Epidemiology of chronic myeloid leukaemia (CML).

Reliable epidemiological information on chronic myeloproliferative disorders (CMPDs), notably Philadelphia (Ph)/BCR-ABL-positive chronic myeloid leukaemia (CML), is rare. Incidence rates vary from 0.6 to 2.0 cases per 100 000 inhabitants, increase with age and are higher in men than in women. Geographic and/or ethnic variations might contribute to the variability of incidences among registries. Prevalence rate has increased by use of tyrosine kinase inhibitors. In daily clinical practice, some CML management areas are not in line with the current recommendations. Problematic areas are sub-optimal timing of treatment decisions under monitoring, and unawareness of new molecular monitoring techniques and of beneficial new tyrosine kinase inhibitors. Median age differs between cancer registries and clinical trials by 10-20 years. Reports of clinical studies underestimate the true age of the CML population. Elderly CML patients are underrepresented in clinical studies and thus have a reduced access to investigational therapies.

Cross-sectional analysis of the influence of currently known pharmacogenetic modulators on opioid therapy in outpatient pain centers.

AIM: A finite number of variants in the OPRM1, COMT, MC1R, ABCB1 and CYP2D6 genes has been identified to significantly modulate the effects of opioids in controlled homogenous settings. We analyzed the imprint of these variants in opioid therapy in a highly variable cohort of pain patients treated in outpatient units to test whether genotyping may play a role in this clinical setting. METHODS: In a multicenter study conducted in tertiary care outpatient pain centers, 352 patients (156 men and 196 women, aged 58.5+/- 14.6 years) treated for 1-600 months (63.4 +/- 92.4 months) with various opioids for pain of various origins were included. Genotyping was performed for all the variants reportedly modulating pain in well-defined cohorts. Association analyses focused on opioid dosing, the actual 24-h pain score on a 0-10 rating scale and the occurrence of side effects. RESULTS: The frequency of the genetic variants in the patients did not significantly differ from that in the average Caucasian population. Daily opioid doses ranged from 4 to 1750 mg oral morphine equivalents (133.4 +/- 203.2 mg) and significantly decreased in a gene dose-dependent manner with the P-glycoprotein variant ABCB1 3435C>T. Pain was rated on average at 3.7 +/- 2.6. There was a tendency towards increased pain in a gene dose-dependent manner with the mu-opioid receptor variant OPRM1 118A>G. CONCLUSION: Genetics were reflected in the outpatient pain therapy only to a modest degree. The need of outpatient therapy of pain of various causes guided by the presently known functional genetic variants cannot be convincingly concluded from the present data. Using the ABCB1 3435 genotype to predefine lower individual opioid doses barely merits the laboratory effort. If any, the results suggest that a genetics guided outpatient pain therapy may be based on ABCB1 and OPRM1 variants.

Can extremely low or high morphine formation from codeine be predicted prior to therapy initiation?

Activation of codeine by O-demethylation into morphine is a prerequisite for its analgesic effects and severe toxicity. Identifying patients in whom morphine is formed either at extremely low or at extremely high amounts may improve efficacy and safety of codeine therapy. To assess how well this identification is possible, we compared the performance of current CYP2D6 phenotype association systems (traditional genotype-based classification, a recently proposed CYP2D6 activity score, and the plasma dextromethorphan metabolic ratio) in 57 healthy Caucasians after oral administration of 30 mg dextromethorphan hydrobromide or 50 mg codeine. Most subjects (87.5%) at the lower 15% of morphine formation from codeine and thus likely to not to respond to codeine therapy were correctly identified by CYP2D6 genotype- or phenotype-based systems. In contrast, in subjects at the upper 15% of morphine formation being at risk for opioid toxicity, CYP2D6 genotyping predicted only the 50% who carried gene duplication, whereas dextromethorphan-based phenotyping identified 67.5% of the subjects with high morphine formation. However, satisfactory prediction (87.5%) of high morphine formation was only achieved when combining genotyping with phenotyping. In conclusion, insufficient morphine formation from codeine and thus likely failure of analgesia can currently be well predicted. However, to make codeine therapy safe, extremely high morphine formation has to be predicted as well, which has to be obtained at the effort of combining genotyping with phenotyping.

A comparison of the steady-state pharmacokinetics of nevirapine in men, nonpregnant women and women in late pregnancy.

AIMS: To evaluate the pharmacokinetics of nevirapine and any possible influencing factors in pregnant women (n = 16), nonpregnant women (n = 13) and men (n = 14), who received nevirapine 200 mg twice daily together with nucleoside reverse transcriptase inhibitors. METHODS: Blood samples were taken for 12 h at steady state. Nevirapine concentrations were measured by liquid chromatography-tandem mass spectrometry. The influence of gender, age, body weight and comedication on minimum and maximum concentrations (C(min), C(max)), area under the concentration-time curve (AUC), total clearance (CL(tot)), half-life (t(1/2)) and volume of distribution (V(d)) was analysed by multivariate techniques. RESULTS: Mean [95% confidence interval (CI)]C(max), AUC(ss) and clearance were 5221 ng ml(-1) (4267, 6175), 50 789 ng (-1)h ml(-1) (43 453, 58 125) and 69.9 ml min(-1) for men, 5871 ng ml(-1) (4848, 6895), 57 045 ng h(-1) ml(-1) (45 997, 68 093) and 65.6 ml min(-1) for nonpregnant women and 4505 ng ml(-1) (3644, 5366), 44 579 ng h(-1) ml(-1) (36 564, 52 594) and 82.1 ml min(-1) for pregnant women. The differences between pregnant and nonpregnant women (% difference, 95% CI) in C(max) (-30.3; -28.5, -33.0), AUC(ss) (-28.0; - 25.8, - 29.5) and clearance (20.2; 26.6, 15.6) reached statistical significance (P = 0.010, P = 0.028 and P = 0.028, respectively). The multivariate analysis underscored the influence of bodyweight on the plasma exposure to nevirapine. CONCLUSIONS: Pregnant women exhibited an increased nevirapine clearance and comparably low plasma concentrations, whereas women with a low bodyweight achieved high plasma nevirapine concentrations. The large variability in nevirapine concentrations in women may lead to loss of efficacy and viral resistance, or drug toxicity, and therefore these patients should be monitored frequently.

Pyrosequencing-based screening for genetic polymorphisms in cytochrome P450 2B6 of potential clinical relevance.

OBJECTIVES: Three exonic single nucleotide polymorphisms (SNPs) in the cytochrome P450 2B6 (CYP2B6) gene, 516G>T, 785A>G and 1459C>T, have been described to be associated with functional changes in the CYP2B6 catalytic activity or protein expression. They are therefore of potential clinical importance for drug efficacy and safety of CYP2B6 substrates, in particular of antiretroviral therapy regimes that include efavirenz. Therefore, we aimed at providing genetic screening assays for these three SNPs. METHODS: Simplex Pyrosequencing assays were developed for the selected CYP2B6 SNPs. A total of 273 DNA samples from healthy volunteers of Caucasian ethnicity were genotyped. RESULTS: The presently developed Pyrosequencing assays afford an accurate determination of the three SNPs in the 273 DNA samples. The assays were verified by routine implementation of control samples obtained by conventional sequencing. The frequencies for the variant alleles 516T, 785G and 1459T were 0.22, 0.24 and 0.13, respectively. All genotype frequencies were in agreement with the Hardy-Weinberg equilibrium. CYP2B6 alleles CYP2B6*5A (1459T), CYP2B6*6 (516T/785G) and *7B (516T/785G/1459T) were found at allelic frequencies of 0.12, 0.20 and 0.01. CONCLUSION: The present reliable and quick Pyrosequencing assays afford facilitating future research on the importance of CYP2B6 pharmacogenetics for personalized drug therapy with CYP2B6 substrates.

Rapid identification of three functionally relevant polymorphisms in the OATP1B1 transporter gene using Pyrosequencing.

INTRODUCTION: Clinical evidence suggests there are three single nucleotide polymorphisms (SNPs) of the solute carrier organic anion transporter family member B1 (SLCO1B1) gene for which in vivo evidence for a functional relevance for organic anion transporter polypeptides subgroup C (OATP1B1, formerly OATP-C) has been provided. These genetic variants have been shown to lead to altered pharmacokinetics of OATP1B1 substrates, mainly pravastatin, but also the irinotecan metabolite SN-38, estrone-3-sulfate, and estradiol-17beta-glucuronide. The authors therefore developed reliable and quick screening assays to identify the SLCO1B1 SNPs -11187G>A, 388A>G and 521T>C, in order to facilitate the judgment of their clinical role and to identify allelic frequencies of SNPs and haplotypes in a Caucasian random sample. METHODS: Three simplex Pyrosequencing assays were developed and the three selected SLCO1B1 SNPs were screened for in 250 DNA samples from healthy young female and male unrelated volunteers of Caucasian ethnicity. SLCO1B1 haplotypes involving DNA positions -11187, 388 and 521 were identified by in silico haplotyping. RESULTS: A clear identification of the three single nucleotide polymorphisms in the 250 DNA samples was possible and was verified by routine implementation of 40 control samples obtained by conventional sequencing. The frequencies of the variant alleles -11187A, 388G and 521C were 0.09, 0.47 and 0.12, respectively. All observed frequencies of heterozygous of homozygous carriers of SLCO1B1 alleles were in agreement with the Hardy-Weinberg equilibrium. SLCO1B1 haplotypes reportedly associated with altered substrate pharmacokinetics, i.e., SLCO1B1*15B (-11187G/388G/521C) and *17 (-11187A/388G/521C), were found at allelic frequencies of 0.09 and 0.02, respectively. CONCLUSION: The presently developed Pyrosequencing assays allowed for quick and reliable identification of those SLCO1B1 SNPs that had been proposed to cause functional alternations in OATP1B1 with shown consequences for the pharmacokinetics of drugs that are OATP1B1 substrates.

Evidence for morphine-independent central nervous opioid effects after administration of codeine: contribution of other codeine metabolites.

OBJECTIVE: Our objective was to investigate whether codeine or one of its metabolites contributes substantially to central nervous effects independent from the cytochrome P450 (CYP) 2D6-mediated O-demethylation to morphine. METHODS: After oral administration of codeine, plasma concentrations of codeine and its metabolites, as well as pupil size as a measure of central nervous effects, were measured in 11 healthy volunteers representing poor, intermediate, extensive, and ultrarapid metabolizers for CYP2D6. Subsequently, the observed plasma morphine concentrations were mimicked by use of computerized morphine infusion, and the miotic effects were compared with those observed after codeine administration. The contribution of codeine, codeine-6-glucuronide, norcodeine, morphine, morphine-6-glucuronide, and normorphine to the miotic effects was analyzed by means of pharmacokinetic-pharmacodynamic modeling. RESULTS: The areas under the curve of the miotic effects after codeine were 1.7 +/- 2 times greater than after morphine (P <0.01). This contrasted to similar or even lower morphine concentrations after codeine than after morphine (area under the curve ratio, 0.5 +/- 0.4; P =.21). A pharmacokinetic-pharmacodynamic fit of the miotic effects by use of morphine as the only active moiety was most significantly (P <.0001) improved when codeine-6-glucuronide as a second active moiety was added. CONCLUSION: CYP2D6-dependent formation of morphine does not explain exclusively the central nervous effects of codeine. Codeine-6-glucuronide is the most likely additional active moiety.