicotine tolerance and ADRs from nicotine, espe­
15-fold higher in PMs than in homozygous EMs; with mul­ cially in CYP2A6 PMs [39,74,75].
tiple dosing, the increase in AUC of omeprazole (but not of
lansoprazole or pantoprazole) decreases to ∼2-fold in EMs 17.3.1.5 CYP2B6
because of inhibition of its own metabolism by CYP2C19 CYP2B6 accounts for 6–10% of the total CYP con­
[68]. This does not occur in PMs who lack a functioning tents in the liver, with a substantial (>100-fold) varia­
CYP2C19 enzyme to inhibit. The AUCs of rabeprazole are tion in expression between individuals [76]; it is involved
also increased but less markedly in CYP2C19 deficiency. in the metabolism of an increasing number of clinically
Individuals with CYP2C19 deficiency have superior acid important drugs (∼8% of those on the market) [39,77],
suppression with conventional doses of omeprazole and including bupropion, cyclophosphamide, efavirenz, and
lansoprazole [69], and increasing the lansoprazole dose methadone. It also metabolizes some procarcinogens (e.g.,
from 30 mg once daily to four times daily in homozygous 6-aminochrysene) and drugs of abuse (e.g., N-methyl-
EMs leads to an increase in mean 24-h intragastric pH from 3,4-methylenedioxyamphetamine, “ecstasy”). CYP2B6 is
4.5 to 7.0 [70]. subject to inhibition and induction by drugs such as clopi­
Overall, omeprazole- and lansoprazole-based regimens dogrel and phenobarbital respectively [78,79]. A number of
produce lower eradication rates in homozygous EMs than CYP2B6 variants have been identified. CYP2B6*6
in heterozygous EMs or PMs [71]. If patients are confirmed (rs3745274, 516G >T and rs2279343, 785A >G) is the most
as being PMs, dual therapy with PPI and amoxicillin may common polymorphism. It commonly occurs in Caucasians
be appropriate, as the eradication rate is likely to be high and Asians, while CYP2B6*16 (rs2279343, 785A >G) and
(>90%) [72]. The PPIs are an exceptionally well-tolerated CYP2B6*18 (rs28399499, 21011T >C) are common in
class of drugs, and there seems to be no clear evidence of Africans [39].
increased toxicity in PMs despite a markedly elevated AUC. CYP2B6 is the main catalyst of efavirenz metabolism
However, individuals with a CYP2C19 deficiency may be (to its inactive 8-OH metabolite); therefore, its polymor­
predisposed to vitamin B12 deficiency during long-term use phisms may have major implications for the PKs and tox­
of this class [73]. icity of this drug, which at present is recommended as an
option in first-line combination therapy for HIV infections
17.3.1.4 CYP2A6 [77]. Individuals homozygous for the 516T variant or the
CYP2A6 is a member of the cytochrome P450 superfamily CYP2B6*6 allele (516G >T and 785A >G) may have two to
and is expressed predominantly in hepatic cells, with some threefold higher efavirenz concentrations and may be pre­
expression in specialized extrahepatic cell types. Compared disposed to side effects. Studies have shown that when the
with CYP2D6 and CYP3A4, relatively few clinically used efavirenz dose is decreased, the plasma concentrations of
drugs are metabolized to a significant point by CYP2A6. the drug decreases proportionally. It is reported that patients
Its substrates include coumarin, halothane, methoxyflurane, who were *6/*6 homozygous and *6/*26 and *1/*26 het­
valproic acid, disulfiram, and losigamone [74]. A number erozygous had lower plasma concentrations of efavirenz
of significant variations in CYP2A6 have been identified, and less frequent CNS effects when the dose was decreased
including CYP2A6*2 (rs1801272, 479T >A), CYP2A6*4 [39,80].
(gene deletion), CYP2A6*5 (rs5031017, 1436G >T), and
CYP2A6*20 (rs28399444, frame shift). These polymor­
phisms are associated with abolished enzyme activity and 17.3.1.6 CYP2C8
have different allele frequencies among ethnic groups. The CYP2C8 accounts for approximately 7% of total hepatic
prevalence of CYP2A6 PMs in the Caucasian population is content and plays a vital role in the metabolism of pio­
≤1% [39]. glitazone, amiodarone, paclitaxel, chloroquine, verapamil,
354 PART | VI  Fundamental Pharmacogenomics

and ibuprofen. It also plays a secondary role in the metab­ These genes are often considered collectively as “CYP3A”
olism of fluvastatin, amitriptyline, diclofenac, omepra­ because of their promiscuous substrate specificity and the
zole, and carbamazepine. The metabolism of paclitaxel to difficulty discerning the relative role of each isoform in
6α-hydroxypaclitaxel, which is essentially inactive, has been drug metabolism [34]. The overall activity of CYP3A is
used as an index of CYP2C8 activity in vitro [81]. The most unimodally distributed, exhibits wide interindividual vari­
common CYP2C8 variants are CYP2C8*2 (rs11572103, ability (>10-fold), and is highly susceptible to the effects of
11054A >T), CYP2C8*3 (rs11572080, 2130G >A and enzyme inhibitors and inducers [87].
rs10509681, 30411A >G), and CYP2C8*4 (I264M substi­ More than 20 variants in the coding region of CYP3A4
tution); they lead to decreased enzyme activity [21,39,82]. have been described [39], and a number of them have altered
CYP2C8 is primarily responsible for the hydroxylation of enzyme activities, ranging from a modest to a significant
R-ibuprofen; CYP2C9, for S-ibuprofen. The mean AUC loss in catalytic efficiency; however, their clinical signifi­
after a single dose of 400 mg of racemic ibuprofen was cance is uncertain. CYP3A4*2 (rs55785340, 664T >C) and
reported to be 2.2- and 8.7-fold higher in individuals with CYP3A4*7 (rs56324128,167G >A) have higher frequencies
the CYP2C8*1/*3 or *3/*3 versus *1/*1 genotype [83]. in Caucasian populations, whereas CYP3A4*16 (rs12721627,
CYP2C9*2 has been associated with altered ibupro­ 554C >G) and CYP3A4*18 (rs28371759, 878T >C) have
fen pharmacokinetics only when it is coinherited with higher frequencies in Asian populations [4].
CYP2C8*3 (linkage disequilibrium) [83]. Several studies A single point mutation (6986A >G) in intron 3 of
suggest that reduced paclitaxel metabolism may occur with CYP3A5 (designated CYP3A5*3) produces a truncated
the CYP2C8*2 and *3 alleles, with the latter producing the and nonfunctional protein. In contrast to the unimodal dis­
greatest reduction [84]. In vitro data suggest that CYP2C8 tribution of CYP3A taken as a whole, CYP3A5 exhibits
and CYP3A4 are responsible for inactivating repaglinide, a bimodal distribution that can be predicted by the pres­
a nonsulfonylurea insulin secretagogue. CYP3A4 inhibi­ ence or absence of this allele. Individuals homozygous for
tors such as ketoconazole and clarithromycin increase repa­ CYP3A5*3 produce little CYP3A5 enzyme (“low expres­
glinide concentrations by small amounts (15% and 40%, sors”), whereas the remainder have at least one wild-type
respectively) compared with a 5.5- to 15.5-fold increase (CYP3A5*1) allele and express a large amount of CYP3A5
with the CYP2C8 inhibitor gemfibrozil [85]. (“high expressors”).
CYP2C8*2 is more common in Africans, while The PKs of the immunosuppressive agent tacrolimus are
CYP2C8*3 and *4 are common in Caucasians. Both CYP2C8 mainly dependent on the CYP3A5 genotype, and in terms
and CYP2C9 play an important role in ibuprofen metabo­ of the dose required to reach target trough blood concen­
lism, and it has been found that CYP2C8 plays a key role trations (C0). Tacrolimus C0 and its dose requirements are
in the hydroxylation of the (R)-enantiomer. For this reason, related to CYP3A5 polymorphisms; for example, individu­
ibuprofen disposition has been used as a guide for CYP2C8 als who carry at least one CYP3A5*1 allele have a functional
activity. When the effects of the different genotypes on ibu­ CYP3A5 and consequently need a higher dose of tacrolimus
profen PKs were investigated, CYP2C8 polymorphisms were to reach the targeted blood concentration. CYP3A5 expres­
found to be common [82,86]. sors experience a delay in reaching target concentrations
Studies have shown that the presence of the CYP2C8*3 [4,88]. It is estimated that 10–20% of Caucasians, 40–50%
allele causes a significant effect on the disposition of ibu­ of East Asians, 60–70% of Hispanics, and >80% of African
profen, which suggests that a considerable proportion of Americans are high expressors of CYP3A5 [89].
Caucasian subjects may show alterations in the disposi­
tion of drugs that are CYP2C8 substrates. Moreover, in one
study CYP2C8*3 carriers who received R-ibuprofen had 17.3.2  Non-CYP450 Enzymes
lower ibuprofen CLs; the CYP2C8*3 heterozygotes who Here we discuss the variations in the non-CYP450 enzymes:
were treated with the antidiabetic repaglinide had a higher UGT, TPMT, NAT, and GST.
metabolism of the drug when compared to CYP2C8*1 and
*4 carriers [39,82,86].
17.3.2.1  UDP Glucuronosyltransferases
17.3.1.7 CYP3A4/5 UDP Glucuronosyltransferases (UGTs) are expressed in a
The CYP3A locus comprises four genes that code for tissue-specific and frequently inducible way in most human
the functional enzymes: CYP3A4, CYP3A5, CYP3A7, tissues; their highest concentration is found in the GI tract
and CYP3A43. Of these CYP3A7 is primarily fetal and and liver. UGTs contribute to about 35% of phase II drug
CYP3A43 is minimally expressed and has low functional metabolism and are involved in the glucuronidation of many
activity. CYP3A4/5 is responsible for metabolizing the larg­ endogenous compounds and xenobiotics [39]. Nineteen
est number of prescribed drugs (more than 50%), includ­ human genes are encoded by UGT proteins: 9 by UGT1 and
ing cyclosporin, indinavir, nifedipine and simvastatin. 10 by UGT2. While both types are involved in the process
Chapter | 17 Pharmacokinetic Pharmacogenomics 355

of drug metabolism, UGT2 seems to have greater speci­ TPMT gene exhibits significant genetic polymorphisms
ficity for the glucuronidation of endogenous substances across all of the ethnic groups studied, and TMPT activ­
(e.g., steroids). UGT1A1 expression plays a vital role in ity is highly variable, as well as polymorphic, in all large
drug metabolism because the glucuronidation of bilirubin populations evaluated up to the present time. About 90%
by UGT1A1 is the rate-limiting step that assures effective of Caucasians inherit high enzyme activity, 10% inherit
bilirubin conjugation levels. This rate can be influenced by intermediate activity (heterozygous), and 0.3% inherit low
both genetic variation and drug treatments. If a drug under­ or no activity. A number of clinically significant SNPs have
goes selective metabolism by UGT1A1, competition for its been identified for TMPT that can alter its activity, and
metabolism with bilirubin, glucuronidation occurs, result­ since methylation is involved in both the activation and
ing in marked hyperbilirubinemia in addition to decreased the metabolism of mercaptopurine, altered enzyme activity
clearance of the metabolized drug [4,20,90]. affects the concentration of both active and toxic metabo­
UGT1A1 recently gained recognition as the first pharma­ lites [4,21,39].
cogenetic test to achieve FDA approval for use in conjunc­ The genetic polymorphisms of TMPT have the strongest
tion with a specific drug (irinotecan). Irinotecan is a prodrug case for prospective pharmacogenetic testing. Generally,
that is metabolized by carboxylesterases to the active topoi­ thiopurine agents have a narrow therapeutic index, with
somerase inhibitor 7-ethyl-10-hydroxycamptothecin (SN- life-threatening myelosuppression being a major concern.
38) and by CYP3A4 to inactive metabolites. Thereafter, Patients with polymorphic TMPT frequently require a sig­
SN-38 is glucuronidated by UGT1A1, with the resultant nificant dose reduction in order to prevent toxicity. More
SN-38 glucuronide excreted into the intestine via bile [91]. than 20 variants of the TPMT gene have been identified;
The activity of UGT1A1 varies widely, with an in vitro however, the most studied are TPMT*2, *3A, *3B, and *3C,
study demonstrating a 17-fold variation in SN-38 gluc­ which are responsible for most cases of TPMT deficiency.
uronidation. UGT1A1*28 is the variant most frequently These three variants account for 80–95% of intermediate
implicated in defective SN-38 glucuronidation and involves and poor metabolizers [4,21,39]. *3A is the most common
an extra thymine-adenine (TA) repeat in the TATA sec­ variant in Caucasians; *3C is the most common in Africans
tion of the UGT1A1 promoter (i.e., (TA)7TAA instead of and Southeast Asians. Homozygotes for a variant allele (e.g.,
(TA)6TAA in the wild type). It is also the primary cause TPMT*3A/*3A) have negligible TPMT activity, whereas
of Gilbert’s syndrome [92]. This variant occurs com­ heterozygotes (e.g., TPMT*1/*3A—intermediate activ­
monly, with the homozygous genotype found in 5–15% ity) have an average activity that is approximately half that
of Europeans, 10–25% of Africans and South Asians, and observed in homozygotes for wild-type alleles (TPMT*1/*1,
1–5% of Southeast Asians and Pacific Islanders. There is normal/high activity). Genotyping is reasonably accurate in
an increased risk of severe neutropenia and diarrhea with predicting TPMT phenotype, which is defined as low, inter­
irinotecan in homozygotes for UGT1A1*28 compared with mediate, or normal/high TPMT activity [95].
homozygotes for UGT1A1*1 [93]. The therapeutic niche of TPMT testing relates to its
Gilbert’s syndrome can be caused by a number of genetic ability to identify prospectively the small proportion of
changes, and patients with it may experience adverse drug patients (0.3–0.6%) with enzyme deficiency who will
reactions (ADRs) because of reduced capacity to metabo­ almost certainly develop life-threatening myelosuppression
lize drugs by UGT1A1. UGT1A1*37 has an 8-TA insertion if standard doses are used. Although it is clear that TPMT
in the promoter and results in more decreased promoter deficiency (particularly complete deficiency) predisposes to
activity than that of the UGT1A1*28 allele. UGT1A1*36 myelotoxicity, approximately 75% of cases of bone marrow
(rs8175347) has only a 5-TA insertion in the promoter and is depression occur in those without mutations (i.e., presumed
associated with increased enzyme activity and a decreased normal enzyme activity) [96]. This indicates that TPMT
risk of neonatal hyperbilirubinemia [20,90]. metabolizer status is a useful adjunct to (but not replace­
ment for) regular blood-count monitoring. The clinical use­
fulness of prospective determination of TPMT metabolizer
17.3.2.2  Thiopurine S-methyltransferase status is supported by pharmacoeconomic studies [97].
Thiopurine S-methyltransferase (TPMT) catalyzes the
S-methylation of 6-mercaptopurine (6-MP), azathioprine 17.3.2.3  Dihydropyrimidine Dehydrogenase
(AZA), and thioguanine to inactivate these drugs, which are Dihydropyrimidine dehydrogenase (DPD), an enzyme
used for treating leukemia and autoimmune diseases. It is a encoded by the DPYD gene, metabolizes two endogenous
cytosolic enzyme found in many tissues, with activity most pyrimidines—thymine and uracil—and facilitates the
commonly determined in red blood cells. In Caucasians, a metabolism of the pyrimidine analog 5-fluorouracil (5-FU).
trimodal distribution exists, with 0.3–0.6% having low or DPD activity in peripheral blood mononuclear (PBM) cells
undetectable activity, 10% having intermediate activity, and has been used as a surrogate for total body DPD activity
the remaining 90% having high (normal) activity [94]. The and varies up to 20-fold. DPD activity is usually described
356 PART | VI  Fundamental Pharmacogenomics

as normally distributed, perhaps reflecting the absence of a G186E substitution [39]. A number of compounds have
cases of absolute deficiency in the studies [98]. DPD poly­ been used as a probe for NAT2, and a good genotype–phe­
morphisms result in DPD-deficient phenotypes with a total notype correlation is generally observed (>90%) with caf­
frequency of about 3–5%. DPD variants, such as DPYD*13 feine as a probe [99].
(rs55886062, 1679T >G), DPYD*9A (rs1801265, 85T >C), Slow acetylators are found in approximately 50% of
DPYD*2A (rs3918290, IVS14+1G >A), and 2846A >T European- and African-derived populations, but they are
(rs67376798, D949V), are among the identified SNPs asso­ less common in Asians. Individuals phenotyped as slow
ciated with grade 3 and grade 4 toxicities in 5-FU–treated acetylators are likely to have two slow activity alleles,
patients. For example, DPYD*2A homozygous patients whereas those phenotyped as fast acetylators can have one
have a complete absence of normal DPD activity, whereas or two high-activity alleles (most likely NAT2*4, which is
heterozygous carriers have a 50% absence of the enzyme considered to be the wild type). In Caucasians, most of the
activity, resulting in 5-FU accumulation and significant life- fast acetylators are heterozygotes for slow and fast alleles,
threatening 5-FU–related toxicities [39]. whereas individuals homozygous for fast alleles (e.g.,
Moreover, DPYD*9A is a common missense muta­ NAT2*4/*4) comprise ∼5% of the population [99].
tion with a C29R substitution; however, its association In contrast, ∼30% of Chinese individuals are homozy­
with reduced DPD activity is still debatable. For exam­ gous for rapid alleles, 45% are heterozygous, and 25% are
ple, two different studies reported that cancer patients homozygous for slow alleles [100]. NAT2 polymorphisms
who were DPYD*9A heterozygous had severe 5-FU tox­ and their association with the slow acetylation of isonia­
icity in. Together, DPYD*2A and DPYD*9A polymor­ zid (an antituberculosis drug) were one of the first fully
phisms have a high concordance with 5-FU toxicity but characterized genotypes shown to influence drug metabo­
a low concordance with enzyme activity. Determination lism, which links the pharmacogenetic (PG) phenotype to a
of PBM cell DPD activity (i.e., phenotype) may identify genetic polymorphism [20] (see Chapter 36). Since NAT1
up to 60% of patients who may develop severe toxicity, and NAT2 catalyze the bioactivation (via O-acetylation)
whereas screening solely for the DPYD*2A allele (geno­ of aromatic and heterocyclic amine carcinogens, genetic
type) identifies approximately 25% of these patients. variations in the NAT1/2 genes may alter the cancer risk
Identification of a patient with absolute deficiency would associated with exposure to these carcinogens. NAT2 poly­
allow selection of alternative chemotherapy, whereas morphisms are related to individual susceptibility to par­
those with partial deficiency can be treated with a lower ticular cancers caused by industrial chemicals (e.g., α- and
dose of 5-FU. The increasing availability of DPD inhibi­ β-naphthylamine); for example, individuals with poor acet­
tors (eniluracil) may make assessment of metabolizer ylator phenotypes have increased risks of lung, bladder, and
status redundant. gastric cancers if exposed to carcinogenic arylamines for a
long period of time [4,21].
17.3.2.4 N-acetyltransferases
Human N-acetyltransferases (NATs) catalyze the acetyla­ 17.3.2.5  Glutathione S-transferases
tion of aromatic amines and hydrazines. There are two func­ The superfamily of human glutathione S-transferases
tional NAT genes in humans, NAT-1 and NAT-2, which carry (GSTs) facilitates the conjugation of glutathione (GSH)
functional polymorphisms that influence enzyme activity to different endogenous metabolites and xenobiotics.
[4]. More than 25 allelic variants of these functional genes GSTs include 10 members, which are divided into 3 main
have been identified. Based on the level of NAT activity, groups: cytosolic/nuclear, mitochondrial, and microsomal.
patients can be classified into two phenotypes: fast acety­ Cytosolic GSTs are also divided into 7 classes: alpha, mu,
lator (FA—wild-type NAT acetylation activity) and slow omega, pi, sigma, theta, and zeta, the most important of
acetylator (SA—reduced NAT enzyme activity). NAT-1 these being GSTM1, GSTT1, GSTP1, and GSTA1. In addi­
activity is usually constant, whereas NAT-2 polymorphisms tion to their enzymatic function, GSTs also act as regulators
result in individual differences in the rate at which drugs are of many physiological processes, including cell signaling
acetylated. While several mutations have been identified in and growth factors and DNA replication [21].
the NAT1 and NAT2 genes, the frequency of the slow acety­ The PKs of many drugs can be affected by GST polymor­
lation patterns is attributed mostly to polymorphisms in the phisms, and since they decrease the activity of metabolizing
NAT2 gene [4,20,21]. enzymes, biologically active parent drugs or metabolites
Altogether, NAT2 polymorphisms result in more than can accumulate and reach toxic levels. A number of known
10 NAT2 alleles, and the variant alleles that account for the GST variants are well characterized in their influence on
majority of SA phenotypes include NAT2*5 (rs1801280, drug disposition. Two polymorphisms of the GSTP1 gene
341T >C), which results in an I114T substitution; NAT2*6 have been identified: 1404A >G SNP (rs947894), with an
(rs1799930, 590G >A), which causes a R197Q substitution; I105V substitution, and 2294 C >T SNP (rs1799811), with
and NAT2*7 (rs1799931, 857G >A), which corresponds to an A114V substitution [39].
Chapter | 17 Pharmacokinetic Pharmacogenomics 357

17.3.3  Drug Transporters epithelial cells. Because of its basolateral localization,

ABCC1 pumps drugs into the body rather than into the bile,
The movement of drugs across the cell membrane is through
urine, or intestine. For this reason, it is thought to serve
a combination of both passive diffusion and active transport,
mainly as a protective barrier in tissue epithelial cells rather
facilitated by certain drug uptake and efflux molecules.
than as a classic drug efflux pump. ABCC2 is functionally
Drug transporters are membrane proteins that exist at vari­
similar to ABCB1 and is expressed on the apical domain of
ous endothelial and epithelial barriers, including the BBB,
epithelial cells in liver, intestine, and kidney [104,105].
intestinal epithelial cells, hepatocytes, and renal tubular
cells. These transporters can significantly affect drug dispo­ ABCB1
sition. For example, the influx of a drug from the blood to
the liver, where it is subsequently metabolized and excreted, ABCB1/MDR1 was the first recognized and most exten­
may increase the rate of elimination. These proteins and sively studied ABC transporter encoding a polypeptide
the genes that encode them are essential to drug uptake, (P-glycoprotein, or P-gp). P-gp has two halves, each con­
bioavailability, targeting, efficacy, toxicity, and clearance. taining six hydrophobic transmembrane domains and an
Genetic variation in the genes encoding these transporters ATP-binding domain. The expression of ABCB1 on the
can result in variable expression levels and transport effi­ apical surface of enterocytes and the canalicular part of
ciency, which can have an impact on drug pharmacokinetics the hepatocyte has been shown to influence intestinal drug
and response to treatment. absorption and limit oral bioavailability of a wide variety of
More than 300 human genes code transporters or trans­ structurally diverse drugs. Additionally, it facilitates hepa­
porter-related proteins, most of which work on endogenous tobiliary excretion and renal excretion, and protects the
substrates, although some also transport xenobiotics. Drug brain and fetus from xenobiotics. ABCB1 overexpression
transporters can generally be classified into two groups: in cancer cells is involved in multidrug resistance to chemo­
the efflux adenosine triphosphate-binding cassette (ABC), therapeutic agents [21,106,107].
known as the multidrug resistance (MDR) family of trans­ ABCB1s are responsible for amphipathic lipid-soluble
porters, and the uptake solute carrier single-level cell (SLC) drugs. They transport a broad spectrum of structurally
family of transporters. SLCs mediate passive movement of and functionally different drugs, such as anticancer agents
solutes down their electrochemical gradient, while ABCs (e.g., anthracyclines), antibiotics (e.g., erythromycin),
are active pumps fueled by ATP [39,101]. immunosuppressants (e.g., cyclosporine), cardiac drugs
­
(e.g., digoxin), calcium channel antagonists (CCB) (e.g.,
diltiazem), and HIV protease inhibitors (e.g., ritonavir).
17.3.3.1  ABC Transporters The most common SNPs are the synonymous 1236C >T
There are a total of 49 members of the human ABC trans­ (rs1128503) and 3435C >T (rs1045642), and the nonsynony­
porter family, and they are grouped into seven subclasses mous 2677G >T (rs2032583) [21,106], all three of which
or families (ABCA through ABCG) [102]. These trans­ have allele frequencies that vary in different ethnic popula­
porters generally counteract uptake through the intestinal tions, with a higher frequency among Caucasians and Asians.
wall, efflux substrates out of tissues into systemic circula­ The 3435C >T SNP has strong linkage disequilibrium with
tion, and eventually mediate the clearance of drugs from other SNPs in the ABCB1 gene, creating common haplotypes
the body. Of all ABC transporters, the best known are consisting of 3435C >T combined with 2677G >T and/or
ABCB1 (P-glycoprotein, Pgp, or MDR1), ABCC1/2 (mul­ 1236C >T. In general, SNP association studies on bioavail­
tidrug resistance–related proteins 1/2, MRP1/2), ABBC2 ability and efficacy are inconclusive [105]. 3435C >T SNP
(multidrug resistance, MRP2) and ABCG2 (breast cancer was first shown to be associated with reduced serum digoxin
resistance protein, BCR). ABCB1 and ABCG2 are the most concentrations, whereas it was also associated with higher
characterized [103]. They are expressed in the enterocytes, plasma digoxin levels. The association was stronger when
colon, intestinal epithelium, canalicular plasma membrane the ABCB1 2677G >T/A and 3435C >T polymorphisms were
of hepatocytes, proximal renal tubule, hematopoietic stem evaluated together as a haplotype [108].
cells, blood–brain barrier, heart, nerves, testes, and pla­ Many investigators have now found similar associations
centa. In all of these tissues, except the blood–brain barrier, between these polymorphisms and plasma concentrations of
they mediate efflux substrates out and into systemic circu­ several other drugs, although these observations have not been
lation. ABCB1 in the choroid plexus, transports molecules consistently confirmed. More recent evidence suggests that
from circulation into cerebrospinal fluid. polymorphic ABCB1 expression influences not only plasma
It is believed that the evolutionary role of ABC trans­ pharmacokinetics but also the degree to which drugs are able to
porters is to limit the penetration of toxic molecules into penetrate into tissues that express ABCB1. In a study of chronic
critical organs, thereby protecting blood–tissue barriers myeloid leukemia patients treated with imatinib, patients with
[104,105]. ABCC1 is expressed ubiquitously and is local­ the 1236C >T had higher imatinib plasma concentrations
ized to the basolateral, rather than apical, membranes of and also showed an improved therapy response, whereas the
358 PART | VI  Fundamental Pharmacogenomics

presence of the wild-type 2677G variant worsened clinical High-dose methotrexate treatment in pediatric ALL induced
response [109]. In a stable recombinant cell model, the anti­ a twofold higher AUC and a ninefold higher risk of inten­
cancer drugs doxorubicin HCl, daunorubicin HCl, vinblastine sification of folinate rescue in female patients carrying the
sulfate, vincristine sulfate, taxanes (paclitaxel), and epipodo­ −24 variant allele [114]. In non-small-cell lung cancer
phyllotoxin (etoposide, VP-16) exhibited selectively reduced patients, ABCC2−24TT and 3972TT genotypes were asso­
Pgp-mediated resistance in 561A carriers [110]. ciated with higher response rates and longer progression-
In general, there is an overlap in substrate specificity and free survival, which was sustained in haplotype analysis.
tissue distribution for ABCB1 and CYP3A4/5. Some drugs This suggests a more effective exposure to irinotecan
are dual substrates for both ABCB1 and OATP transport­ [115]. A missense SNP 1249G >A (Val417Ile) is located
ers (e.g., digoxin, fexofenadine, atenolol). Cyclosporine is in the substrate-binding region of the first transmembrane
not only transported by ABCB1, but is also metabolized by domain and is associated with lower oral bioavailability and
CYP3A4; consequently, the possible ABCB1 effects can be increased residual clearance after intravenous administra­
influenced by the activity of OATP transporters or CYP3A4 tion of the beta-blocker talinolol, which indicates higher
[21,39]. These may explain the conflicting results obtained intestinal transporter activity [116]. It has also been found
with ABCB1 studies. to be correlated with renal proximal tubulopathy after treat­
ment with the HIV protease inhibitor tenovir disoproxil
ABCC1 and ABCC2 fumarate, probably because of a toxic concentration of the
ABCC1 and ABCC2 have overlapping substrate speci­ drug in renal tubular cells after being actively secreted into
ficities, such as many anticancer agents (e.g., vincristine, them from the blood by ABCC2 [117]. The silent polymor­
doxorubicin), HIV protease inhibitors (e.g., ritonavir, saqui­ phism 1446C >G is associated with higher ABCC2 mRNA
navir), and antibiotics (e.g., difloxacin, grepafloxacin). expression in the liver and with a decreased AUC and peak
Both ABCC1 and ABCC2 need co-transport of reduced concentration (Cmax) of the cholesterol-lowering drug
glutathione (GSH) to transport some of their substrates pravastatin [118].
[12,21,111,112].
ABCC1 is ubiquitously expressed, whereas ABCC2 ABCG2
is mostly expressed in hepatocytes, renal proximal tubule ABCG2—also known as breast cancer resistance protein
cells, the intestine, and the brain. Genetic variants in ABCC1 (BCRP) or mitoxantrone-resistant protein (MXR) or pla­
are relatively rare, and around 16 SNPs in both of its non­ centa-specific ATP binding cassette transporter (ABCP)—is
coding and coding regions have been determined to cause an ABC half-transporter with six transmembrane domains
amino acid changes [21,112]. However, none of them sig­ and only one ATP-binding domain. Overall, it is expressed
nificantly influence the expression level, indicating that the at various sites, including the liver, small intestine, colon,
amino acid exchanges do not substantially affect the syn­ placenta, lung, kidney, adrenal and sweat glands, and cen­
thesis or stability of the protein. Gly671Val (rs45511401) tral nervous system vasculature.
in ABCC1 and a haplotype of ABCC2 were found to cause More than 80 polymorphisms in the ABCG2 gene
anthracycline-induced cardiotoxicity, as a consequence of have been identified in different ethnic populations, with a
the higher concentration of the drug, among non-Hodgkin higher frequency among Asians and Caucasians. A number
lymphoma patients treated with doxorubicin [21]. of ABCG2 SNPs have been found to influence the function
In general, the influence of ABCC2-medicated transport and/or expression of the encoded protein. For example,
on the pharmacokinetics of drug substrates in humans is ABCG2 variant alleles alter drug exposure by reducing the
not fully understood. Tumor cells often show an inducible biliary excretion of diflomotecan and rosuvastatin, causing
expression of ABCC2, which contributes to drug resistance. variations in drug effects [4,119].
Because of the transport of bile acids and glutathione from The nonsynonymous variant, 421C >A SNP (rs2231142),
the hepatocytes into the bile duct, ABCC2 plays a physio­ affects the PK of many drugs, including irinotecan, rosuvas­
logically important role in forming bile flow and potentially tatin, sulfasalazine, and topotecan. It has been reported that
in detoxification by delivering glutathione for conjugation the 421A variant exhibits 1.3-fold decrease in ATPase activ­
of xenobiotics. ity compared to the wild type, with elevated bioavailability
The polymorphism −24C >T in the 5′-UTR is in strong of diflomotecan and topotecan. The AUC of rosuvastatin
linkage disequilibrium with 3972C >T. Renal allograft following a single oral administration has been shown to be
transplant recipients harboring the −24T allele show greater in 421C >A heterozygotes and homozygotes, but the
a decreased oral clearance for the immunosuppressant heterozygotes did not show any difference in the PK profile
mycophenolic acid (MPA), which is the active metabolite of irinotecan and its active metabolite, SN-38 [119]. The
of mycophenolate mofetil. In consequence, these patients AUC and peak concentration of rosuvastatin increased 2.4-
are more protected from a decrease in MPA exposure but fold in healthy individuals with the homozygous 421AA
with a higher association to mild liver dysfunction [113]. genotype compared to that in individuals with the 421CC
Chapter | 17 Pharmacokinetic Pharmacogenomics 359

genotype, but did not affect the elimination of t1/2, which The most commonly studied OATP1B1 variants are
signifies that 421C >A affects the intestinal absorption of the 521T >C SNP (rs4149056) and the 388A >G SNP
rosuvastatin [120]. (rs2306283), which are in linkage disequilibrium and exist
together in several haplotypes. The variant allele 521T >C
17.3.3.2  SLC Transporters is more common among Caucasians (8–20%) and Asians
The SLC family comprises 360 members, subdivided into (9–16%) than Africans [39,107]. It has consistently been
47 subfamilies, that encode membrane proteins identi­ found to cause a functional decrease in OATP1B1 activity
fied as passive transporters, ion-coupled transporters, and based on altered in vitro transport of a number of substrates,
exchangers. The better-known SLC transporters are the including estrone-3-sulphate, estradiol-17β-D-glucuronide,
organic anion–transporting polypeptides (OATPs) and the pravastatin, atorvastatin, cerivastatin, rifampicin, and SN-38.
organic cation transporters (OCT). Generally, there is a variant-dependent change in pharmaco­
kinetics such that individuals homozygous for the 521T >C
Organic Anion–Transporting Polypeptides variant (CC) have the highest plasma concentrations, which
Organic anion–transporting polypeptides (OATPs) have 12 is in line with in vitro data suggesting that this variant leads to
transmembrane domains, with a large, highly conserved a decrease in the function of OATP1B1 [111,125].
extracellular loop between the 9th and 10th transmembrane A genome-wide association study (GWAS) of 85 patients
domains. N-glycosylation sites in extracellular loops 2 and with myopathy and 90 matched controls from Study of the
5 are consistent among the various members of the OATP Effectiveness of Additional Reductions in Cholesterol and
family [121]. OATPs mediate the sodium-independent Homocysteine (SEARCH) identified an association with
transport of a wide range of amphipathic organic com­ rs4149056 in the SLCO1B1 gene [126]. Following the
pounds, including steroid conjugates, anionic oligopepties, accumulation of evidence on the SLCO1B1 521T >C poly­
thyroid hormones, bile salts, xenobiotics, and pharmaceuti­ morphism, the FDA announced an update to its simvastatin
cals. A total of 11 OATPs have been identified and classi­ product-label recommendations in 2011.
fied into 6 families, and in humans OATP1A2, OATP1B1, SLCO2B1 encodes OATP2B1, which is also known
OATP1B3 and OATP2B1 are the best characterized for their as OATP-B, and shows substrate selectivity similar to
roles in drug PK [4,39,122]. that of OATP1B1. OATP2B1 is expressed in the lumi­
OATP1A2s encoded by the SLCO1A2 gene are mainly nal membrane of small-intestinal enterocytes, and have
expressed on the luminal membrane of small intestinal a role in drug absorption/disposition [39,122]. A num­
enterocytes and at the BBB, and play a role in the intes­ ber of OATP2B1 SNPs have been identified, including
tinal absorption and brain penetration of their substrates. 1457C >T (rs2306168), 601G >A (rs35199625), 935G >A
OATP1A2 substrates include rosuvastatin, methotrexate. (rs12422149), and 43C >T (rs56837383). Patients who
and D-penicillamine. A number of nonsynonymous poly­ received montelukast, a leukotriene receptor antagonist, and
morphisms have been identified in the SLCO1A2 gene, who carry the 935A variant allele of the 935G >A SNP were
some of which exhibit diminished in vitro transport activity reported to show lower plasma concentration of the drug as
toward OATP1A2 substrates [21,122,123]. well as lower pharmacological response [39,122,123].
The SLCO1B1 gene encodes OATP1B1, also known as OATP1B3 (encoded by SLCO1B3) and OATP2B1 are
OATP-C, and is mainly expressed on the basolateral mem­ mainly expressed on the sinusoidal membrane of hepato­
brane of hepatocytes in the human liver. It plays a role in cytes, and mediate the hepatic uptake of their substrate drugs.
the hepatic uptake of substrate drugs, including statins, OATP1B3 substrates include, digoxin, rifampin, methotrex­
D-penicillamine, and rifampin [21,39]. The primary role ate, D penicillamine, and cyclosporine. According to cur­
of OATP1B1 is believed to be removal of substrates from rently published findings, OATP1B3 appears to be unique in
the blood into the liver for subsequent elimination. More transporting digoxin and possibly also the taxanes docetaxel
than 40 nonsynonymous variants have been identified in and paclitaxel [127]. Polymorphisms in SLCO1B3 include
the SLCO1B1 gene, some of them being associated with 334T >G (rs4149117) and 699G >A (rs7311358), both
decreased transport activity and whose allele frequen­ of which occur at a high frequency in Caucasian popula­
cies vary markedly across different ethnic populations. tions. While OAT1B3 mediates the hepatic uptake of many
Functionally impaired OATP1B1 SNPs may decrease the drugs, the role of its polymorphisms in drug disposition and
uptake of substrate drugs into the hepatocytes, resulting in response is not fully understood [111].
decreased biliary excretion or hepatic metabolism, which is
a consequence of increased systemic exposure [21,120,124]. Organic Cation Transporters
OATP1B1 is one of the mechanisms underlying both drug– Organic cation transporters (OCTs) belong to the solute
drug interactions, due to competition at the transporter, and carrier SLC22A family, which facilitates the intracellu­
pharmacokinetic variation, due to genetic polymorphisms lar uptake of a broad range of structurally diverse, small
in the gene encoding the OATP1B1 protein SLCO1B1. organic cations. Three OCT isoforms have been identified
360 PART | VI  Fundamental Pharmacogenomics

in humans: OCT1, which is encoded by SLC22A1; OCT2, been associated with a significantly decreased glucose-low­
which is encoded by SLC22A2; and OCT3, which is encoded ering metformin response in healthy volunteers, probably
by SLC22A3. OCT1 is primarily expressed in the basolat­ by reducing metformin metabolism in hepatocytes—the
eral membrane of hepatocytes, whereas OCT2 is expressed major target sites of metformin’s action. For OCT3, sev­
in the basolateral membrane of kidney proximal tubules. eral synonymous SNPs have been identified in SLC22A3;
OCT1 and OCT2 substrates include metformin, cisplatin, however, their functional consequence has not been fully
imatinib, procainamide, citalopram, cimetidine, and quini­ clarified and needs further study [21,39].
dine. OCT3 is expressed in various tissues, including the
placenta, heart, liver, and skeletal muscle. Additionally, Organic Anion Transporters
OCT expression has been detected in several cancer cell Organic anion transporters (OATs) belong to the SLC22A
lines and tumor tissue samples [21,39,107]. family of solute-carriers, which facilitate the cellular uptake
The 1393G >A polymorphism in SLC22A1 was found to of a wide range of structurally diverse small hydrophilic
reduce the localization of OCT1 to the surface of the baso­ organic anions. Several clinically important anionic drugs
lateral membrane of hepatocytes. Other variants, including are OAT substrates, such as β-lactam antibiotics, diuret­
41C >T, 566C >T, 1201G >A, and 1256delATG (a deletion ics, and nonsteroidal anti-inflammatories (NSAIDs).
variant) have all been associated with decreased metformin There are at least six OAT members (OAT1–6) [21], and
uptake activity; increased AUC and Cmax; and the signifi­ four SLC22A genes that have been identified for encod­
cantly decreased ability of metformin to lower glucose lev­ ing OATS: SLC22A6, which encodes OAT1; SLC22A7,
els [111,128]. which encodes OAT2; SLC22A8, which encodes OAT3;
While several SNPs have been identified for the and SLC22A11, which encodes OAT4. In terms of tissue
SLC22A2 gene, the most important is the 808G >T SNP location, OAT1, OAT2, and OAT3 are expressed (mostly)
(rs316019). Since metformin’s active renal secretion is in the basolateral membrane of the renal proximal tubules,
through OCT2, any functional defect in OCT2 trans­ mediating the uptake of drug substrates from the blood into
port results in decreasing the drug’s renal clearance. the proximal tubule cells; OAT4, in contrast, is located at
Homozygotes of low activity (808G >T SNP) have lower the apical side of the renal proximal tubule, functioning in
renal clearance and higher plasma concentrations of metfor­ the secretion of drug substrates into urine [21,107]. OAT1,
min compared to homozygous carriers of wild-type 270A OAT2, and OAT3 are responsible for the uptake of drugs
[39,129]. Additionally, homozygous and heterozygous car­ into the tubular cells, and OAT4 mediates their secretion into
riers of various haplotypes of low-activity alleles of some the renal tubule [19,39]. Additionally, OAT1 is an example
OCT1 variants—R61C (rs12208357), G401S (rs34130495), of transporter-related toxicity. Different studies have shown
M420del (rs35191146), and G465R (rs34059508) among that OAT1substrates, such as cephaloridine and ß-lactam
them—have shown significantly higher metformin renal antibiotics, sometimes cause nephrotoxicity. OCT1 trans­
clearance (20–30%). ports a number of drugs, such as metformin, which act partly
The clinical use of cisplatin is related to dose-limit­ through intracellular effects in hepatocytes [19].
ing nephrotoxicity, which occurs in one-third of patients Genetic variations in genes encoding OATs can contrib­
regardless of intensive prophylactic measures. OCT2 has ute to interindividual variability in the renal clearance of
been involved in the cellular uptake of cisplatin, but its many drug substrates. To date, a number of polymorphisms
role in cisplatin-induced nephrotoxicity is not fully under­ have been identified in the coding region and 5′ regulatory
stood. Moreover, the nonsynonymous SNP 808G >T has region of the SLC22A6, SLC22A7, SLC22A8, and SLC22A11
been associated with reduced cisplatin-induced nephrotox­ gene variants, and some of them have caused changes in the
icity in patients. These results indicate the critical impor­ transport activity of their encoded proteins. While differ­
tance of OCT2 in PK and related cisplatin renal toxicity ent polymorphisms have been reported for genes encoding
[39,129,130]. OAT—mainly SLC22A8 (encoding OAT3)—their allele
Previous studies showed that homozygous carriers of frequency is ≤1%, and their functional significance has not
the low-activity OCT2 variant 270S have a significantly been fully explained [21,39].
lower renal clearance and a higher plasma concentration of
metformin than do homozygous carriers of the active vari­
ant 270A [21,129]. Additionally, homozygous and hetero­
17.4 CONCLUSIONS
zygous carriers of various haplotypes of low-activity alleles This chapter presented a broad outline of genetic varia­
of some OCT1 variants—including R61C (rs12208357), tion affecting drug pharmacokinetics and consequently
G401S (rs34130495), M420del (rs35191146), and G465R drug efficacy and toxicity that highlights the potential of
(rs34059508)—have shown significantly higher renal clear­ pharmacogenomics to facilitate improved and more effec­
ance of metformin PK (20–30%). In addition, low-function tive therapy. Important genetic associations that have been
OCT1 variants (R61C, G401S, M420del, and G465R) have identified between variant genotypes and drug response
Chapter | 17 Pharmacokinetic Pharmacogenomics 361

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