Pharmacogenetics: a drug for each person

Sometimes, some people say that the medications prescribed by doctors are not good. Can this be true? Not all drugs work for the same population. Keep reading and discover the secrets of pharmacogenetics.

INTRODUCTION

The same that happens with nutrients, happens with drugs. Another objective of personalized medicine is to make us see that not all medicines are for everyone. However, it does not come again because around 1900, the Canadian physician William Osler recognized that there was an intrinsic and specific variability of everyone, so that each one reacts differently to a drug. This is how, years later, we would define pharmacogenetics.

It is important to point out that it is not the same as pharmacogenomics, which studies the molecular and genetic bases of diseases to develop new treatment routes.

First, we need to start at the beginning: what is a drug? Well, a drug is any physicochemical substance that interacts with the body and modifies it, to try to cure, prevent or diagnose a disease. It is important to know that drugs regulate functions that our cells do, but they are not capable of creating new functions.

Apart from knowing if a drug is good or not for a person, you also have to take into account the amount that should be administered. And we still do not know the origin of all diseases, that is, we do not know most of the real molecular and genetic causes of diseases.

The classification of diseases is based mainly on symptoms and signs and not on molecular causes. Sometimes, the same group of pathologies is grouped, but among them there is a very different molecular basis. This means that the therapeutic efficacy is limited and low. Faced with drugs, we can manifest a response, a partial response, that produces no effect or that the effect is toxic (Figure 1).

Figure 1. Drug toxicity. Different colours show possible responses (green: drug not toxic and beneficial; blue: drug not toxic and not beneficial; red: drug toxic but not beneficial; yellow: drug toxic but beneficial) (Source: Mireia Ramos, All You Need is Biology)

DRUGS IN OUR BODY

Drugs usually make the same journey through our body. When we take a drug, usually through the digestive tract, it is absorbed by our body and goes to the bloodstream. The blood distributes it to the target tissues where it must take effect. In this case we talk about active drug (Figure 2). But this is not always the case, but sometimes it needs to be activated. That’s when we talk about a prodrug, which needs to stop in the liver before it reaches the bloodstream.

Most of the time, the drug we ingest is active and does not need to visit the liver.

Figure 2. Difference between prodrug and active drug (Source: Agent of Chemistry – Roger Tam)

Once the drug has already gone to the target tissue and has interacted with target cells, drug waste is produced. These wastes continue to circulate in the blood to the liver, which metabolizes them to be expelled through one of the two routes of expulsion: (i) bile and excretion together with the excrement or (ii) purification of the blood by the kidneys and the urine.

THE IMPORTANCE OF PHARMACOGENETICS

A clear example of how according to the polymorphisms of the population there will be different response variability we find in the transporter genes. P glycoprotein is a protein located in the cell membrane, which acts as a pump for the expulsion of xenobiotics to the outside of the cell, that is, all chemical compounds that are not part of the composition of living organisms.

Humans present a polymorphism that has been very studied. Depending on the polymorphism that everyone possesses, the transporter protein will have normal, intermediate or low activity.

In a normal situation, the transporter protein produces a high excretion of the drug. In this case, the person is a carrier of the CC allele (two cytokines). But if you only have one cytosine, combined with one thymine (both are pyrimidine bases), the expression of the gene is not as good, and the expulsion activity is lower, giving an intermediate situation. In contrast, if a person has two thymines (TT), the expression of the P glycoprotein in the cell membrane will be low. This will suppose a smaller activity of the responsible gene and, consequently, greater absorption in blood since the drug is not excreted. This polymorphism, the TT polymorphism, is dangerous for the patient, since it passes a lot of drug to the blood, being toxic for the patient. Therefore, if the patient is TT the dose will have to be lower.

This example shows us that knowing the genome of each individual and how their genetic code acts based on it, we can know if the administration of a drug to an individual will be appropriate or not. And based on this, we can prescribe another medication that is better suited to this person’s genetics.

 APPLICATIONS OF THE PHARMACOGENETICS

The applications of these disciplines of precision medicine are many. Among them are optimizing the dose, choosing the right drug, giving a prognosis of the patient, diagnosing them, applying gene therapy, monitoring the progress of a person, developing new drugs and predicting possible adverse responses.

The advances that have taken place in genomics, the design of drugs, therapies and diagnostics for different pathologies, have advanced markedly in recent years, and have given way to the birth of a medicine more adapted to the characteristics of each patient. We are, therefore, on the threshold of a new way of understanding diseases and medicine.

And this occurs at a time when you want to leave behind the world of patients who, in the face of illness or discomfort, are treated and diagnosed in the same way. By routine, they are prescribed the same medications and doses. For this reason, the need has arisen for a scientific alternative that, based on the genetic code, offers to treat the patient individually.

REFERENCES

• Goldstein, DB et al. (2003) Pharmacogenetics goes genomic. Nature Review Genetics 4:937-947
• Roden, DM et al. (2002) The genetic basis of variability in drug responses. Nature Reviews Drug Discovery 1:37-44
• Wang, L (2010) Pharmacogenomics: a system approach. Syst Biol Med 2:3-22
• Ramos, M. et al. (2017) El código genético, el secreto de la vida. RBA Libros
• Main picture: Duke Center for Applied Genomics & Precision Medicine

 

Rare diseases: fight against oblivion

We are ending the month of February, and this means that the Rare Disease Day is approaching. Marfan syndrome, Williams syndrome, DiGeorge syndrome, Crohn’s disease, Fanconi anaemia, mucopolysaccharidosis, among many others make up the list of these diseases. Why are they called minority diseases or rare diseases?

WHAT ARE MINORITY DISEASES?

A minority disease is that which affects less than 1 in 2,000 people. Although individually they are rare, there are many diseases of this type (6,000-7,000), so there are many affected patients.

Although the definition of minority disease is what I have just said, in the pharmaceutical industry it is that disease in which it is not profitable to develop a drug due to the low number of patients, the limited information available, the poor diagnosis, the lack of clinical studies and the difficult location of patients. It is for this reason that the families themselves create their own foundations to obtain financing for the investigation of these diseases.

A few years ago these diseases were socially forgotten, but, fortunately, they are now socially transcendental and recognized.

As I said, there are around 7,000 minority diseases described and every year between 150 and 250 new ones are described, thanks to new technologies.

A large number of these diseases affects children, that is, they manifest themselves at an early age. It is necessary to know that most have a genetic basis, caused by mutations in specific genes such as cystic fibrosis or several muscular dystrophies. But there are also related to environmental factors, such as some types of anaemia due to lack of vitamins or due to medications. This is the case of malignant mesothelioma, a breast cancer, in which more than 90% of cases are due to asbestos exposure. However, there are still many without knowing their origin or data on their prevalence.

MINORITY DISEASES IN NUMBERS

The fact that these diseases affect few people and the ignorance of their symptoms by the public and professionals, it is estimated that the time that elapses between the appearances of the first symptoms until diagnosis is 5 years. In 1 of every 5 cases, more than 10 years may pass until the correct diagnosis is obtained. This means not receiving support or treatment or receiving inadequate treatment and worsening the disease.

Not all hospitals have the means to treat those affected, for this reason it is estimated that practically half of sufferers have had to travel and travel in the last 2 years out of their province because of their illness, either in look for a diagnosis or treatment.

Minor diseases represent a significant economic cost. The cost of diagnosis and treatment accounts for around 20% of the annual income of each affected family. This means an average of more than 350€ per family per month, a figure very representative of the high cost involved in the care of rare diseases. The expenses to cover in the majority of cases are related to the acquisition of medicines and other health products, medical treatment, technical aids and orthopaedics, adapted transport, personal assistance and adaptation to housing.

TREATMENT FOR MINORITY DISEASES

Only 1-2% of minority diseases currently have some type of treatment, therefore, much remains to be investigated.

There are 4 basic types of treatment for rare genetic diseases:

PHARMACOLOGICAL THERAPIES

It consists in the modification of a normal or pathological biochemical reaction by an external chemical agent.

The development of a drug is a very expensive process and difficult to quantify. Currently many millions have to be invested for a new drug to reach the patient.

But what is a medication? A medicine is a small organic molecule, which typically has to be:

• Specific to solve a molecular problem (ex: prevent an abnormal interaction between two proteins)
• Very active and very tuned for your target
• Very little toxic
• Distribute well throughout the body and reach the target tissue
• Cheap to produce or, at least, that can be synthesized in industrial quantities
• Stable
• New (patentable)
• It has to be commercialized

GENE THERAPY

Attempt to correct defective genes responsible for diseases in the somatic (non-sexual) line, either by:

• Loss of function: incorporate the normal gene (ex: phenylketonuria)
• Function gain: eliminate the responsible mutation, eliminating the protein (ex: Huntington)

Limitations:

• Only the reversible characteristics of a genetic disease can be corrected
• The size of the DNA to be incorporated in the patient’s genome
• Immune response against the viral vector (retroviruses, adenoviruses, adenoassociates)
• Inactivation of an essential gene that can cause a problem greater than the disease
• Directionally to appropriate target cells

CELLULAR THERAPY

Describes the process of introducing new cells into an affected tissue, with or without previous gene therapy. It is necessary to introduce many cells because the treatment is effective and, sometimes, these cells can go to unwanted tissues or have some types of abnormal growth.

SURGERY

For example in congenital heart defects.

RARE DISEASE DAY

For rare diseases to cease to be, Rare Disease Day is celebrated on the last day of February, with the aim of raising awareness and awareness among the public about rare diseases; as well as showing the impact on patients’ lives and reinforcing their importance as a priority in public health.

It was established in 2008 because, according to the European Organization for Rare Diseases (EURORDIS), the treatment of many rare diseases is insufficient, as well as in social networks to support people with minority diseases and their families. In addition, while there were already many days devoted to people suffering from individual diseases (such as AIDS, cancer, etc.) before there was not a day to represent people suffering from minority diseases. It was chosen on 29^th February because it is a “rare” day. But it is celebrated on the last day of February in years that are not leap years.

Then I leave the promotional video for the Rare Disease Day 2015:

Video 1. Rare Disease Day 2015 Official Video (Source: YouTube)

REFERENCES

• FEDER
• EURORDIS
• Fundación Mehuer
• Rare Disease Day

From traditional medicine to personalized medicine

From prehistory, where medicine started began with plants, minerals and parts of animals; until today, medicine has evolved very quickly. Much of the “fault” of his fact is due to genetics, which allows us to talk about personalized medicine. In the following article we discuss this.

THE EVOLUTION OF DISEASES

To talk about medicine, we have first to know diseases. We cannot think that all diseases are genetic, but there are diseases related to anatomical changes, fruit of our evolution.

Chimpanzees are the closest animal to us, humans, with which we share 99% of our genome. Despite this, humans have very particular phenotypic characteristics as the brain most develop, both in size and expansion of the cerebral cortex; hairless sweaty skin, bipedal posture and prolonged dependence on offspring, allowing the transmission of knowledge for longer; among other.

Possibly, the bipedal position was key to the early development of the divergence between the chimpanzee lineage and that of humans; and is also the reason for the appearance of some diseases related to anatomical factors. Among them are hernias, haemorrhoids, varices, disorders of the spine, such as herniated intervertebral discs; osteoarthritis in the knee joint, uterine prolapse and difficulties in childbirth.

The fact that the pelvis was remodelled (Figure 1) and narrower resulted in obstetric problems millions of years later, when the brain expanded. Consequently, the skull as well. The heads of the foetuses were longer and larger, making birth difficult. This explains why the deliveries of humans are longer and longer compared to those of chimpanzees and other animals.

Figure 1. Comparison between human pelvis and chimpanzee pelvis in bipedal position (Source: Libros maravillosos – La especie elegida (capítulo 5))

The evolution towards modern life has behaved many changes in every way. In comparison to our hunter-gatherer ancestors (Figure 2), our diet has changed a lot and has nothing to do with what other primates eat. For the latter, the fruit represents most of the intake, but for us it is red meat. In addition, we are the only animals that continue to feed us milk after the lactation period.

Figure 2. Picture of hunter-gatherer humans (Source: Río Verde en la historia

If we add to the sedentary lifestyle and the limited physical activity of modern humans, it can help explain the seriousness and frequency of some modern human diseases.

Lifestyle can also affect us. For example, myopia, which rate is higher in western individuals who read a lot or do activities of near vision, compared to individuals of Aboriginal’s towns.

Another clear example is the alteration in the female reproductive stage. Currently, women have children more and more later. This is also linked to a decrease in the duration of breastfeeding. These changes, which can be considered socially positive, have negative effects on the health of the reproductive organs. It has been shown that the combination of early menarche, limited or no breastfeeding and later menopause are the main risk factors for breast and ovarian cancer.

Humans increasingly live more years and we want the best quality of life. It is easy for more longevity to appear more diseases, by the deterioration of the organism and its cells.

THE EVOLUTION OF MEDICINE

The history of medicine is the history of the struggle of men against disease and since the beginning of this century, is also the history of human effort to maintain health.

We have acquired the scientific knowledge of medicine based on observation and experience, but it has not always been so. Our ancestors experienced sickness and the fear of death before a rational picture could be made of them, and the medicine of that time was immersed in a system of beliefs, myths and rites.

However, in the last years it has been born personalized genomics, which tells you your risk factors. This opens a door to personalized medicine, which adjusts treatments to patients depending on their genome (Figure 3). It uses information from a person’s genes and proteins to prevent, diagnose and treat a disease, all thanks to the sequencing of the human genome.

Figure 3. Personalized medicine that treats people individually, according to their genome (Source: Indiana Institute of Personalized Medicine)

Molecular methods that make precision medicine possible include tests of gene variation, proteins, and new treatments targeting molecular mechanisms. With the results of these tests and treatments can determine the state of the disease, predict the future state of the disease, the response to the drug and treatment or even the role of the food we eat at certain times, which results of great help to the doctors to individualize the treatment of each patient.

To do this, we have within our reach the nutrigenetics and the nutrigenomics, that like the pharmacogenetics and the pharmacogenomics, they help the advance of a medicine is more and more directed. Therefore, these disciplines are today one of the pillars of personalized medicine since it involves treating each patient individually and tailor-made.

The evolution towards precision medicine is personalized, preventive, predictive and participatory. There is increasing access to information and the patient is more proactive, getting ahead of problems, preventing them or being prepared to deal with them efficiently.

REFERENCES

• Varki, A. Nothing in medicine makes sense, except in the light of evolution. J Mol Med (2012) 90:481–494
• Nesse, R. and Williams, C. Evolution and the origins of disease. Sci Am. (1998) 279(5):86-93
• Mackenbach, J. The origins of human disease: a short story on “where diseases come from”. J Epidemiol Community Health. (2006) 60(1): 81–86
• Main picture: Todos Somos Uno

What is gene therapy?

In the last years we have heard discuss gene therapy and its potential. However, do we know what gene therapy is? In this article, I want to make known this promising tool that can cure some diseases that therapies with conventional drugs cannot it. I discuss approaches of gene therapy and their key aspects, where we find animal models.

INTRODUCTION

A clinical trial is an experimental study realized in patients and healthy subjects with the goal to evaluate the efficiency and/or security of one or various therapeutics procedures and, also, to know the effects produced in the human organism.

Since the first human trial in 1990, gene therapy has generated great expectations in society. After over 20 years, there are a lot of gene therapy protocols have reached the clinical stage.

Before applying gene therapy in humans it is necessary to do preclinical studies; these are in vitro or in vivo investigations before moving to clinical trials with humans. The aim of these is protect humans of toxic effects that the studied drug may have.

An important element in preclinical studies are animal models. First, tests are made with small animals like mice. If they are successful, then tests are made with larger animals, like dogs. Finally, if these studies give good results then they are passed to higher animals: primates or humans.

WHAT IS GENE THERAPY?

Gene therapy represents a promising tool to cure some of those diseases that conventional drug therapies cannot. This therapy consists in the transfer of genetic material into cells or tissues to prevent or cure a disease.

Initially gene therapy was established to treat patients with hereditary diseases caused by single gene defects, but now, at present, many gene therapy efforts are also focused on curing polygenic or non-inherited diseases with high prevalence (Video 1).

Video 1. Explanation about what gene therapy is (Source: YouTube)

APPROACHES IN GENE THERAPY

There are two types of approaches in gene therapy (Figure 1):

• In vivo gene therapy: introduce a therapeutic gene into a vector which then is administered directly to the patient. The vector will transfer the gene of interest in the target tissue to produce the therapeutic protein.
• Ex vivo gene therapy: transfer the vector carrying the therapeutic gene into cultured cells from the patient. After, these genetically engineered cells are reintroduced to the patients where they now express the therapeutic protein.

Figure 1. Differences between the two types of approaches in gene therapy (Source: CliniGene – Gene Therapy European Network)

KEY ASPECTS OF GENE THERAPY

When designing a gene therapy approach there are some key aspects to be considered:

1/ THERAPEUTIC GENE

The gene of interest is that which is introduced into the body to counteract the disease. For the one hand, for the diseases are caused by the lost or dysfunction of a single protein, the gene to be transferred is more identifiable, being that only a correct copy of the gene whose dysfunction causes the diseases will be introduced. For the other hand, for the diseases whose origin is more complex the choice of the therapeutic gene may be more difficult and will have to make several studies and know well the disease.

2/ VECTOR

Vehicle by which the gene of interest is transported to the target cells. The perfect vector should be able to transduce target cells without activating an immune response either against itself or the therapeutic gene. But there aren’t a universal vector to treat any disease.

2.1/ VIRAL VECTORS

These type of vectors derives from viruses, but this is not a problem because much or all of the viral genes are replaced by the therapeutic gene. This means that the viral vectors do not cause pathogenic disease because the gene was deleted.

2.2/ NON-VIRAL VECTORS

These type of vectors does not derive from viruses, but the therapeutic gene is part of a plasmid.

3/ TARGET CELLS

Any cell that has a specific receptor for an antigen or antibody, or hormone or drug… The therapeutic gene must be directed to target cells in specific tissues.

4/ ROUTES OF ADMINISTRATION

The therapeutic gene must be administered through the most appropriate route. The type of route depends, as like as vector, the target tissue, the organ to manipulate or the disease to be treated.

5/ ANIMAL MODELS

Are used to find out what happens in a living organism. They are mainly used in research to achieve progress of scientific knowledge, as many basic cellular processes are the same in all animals and can understand what happens to the body when it has a defect; as models for the study of a disease, because humans and animals share many diseases and how to respond to the immune system; to develop and test potential methods of treatment, being an essential part of applying biological research to real medical problems and allowing the identification of new targets for the intervention of the disease; and, finally, to protect the safety of people, animals and environment, researchers have measured the effects of beneficial and harmful compound on an organism, identifying possible problems and determine the dose administration.

Gene therapy represents a promising tool to cure some of those diseases that conventional drug therapies cannot. The availability of animal models is key to preclinical phases because it allows thorough evaluation of safety and efficacy of gene therapy protocols prior to any human clinical trials.

In the near future, gene therapy will be an effective alternative to pharmacological efforts, and enable treatment of many diseases that are refractory or not suitable for pharmacologic treatment alone. Thus, gene therapy is a therapeutic tool that gives us virtually unlimited possibilities to develop better and more effective therapies for previously incurable diseases.

REFERENCES

• Ramos Muntada M. “Animal Models for Gene Therapy of Glycogenosis” Final Degree Project. UAB, Genetics Bachelor’s Degree 2015
• Bosch F, Roca C, Anguela X and Ruzo A. “Gene Therapy, a new tool to cure human diseases” CliniGene-NoE. CBATEG-UAB 2011, CliniGene – Gene Therapy European Network
• Gene Therapy Technology Explained
• Australian Clinical Trials
• Main picture: Genetic Literacy Project