Post on 10-Nov-2018
Farmacología y Farmacogenética de losmedicamentosantirretrovirales
Farmacología y Farmacogenética de losmedicamentosantirretrovirales
A Telenti
Institute of Microbiology
Biology and Medical School
www.chuv.ch/imul
A Telenti
Institute of Microbiology
Biology and Medical School
www.chuv.ch/imul
El « Dogma Central »de la Farmacología clínica
PharmacokineticsPK
PharmacodynamicsPDNH
NN
N
OH O
N
N
Doses,intervals,route
Concentration profile ataction site
Intendedor adverseeffects
Relación PK-PD
D D D DD D D D
PK : «what thebody does
with a drug»
� Relation between the administration schedule of an agent and the resulting development of a clinical effect profile
PD : «what a drugdoes to
the body»
time
co
nc
en
tra
tio
ne
ffe
ct
Optimalrange
130 unselected patients under Efavirenz 600 mg q.d. :
C. Marzolini & al. AIDS 2001, 15:71±75
0
20
40
60
80
100
Average Efavirenz concentration (µg/l)
100 1000 10000
Viral control
CNS toxicity
Pro
ba
bili
ty(%
)
Perfil PD In vivo
Gibbons, et al. AIDS. 2000;14(suppl 4):S89.
Hard gel
caps
Soft gel
caps
SQV
Soft gel
caps + RTV
Alone + RTV
IDV NFV
10
100
1000
10,000
Pla
sm
a c
on
ce
ntr
atio
n(n
g/m
L)
Unselected patients under various PIs :
PK Variabilidad
Intracellularlevels
HIV
CD4 lymphocytes
and HIV targetcells
Transporters
Total circulating levels
liver
Transporters
CYP
blood
GI Lumen enterocytes
Transporters
CYP3A
Antiretroviraldrugs
Determinantes de la concentración
intracelular de los antirretrovirales
-el proceso ADME-
αααα1-glycoprotein acid isoforms
Free-bound
Ritonavir CYP3A4/5, 2D6Indinavir 3A4/5Saquinavir 3A4/5Nelfinavir 3A4/5, 2D6, 2C9, 2C19Amprenavir 3A4/5Efavirenz 3A4, 2B6Nevirapina 3A4, 2B6
Metabolismo de los inhibidores de la proteasa y de los NNRTI
Fellay et al. Lancet 2002
Rotger et al. Pharmacogenetics 2005
Haas et al. AIDS 2005
Tsuchiya et al.Biochem Biophys Res Comm 2004
Intracellularlevels
HIV
CD4 lymphocytes
and HIV targetcells
Transporters
Total circulating levels
liver
Transporters
CYP
blood
GI Lumen enterocytes
Transporters
CYP3A
Antiretroviraldrugs
αααα1-glycoprotein acid isoforms
Free-bound
Determinantes de la concentración intracelular de los antirretrovirales
Concentraciones intracelulares vs. plasmáticas del NFV
Nelfinavir logIC = f (logEC)
2.5 3.0 3.5 4.0
2.5
3.5
4.5
p < 0.0001r = 0.85slope =0.93
log (EC)
log
(IC
)
Nelfinavir logIC = f (logEC)
2.5 3.0 3.5 4.0
2.5
3.5
4.5
p < 0.0001r = 0.85slope =0.93
log (EC)
log
(IC
)
Concentraciones intracelulares vs. plasmáticas del EFV
Efavirenz logIC = f (logEC)
2.0 2.5 3.0 3.5 4.0 4.5
2
3
4
p < 0.0001r = 0.6slope = 0.69
log (EC)
log
(IC
)
Efavirenz logIC = f (logEC)
2.0 2.5 3.0 3.5 4.0 4.5
2
3
4
p < 0.0001r = 0.6slope = 0.69
log (EC)
log
(IC
)
Nucleoside- and nucleotide-analogue reverse-transcriptase inhibitors (NRTIs)
require intracellular phosphorylation for activity (Anderson, CID 38:743, 2004)
Farmacología de los NRTI
Conclusiones I
• La farmacología de los antirretrovirales es compleja
• Los niveles plasmáticos son muy variables
• Múltiples etapas caracterizan el proceso ADME
• La medida de niveles plasmáticos puede ayudar en la práctica
• La farmacología intracelular o intracompartimental es poco conocida
Interindividual variation in efavirenz plasma values
All4.0
4.5
5.0
5.5
6.0
log
10 E
FV
pla
sm
a A
UC
Rotger et al Pharmacogen Gen 2005
1. Observe si hay diferencias entre individuos(“fenotipo”).
2. Identifique patrones de fenotipo singulares
Un estudio de genética
Co
un
t
0
5
10
15
20
25
30
35
log10 EFV AUC (µg*h/ml)
0.5 1.0 1.5 2.0 2.5 3.0 3.5
Cu
mu
lative
Fre
qu
en
cy
1
10
30
50
70
90
99
99.9
99.99
Co
un
t
0
5
10
15
20
25
30
35
log10 EFV AUC (µg*h/ml)
0.5 1.0 1.5 2.0 2.5 3.0 3.5
Cu
mu
lative
Fre
qu
en
cy
1
10
30
50
70
90
99
99.9
99.99
Distribution of Efavirenz AUC valuesRotger et al. Clin Pharm Ther 2007
Extensive metabolizer
Slow metabolizer
Rapid metabolizer
1. Observe si hay diferencias entre individuos(“fenotipo”).
2. Identifique patrones de fenotipo singulares3. Qué se conoce?
Un estudio de genética
<5% total CYPs in human liver
Metabolism of efavirenz
Highly polymorphic (21 alleles described)
CYP2B6
Cluster of basic residues
Cluster of prolines
Membrane binding domaine
Conserved domain: Glu-X-X-Arg
Heme Binding site: Phe-X-X-Gly-X-Arg-X-Cys-X-Gly
SRS: Substrates-recognition sites
P167AR487C
D257NM46V
Q172H I328TQ21L
R22CR29S/P K139R
R140K T168I
S259RI391N
P428TM459V
Q485LG476D
T26S R336CD28G
G99E
K262R
491AA
SRS1
1 26
MBD
98 117
SRS2 SRS3 SRS5SRS4 SRS6HBS
199 210 235 240 290 304 360 369 429 438 470 47934
Allelic frequency Q172H
Blacks: 30-47%
Whites: 21-28%
Asians: 14-19%
1. Observe si hay diferencias entre individuos(“fenotipo”).
2. Identifique patrones de fenotipo singulares3. Qué se conoce?4. Ya sabemos todo?
Un estudio de genética
Extensive genotyping and resequencing of CYP2B6The grey interval: thresholds above and below which AUC values deviate from the normality distribution.
1. Observe si hay diferencias entre individuos(“fenotipo”).
2. Identifique patrones de fenotipo singulares3. Qué se conoce?4. Ya sabemos todo?5. Qué hacer después?
Un estudio de genética
CYP2B6*1
Exons 1 5 97 84 62 3
Amino acid change
CYP2B6*27
Exons 1 5 97 84 62 3
M198T
15708T>C
18273G>A
CYP2B6*28
Exons 1 5 97 84 62 3
T306S, R378stop
18783C>G 21160C>T
15837C>T 18273G>A18627G>A18912G>C
CYP2B6*1
Exons 1 5 97 84 62 3
Amino acid change
CYP2B6*27
Exons 1 5 97 84 62 3
M198T
15708T>C
18273G>A
CYP2B6*28
Exons 1 5 97 84 62 3
T306S, R378stop
18783C>G 21160C>T
15837C>T 18273G>A18627G>A18912G>C
Schematic view of novel alleles. Black arrows: non-synonymous SNPs. Light-
grey arrows: intronic SNPs. Dark-grey arrows: SNPs in promoter region.
% o
f W
T
activity
WT *6 M198T0
10
20
30
40
50
60
70
80
90
100
∗
∗∗
M198T0
10
20
30
40
50
60
70
80
90
% o
f W
T
activity
WT *6 M198T0
10
20
30
40
50
60
70
80
90
100
∗
∗∗
M198T0
10
20
30
40
50
60
70
80
90
Heterologous expression of CYP2B6*6 and of novel allele 2B6*27 in COS-1 cells.Bupropion hydroxylase activity of CYP2B6 variants normalized to CYP2B6 protein amount
Transportadores y antirretrovirales
TransporterTransporterTransporterTransporter ARTARTARTART
MRP1 (ABCC1MRP1 (ABCC1MRP1 (ABCC1MRP1 (ABCC1)))) PIsPIsPIsPIs
PIs PIs PIs PIs MRP2 (ABCC2MRP2 (ABCC2MRP2 (ABCC2MRP2 (ABCC2))))
MRP4 (ABCC4)MRP4 (ABCC4)MRP4 (ABCC4)MRP4 (ABCC4) AzidothymidineAzidothymidineAzidothymidineAzidothymidineLamivudineLamivudineLamivudineLamivudine, , , , StavudineStavudineStavudineStavudine
MRP5 (ABCC5)MRP5 (ABCC5)MRP5 (ABCC5)MRP5 (ABCC5) AzidothymidineAzidothymidineAzidothymidineAzidothymidineLamivudineLamivudineLamivudineLamivudine, , , , StavudineStavudineStavudineStavudine
Inhibitors: PIsInhibitors: PIsInhibitors: PIsInhibitors: PIsBCRP (ABCG2)BCRP (ABCG2)BCRP (ABCG2)BCRP (ABCG2)
PIsPIsPIsPIsMDR1 (ABCB1)MDR1 (ABCB1)MDR1 (ABCB1)MDR1 (ABCB1)
SNPsSNPsSNPsSNPs
7777
27 27 27 27
16161616
39393939
Colombo et al. Pharmacogen Genet 2005
ABCB1_N21D ABCB1_C3435T ABCB1_Intron 26
Intracellular Nelfinavir AUC (ng*h/ml) for MDR1
(ABCB1) genotypes with a significant association with
phenotype
Colombo et al. Pharmacogen Genet 2005
Conclusiones II
• La farmacogenética ha identificado asociaciones
entre:
- CYP2B6 y PK de Efavirenz y Nevirapina
- CYP3A5 y PK de Saquinavir e indinavir
- CYP2C19 y PK de Nelfinavir
- MDR1 y transporte de varias IP
- MRP4 y fosforilación de varios NRTIs
- ORM y niveles plasmáticos libres de varias IP
• efavirenz + lamivudine/FTC+ (zidovudine or tenofovir or abacavir)
• lopinavir/ritonavir (Kaletra®) + lamivudine/FTC + (zidovudine or tenofoviror abacavir)
• atazanavir + lamivudine/FTC+ (zidovudine or tenofovir or abacavir)
Equivalentes ……pero no iguales
Podemos escoger entreopciones similares con tests
genéticos?
EfavirenzLopinavir/r
AtazanavirAbacavir
EfavirenzLopinavir/r
AtazanavirAbacavir
Neuropsychological toxicityHyperlipidemia
HyperbilirubinemiaHypersensitivity reactions
Neuropsychological toxicityHyperlipidemia
HyperbilirubinemiaHypersensitivity reactions
Co
un
t
0
5
10
15
20
25
30
35
log10 EFV AUC (µg*h/ml)
0.5 1.0 1.5 2.0 2.5 3.0 3.5
Cu
mu
lative
Fre
qu
en
cy
1
10
30
50
70
90
99
99.9
99.99
Co
un
t
0
5
10
15
20
25
30
35
log10 EFV AUC (µg*h/ml)
0.5 1.0 1.5 2.0 2.5 3.0 3.5
Cu
mu
lative
Fre
qu
en
cy
1
10
30
50
70
90
99
99.9
99.99
Extensive metabolizer
Slow metabolizer
Rapid metabolizer
Distribución de las concentraciones de efavirenz
Rotger et al. Clin Pharm Ther 2007
Infarto de miocardio y Infarto de miocardio y Infarto de miocardio y Infarto de miocardio y
exposiciexposiciexposiciexposicióóóón a antirretroviralesn a antirretroviralesn a antirretroviralesn a antirretrovirales
0
1
2
3
4
5
6
7
8
None <1 1-2 2-3 3-4 >4
Incidence per 1000 PY/ 95% CI
No. events
No. PYFU
3 9 14 22 31 47
5,714 4,140 4,801 5,847 7,220 8,477
CART Exposure/Yrs Total
126
36.199
Test for trendP<0.00001
Friis-Moeller, NEJM 2003
IIIII
Genotype
Score
I
1
2 ART Group
3
0
10
20
30
40
50
60
70
%
I II
Genotype Score III
1
2 ART Group
3
0
10
20
30
40
50
60
70
80
%
Efecto del genotipo ABCA1/APOA5/APOC3/APOE/CETP y tipo de ART sobre los niveles de lípidos
High triglyceride levels Low HDL levels.
Arnedo et al Pharmacogenetics and Genomics 2007
Síndrome de Gilbert e ictericia en individuos que reciben indinavir o atazanavir
•The polymorphism in the promoter of UGT1A1, leads to a 50% reduction in bilirubin-conjugating activity
promoter TATA element of the gene encoding UGT1A1
Rotger et al, JID 2006
4208 prescriptions4208 prescriptions4208 prescriptions4208 prescriptions(1512 patients, 1 (1512 patients, 1 (1512 patients, 1 (1512 patients, 1 yearyearyearyear, , , , ’’’’02020202----’’’’03)03)03)03)
82 prescriptions (2%) 82 prescriptions (2%) 82 prescriptions (2%) 82 prescriptions (2%) discontinueddiscontinueddiscontinueddiscontinued because of because of because of because of
«««« hypersensitivityhypersensitivityhypersensitivityhypersensitivity »»»»(45 patients, 3%)(45 patients, 3%)(45 patients, 3%)(45 patients, 3%)
M. Rickenbach
Discontinuación del tratamiento por reacción de hipersensibilidad (‘02-‘03)
Región HLA de hipersensibilidad al abacavirMallal et al. Lancet 2002
�MHC-restricted presentation of drug or drug metabolites with direct binding of these non-peptide antigens to MHC molecules and/or haptenation to endogenous proteins prior to T cell presentation
Mal
lal
CN
A30
027
CN
A30
032
(RC
D)
CN
A30
032
(SC
D)
CN
A30
032
(RC
D)
CN
A30
032
(SC
D)
CN
A30
032
(RC
D)
CN
A30
032
(SC
D)
0
25
50
75
100
%
White Hispanics Black
SensitivityPositive predictive value
SpecificityNegative predictive value
HLA-B*5701 en diversas poblaciones y definición de caso. Hughes et al. Pharmacogenomics 2004
•Similar to abacavir hypersensitivity it occurs between 1 and 6 weeks after treatment initiation.
Reacciones de hipersensibilidad a la NevirapinaMHC class I or class II ??
•In contrast, more frequent at high CD4 T cell count suggestive of HLA Class II involvement.
•CD4+ T cell infiltration has been observed in animals treated with nevirapine.
‘NVP HSR’ (14)
HLA-DRB1*0101: OR = 4.9 (P = 0.009)
Reacciones de hipersensibilidad a la Nevirapina(n=26)
Isolated rash (12)
Rash
Fever
Hepatitis12
2
2
1
45
0
Mallal et al. AIDS 2005
JAPAN 11-18%
UK
22%
AUSTRALIA
~18%
US
Caucasian
~18%US Asian
~7%
US
African-
American
~3-4%
THAILAND
1%
MEDITERRANEAN
15-18%
US
Hispanic
~6%
Frecuencia HLA-DRB1*0101
Mallal et al. AIDS 2005
CCR5-CCR2
SDF1
TSG101RANTES
IL-10
CX3CR1
MIP1αααα
+HLA/KIR
ABCA1/APOA5/C3/E/CETPCYP2B6
MDR1UGT1A1CYP3A5CFTR/SPINK1
TNF
• 20% of disease evolution, 10% of the explained fraction• Abacavir hypersensitivity, Nevirapine ? • Hyperlipidemic response to several boosted antiproteases• Gilbert syndrome with atazanavir• Pharmacokinetics of efavirenz (nelfinavir, saquinavir?)• Some fraction of virological / immunological response to ART• Predisposition to pancreatitis• (Predisposition to lipodystrophy)
• 20% of disease evolution, 10% of the explained fraction• Abacavir hypersensitivity, Nevirapine ? • Hyperlipidemic response to several boosted antiproteases• Gilbert syndrome with atazanavir• Pharmacokinetics of efavirenz (nelfinavir, saquinavir?)• Some fraction of virological / immunological response to ART• Predisposition to pancreatitis• (Predisposition to lipodystrophy)
Lo que conocemos cabe un chip de 50 pocillos
Intracellularlevels
HIV
CD4 lymphocytes
and HIV targetcells
Transporters
Total circulating levels
liver
Transporters
CYP
blood
GI Lumen enterocytes
Transporters
CYP3A
Antiretroviraldrugs
αααα1-glycoprotein acid isoforms
Free-bound
Determinantes de la concentración
intracelular de los antirretrovirales
-el proceso ADME-
n=174
n=1783
n=471
Genes y variantes necesarias para explorar la farmacogenética de los antirretrovirales
126 Gene candidates2428 SNPs20 SNPs/gene
R. Lubomirov