Pharmacogenetics: an introduction

Alain Li-Wan-Po and Peter Farndon introduce the science of pharmacogenetics and discuss its implications for pharmacy practice
Advances in genomic sciences are rapidly being translated into clinical applications. For example, azithromycin is being made available for OTC treatment of chlamydia infections. However, sale is restricted to those with a positive nucleic acid amplification test and their sexual partners. In the cancer and infectious diseases clinics, pharmacogenetic testing is being increasingly used to inform treatment choice so as to minimise adverse effects and improve outcome. Concurrent with these developments are rapid technological developments in molecular testing, which promise to make pharmacogenetic tests, already available over the Internet or currently restricted to secondary care, accessible for OTC use at affordable prices. These tests will inform on the likelihood of drug efficacy, drug-drug interactions and adverse effects. Yet the pharmacist who graduated as recently as a few years ago would have missed out on any significant formal training in pharmacogenetics. To respond effectively to the anticipated demand for advice on the interpretation of pharmacogenetic test results, a good understanding of the associated genomic sciences is essential. In this article we highlight some of the relevant terminology and illustrate how pharmacogenetics is most likely to impinge on pharmacy practice. the scale of the investigations became more ambitious and the enabling technologies more sophisticated, the term pharmacogenomics was coined to allow association studies on a genome-wide basis. In the clinical arena, both terms can be used interchangeably.

What does pharmacogenetics promise?

Those prescribing and dispensing drugs have had to deal with the implications of pharmacogenetics for a long time now, perhaps without recognising it as such. The glutenfree products, the lactose-free tablet and the peanut oil-free emulsion stocked at the local pharmacy, as well as the aspirin-hypersensitive patient, are all testimonies to this. What has changed over recent years is our ability to associate clinical abnormalities with molecular genetic markers. With this approach we should theoretically be able to predict response to an increasing array of drugs and thereby personalise therapy with appropriate pharmacogenetic testing.

What is a pharmacogenetic test?

A pharmacogenetic test is one aimed at identifying the presence of a genetic characteristic that predicts a drug response, either beneficial or adverse. Some commentators restrict the term to tests involving the identification of a particular DNA profile, sequence or single nucleotide mutation. Single nucleotide mutations, which occur with a frequency of at least 1 per cent at the population level, are referred to as single nucleotide polymorphisms (SNPs pronounced snips). Increasingly, several linked mutations are tested for simultaneously and the set is referred to as a haplotype. Haplotypes often give better predictions of drug response than SNPs. The full set of DNA instructions (the genome) of an organism is translated into a corresponding set of RNA (the transcriptome) and thence to a set of proteins (the proteome). The related specialist fields

What is pharmacogenetics?
Pharmacogenetics can be defined as the study of hereditary factors contributing to variability in human drug response. A major impetus for such studies was the suggestion, made over half a century ago, that many abnormal responses to drugs might be due to genetically determined variation1,2. With the unravelling of the structure of DNA3, and subsequent development of molecular biology, it soon became possible to study associations between genotype (DNA mutations) and phenotype (observable or measurable traits including clinical presentation). As
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of study are referred to as genomics, transcriptomics and proteomics. Some others have suggested that, as proteins operate within biochemical pathways and networks, studying these interactions within an integrated framework (metabolomics) might lead to better interventions more quickly. All these subspecialities form part of pharmacogenomics. Relatively recent work has shown that the path from DNA sequence to protein is considerably more complex than originally thought. Alternative splicing of pre-messenger RNA makes possible the formation of several proteins from the same DNA sequence. This explains why we have fewer genes than we originally thought from estimations of our proteome. Moreover, it is now known that subsets of small RNA are frequently involved in controlling gene expression. Application of this new insight, in a field of activity known as gene silencing, is currently one of the most active research areas in drug discovery and development. Against this background, the term genetic testing now refers to a considerably broader range of diagnostic procedures, including: n Examination for the presence of abnormal chromosomes; n Identification of genetic sequence variations; n Identification of abnormal proteins; n RNA expression profiling (gene signatures); n Immunofluorescence protein assays. In the cancer arena, genetics is involved at two levels: n The level of mutations that confer an altered susceptibility to cancer; n The level of the cancerous cell. It is now generally recognised than cancer is essentially a genetic disease with the formation of a renegade cell from mutations, which lead to activation of an oncogene, or inactivation of a tumour suppressor gene. The mutant cell then undergoes uncontrolled growth and metastasis. Screening is used to identify those at risk of particular cancers, with screening for mutations of the BRCA1 gene perhaps the most commonly adopted. This is referred to as screening for germline mutations, in contrast to testing for mutations or gene amplification of the tumour. In the control of infectious diseases, genetic testing is being applied to characterise the micro-organisms involved so that the best therapy can be identified. In the case of the avian flu, for example, new genetic insights are forming the basis for the development of vaccines against mutants yet unseen.

Examples of major successes achieved so far

n Identification of breast cancer patients more likely to respond to trastuzumab (Herceptin) by testing for HER-2 overexpression and gene amplification in the tumour this is required prior to prescribing; n Identification of more likely responders to cetuximab by testing for EGFR overexpression and gene amplification in the tumour; n Identification of those likely to develop hypersensitivity reaction to abacavir by testing for the presence of the human leucocyte antigen HLA-B*5701 allele this is increasingly being adopted by specialist NHS clinics caring for patients infected by the human immunodeficiency virus; n Rapid identification of multidrug resistant tuberculosis by DNA strip testing an ambitious programme for use of this molecular test in the developing world is currently being funded by the World Health Organization as part of its worldwide programme to control the spread of the disease; n Identification of molecular features associated with drug resistance in the fight against cancer, micro-organisms and self (in the form of transporter gene mutations leading to resistance). From the new insights, better drugs are being developed.

predicts metabolic activity and hence blood profiles. But in most cases this would be unreliable because blood levels for most drugs are influenced not only by single genetic mutations of metabolic enzymes, but by a variety of other factors. These include concomitant interacting drugs, mutation of drug transporters and altered physiological function, notably renal and hepatic function. For drugs with narrow therapeutic indices, drug level monitoring is still required. However, as the technology for identifying polymorphisms with functional consequences become cheaper and more widely used, the results will be more useful for informing choice of treatment.

Pharmacogenetic testing and policy-making

The National Institute of Health and Clinical Excellence (NICE) recently issued its preliminary ruling that four new drugs for advanced renal cancer were not cost-effective enough to be funded by the NHS. They prolong mean survival of the patients only marginally. In protest a group of cancer specialists argued that: Mean survivals obscure the fact that some patients will obtain prolonged benefit from these drugs. If pharmacogenetic tests were available to identify likely responders more reliably, then use of even the expensive drugs would be more likely to be cost-effective.

The limits of pharmacogenetics

In the excitement generated by the successes obtained so far, some commentators have found it hard to resist proclaiming that pharmacogenetics will revolutionise medicine by enabling the personalisation of therapy. While this is already happening for some specific diseases, most notably cancer, the contribution of pharmacogenetics for the majority of diseases is still very modest. For example, it has been suggested that dosing could be based on the results of pharmacogenetic testing, which

Pharmacist involvement
As the clinical role of the pharmacist develops there will be more opportunity for greater engagement
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Case illustration
A 62-year-old man with a history of chronic lymphocytic leukaemia was admitted to hospital for suspected pneumonia. Except for chemotherapy three months prior to admission, his only therapy on admission was valproic acid, an antiepileptic. He was given ceftriaxone, clarithromycin and voriconazole as antimicrobial therapy and a normal dose of codeine (25mg tid) for his cough. On day four his level of consciousness deteriorated and he became unresponsive. Subsequent investigations indicated codeine intoxication due to drug-drug interaction, presence of genetically impaired metabolic enzyme and poor renal function.4
H3CO H3CO

What caused the intoxication? n Codeine exerts its analgesic and opioid side-effects largely through morphine, its metabolite (Figure 1). n The patient had a CYP2D6 genotype, which led to ultrarapid metabolism to morphine. n He was taking drugs that inhibited CYP3A4 metabolism, leading to more codeine being available for metabolism to morphine. n Renal impairment led to less morphine being removed from the circulation. n The morphine accumulation from this combination of factors led to toxicity.
HO

CYP3A4 O H NH

CYP2D6 H NCH3 O H NCH3 HO Codeine Morphine

HO Norcodeine or N-desmethylcodeine

HO

Figure 1. Codeine exerts its analgesic and opioid side-effects.

in the interpretation of the complex information contained in a pharmacogenetics test result. For example, a test result may identify a genetic defect that predisposes to a potentially lethal arrhythmia. This may make it necessary to avoid a whole range of potential drug interactants. In such situations reliable pharmaceutical advice can save lives. Another pharmacogenetic test result could identify a defective drug excretory pathway. The defect alone may not be clinically significant, but coupled with a drug interactant that blocks an alternative metabolic or excretory pathway, it could lead to potentially fatal complications. Conversely, a pharmacogenetic test may identify a rapid metaboliser of an antimalarial drug. Couple this with concomitant ingestion of a drug that induces the metabolism of the antimalarial drug further and failure of prophylaxis becomes more likely. An increasing array of genetic tests is being made available, often with little control, over the Internet. The US state of California recently banned the marketing of such tests to its citizens without a licence and sent cease and desist letters to 13 companies offering genetic testing directly to consumers. Soon after, two companies were licensed to provide those services. The companies had, according to the New York Times, argued that, they were not offering medical testing but rather personal genetic information services, and that consumers had a right to information from their own DNA. The companies subcontract the testing from licensed laboratories. It would seem that as the technology becomes more accessible and more reliable,

a high street professional pharmacogenetic advisory service may be appropriate to meet the demand.

Conclusion
The enabling technology for reliable pharmacogenetic testing is advancing fast, the need for optimising pharmacotherapy is ever present and the Department of Health is keen to contribute to the development of clinical services by the community pharmacist. Will the pharmacist rise to the challenge of providing an appropriate wellinformed pharmacogenetics advisory service?
References 1. Motulsky AG. Drug reactions enzymes, and biochemical genetics. J Am Med Assoc 1957; 165(7): 83537. 2. Vogel F. Moderne probleme der humangenetik. Ergebnisse der innerre Medizinische und Kinderheilkunde 1959; 12: 5262. 3. Watson JD, Crick FH. Molecular structure of nucleic acids; a structure for deoxyribose nucleic acid. Nature 1953; 171(4356): 73738. 4. Gasche Y, Daali Y, Fathi M et al. Codeine intoxication associated with ultrarapid CYP2D6 metabolism. N Engl J Med 2004; 351(27): 282731.

Professor Alain Li-Wan-Po is the Lead Professional, Pharmacogenomics, and Professor Peter Farndon is a Clinical Geneticist and Director at the National Genetics Education and Development Centre.
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