Drug Interactions

Evolution of Drug Metabolism As a

Science
Richard Tecwyn Williams Great Britain
1942, worked on the metabolism on TNT with regard to toxicity in munitions workers; due to the war he assembled teams to work on metabolism of sulfonamides, benzene, aniline, acetanilide, phenacetin, and stilbesterol Developed concept of Phase 1 & Phase 2 Reactions. Biotransformation involves metabolic oxygenation, reduction, or hydrolysis; result in changes in biological activity (increased or decreased) Second phase, conjugation, in almost all cases resulted in detoxication.

Drug Metabolism

Extrahepatic microsomal enzymes

(oxidation, conjugation)

Hepatic microsomal enzymes

(oxidation, conjugation)

Hepatic non-microsomal enzymes

(acetylation, sulfation,GSH, alcohol/aldehyde dehydrogenase, hydrolysis, ox/red)

Liver Microsomal System

Oxidative Reactions: Cytochrome P450 mediated Examples
Formation of an inactive polar metabolite
Phenobarbital

Formation of an active metabolite

By Design: Purine & pyrimidine chemotherapy prodrugs Inadvertent: terfenadine fexofenadine

Formation of a toxic metabolite

Acetaminophen NAPQI

NADP+

Drug CYP eR-Ase

CYP Fe+3
PC

Drug

Drug OH CYP Fe+3 Drug OH e-

NADPH

CO
CYP-Fe+2 Drug

CO

hu

CYP Fe+2 Drug O2 O2 CYP Fe+2 Drug

H2O 2H+

Electron flow in microsomal drug oxidizing system

Cytochrome P450 Isoforms (CYPs) - An Overview

NADPH + H+ + O2 + Drug NADP+ + H2O + Oxidized Drug Carbon monoxide binds to the reduced Fe(II) heme and absorbs at 450 nm (origin of enzyme family name) CYP monooxygenase enzyme family is major catalyst of drug and endogenous compound oxidations in liver, kidney, G.I. tract, skin, lungs Oxidative reactions require the CYP heme protein, the reductase, NADPH, phosphatidylcholine and molecular oxygen CYPs are in smooth endoplasmic reticulum in close association with NADPH-CYP reductase in 10/1 ratio The reductase serves as the electron source for the oxidative reaction cycle

CYP Families
Multiple CYP gene families have been identified in humans, and the categories are based upon protein sequence homology Most of the drug metabolizing enzymes are in CYP 1, 2, & 3 families . CYPs have molecular weights of 45-60 kDa. Frequently, two or more enzymes can catalyze the same type of oxidation, indicating redundant and broad substrate specificity. CYP3A4 is very common to the metabolism of many drugs; its presence in the GI tract is responsible for poor oral availabilty of many drugs

CYP Nomenclature
Families - CYP plus arabic numeral (>40% homology of amino acid sequence, eg. CYP1) Subfamily - 40-55% homology of amino acid sequence; eg. CYP1A Subfamily - additional arabic numeral when more than 1 subfamily has been identified; eg. CYP1A2 Italics indicate gene (CYP1A2); regular font for enzyme Comprehensive guide to human http://drnelson.utmem.edu/human.P450.table.html Cyps

CYP Tables
Human CYPs - variability and importance in drug metabolism Isoforms in metabolism of clinically important drugs Factors that influence CYP activity Non-Nitrogenous CYP inhibitors Extrahepatic CYPs

ROLE OF CYP ENZYMES IN HEPATIC DRUG METABOLISM

CYP1A2 2% CYP2C9 10%

Others 3%

Others 20% CYP1A 8%

CYP3A 31%

CYP2D6 30%

CYP3A4 55%

CYP2C6 12%

CYP2E1 13%

CYP2C11 16%

Proportion of drug metabolized by CYP

Percentage in the human liver microsomes

As of October 2006 there were 6422 P450 enzymes, organized into 708 families, which were identified in species, although only 2279 in 99 families in animals. Only the 50 P450 enzymes described in man are likely to be of any clinical relevance, and even then only the P450s in families 1, 2, and 3 appear to be responsible for the metabolism of drugs and therefore are potential sites for drug interactions.

Human Cytochrome P450 Superfamily

Human Liver Drug CYPs

CYP enzyme 1A2 1B1 2A6 2B6 2C 2D6 2E1 2F1 2J2 3A4 4A, 4B
2 E

Level (%total) ~ 13 <1 ~4 <1 ~18 Up to 2.5 Up to 7

Extent of variability ~40-fold ~30 - 100-fold ~50-fold 25-100-fold >1000-fold ~20-fold

Up to 28 30-60*

~20-fold 90-fold*

S. Rendic & F.J. DiCarlo, Drug Metab Rev 29:413-80, 1997 *L. Wojnowski, Ther Drug Monit 26: 192-199, 2004

Participation of the CYP Enzymes in Metabolism of Some Clinically Important Drugs

CYP Enzyme Examples of substrates
1A1 1A2 2A6 2B6 2C-family Caffeine, Testosterone, R-Warfarin Acetaminophen, Caffeine, Phenacetin, R-Warfarin 17-Estradiol, Testosterone Cyclophosphamide, Erythromycin, Testosterone Acetaminophen, Tolbutamide (2C9); Hexobarbital, SWarfarin (2C9,19); Phenytoin, Testosterone, R- Warfarin, Zidovudine (2C8,9,19); Acetaminophen, Caffeine, Chlorzoxazone, Halothane Acetaminophen, Codeine, Debrisoquine Acetaminophen, Caffeine, Carbamazepine, Codeine, Cortisol, Erythromycin, Cyclophosphamide, S- and RWarfarin, Phenytoin, Testosterone, Halothane, Zidovudine

2E1 2D6 3A4

Adapted from: S. Rendic Drug Metab Rev 34: 83-448, 2002

Factors Influencing Activity and Level of CYP Enzymes

Nutrition Smoking Alcohol Drugs 1A1;1A2; 1B1, 2A6, 2B6, 2C8,9,19; 2D6, 3A4,5 1A1;1A2, 2E1 2E1

1A1,1A2; 2A6; 2B6; 2C; 2D6; 3A3, 3A4,5 1A1,1A2; 2A6; 1B; 2E1; Environment 3A3, 3A4,5 Genetic 1A; 2A6; 2C9,19; 2D6; Polymorphism 2E1
Red indicates enzymes important in drug metabolism

Adapted from: S. Rendic Drug Metab Rev 34: 83-448, 2002

Non-nitrogenous Substances that Affect Drug Metabolism Grapefruit juice - CYP 3A4 inhibitor; highly variable effects; fucocoumarins
Bailey, D.G. et al.; Br J Clin Pharmacol 1998, 46:101-110 Bailey, D.G et al.; Am J Cardiovasc Drugs 2004, 4:281-97.

St Johns wort, other herbal products

Tirona, R.G and Bailey, D.G. ; Br J Clin Pharmacol. 2006,61: 677-81

Isosafrole, safrole
CYP1A1, CYP1A2 inhibitor; found in root beer, perfume

Effect of Grapefruit Juice on Felodipine Plasma Concentration

5mg tablet with juice

without

Cl Cl CO 2 CH3 CH3

Cl

CH3 O 2 C CH3 N H

3A4

CH3 O 2 C CH3 N

Cl CO 2 CH3 CH3

Review- D.G. Bailey, et al.; Br J Clin Pharmacol 1998, 46:101-110

Grapefruit Juice Facts

GJ or G, lime, or Sun Drop Citrus soda, Seville OJ(not most OJ) elevates plasma peak drug concentration, not elimination t1/2 GJ reduced metabolite/parent drug AUC ratio GJ caused 62% reduction in small bowel enterocyte 3A4 and 3A5 protein; liver not as markedly affected (i.v. pharmacokinetics unchanged) GJ effects last ~4 h, require new enzyme synthesis Effect cumulative (up to 5x Cmax) and highly variable among individuals depending upon 3A4 small bowel basal levels

Human Drug Metabolizing CYPs Located in Extrahepatic Tissues

CYP Enzyme 1A1 1B1 2A6 2B6 2C 2D6 Tissue Lung, kidney, GI tract, skin, placenta, others Skin, kidney, prostate, mammary,others Lung, nasal membrane, others GI tract, lung GI tract (small intestine mucosa) larynx, lung GI tract

S. Rendic & F.J. DiCarlo, Drug Metab Rev 29:413-80, 1997

Human Drug Metabolizing CYPs Located in Extrahepatic Tissues (contd)

CYP Enzyme 2E1 2F1 2J2 3A 4B1 4A11 Tissue Lung, placenta, others Lung, placenta Heart GI tract, lung, placenta, fetus, uterus, kidney Lung, placenta Kidney

S. Rendic & F.J. DiCarlo, Drug Metab Rev 29:413-80, 1997

CYP Biotransformations
Chemically diverse small molecules are converted, generally to more polar compounds Reactions include
Aliphatic hydroxylation, aromatic hydroxylation Dealkylation (N-,O-, S-) N-oxidation, S-oxidation Deamination Dehalogenation

Non-CYP Drug Biotransformations

Oxidations Hydrolyses Conjugation (Phase 2 Rxs)
Major Conjugation Reactions Glucuronidation (high capacity) Sulfation (low capacity) Acetylation (variable capacity)
Examples:Procainamide, Isoniazid

Other Conjugation Reactions: O-Methylation, SMethylation, Amino Acid Conjugation (glycine, taurine, glutathione) Many conjugation enzymes exhibit polymorphism

Non-CYP drug oxidations (1)

Monoamine Oxidase (MAO), Diamine Oxidase (DAO) - MAO (mitochondrial) oxidatively deaminates endogenous substrates including neurotransmitters (dopamine, serotonin, norepinephrine, epinephrine); drugs designed to inhibit MAO used to affect balance of CNS neurotransmitters (L-DOPA); MPTP converted to toxin MPP+ through MAO-B. DAO substrates include histamine and polyamines. Alcohol & Aldehyde Dehydrogenase - non-specific enzymes found in soluble fraction of liver; ethanol metabolism Xanthine Oxidase - converts hypoxanthine to xanthine, and then to uric acid. Drug substrates include theophylline, 6mercaptopurine. Allopurinol is substrate and inhibitor of xanthine oxidase; delays metabolism of other substrates; effective for treatment of gout.

Non-CYP drug oxidations (2)

Flavin Monooxygenases
Family of enzymes that catalyze oxygenation of nitrogen, phosphorus, sulfur particularly facile formation of N-oxides Different FMO isoforms have been isolated from liver, lung (S.K. Krueger, et al. Drug Metab Rev 2002; 34:523-32) Complete structures defined (Review: J. Cashman, 1995, Chem Res Toxicol 8:165-181; Pharmacogenomics 2002; 3:32539) Require molecular oxygen, NADPH, flavin adenosine dinucleotide (FAD) Single point (loose) enzyme-substrate contact with reactive hydroperoxyflavin monoxoygenating agent FMOs are heat labile and metal-free, unlike CYPs Factors affecting FMOs (diet, drugs, sex) not as highly studied as CYPs

Conjugation Reactions Glucuronidation

CO2H O OH OH HO O O P O P O CH2 OH O OH ON NH O O

+ ROH or R 3N UGT

CO2H OO R OH OH OH

O-glucuronide
CO2H R +R ON R OH OH OH

UDP- -D-glucuronic acid

N+-glucuronide

Liver has several soluble UDP-Gluc-transferases

HO 3 N O CH3

O N CH3
6

N N

HO

Morphine

Amitriptyline

Cotinine

Glucuronic acid conjugation to phenols, 3-amines, aromatic amines

Conjugation Reactions Sulfation

R OH
NH2 N N

+
N N H O H OH O OH O P O S O O

O R O S OH O

(PAPS, 3-phosphoadenosine5-phosphosulfate)

H HO

H OH

Examples: ethanol, p-hydroxyacetanilide, 3-hydroxycoumarin

H2N N O

H2N O N HO S O

NH2

NH

Minoxidil

Minoxidil-sulfate

Sulfation may produce active metabolite

Conjugation Reactions Acetylation

O A r NH2 Co A S O A r R NH2 R OH R SH N H R O CH3 O R N H CH 3 R S

O CH3 O CH3

Acetyl transferase

Examples: Procainamide, isoniazid, sulfanilimide, histamine

NAT enzyme is found in many tissues, including liver

Procainamide
O

Unchanged in Urine, 59%

H2 N

N H

24% Fast 17% Slow Unchanged in Urine, 85%

H N O

3%
O N H N

1%

NAPA

0.3%
H N O O N H H N
O H2 N N H H N

Procainamide
O H2 N N H N

trace metabolite

HO

H N

O N H N

non-enzymatic

O O N N H N
Lupus?

Additional Effects on Drug Metabolism

Species Differences Major differences in different species have been recognized for many years (R.T. Williams).
Phenylbutazone half-life is 3 h in rabbit, ~6 h in rat, guinea pig, and dog and 3 days in humans.

Induction Two major categories of CYP inducers

Phenobarbital is prototype of one group - enhances metabolism of wide variety of substrates by causing proliferation of SER and CYP in liver cells. Polycylic aromatic hydrocarbons are second type of inducer (ex: benzo[a]pyrene).

Induction appears to be environmental adaptive response of organism Orphan Nuclear Receptors (PXR, CAR) are regulators of drug metabolizing gene expression

PXR and CAR Protect Against Xenobiotics

co-activator PBP target genes CAR xenobiotics RXR PXR

xenoprotection

cytoplasm

nucleus
S.A. Kliewer

CYP3A Regulation

Diverse drugs activate through heterodimer complex Protect against xenobiotics Cause drug-drug interactions
T.M. Wilson, S. A. Kliewer 2002:1, 259-266

CYP3A Inducers Activate Human, Rabbit, and Rat PXR

rifampicin
PCN dexamethasone RU486 clotrimazole troglitazone Cell-based reporter assay

tamoxifen
1 3 5 7 9 11 13 15 17 19

Reporter activity (fold)

S.A. Kliewer

Pregnane X Receptor (PXR)

human PXR rabbit PXR mouse PXR rat PXR

DNA 94% 96% 96%

Ligand 82%

77%
76%

PXR is one of Nuclear Receptor (NR) family of ligand-activated transcription factors. Named on basis of activation by natural and synthetic C21 steroids (pregnanes), including pregnenolone 16-carbonitrile (PCN) Cloned due to homology with other nuclear receptors Highly active in liver and intestine Binds as heterodimer with retinoic acid receptor (RXR)
S.A. Kliewer

Constitutive Androstane Receptor (CAR)

CAR CAR CAR PXR PXR PXR

DNA
66%

Ligand
S.A. Kliewer

41%

Highly expressed in liver and intestine Sequestered in cytoplasm Co-factor complex required for activation; anchored by PPAR-binding protein (PBP) Binds response elements as RXR heterodimer High basal transcriptional activity without ligand Activated by xenobiotics phenobarbital, TCPOBOP (1,4-bis[2-(3,5dichloropyridyloxy)]benzene)

Acetaminophen (Paracetamol)
Acetanilide 1886 accidentally discovered antipyretic; excessively toxic (methemoglobinemia); para-aminophenol and derivatives were tested. Phenacetin introduced in 1887, and extensively used in analgesic mixtures until implicated in analgesic abuse nephropathy Acetaminophen recognized as metabolite in 1899 1948-49 Brodie and Axelrod recognized methemoglobinemia due to acetanilide and analgesia to acetaminophen 1955 acetaminophen introduced in US

Acetaminophen and p-Aminophenols

HN COCH 3
NH2

HN

COCH 3

Acetanilide, 1886 (accidental discovery of antipyretic activity; high toxicity) 70-90%

NH2

OC 2 H5

OC 2 H5

75-80%

Phenacetin or acetophenetidin, 1887 (nephrotoxic, methemoglobinemia)

HN

COCH 3
Metabolic pathway quantified; (Brodie &Axelrod, 1948) popular in US since 1955

OH
Acetaminophen, 1893

Acetaminophen Toxicity
Acetaminophen overdose results in more calls to poison control centers in the United States than overdose with any other pharmacologic substance. The American Liver Foundation reports that 35% of cases of severe liver failure are caused by acetaminophen poisoning which may require organ transplantation. N-acetyl cysteine is an effective antidote, especially if administered within 10 h of ingestion [NEJM 319:15571562, 1988] Management of acetaminophen overdose [Trends Pharm Sci 24:154-157, 2003

Acetominophen Metabolism
HN COCH 3

~60%

~35%
OH

HN

COCH 3

O HO

CO 2 H OH

CYP2E1* CYP1A2 CYP3A11

N COCH 3

HN

COCH 3

OH

SO 3 H

*induced by ethanol, isoniazid

Protein adducts, O NAPQI Oxidative stress N-acetyl-p-benzoquinone imine Toxicity

Acetaminophen Protein Adducts

HN COCH 3
N COCH 3

CYPs HS-Protein
OH
O

H2NProtein
COCH 3

Protein S N

HN

COCH 3

HN

COCH 3

S Protein
O

NH Protein OH

OH

S.D. Nelson, Drug Metab. Rev. 27: 147-177 (1995) K.D. Welch et al., Chem Res Toxicol 18:924-33 (2005)

Acetaminophen toxicity mechanism

N-acetyl cysteine is an effective agent to block GSH depletion and rescue from liver damaging toxicity CAR and PXR modulate acetaminophen toxicity (2002, 2004) CAR-null mice are resistant to acetaminophen toxicity hepatic GSH lowered in wild type (but not in KO) after acetaminophen CAR-humanized mice demonstrate same toxicity response

Activation of PXR induces CYP3A11 and markedly enhances acetaminophen toxicity in wild type mice CAR transcription co-activator KO blocks toxicity (2005)

Drug Metabolism - WWW Information Resources

http://www.icgeb.trieste.it/p450/
Directory of P450 Containing Systems; comprehensive web site regarding all aspects of chemical structure (sequence and 3D) of P450 proteins from all species; steroid ligands; links to related sites including leading researchers on P450

http://www.fda.gov/cder/guidance/
Site contains many useful documents regarding drug metabolism and FDA recommendations including "Drug Metabolism/Drug Interaction Studies in the Drug Development Process: Studies in Vitro", FDA Guidance for Industry

http://www.sigmaaldrich.com/Area_of_Interest/Biochem icals/Enzyme_Explorer.html
Site has many commercially available drug metabolizing enzymes and useful links to multiple drug metabolism resources

http://www.biocatalytics.com/p450.html
Six freeze dried human CYPs (1A2, 2C9, 2C19, 2D6, 2E1, 3A4) available for drug metabolism studies