Transcript Document 7119307

U.S. Department of
Health and Human
Services
National Institutes
of Health
National Heart, Lung,
and Blood Institute
BIOCHEMICAL MECHANISMS OF
DRUG TOXICITIES
Lance R. Pohl, Pharm.D., Ph.D.
Chief, Section of Molecular and Cellular Toxicology
Laboratory of Molecular Immunology
[email protected]
1/4/2007
TOXICITIES PRODUCED BY DRUGS
Hepatic
Skin
Renal
Pulmonary
Cardiac
Neurological
Lupus
Anaphylaxis
Hemolytic anemia
Granulocytopenia
Thrombocytopenia
Aplastic anemia
Vasculitis
LEADING CAUSES OF DEATH IN USA IN
1994
Heart disease
Cancer
Stroke
Adverse drug reactions
Pulmonary disease
Accidents
Pneumonia
Diabetes
Lazarou et al., JAMA, 279, 1208
(1998)
743,460
529,904
150,108
106,000
101,077
90,523
75,719
53,894
TYPE A ADRs
•
•
•
•
•
Accounts for 80% of ADRs
Dose-dependent and often predictable
Often due to excessive expression of
known pharmacologic effects
Often caused by drug-drug interactions
Often reproduced in animals
Role of transporters in drug interactions, C.J. Endres, et al., European Journal of
Pharmaceutical Sciences, 27, 501 (2006)
EXAMPLES OF TYPE A ADRS
•
•
•
•
•
Drowsiness from the use of
antihistamines
Exacerbated therapeutic responses of
warfarin and phenytoin-low therapeutic
indices
Posicor, anti-hypertensive withdrawn from
market because inhibited the metabolism
of over 30 drugs
Acetaminophen
Fialuridine
FIALURIDINE-INDUCED MITOCHONDRIAL
INJURY IN PATIENTS
•
•
•
•
•
FIAU is a uridine analog developed for hepatitis B
treatment
Administration to 15 patients resulted in 7 developing
severe mitochondrial liver damage with 5 dying and 2
receiving liver transplants
Toxicity was not predicted from rodent studies
Toxicity of FIAU is apparently due to FIAU-TP which
inhibits mitochondrial DNA polymerase-γ and DNA
synthesis
Humans and not rodents have human nucleoside
transporter 1 (hENT1) in the mitochondrial membrane
E.W. Lee, et al., J.Biol.Chem., 281, 16700 (2006)
TYPE B ADRs
•
•
Accounts for 20% of ADRs
Rare, unpredictable, and highly hostdependent
• Mechanisms usually unknown, but in
some cases they have been attributed to:
 Allergic reactions
 Pseudoallergic reactions
 Deficiency in cytoprotective factors
 Polymorphisms
• Rarely reproduced in animals
HAPTEN HYPOTHESIS AND DRUGINDUCED ALLERGIC REACTIONS
Drug
or
Metabolite
+
Toxicity
B and T Cell Responses
FORMATION OF PROTEIN ADDUCTS
WITHOUT DRUG METABOLISM
Penicillins
R CH2
S
CONH
N
O
CH3
R CH2 CONH CH
O C HN
CH3
S
NH
COOH
CH3
CH3
COOH
Lys
Protein
Cephalosporins
R1
S
S
CONH
R1
N
CONH CH
O C
R2
O
HN
NH
COOH
R2
COOH
Lys
Protein
Penicillamine
NH2CH3
NH2CH3
HOOC C C CH3
HOOC C C CH3
H SH
H S
S
Cys
Protein
Captopril
COOH
COOH
N
C CH CH2
O CH3
N
SH
C CH CH2 S S Cys
O CH3
Protein
ROLE OF IMMUNE SYSTEM IN INITIATING
DRUG-INDUCED ALLERGIC REACTIONS
Secreted
Injured Cell
Immature Dendritic Cell
Drug Protein Conjugate
Formed in a Cell
B Cell
IgG, IgE,
IgA
Ag Processing
Regulatory T Cells
Migration to Periphery
Block Drug Allergy
Migration to Periphery
Drug Allergy
Ag Presentation by
MHC Class 1 and 2
CD4+
CD8+
HSPs, INF-,
TNF-, IL-1
IL-10, PGE2,TGF-
Migrate to Lymph Nodes
Immunization of T Cells
Migrate to Lymph Nodes
Tolerization of T Cells
+
CD4
CD8+
PATHWAYS OF IMMUNOPATHOLOGY
DRUG-INDUCED LIVER DISEASE IS A
MAJOR HEALTH PROBLEM
It is a major cause of acute liver failure
and a major safety reason for:
• Stopping preclinical development of
drugs
• Terminating clinical trials of drugs
• Withdrawing drugs postmarketing
F. Ballet, J. Hepatol., 26 (Suppl. 2), 26 (1997)
LIVER DISEASE IS CAUSED BY MANY
COMMONLY USED CLASSES OF DRUGS
•
•
•
•
•
Antihypertensives
Lipid-lowering
agents
NSAIDs
Antimicrobials
Antidiabetic
agents
•
Anticonvulsants
• Psychotropic
agents
• Inhalation
anesthetics
• Herbal medicines
DRUGS WITHDRAWN / NOT APPROVED
DUE TO LIVER DISEASE
Iproniazid
Ibufenac (Europe)
Ticrynafen
Benoxaprofen
Perhexilene (France)
Dilevalol (Portugal and Ireland)
Bromfenac
Troglitazone
Nefazodone (Serzone)
Ximelagatran (Exanta)
1956
1975
1980
1982
1985
1990
1998
2000
2003
2004
COMPLEXITY OF DRUG-INDUCED LIVER
DISEASE
Initiation
Progression
Reactive
Metabolites
Innate Immune
System Activation
Kupffer
Cells
Protein
Adducts
ROS, RNS
Injury
Release of Protein
Adducts
Release of
Adjuvants
Dendritic
Cells
NK and NKT Cells,
Monocytes, PMNs,
and Eosinophils
Adaptive Immune
System Activation
Effector Abs and T
Cells
Secondary Injury
Death
Repair
PATHWAY OF HALOTHANEINDUCED ALLERGIC HEPATITIS
F
F
H
C
C
F
Cl
Br
P450
F
F
O
C
C
O
F
C
C
F
F
Cl
F
Hepatocyte
Halothane
Trifluoroacetyl Chloride
Humoral and Cellular Immune Responses
Toxicity
HALOTHANE HEPATITIS PATIENTS’
SERUM ANTIBODIES (% REACTIVITY)
Antigen
TFA-Protein
Native-Protein
PDI
10
5
PDI isoform
55
25
Carboxylesterase
13
5
Calreticulin
5
3
ERP72
30
25
GRP94
65
28
CYP2E1
45
OTHER FLUORINATED INHALATION
ANESTHETICS FORM IDENTICAL
PROTEIN ADDUCTS
F H
F C C Br
F Cl
Halothane
F Cl
F
F
F C C O C H
F H
F
F C C O C H
F
F H
F
Desflurane
Isoflurane
P450
O F
C C
F
Hepatocyte
F
F
CYP AUTOANTIBODIES ASSOCIATED WITH OTHER
DRUGS CAUSING ALLERGIC HEPATITIS
Drug
Antigen
Tienilic acid
CYP2C9
Dihydralazine
CYP1A2
Ethanol
CYP2E1, CYP3A4,
CYP2E1-hydroxyethyl
radical
T CELL REACTIVITY ASSOCTIATED WITH
DRUGS CAUSING ALLERGIC HEPATITIS
Cotrimoxazole
Erythromycin
Ketoconazole
Ampicillin
Allopurinol
Ibuprofen
Captopril
-Methyldopa
Enalapril
Maria and Victorino, Gut, 41, 534
(1997)
Chlorpromazine
Amineptine
Dothiepine
Phenytoin
Carbamazepine
Tamoxifen
Glibenclamide
Lovastatin
Propylthiouracil
MECHANISM OF ACETAMINOPHEN
(APAP) HEPATOTOXICITY
SERUM CYTOKINE LEVELS AFTER APAP
TREATMENT OF MICE
15000
ALT
IU/L
12000
9000
6000
3000
0
4
8
12
300
IL-10
pg/mL
pg/mL
300
200
200
4
8
12
4
8
12
24
8
12
24
500
IL-6
IL-13
400
pg/mL
pg/mL
200
0
24
160
120
80
40
0
IL-4
100
100
0
24
300
200
100
4
8
12
24
0
Time (hr)
4
IL-10 DEFICIENCY INCREASES APAPINDUCED LIVER INJURY AND DEATH
Survival (%)
100
80
60
40
Wild Type
IL-10 KO
20
0
0
10
20
30
Time (hours)
40
50
APAP-LIVER NECROSIS IN IL-10-/- MOUSE
IL-10 REGULATES iNOS
0.75
Liver iNOS mRNA Level
(Arbitrary Unit)
Wild-Type
Knockout
*
0.50
0.25
0.00
Wild-Type
Knockout
IL-10/iNOS KO MICE ARE NO MORE
SUSCEPTIBLE TO APAP THAN WT
MICE
ALT (IU/L)
5000
*
4000
A=
B=
C=
D=
3000
Wild Type APAP
IL-10 KO APAP
iNOS/IL-10 KO APAP
iNOS KO APAP
2000
1000
0
A
B
C
D
IL-10 PROMOTER POLYMORPHISMS
IN DRUG-INDUCED LIVER DISEASE
• Diclofenac: G. P. Aithal et al., Gastroenterology,
118(4), 1077, Part 1, Supplement. 2. April 2000
• Ethanol: J. Grove et al., Gut 46, 540-545 (2000)
OTHER HEPATOPROTECTIVE FACTORS
UNCOVERED WITH KNOCK OUT MICE
•
•
•
•
•
IL-6: liver regeneration, prevents apoptosis,
induces HSPs
COX-2: prostaglandin products induce HSPs and
prevent inflammation
IL-4 and IL-13: mechanisms not yet defined
Nrf2: regulates induction of GSH synthesis,
UGTs, GSTs, NADPH quinone reductase, heme
oxygenase, catalase
CCR2: down regulates INF-γ and TNF-α
Y. Masubuchi K. Chan, et. al., PNAS, 98, 4611 (2001); C.M. Hogaboam, et. al., Am.
J. Pathol., 156, 1245 (2000).
NIH FUNDS NETWORK TO STUDY DRUGINDUCED LIVER INJURY (DILIN)
•
•
•
Sponsored by the National Institute of Diabetes
and Digestive and Kidney Diseases (NIDDK) in
2004
The DILIN centers are located at U. of North
Carolina, Duke, U. of Michigan, U. of Connecticut,
and U. of California in SF
The goal is to establish a registry of patients who
have experienced severe drug-induced liver
disease and collect biological samples for
biochemical, serological, and genetic testing by
investigators throughout the country
DRUG-INDUCED CUTANEOUS ADRS
•
Exanthems-95% are erythematous or
maculo-papular in nature and are usually
self-limiting when the drug is withdrawn,
Steven-Johnson syndrome and toxic
epidermal necrolysis are life-threatening
• Exanthems from β-lactam antibiotics are
often mediated by drug-specific IgE
antibodies while many others by CD4+ and
CD8+ T cells
N. Yawalkar, Toxicology, 209, 131(2005)
T CELL REACTIVITY TO DRUGS CAUSING
CUTANEOUS ADRS
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•
•
•
•
Lidocaine
Sulfonamides
-Lactam antibiotics
Phenytoin
Carbamazepine
Lebrec et al., Cell Biology and Toxicology, 15, 57 (1999)
MACULO-PAPULAR EXANTHEM AND TOXIC
EPIDERMAL NECROLYSIS
MECHANISM OF T-CELL MEDIATED
CUTANEOUS ADRS

S. Roychowdhury and. C.K. Svensson,
The AAPS Journal, 7, E834 (2005)
MECHANISMS OF DRUG-INDUCED IMMUNEMEDIATED BLOOD DYSCRASIAS
Bind and activate
complement
HAPTEN MECHANISM
Drug
Cell lysis
Anti-Drug
Ab
Bind to Fc receptor
of macrophages
IMMUNE COMPLEX MECHANISM
Immune
Complex
Lysis by complement
and/or macrophages
AUTOANTIBODY MECHANISM
AutoAb
Lysis by complement
and/or macrophages
DRUG-INDUCED IMMUNE-MEDIATED
HEMOLYTIC ANEMIA
Hapten
Mechanism
Immune Complex
Mechanism
Autoantibody
Mechanism
Ampicillin
Diclofenac
Cephalosporins
Carbenicillin
Isoniazid
Diclofenac
Penicillin
Tetracycline
Levodopa
Methicillin
Quinidine
Methyldopa
Cephalosporin
Thiopental
Procainamide
Tetracycline
Chlorpromazine
Nomifensine
Tolbutamide
Nomifensine
Tolmentin
T. Deloughery, Immunol.
Allergy Clin. of North Am. 18,
829 (1998)
Lists drugs causing aplastic
anemia, agranulocytosis, and
thrombocytopenia
IgE-MEDIATED ANAPHYLACTIC DRUG
REACTIONS
Alcuronium
Cephalosporins
Penicillins
Protamine
Streptokinase
Park et al., Chem. Res. Toxicol., 11, 969 (1998);
B.Y.H. Thong and Y. Chan, Ann. Allergy Asthma
Immunol., 92, 619 (2004).
Sulfamethoxazole
Suxamethonium
Thiopentone
Trimethoprine
Tubocurarine
MECHANISM OF DRUG-INDUCED
ANAPHYLAXIS
Drug
IgE-secreting
plasma cell
1. Airway smooth muscle contraction
leading to bronchospasm
2. Increase permeability of blood vessels
and mucous gland secretion
3. Inflammation (eosinophils and
neutrophils)
4. Respiratory, gastrointestinal, cutaneous,
and cardiovascular systems can be involved
Mast cell or basophil
Histamine, leukotrienes,
and cytokines
ASSOCIATION OF GENETIC VARIANTS OF
HLA-B AND HSP70 WITH HYPERSENTIVITY
TO ABACAVIR
•
•
•
•
Abacavir is a nucleoside reverse transcriptase inhibitor
used to treat HIV type 1
Approximately 5% of patients who receive abacavir develop
a treatment-limiting hypersensitivity reaction, characterized
by fever, rash, gastrointestinal symptoms (nausea,
vomiting, diarrhea or pain) and lethargy or malaise
Median time to onset is 11 days, but symptoms occur within
hours when patients are rechallenged
Susceptibility is associated with specific variants of HLA-B
and HSP70 and CD8+ T cells that are activated in presence
of abacavir to produce TNF
A.M. Martin, et. al., PNAS, 101, 4180 (2004)
PSEUDOALLERGIC (ANAPHYLACTOID)
REACTIONS WITH NSAIDS
•
Most cases occur with aspirin, although
other NSAIDs can be involved except for
COX-2 inhibitors
• Reactions include asthma, rhinitis,
urticaria and/or anaphylactic shock.
• Not mediated by IgE antibodies
• COX-1 inhibitors may divert arachidonic
acid metabolism to 5-lipoxygenase
pathways and formation of proinflammatory cysteine-leukotrienes
PSEUDOALLERGIC (ANAPHYLACTOID)
REACTIONS WITH NSAIDS
•
Leukotrienes cause bronchial smooth
muscle contraction, mucous secretion,
vasodilation, and cellular infiltration
• Cysteine-leukotriene receptor 2 polymorphisms associated with aspirin
intolerance
J.S. Park et al., Pharmacolgenics and Genomics, 15, 483 (2005)
ANAPHYLACTOID REACTIONS WITH
IODINATED RADIOCONTRAST AGENTS
•
•
Reactions can be similar to aspirin and include
asthma, rhinitis, urticaria, gastrointestinal
symptoms, and/or anaphylactic shock consisting
of hypotension, pulmonary edema, respiratory
arrest, cardiac arrest, and convulsions
Mechanisms?
J. Szebeni, Toxicology 216, 106 (2005)
MECHANISMS OF REACTIONS TO
RADIOCONTRAST REAGENTS
ENZYME POLYMORPHISMS AND TYPE B
ADVERSE DRUG REACTIONS
•
Sensitivity to warfarin and phenytoin due to
metabolic deficiency caused by CYP2C9*3
Rettie et al., Epilepsy Research, 35, 253 (1999); Brandolese et al., Clin.
Pharmacol. Ther., 70, 391 (2001)
•
Irinotecan side effects of serious and potentially
fatal diarrhea and neutropenia are associated
with metabolic deficiency caused by UGT1A1*28
and other allelic forms of UGT1A
Han et al., J. Clin. Oncol., 24, 2237 -2244 (2006)
THIOPURINE-S-METHYLTRANSFERASE
POLYMORPHISMS AND TYPE B ADR
•
•
Thiopurine drugs 6-mercaptopurine and azathioprine are used to treat acute lymphoblastic
leukemia in children, inflammatory bowel disease,
autoimmune disease, and organ transplant
recipients
Polymorphisms of TPMT that lead to low enzyme
activity result in life-threatening pancytopenia
L. Wang and R. Weinshilboum, Ongene, 25, 1629-1638 (2006)
THIOPURINE METABOLISM RESULTS IN
THERAPEUTIC ACTIVITY AND TOXICITY
DRUG-INDUCED-LONG QT SYNDROME
•
•
•
•
•
•
Results in prolonged ventricle repolarization that can lead
to polymorphic ventricular tachycardia (torsade de pontes),
and ultimately ventricular fibrillation and death
Rare, unpredictable, and a major reason for withdrawal or
restriction of many drugs
Antiarrhythmic drugs such as quinidine, procainamide,
sotalol and others
Other classes of drugs cause this syndrome including
astemizole (antihistamine), terfenadine (antihistamine),
mibefradil (anti-hypertensive), and grepafloxacin (antibiotic)
Linked to genetic variants of drug-metabolizing enzymes
Linked to cardiac K ion channel subclinical mutations
P.J. Kannankeril and D.M Roden, Current Opinion in Cardiology, 22, 39 (2007)
Summary
•
•
•
•
•
Drug-drug interactions are a major cause of Type A
ADRs and are in many cases predictable
Type B ADRs may be caused by rare allelic forms of
enzymes, receptors, ion channels, transporters,
transcription factors, etc
Many Type B ADRs also appear to be mediated by
specific Abs and T cells that are induced by protein
adducts of reactive metabolites
It is likely that numerous factors protect most people
from getting Type B ADRs and rare polymorphisms of
one or more of these factors determine individual
susceptibility
Toxicogenomics and proteomics should provide new
information about other important regulatory factors
that normally protect cells from TYPE B ADRs
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