Pharmacogenomics Study in a Taiwan Methadone Maintenance Cohort

Dr. Yu-Li LiuNational 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

– Register at NIH with a trial number

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)

China Medical University Hospital中國醫藥大學附設醫院

Wei-Gong Memorial Hospital為恭紀念醫院醫院

Taipei City Hospital-Yangming Branch臺北市立聯合醫院 陽明院區

En Chu Kong Hospital恩主公醫院

Taoyuan Mental Hospital桃園療養院

Taipei City Hospital-Songde Branch臺北市立聯合醫院 松德院區Far Eastern Memorial Hospital亞東紀念醫院

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

• Urine drug screening (morphine/amphetamine)• Clinical interview: TOP (Treatment Outcomes Profile)• Self-report of illicit drug use and SDS (severity of drug dependence)

• 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• 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

P-valueN=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

Hepatitis C virus (HCV) 334 (94.9%) 　 173 (96.1%) 　 158 (93.5%) 0.27b

Values are shown as mean ± SD or N (%). Bold P-value: P<0.05. 　　 　a Wilcoxon rank-sum test. b Chi-Square test.

Withdrawal Symptoms　 Overall 　Urine Morphine Positive 　Urine Morphine Negative

P-valuea P-valueb,cN=366 N=185 N=178

　 n % Mean ± SD 　n % Mean ± SD 　n % Mean ± SD

Sum of COWS 366 1.49 ± 1.86 185 1.51 ± 1.93 178 1.44 ± 1.78 0.85

Heart Rate 365 77.55 ± 11.86 184 76.83 ± 11.29 178 78.20 ± 12.24 0.37

Pupil size 69 18.9% 0.21 ± 0.46 34 18.5% 0.20 ± 0.44 35 19.7% 0.22 ± 0.48 0.74 0.77b

Sweating 41 11.2% 0.13 ± 0.40 26 14.1% 0.17 ± 0.48 14 7.9% 0.08 ± 0.30 0.06 0.06b

Tremor 39 10.7% 0.15 ± 0.46 20 10.8% 0.13 ± 0.40 19 10.7% 0.17 ± 0.53 0.91 0.97b

Anxiety or Irritability 39 10.7% 0.12 ± 0.35 19 10.3% 0.12 ± 0.37 19 10.7% 0.11 ± 0.31 0.94 0.90b

Bone or Joint aches 36 9.8% 0.11 ± 0.36 24 13.0% 0.14 ± 0.38 11 6.2% 0.08 ± 0.33 0.033 0.028b

Runny nose or tearing 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

Values are shown as mean ± SD or n, %. Bold P-value: P<0.05. 　 　　 　 　 　 　a Wilcoxon rank-sum test. b Chi-Square test. c Fisher Exact test.

Methadone Induced Side Effects　 Overall 　Urine Morphine Positive 　Urine Morphine Negative

P-valuea P-valuebN=366 N=185 N=178

　 n % Mean ± SD 　 n % Mean ± SD 　 n % 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, %. Bold P-value: P<0.05. 　 　　 　 　 　 　a Wilcoxon rank-sum test. b Chi-Square test.

Other Substance Use　 Total

N=366 　 Urine Morphine PositiveN=185 　Urine Morphine Negative

N=178P-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, %. Bold P-value: P<0.05.

a Chi-Square test.

Pharmacokinetics

Absorption Distribution Metabolism Excretion

Genes

SNP or Gene Dose or Matrix

Dose

Plasma Concentration

Co-medicationsTreatment ResponsesOther Substances

Infectious status Side Effects

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.

CYP2C19Summary•Gene dose in CYP2C19 is associated with methadone dose, and ratios of R-methadone/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.

Genes

SNP or Gene Dose or Matrix

Dose

Plasma Concentration

Co-medicationsTreatment ResponsesOther Substances

Pharmacodynamics

Drug action Receptor interaction Receptor-coupled Response

Infectious status Side Effects

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

Genes Genes

SNP or Gene Dose or Matrix

SNP or Gene Dose or Matrix

Dose

Plasma Concentration

Co-medicationsTreatment ResponsesOther Substances

Pharmacodynamics(Psychological Dependence) Drug action Receptor interaction Receptor-coupled Response

Infectious status Side Effects

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