Pharmacogenomics Study in a Taiwan Methadone Maintenance Cohort Dr. Yu-Li Liu National Health Research Institutes April 18, 2013 Acknowledgement • NHRI – Dr. Ho, IK (何英剛), Dr. Lin, KM (林克明), Dr. Wang, SC (王聲昌) – Dr. Tsou, HH (鄒小蕙), Dr. Hsiao, CF (蕭金福), Dr. Lin, PS (林培生), Dr. Tsai, HJ (蔡慧如), Dr. Chung, RH (鍾仁華) – Research Assistants Kuo, HW (郭湘維), Liu, SC (劉淑芝), Fang, CP (方秋萍), Chang, YS (張耀升), Liu, SW (劉 聖文), Chen, CY (陳俊宇), Chen, YT (陳昱廷), Lin, YC (林義傑) – Research Nurses Tsui-Mei Hung (洪翠妹), Yu-Ching Lin (林玉琴), Miao-Fang Lee (李妙芳), Ming-Chu Tseng (鄭明珠), Yu-Hun Tsai (蔡玉涵), and Shu-Chuan Ting (丁淑娟) • Collaboration hospitals and psychiatrists – Happy Kuy-Lok Tan (陳快樂), Li-Nen Lin (林立寧), Lien-Wen Su (束連文), Chieh-Liang Huang (黃介良), Yih-Hong Yang (楊逸鴻), Chen, CH (陳佳惠) • No conflict of interests Pharmacogenomics • A new field of study belongs to the branch of pharmacology • Correlating single-nucleotide polymorphisms (SNPs) or gene expression with a drug's efficacy or toxicity. • Pharmacogenetics examine the single gene interactions with drugs. • Pharmacogenomics is the whole genome application of pharmacogenetics. Requires in Pharmacogenomics Study • Patient Compliance – Research nurse observation – Therapeutic drug monitoring (steady-state plasma concentration) • Well Designed Clinical Trial – Institutional Review Boards (IRBs) – Patient demographics (age, gender, body weight..) – Define inclusion and exclusion criteria – Patient co-medication record – Treatment efficacy (or responses) – Adverse reactions Methadone Maintenance Treatment (MMT) in Taiwan • First Started at 2006 – More than 90 hospitals provided patients methadone – 11,000 heroin dependent patients under MMT – Purposes: reducing heroin abuse, reducing spread of infectious diseases, ex. HIV, HCV, and reducing crime rate • Large inter-patient variation – Methadone dosing strategy ranging from 5 mg/d to 180 mg/d • Lethal complication (cardiac arrest, respiratory depression etc.) – Inter-individual variability on drug metabolism – Drug-drug interaction: other illicit substances, alcohol, anti-HIV drugs Study design • Cross-sectional design • Plasma methadone and metabolite concentrations were measured • Genes were selected and genotyped for single nucleotide polymorphisms (SNPs) – Literature report – Han Chinese tagSNPs from HapMap – Functional SNPs • Clinical response information were recorded and cleaned up by the Clinical Trial Information Management System (CTIMeS) Taipei City Hospital-Yangming Branch 臺北市立聯合醫院 陽明院區 Taipei City Hospital-Songde Branch 臺北市立聯合醫院 松德院區 Taoyuan Mental Hospital 桃園療養院 Far Eastern Memorial Hospital 亞東紀念醫院 Wei-Gong Memorial Hospital 為恭紀念醫院醫院 En Chu Kong Hospital 恩主公醫院 China Medical University Hospital 中國醫藥大學附設醫院 Sample size: 366 Subjects Inclusion criteria: • Chinese ethnicity. • Men or women above age of 18. • Able to participate in a clinical assessment in Chinese (including Mandarin and Taiwanese dialects). • Individuals who were willing to provide blood and urine samples for analyses. • Heroin dependence rated by DSM-IV definition. • Enter methadone maintenance therapy for at least 3 months. • Methadone dosage change < 10 mg in the past 1 week. • Individuals who have completed a written consent form. Subjects Exclusion criteria: • Patients with comorbid severe mental disorders including 1) Organic mental disorders, 2) Schizophrenia • Patients who were pregnant. • Severe cognitive impairment. Assessments • Outcome measurement • • • • Drug effect assessment • • • • Opioid withdrawal symptom/sign: Clinical opioid withdrawal scale (COWS); 11 items Opioid intoxication sign: pupil size, respiratory rate, heart rate Adverse effects: Treatment emergent symptoms scale (TESS); 31 items Plasma drug concentration monitoring • • • Urine drug screening (morphine/amphetamine) Clinical interview: TOP (Treatment Outcomes Profile) Self-report of illicit drug use and SDS (severity of drug dependence) Methadone enantiomeres: R-methadone, S-methadone EDDP enantiomers: R-EDDP, S-EDDP DNA genotyping • CYP3A4, CYP2B6, CYP2C19, UGT2B7, opioid receptors General Demography Overall Urine Morphine Positive Urine Morphine Negative N=366 n=185 n=178 Mean ± SD Mean ± SD Mean ± SD Age (years) 38.17 ± 7.72 38.37 ± 7.96 37.87 ± 7.46 0.57a Male 297 (81.2%) 152 (82.2%) 142 (79.8%) 0.56b BMI (kg/m-1) 23.58 ± 3.52 23.62 ± 3.57 23.59 ± 3.49 0.89a Starting dose of Methadone (mg/day) 32.04 ± 11.15 31.64 ± 10.07 32.44 ± 12.22 0.77a Current dose of Methadone (mg/day) 54.67 ± 28.12 54.53 ± 26.07 55.32 ± 30.13 0.88a R-Methadone/methadone dose ratio 3.86 ± 2.32 3.7 ± 2.71 4.03 ± 1.82 0.001a S-Methadone/methadone dose ratio 2.77 ± 1.57 2.58 ± 1.45 2.98 ± 1.66 0.012a R-EDDP/methadone dose ratio 0.31 ± 0.5 0.26 ± 0.33 0.33 ± 0.54 0.26a S-EDDP/methadone dose ratio 0.33 ± 0.49 0.31 ± 0.38 0.33 ± 0.58 0.95a Human immunodeficiency virus (HIV) 86 (24.0%) 50 (27.3%) 36 (20.8%) 0.15b 334 (94.9%) 173 (96.1%) 158 (93.5%) 0.27b Hepatitis C virus (HCV) Values are shown as mean ± SD or N (%). a Wilcoxon rank-sum test. b Chi-Square test. Bold P-value: P<0.05. P-value Withdrawal Symptoms n Overall Urine Morphine Positive Urine Morphine Negative N=366 N=185 N=178 % Mean ± SD n 1.49 ± 1.86 185 % Mean ± SD n 1.51 ± 1.93 178 % P-valuea P-valueb,c Mean ± SD 1.44 ± 1.78 0.85 78.20 ± 12.24 0.37 35 19.7% 0.22 ± 0.48 0.74 0.77b 0.17 ± 0.48 14 7.9% 0.08 ± 0.30 0.06 0.06b 20 10.8% 0.13 ± 0.40 19 10.7% 0.17 ± 0.53 0.91 0.97b 0.12 ± 0.35 19 10.3% 0.12 ± 0.37 19 10.7% 0.11 ± 0.31 0.94 0.90b 9.8% 0.11 ± 0.36 24 13.0% 0.14 ± 0.38 11 6.2% 0.08 ± 0.33 0.033 0.028b 31 8.5% 0.11 ± 0.39 14 7.6% 0.10 ± 0.36 17 9.6% 0.13 ± 0.43 0.49 0.50b Restlessness 24 6.6% 0.07 ± 0.25 15 8.1% 0.08 ± 0.27 8 4.5% 0.04 ± 0.21 0.16 0.16b GI Upset 16 4.4% 0.07 ± 0.33 9 4.9% 0.08 ± 0.39 7 3.9% 0.05 ± 0.27 0.65 0.67b Yawning 10 2.7% 0.04 ± 0.23 6 3.2% 0.04 ± 0.25 3 1.7% 0.02 ± 0.18 0.34 0.50c Gooseflesh skin 8 2.2% 0.07 ± 0.44 4 2.2% 0.06 ± 0.44 4 2.3% 0.07 ± 0.45 0.96 1.00c Sum of COWS 366 Heart Rate 365 Pupil size 69 18.9% 0.21 ± 0.46 34 18.5% 0.20 ± 0.44 Sweating 41 11.2% 0.13 ± 0.40 26 14.1% Tremor 39 10.7% 0.15 ± 0.46 Anxiety or Irritability 39 10.7% Bone or Joint aches 36 Runny nose or tearing 77.55 ± 11.86 184 Values are shown as mean ± SD or n, %. a Wilcoxon rank-sum test. b Chi-Square test. 76.83 ± 11.29 178 Bold P-value: P<0.05. c Fisher Exact test. Methadone Induced Side Effects n Overall Urine Morphine Positive Urine Morphine Negative N=366 N=185 N=178 % Mean ± SD n % Mean ± SD n % P-valuea P-valueb Mean ± SD Constipation 248 67.8% 1.96 ± 0.84 125 67.6% 2.01 ± 0.85 121 68.0% 1.92 ± 0.83 0.40 0.93 Sedation 172 47.0% 1.51 ± 0.70 94 50.8% 1.51 ± 0.68 77 43.3% 1.49 ± 0.72 0.73 0.15 Change in Libido 111 30.3% 1.72 ± 0.79 63 34.1% 1.70 ± 0.75 47 26.4% 1.77 ± 0.84 0.76 0.11 Dry Mouth 101 27.6% 1.55 ± 0.70 59 31.9% 1.61 ± 0.74 41 23.0% 1.49 ± 0.64 0.49 0.06 Impaired Mentation 79 21.6% 1.61 ± 0.72 41 22.2% 1.78 ± 0.76 37 20.8% 1.43 ± 0.65 0.032 0.75 Excessive Sweating 71 19.4% 1.86 ± 0.85 38 20.5% 1.95 ± 0.87 32 18.0% 1.75 ± 0.84 0.34 0.54 Insomnia 67 18.3% 1.93 ± 0.78 32 17.3% 2.03 ± 0.78 34 19.1% 1.85 ± 0.78 0.36 0.66 Fatigue 65 17.8% 1.62 ± 0.78 32 17.3% 1.78 ± 0.79 32 18.0% 1.47 ± 0.76 0.08 0.87 Difficulty with Urination 52 14.2% 1.38 ± 0.60 28 15.1% 1.50 ± 0.69 23 12.9% 1.26 ± 0.45 0.24 0.54 Increase in Appetite 46 12.6% 1.48 ± 0.59 25 13.5% 1.52 ± 0.51 21 11.8% 1.43 ± 0.68 0.37 0.62 Decrease in Appetite 44 12.0% 1.55 ± 0.70 26 14.1% 1.50 ± 0.71 18 10.1% 1.61 ± 0.70 0.54 0.25 Weight Gain 38 10.4% 1.68 ± 0.74 18 9.7% 1.67 ± 0.59 20 11.2% 1.70 ± 0.86 0.86 0.64 Weakness 33 9.0% 1.36 ± 0.70 18 9.7% 1.56 ± 0.86 14 7.9% 1.14 ± 0.36 0.17 0.53 Malaise 27 7.4% 1.48 ± 0.64 13 7.0% 1.62 ± 0.65 13 7.3% 1.38 ± 0.65 0.31 0.92 Tachycardia/Palpitations 25 6.8% 1.44 ± 0.71 14 7.6% 1.43 ± 0.65 10 5.6% 1.50 ± 0.85 1.00 0.45 Values are shown as mean ± SD or n, %. a Wilcoxon rank-sum test. b Chi-Square test. Bold P-value: P<0.05. Other Substance Use Total N=366 Urine Morphine Positive N=185 Urine Morphine Negative N=178 P-valuea n % n % n % Opiates 234 63.9% 171 92.4% 61 34.3% <0.0001 Alcohol 116 31.7% 56 30.3% 59 33.1% 0.56 Betel nut 95 26.0% 42 22.7% 52 29.2% 0.16 Amphetamine 64 17.5% 38 20.5% 25 14.0% 0.10 Cocaine 0 0.0% 0 0.0% 0 0.0% Cannabis 0 0.0% 0 0.0% 0 0.0% Values are shown as n, %. a Chi-Square test. Bold P-value: P<0.05. Pharmacokinetics Absorption Distribution Metabolism Excretion Genes SNP or Gene Dose or Matrix Co-medications Other Substances Dose Infectious status Treatment Responses Side Effects Plasma Concentration Withdrawals Methadone Metabolism CYP2B6 (S) CYP2C19 (R) CYP3A4 Development of a method to measure methadone enantiomers and its metabolites without enantiomer standard compounds for the plasma of methadone maintenance patients. Biomed. Chromatogr. 2010, 24(7): 782-788. CYP2B6 Summary • SNP markers in CYP2B6 are associated with plasma S-methadone concentration, ratio of S-methadone/dose, and S-methadone clearance. CYP2B6 Polymorphisms Influence the Plasma Concentration and Clearance of the Methadone S-Enantiomer. J. Clin. Psychopharmacol. 2011, 31(4): 463-469. HCV Infection Status (Poster C8) CYP3A4 Summary • Three SNPs located at CYP3A4 intron region showed significant association with withdrawal symptom score, side effect symptom score, and betel nut use. • The higher the withdrawal symptoms scores, the higher the side effect symptom score, but lower the betel nut use. Genetic polymorphisms of CYP3A4 indicate the withdrawal symptoms, adverse reactions and betel nut use in methadone maintenance patients. Pharmacogenomics 2011, 12(10): 1397-1406. CYP2C19 Summary •Gene dose in CYP2C19 is associated with methadone dose, and ratios of Rmethadone/dose, and R-EDDP/dose. •Gene dose is associated with TESS scores in urine morphine test positive patients. The extensive metabolizer had higher side effect score than poor metabolizer. CYP2C19 x CYP2B6 Interaction CYP2C19 x CYP3A4 Interaction CYP2C19 x CYP2B6 x CYP3A4 Tolerance (Poster C14) Morphine Metabolism UGT2B7 UGT2B7 genetic polymorphisms are associated with the withdrawal symptoms in methadone maintenance patients. Pharmacogenomics 2012, 13(8):879-888. Pharmacodynamics Drug action Receptor interaction Receptor-coupled Response Genes SNP or Gene Dose or Matrix Co-medications Other Substances Dose Infectious status Treatment Responses Side Effects Plasma Concentration Withdrawals OPRM1 Opioid receptor Mu1 genetic polymorphisms are associated with adverse reactions in methadone maintenance Patients. Eur. Neuropsychopharmacol. 2012, 22(10): 695-703. OPRM1 and Smoking OPRM1 genetic polymorphisms are associated with the plasma nicotine metabolite cotinine concentration in methadone maintenance patients: a cross sectional study. J. Hum. Gen. 2013, 58: 84-90. Pharmacokinetics (Physical Dependence) Absorption Distribution Metabolism Excretion Pharmacodynamics (Psychological Dependence) Drug action Receptor interaction Receptor-coupled Response Genes Genes SNP or Gene Dose or Matrix SNP or Gene Dose or Matrix Co-medications Other Substances Dose Infectious status Treatment Responses Side Effects Plasma Concentration Withdrawals Limitations • • • • • 81% male 95% HCV positive 50% Patients urine morphine test positive Sample size is small More studies in replicating these results are essential for future treatment guidelines. In Summary • Methadone dosage regiment is combined the influence of pharmacokinetic and pharmacodynamic genetic variants. • The pharmacokinetic genes of SNPs may predict the plasma methadone concentration, methadone dosage and withdrawal severities. • The pharmacodynamic genes of SNPs may influence the dosage prediction and the treatment side effects. • Pharmacogenomics study promises the advent of personalized medicine. • More methods warrant further investigation to optimize drug therapy, with respect to the patients' genotype, to ensure maximum efficacy with minimal adverse effects. • Methadone pharmacogenomics study may provide a key to decipher the mechanism for opioid dependence. Acknowledgement • Funding – A pharmacogenomic study on methadone therapeutics (NSC98-3112-B-400-011-, NSC99-3112-B-400-003-, NSC100-3112-B-400-015-, from May, 2009- April, 2012) – Pharmacogenomics study of opioid receptor and UGT2B7 genes in methadone treatment (NSC 100-2314-B-400-002-MY3, from Aug 2011 – Jul, 2014) – Liver cytochrome P-450 isozyme alterations after prenatal opiates exposure and extend clinical study (PH-098-PP-36; PH-099, 100-PP-37; PH-101-32, from 2009 - 2012) • Technical Supports – Clinical Trial Information Management System (CTIMeS) – National Center for Genome Medicine (NCGM) at Academia Sinica, Taiwan, for genotyping/technical support Thanks for Attention