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From DNA to Drug Treatment
Andrew Schork
COGS 174
“It is more important
to know what sort of
person has a disease
than to know what sort
of disease a person
(460 BC – 370 BC)
• Pharmacogenomics
– The science of how genes affect the way people people
respond to drugs
– How genes affect…
…the way our body processes drugs (pharmacokinetics)
…the interaction of drugs with receptors (pharmacodynamics)
…the treatment efficacy and adverse side effects
• Pharmacogenetics
– A subset of ‘pharmacogenomics’
– The study of how inherited variation affects drug
response and metabolism
Why is this a good approach?
• Drugs can be dangerous
– Many people have severe adverse reactions to drugs
– Many people respond to drugs at different doses
– Many drug treatments are horribly unpleasant, painful
• Drugs are expensive (to take and to make)
– Ineffective drugs are a waste of money to take
– Drug development needs to account for response
• Genetics provide a priori information
– Genetics don’t change (except in cancer)
– Genetics can point to the cause not just the symptom
The waaay waaay back….
• Pythagoras (the triangle guy)
– Ancient Greek mathematician and
• Pythagoreanism (his belief system
and moral code) forbid eating and
even touching of beans
• Reasons: ‘seed of life,’ looks like
genitals, flatulence, damaging
• Genetic glucose-6-phosphate
dehydrogenase (G6PD) deficiency
causes induced hemolytic anemia
or ‘favism’
“…I ate his liver with some
fava beans and a nice
The waaaay back…
• 1931 - DuPont chemist
Arthur Fox
• Lab accident led to the
discovery of ‘taste
• 1959 - Freidrich Vogel
coined the term
“pharmacogenetics” after
discovering polymorphic
Early studies…
• Fast increase in awareness
of the interaction of drug
and drug response
• Many family studies, twin
studies and ‘top-down’
genetic studies
• Very laborious
experimental work
through the study enzyme
actions and clinical
• PCR sped things up a bit
•1975 Smith and colleagues
ingest a drug they are testing
•He had a bad reaction but his
colleagues did not
•Family studies revealed
genetic inheritance
•Enzyme discovered and
•Enzyme cDNA sequenced and
variants found (1990)
•This family of gene important
for many drugs
The transition to the modern era…
• Human Genome Project
and technological
developments expanded
the possibilities
A brief aside into modern genetics
• Single Nucleotide
• Most common and
well studied form of
• Defined by a
population frequency
> 1%
The Technology: Genotyping
• Uses a microarray to measure a
limited predefined set of SNPs
• Very high throughput (fast)
• Very inexpensive (cheap)
• Excellent coverage of common
variation (up to 5,000,000 SNPs)
• Relies on Linkage Disequilibirum
Common Variation
Rare Variation
No Recorded Variation
The Technology: Deep Sequencing
• Captures every base pair in the
genome (3,000,000,000)
• (Currently) low throughput (slow)
• (Currently) Very expensive (> 10k)
• Captures common, rare, and
personal variation
• New and hard to analyze
Common Variation
Rare Variation
No Recorded Variation
Back to the drugs…
• The utility of pharmacogenetics:
– Determining appropriate dosing
– Avoiding unnecessary toxic treatments
– Ensuring maximal efficacy
– Reducing adverse side effects
– Developing or choosing novel treatments
– Can also explain variable response to illicit drugs
Warfarin: A dosage story
• Most widely used
anticoagulant in the world
– A “blood thinner”
• Prescribed doses vary widely
(1-40mg / daily)
• Therapuetic index is very low
– High risk of bleeding early in
• Two genes involved in
metabolism: CYP2C9 and
Homozygous wild-type CYP2C9 and VKORC1
Carrier of CYP2C9 mutant allele
Carrier of VKORC1 mutant allele
CYP2C9 genotype
Time to stable dose
*1/*1 extensive(normal) metabolizer
4 - 5 days
*1/*2 intermediate metabolizer
8 -10 days
*1/*3, *2/*2, *3/*3 intermediate or
poor metabolizer
12-15 days
Plavix: A story about effectiveness
• Anti-clotting drug
• Prescribed for coronary
artery disease and
those who have
suffered a heart attack
or stroke or have a stent
• A “pro-drug”
– Converted to active form
in the liver by CYP2C19
CYP2C19 mutant carriers had reduced presence of
the active ingredient (pharmacokinetics) and
reduced ‘thinning’ (pharmacodynamics
Pegasys: A toxic treatment story
• Pegylated Interferon α-2a
– Interferons are proteins
made in response to virus
• Treatment for Hepatitis B
and C Virus
• Highly toxic treatment
• Highly variable response,
especially in African
• Very expensive
• One mutation in the IL28B gene (a natural interferon) increased
efficacy two-fold
• This mutation is different in different ethnicities and explains half
of the ethnic variability in treatment
Cancer Treatments: A story about the future?
Ozzy Osbourne: A story about different drugs
Personalized Medicine
• There is an emerging goal among ‘translational
scientists’ to make medical practice more
• Pharmacogenetics is
an important step
towards that goal
• The effects of this
movement are seen in
many aspects of society
Direct to consumer genetic testing
• Companies now offer genetic testing services
directly to customers
• Pharmacogenetic testing is becoming an
important aspect of this service
• Controversy about whether this should be
available to anyone or only doctors and about
its accuracy
Economic investment is huge
• Roche is a Swiss
• Illumina is the world’s
largest supplier of
genome sequencing
(San Diego based!)
• Interested in
sequencing applications
to drug development
and diagnostics
Concerns with this approach?
• How reliable are the tests?
• Are health care providers prepared to use this
• Will Insurance companies pay for the tests?
• Will tailor made medicine lead to discrimination?
• Will ethnic biases in science bias treatment
• Will this affect people’s privacy?