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