1、PharmacogenomicsandPersonalizedMedicine OutlinePharmacogenomics and Pharmacogenetics;Single nucleotide polymorphism (SNP);Personalized medicine and Personalized therapy.Part I：Pharmacogenomics and PharmacogeneticsPharmaceutical companies adopt “one-drug-fits-all” policy.Drugs do not work in many peo

2、ple.More than 90% drugs work only in 3050% of people.Adverse drug reactions (ADRs) are a common cause of morbidity and mortality.Factors Contributing to Interindividual Variability in Drug Disposition and ActionInterindividual differenceAgeGenderRace/ethnicityNutrition statusCo-medicationsCo-mobidit

3、iesLifestyle variablesSocial factorsGENETICSPercentages of non-respondersDiseaseClassPercentages of non-respondersAsthma2-adrenergic agents40-75%Duodenal UlcerProton Pump Inhibitors20-70%HyperlipidemiaStatins35-75%HypertensionThiazide diuretics10-70%Solid CancersVarious drugs70%Rheumatoid ArthritisA

4、nti-metabolic therapy20-50%Potential of PharmacogenomicsAll patients with same diagnosis12Responders and patients not predisposed to toxicityNon-respondersand toxic respondersTreat with alternativedrug or doseTreat with conventionaldrug or doseHGP (Human Genome Project) Oct 1990 to 2003.Identify app

5、roximately 30000 human genome DNADetermine composition of the human genome DNA is about 3 billion nucleotides The Era of Genomic MedicineEarlier detection of genetic predisposition to disease;Improve the diagnosis of disease; Improve prediction of drug efficacy or toxicity.Pharmacogenomics and Pharm

6、acogenetics遺傳藥理學（Pharmacogenetics, PGt) : 研究DNA變異如何引起藥物反應差異屬于藥物基因組學的范疇藥物基因組學 ( Pharmacogenomics, PGx) :研究DNA如何影響藥物反應= 藥理學 + 基因組學, 目標:藥物反應的遺傳易感性個體化藥物治療新醫療模式的變革Part II：Single nucleotide polymorphism (SNP)10q24.2Chromosome 10CYP2C9 gene9 Exon55kb490 AA10q24.2CGTASNPCYP2C9*1Normal enzymatic activityGAGG

7、ACCGTGTTCAAGluAspArgValGln53CYP2C9*2No enzymatic activityT430CT (Arg144Cys)CysThe biological basis of individualized treatment is single nucleotide polymorphisms（SNPs）- Accounting for 90% human genetic variation 導致人類遺傳易感性的重要因素導致人類藥物代謝和反應差異的重要因素GT突變野生型 突變型Difference in DNA sequence(SNP) Difference in

8、 encoding amino acid and protein structure and functionAlaAlaAlaArgArg Lys Asp Asp Asp Asn Asn Asn Cys Cys Cys As geneBs gene編碼改變但不改變氨基酸序列Cs gene編碼改變使氨基酸序列改變G C A A G A G A T A A T T G TG C G A G A G A T A A T T G TG C A A A A G A T A A T T G T1 2 3 4 5 1 2 3 4 51 2 3 4 5.C C A T T G A C.C C A T T G

9、 A C.G G T A A C T G.G G T A A C T G.C C A T T G A C.C C G T T G A C.G G T A A C T G.G G C A A C T G.C C G T T G A C.C C G T T G A C.G G C A A C T G.G G C A A C T G.wt/wtHomozygous wild-typeSNP forms three genotypesXXXwt/mHeterozygote wild type m/mHomozygous mutations等位基因（allele）-人的基因位于成對的染色體上（性染色體除

10、外），因此每一種基因都有一對。 基因多態性（genetic polymorphism）-在正常人群中，由于同一基因位點上多個不同等位基因作用而出現兩種或兩種以上遺傳決定的基因型，如果每種基因型的發生頻率超過 1% 。 單核苷酸多態性（single nucleotide polymorphism，SNP）-在基因組水平上由單個核苷酸的變異所引起的DNA序列多態性。它是人類可遺傳變異中最常見的一種，占所有已知多態性90% 以上。 表型（phenotype）-個體在一定環境條件下表現的性狀。 基因型（genotype）-形成表型這種性狀有關的遺傳結構。 Individual differences

11、in drug toxicitySame dose, but different drug concentration in vivo and total amountineffectiveness safe and effective toxicity Serious ADR全球死亡主要原因第 5 位美國每年因嚴重ADR死亡10萬人我國因ADR住院：250萬/年; 因ADR死亡：20萬/年Drug effect is determined by the polymorphism of drug metabolic enzymes，transporters and drug targets p

12、harmacokineticspharmacodynamicsDrug efficacy and toxicity of individual differencesGenomousgenovariation (single nucleotide polymorphism)drug targetsdrug transporterdrug metabolic enzymeDME in human liverSNPs and phenotype distribution of DMEPhenotype distribution of CYP2D6 and drugs metabolized by

13、CYP2D6MetoprololProponololCarvedilolFlecainideDiacetolol DebrisoquineMexiletinePropafenone Log10 urinary debrisoquine/4-hydroxydebrisoquine ratioNumber of subjectsPoor metabolizerExtensive metabolizerUltra-rapid metabolizer服用40 mg 奧美拉唑后 奧美拉唑 (mg/L)CYP2C19*2/*2CYP2C19*1/*2CYP2C19*1/*1CYP2C19 基因型/表型基因

14、劑量效應AUC:1.1 0.60.6 0.3mg.h/L5.32.21. 藥物代謝酶基因變異與藥物反應實例0102030405060708090100UMEMEM/het.IMPMMetoprolol plasma con.(ng/ml)1.33.914.250.880.5Dose mg1001001007874 濃度相差： 60 倍美托洛爾血漿藥物濃度與CYP2D6基因多態性的關系 Fux et al., CPT 2006根據CYP2D6基因型調整劑量藥物 平均劑量（Mg） 調整劑量(%)單位 PM IM EM卡維地洛 50 80 110 110美托洛爾 100 30 60 140傳統用藥個

15、體化用藥100mg500mg100mg10mg超強代謝者強代謝者中等代謝者弱代謝者根據CYP2D6基因型選擇去甲替林劑量功能性：CYP2D6*1功能降低：CYP2D6*2,*9, *10,*17無功能：CYP2D6*3,*4,*6基因缺失：CYP2D6*5Xie HG, Personalized Medicine (2005)ALDH2*2多態影響硝酸甘油的心血管效應*Guo R, et al. J Am Coll Cardiol 2008 Examples of drugs “pharmacogenomic (PGX) testing proved to be benecial.DrugAc

16、tive metaboliteMain UseMajor Gene(s) involvedConsequence of abnormal phenotypeClopidogrel (prodrug)R-130964Prevent thrombosis in myocardial infarction, stroke CYP2C19Less active drug available and greater risk of cardiovascular events.Thiopurine e.g. azathiopurine, 6-mercaptopurineThioguanine nucleo

17、tide(6-TGN)Inammatory bowel disease, childhood acute lymphoblastic leukaemiaTPMTPMs have high risk of myelosuppression and neutropaenia. Tamoxifen (prodrug)Endoxifen Adjuvant therapy for breast cancer to prevent recurrenceCYP2D6PMs have lower blood concentrations of endoxifen and earlier relapse of

18、breast cancer. AmitriptylineNortriptylineDepression CYP2D6 (and CYP2C19)PMs have more adverse effects UMs are likely to have the least therapeutic response. Complicated by the involvement of CYP2C19.血漿Endoxifen濃度與CYP2D6基因型的關系他莫西芬與CYP2D6*4/*4代表CYP2D6弱代謝者，生成活性endoxifen能力降低，所以A圖的無復發時間縮短，B圖代表的無病生存時間也縮短。

19、CYP2D6基因型復發風險OR值PEM1HetEM2.370.03PM3.30.04PM由于生成活性產物Endoxifen少，復發風險增高3.3倍。他莫西芬與CYP2D6RF表示無復發生存率在CYP2D6 EM最高，PM或IM或HetEM都會降低，只要攜帶功能降低突變的合并組也降低。2C19*17/*17純合子超快代謝者因可產生更多4-OH-TAM，間接產生更多Endoxifen而升高療效，導致無病生存期延長。 定義CYP2D6 EM和CYP2C19*17是導致生存期延長的有益突變，攜帶兩個有益因素的黃色線條代表無病生存期最長，其次是攜帶一個有益突變，生存率最低的是2種有益突變都缺乏的患者群。

20、 CYP2D69年復發率15年復發率EM（含UM）3.4%7.2%PM10.7%19%他莫西芬與CYP2D61325例乳腺癌患者；除EM外，IM和PM都是復發風險因子，類似腫瘤體積、淋巴結轉移、癌癥分期這些臨床指標。 續表DrugActive metaboliteMain UseMajor Gene(s) involvedConsequence of abnormal phenotypeCodeine (prodrug) MorphinePain reliefCYP2D6PMs are unable to convert codeine to morphine and have no pain

21、 relief. UMs have increased sedation and opioid toxicity.Paroxetine(active)None relevantDepression and other mood disorders CYP2D6PMs have increased plasma concentrations of paroxetine and increased side effects. Paroxetine strongly inhibits CYP2D6 and so may affect concentrations of other drugs tha

22、t use CYP2D6 pathways.Sertraline(active)None relevant. Wide range of mood disordersCYP2C19PMs have accumulation of sertraline and more side effects UMs have lack of response.Omeprazole5-hydroxy-omeprazole Gastric ulcersCYP2C19UMs have treatment failure. EMs require more frequent doses than PMs.Irino

23、tecanSN-38CancerUGT1A1Individuals homozygous for UGT1A1*28 have increased exposure to SN-38 with increased toxicity,diarrhoea,neutropaenia Clinical Use of Pharmacogenomic Tests in 2009，Clin Biochem Rev Vol 30 May 2009可待因與CYP2D662 y.o. man hospitalized for pneumoniaTreated with “standard” doses of co

24、deine as a cough supressantComa Morphine levels 20 x expected levelsCYP2D6 ultrarapid metabolizerNEJM, 30 Dec 2004原因分析：可待因經患者肝臟代謝生成嗎啡 呼吸抑制死亡藥物代謝酶CYP2D6*2突變超快代謝者可待因與CYP2D62. 藥物轉運體基因變異與藥物反應實例藥物轉運蛋白基因的遺傳多態性倍受關注; 轉運蛋白存在于細胞膜上，調節藥物的吸收、分布和排泄。分兩大類：三磷酸腺苷結合盒轉運體超家族（ATP-binding cassette transporters，ABC轉運體）和溶質轉

25、運蛋白（Solute carriers，SLC）家族。ABC超家族含約50個成員，如ABCB1(MDR1)、ABCC2 (MRP2)、ABCG2 (BCRP)。多藥耐藥（multidrug resistance, MDR）基因的產物在ATP能量作用下排出細胞內底物，包括膽紅素、抗腫瘤藥、強心苷、免疫抑制劑、糖皮質激素等在血腦屏障脈絡叢，P-糖蛋白抑制多種藥物在腦中的蓄積，如地高辛、依維菌素、長春緘、地塞米松、環孢素、多潘立酮等.P糖蛋白 (P-glycoprotein, P-gp)P-glycoprotein2677G/T3435C/TABCB1 (MDR1) 3435CT多態性TT基因型個體

26、地高辛的生物利用度增加多態性藥物臨床效應3435CT地高辛T/T：BA ; 單劑量和多劑量AUC 與 Cmax 非索非那定T/T：單劑量AUC 和 Cmax 環孢素T/T：多劑量的穩態AUC 他克莫司T/T： 穩態時的 Cmin 苯妥英T/T：多劑量的穩態AUC 2677G(T/A)地高辛T/T：AUC 和 Cmax 環孢素T/T：多劑量的穩態AUC 他克莫司T/T & G/T：穩態血濃度和Cmin 他林洛爾T/T & T/C：多劑量的穩態AUC ABCB1遺傳變異對底物代謝動力學的影響多藥耐藥相關蛋白（multi-drug resistance protein, MRP）基因變異位點具有種族

27、差異性。已發現 MRP1 基因 SNP 變異位點 81個、MRP2 基因 41個、MRP3 基因 30個、MRP4 基因 230個、MRP5 基因 76 個、MRP8 基因 102個和 MRP9 基因70個。多藥耐藥相關蛋白(MRP)MRP 的功能：腫瘤多藥耐藥、藥物處置。MRP2 為特異性有機離子通道蛋白，主要與鉑類、依托泊甙、阿霉素、表柔比星等藥物的耐藥性和藥物轉運相關。MRP1與乳腺癌、肺癌等耐藥密切相關。藥物轉運體的基因變異可導致抗腫瘤藥物化療敏感性的改變MRP1/ABCC1的過表達與腫瘤的多藥耐藥相關 MRP1 Arg723Gln 多態性可增加過表達MRP1細胞株對于柔紅霉素、阿霉素

28、、依托泊苷、長春新堿和長春堿的敏感性。3.藥物作用靶點基因變異與藥物反應實例基因或基因產物藥物受多態性影響的效應ACE (I/D)ACE 抑制藥，如依那普利ACE II：更久而強的效應；氟伐地汀血脂改變（如LDL、TC和載脂蛋白B降低）;冠脈粥樣硬化的進展和衰退-內收蛋白氫氯噻嗪460Gly/Trp：限鹽和氫氯噻嗪治療引起BP降低增加鉀通道（KCNE2）磺胺甲基異噁唑、甲氧芐氨嘧啶突變型：QT間期延長綜合癥花生四烯酸5脂氧合酶 白細胞三烯抑制藥1秒用力呼氣容量（FEV1）2受體2受體激動藥（如沙丁胺醇）支氣管擴張、激動藥導致的脫敏作用的易感性、心血管效應I型血管緊張素受體AGTR1 (A116

29、6C)血管緊張素II受體拮抗藥缺血性心臟病動脈對血管緊張素II的反應增強；高血壓主動脈僵硬度增加血管緊張素原AGT (Met235/Thr)抗高血壓藥血壓和左室心肌重量降低緩激肽B2 受體ACE抑制藥-58TC的TT降壓顯著，易發生咳嗽 基因或基因產物藥物受多態性影響的效應DA受體D2,D3,D4抗精神病 (如氟哌啶醇、氯氮平)抗精神病效應 (D2, D3, D4), 抗精神病藥引起的遲發性運動障礙 (D3和急性靜坐不能 (D3)雌激素受體-a結合雌激素骨礦物質密度增加激素替代治療HDLC增加凝血因子V, FV Leiden (Arg506Gln)雌激素，口服避孕藥靜脈血栓形成危險增加載脂蛋白

30、EAPOE (E2/E4)他汀類，激素替代治療, VitK影響膽固醇和載脂蛋白的降低膽固醇酯轉運蛋白 CETP (1/ 2)普伐他汀1 1 ：普伐他汀延緩冠脈硬化進程糖蛋白IIb/IIIa中IIIa的亞單位阿司匹林和糖蛋白IIIa抑制藥抗血小板效應5-羥色胺轉運體抗抑郁藥(如氯米帕明、帕羅西汀、氟西汀5-羥色胺神經傳遞、抗抑郁效應影響藥物效應的藥物靶點基因多態性（續）ACEIs臨床藥理學效應II vs DD依那普利ACE活性降低 II DD左心室肥厚康復和左室損傷性舒張期充盈度改善II DD卡托普利腎血流量增加、腎血管阻力降低II DD咪達普利DBP降低II DD福辛普利SBP和DBP降低II

31、 DDACE的II基因型個體中ACE抑制藥的效應增強NH2HOOCSer49GlyGly389ArgArg389Gly389Concentration of isoprenalineActivity of cAMP (pmol/min/mg)異丙腎上腺素的1-AR激動作用與基因多態性相關1受體基因多態性ADRB1 haplotype and mortality during -blocker therapy in hypertensionPacanowski MA, et al. Clin Pharmacol Ther 20084. 藥物代謝酶和靶點基因多態性綜合作用實例阿托伐他汀CYP3A5

32、CYP3A5*3降TC和LDL作用增強P-GPMDR1 C3435T降TC、LDL和升HDL：CC 強于TT和CTOATP-CSLCO1B1 521TC降TC：TTCC辛伐他汀CYP3A4CYP3A4*4降脂療效增強CYP3A5CYP3A5*3降TC和LDL作用增強CYP2D6*2XN無不良反應、療效最低各種導致無功能突變不良反應多。療效增強OATP-CSLCO1B1 521TC降TC：TTCC洛伐他汀CYP3A5CYP3A5*3降TC和LDL作用增強普伐他汀OATP-CSLCO1B1 521TC將TC作用：TTTC華法林起始劑量和毒性反應預測臨床用藥存在問題：口服抗凝藥，用于深部靜脈栓塞、房

33、顫、瓣膜置換術后的抗凝防栓，體內藥物濃度個體差異大，易造成出血甚至致命。治療指數小、抗凝不當所致的并發癥困擾臨床。近年來突破性明確CYP2C9多態性與華法林敏感有關。維生素K環氧化物還原酶亞基1（VKORC1)是華法林作用靶點，其啟動子區1639GA多態性導致藥物敏感性增加，須降低劑量以防不良反應。CYP2C9*3純合子病人每天只需 0.5 mg 消旋華法林，而CYP2C9野生型病人每天需 5-8 mg (相差十多倍) 才能達到相同的治療效果。CYP2C9*3 病人在治療之初表現更多的不良反應以及出血并發癥的危險性 。華人與高加索人間的華法林維持劑量與VKORC1 -1639GA多態性間具有相

34、關性。VKORC1變異可解釋31%的維持劑量差異。用藥建議：病人須按照以下基因型組合給予起始劑量，可預防出血并取得療效。CYP2C9*1/*1*1/*3*3/*3*1/*1*1/*3*3/*3*1/*1*1/*3*3/*3VKORC1GGGGGGGAGAGAAAAAAA推薦起始劑量（mg/天）53.753.753.752.52.52.51.251.25WSD (mg/day) = 1.363+0.323 (VKORC1 AG) 0.33 (CYP2C9*3) + 0.618 (VKORC1 GG) - 0.005 Age + 0.288 BSA + 0.06 AVR + 0.065 Sex +

35、 0.105 Smoking habit + 0.042 Atrial fibrillation + 0.138 Aspirin -0.152 Amiodarone2Note：VKORC1 -1639AG, 1 = AG, 0 = AA or GG; VKORC1 -1639AA, 1 = GG, 0 = AG or AA; CYP2C9*3 allele, 1 = *3 allele carrier, 0 = *1*1; Age（year）；Sex, female =1，male = 0；Smoking habit, AVR (aortic valve replacement), Atria

36、l fibrillation, Aspirin, Amiodarone, Thyroxine, 1 = if statement is ture, 0 = if statement is false.華法林穩定劑量預測湘雅模型Over (%)Ideal (%)Under (%)MAE 95%CIAll (N=326)95 (29.1%)185 (56.7%)46 (14.1%)0.0633(-0.72, 0.85)Dose 1.88mg/day (N=70)53 (88.3%)7 (11.7%)00.42 (0.46, 1.30)Do 1.88-4mg/day42 (19.1%)154 (68

37、.0%)24 (10.9%)0.068 (-0.51, 0.65)Dose 4mg/day (N=19)024 (47.8%)22 (52.2%)-1.02 (-1.06, -0.35)Note: MAE, mean absolute error = the mean of (clinical observed WSD predicted WSD); Ideal prediction, predicted dose at clinical observed dose 20%; over prediction, predicted dose higher than 1.2* clinical o

38、bserved dose; under prediction, predicted dose lower than 0.8* clinical observed dose.Figure 1-2 The Q-Q chart of observed WSD and predicted WSD.Table 1-3 Sensitive analysis of the new modelPart III：Personalized Medicine and Personalized therapyWhat Is Personalized Medicine?Personalized medicine is a rapidly advancing field of health care that promises greater precision and effectiveness than traditional medicine because it is informed by each persons unique clinical, social, ge