基因检测与糖尿病

1,国家卫生部 全国合理用药监测系统 孙忠实 2011,6,13,长沙,Pharmacogenomics and Personalized Medicine for Diabetes,药物基因组学与糖尿病个体化给药,2,WHO:控制糖尿病,刻不容缓,糖尿病(T2D)是四大非传染病之一,是仅次于心脑血管疾病和癌症的第三位死亡原因;全球每9秒钟就有1人死于糖尿病,每年约死亡400万人,失明约1500万人;使心脏病与脑卒中增加34倍(US ,CDC 2007);仅2010年全球为此支出3,780亿美元,占全球支出的12%!钱荣立 中国糖尿病杂志2010;18:881882,2010联合国糖尿病日;中国蓝光行动,3,糖尿病严重威胁人类健康,Source: WHO and IDF,流行性日益加剧,2000,2030,死亡 3+ million,截肢 1+ million,肾衰 500,000+,失明 300,000+,医疗开支 USD 156+ billion,糖尿病每年给全球带来的巨大损失,全球糖尿病患者（百万）,4,中国糖尿病患者居全球之首,“Prevalence of Diabetes among Men and Women in China”中国成年人中糖尿病发病率为9.7%(远高于全球平均患病率6.4%),现有患者9,240万例,约占全球糖尿病患者1/3,居全球之首,第二位为印度,5080万例;Wenying Yang etal. N Engl J Med 2010;362:1090-1101CDS与IDF联合调研结果指出:我国糖尿病治疗费用每年高达1,734亿元(约250亿美元),是非糖尿病人的34倍;占全国医疗总支出的13%!2010,11,14第4个联合国糖尿病日IDF主席Mbanya报告,5,全球现有十一大类抗糖尿病药,1,胰岛素及其衍生物;2,磺脲类;3,双胍类;4,噻唑烷二酮类;5,-糖苷酶抑制剂;6,格列奈类胰岛素促泌剂(Meglitinides);7,胰岛淀粉样肽(Amylin analogues);普兰林肽注射液 8,肠促胰岛素激素拟似药(Incretin hormone mimetics);艾塞那肽注射液9,二肽基肽酶抑制剂(DPP4-I);西他列汀10,胰高血糖素样肽受体激动剂(GLP-1);利拉鲁肽11,钠-葡萄糖共同转运体抑制剂(Sodium-Glucose Co-Transport Inhibitors; SGLTs-I )。,注:黄色标记药物系目前认为与基因多态性密切相关者,6,当前T2D的控制率仅约40%,而T2D 却占全部糖尿病患者的90%95%!,Presented byTrudy N. Griffith BSc. Pharm (Hons)13 August 2010,7,服用降糖药的患者40%未能达标尤其是单一药物!,过去的10年,约40%T2D患者的糖化血红蛋白(glycosylated hemoglobin ,HbA1c) 未能达到80岁老人!,23,在服用二甲双胍的患者中,有35-40%禁食血糖水平未达标!,Diabet. Care 1994, 17, 1100-1109Diabet. Med. 1994, 11, 953-960,Metformin is not without adverse events such as diarrhea and nausea that occur in about 30% of patients; or a more serious but very rare side effect, lactic acidosis. Despite an exceptional efficacy and safety profile, several T2Ds (about 38%) still fail to reach glycemic goals in metformin therapy.Pharmacogenomics and Personalized Medicine 2009:2 7991,24,临床证明单用二甲双胍易出现继发性失效Secondary Failure of Metformin Monotherapy in Clinical Practice,作者报告,在20042006年间,用二甲双胍共治疗T2D患者1,799例,以7%!注:继发性失效定义 1,需加用或换用第二种降糖药; 2,随后的HbA1C7.5%。 Diabetes Care 2010;33:501506,25,二甲双胍在体内的转运,二甲双胍为一亲水性有机阳离子(pKa 12.4) ,是有机阳离子转运体(organic cation transporters ;OCTs)包括OCT1, OCT2的底物, OCT1主要在肝细胞表达, OCT2则在肾细胞中表达,二者分別将二甲双胍转运至肝细胞内和肾脏上皮细胞内.Pharmaceuticals 2010;3:2610-2646,26,二甲双胍的摄取及其作用机制,LKB, alias of serine-threonine kinase 11 (STK11);PGC-1, peroxisome proliferator activated receptor coactivator 1 ;TORC2, target of rapamycin complex 2.,J. Clin. Invest 2007:17:1422-1431,27,涉及二甲双胍的PGx转运体基因多态性, OCTs :Organic cation transporter gene(有机阳离子转运体基因)OCT 1: 由SLC22A1编码,承载肝摄取;OCT 2: 由SLC22A2编码,承载肾排泄; MATE :Multidrug and toxin extrusion gene(多药与毒素外排基因)MATE1:由SLC47A1编码,承载从肝细胞转运至胆汁;MATE2:由SLC47A2编码,承载肾排泄.Acta Pharm 60;387406,28,OCTs的表达及其基因多态性, OCT1 主要在肝细胞和肠上皮细胞表达,介导二甲双胍在这些细胞的摄取; OCT2,主要在远端肾小管细胞表达,介导、促进包括二甲双胍在内的许多生物异源性物质在尿中的排泄 OCT1的变异已知有12个: S14F, R61C, F160L,S189L, G220V, P341L, R342H, G401S, V408M, 420del,G465R, R488M,其中标记为兰色者为功能降低的转运体。Pharmacogenomics and Personalized Medicine 2009:2 7991,29,为什么二甲双胍必需个体化给药?,应用最广泛;在美国处方量排名前15位!治疗指数窄;为多因素病;疗效差异大;有的有效,有的无效,有的甚至发生乳酸中毒!(MALA range from three to nine cases per 100,000 patient-years) once it develops, it has been associated with a 50% to 75% mortality rate. N Engl J Med. 1998; 338:265-6. Letter; Diabetes Care. 1999; 22:925-7. Ellenhorns medical toxicology: 1997;728-731. 在肝脏起效;转运体或肝功能影响很大主经肾排泄;转运体或肾功能影响很大,30,OCT1等位基因对二甲双胍摄取的影响,*P 180 mg/dl)高达34%,而罗格列酮为15%;二甲双胍为 21% ;UKPDS试验表明,每年约有1%服用磺脲类的患者发生严重低血糖!. N. Engl. J. Med. 2006;355(23):24272443,38,磺脲类降糖机制Schematic Representation of the Pancreatic Beta Cell, Illustrating the Role of the ATP-Sensitive Potassium(KATP) Channel in Insulin Secretion.,N Engl J Med 2004;350:1838-49.,39,影响磺脲类作用的基因多态性,Acta Pharm. 60 (2010) 387406,transcription factor 1 (TCF1,transcription factor 2 (TCF2),40,涉及磺脲类的基因多态性, Kir6.2 pore : 为KATP channels的亚单位,由KCNJ11 gene编码,系SU的靶点; SUR1 subunits:为KATP channels的亚单位由ABCC8 gene编码, 系SU的靶点;Inactivating mutations cause the channel to be closed and thus the -cells to over-secrete insulin, causing hyperinsulinaemichypoglycaemia.Activating mutations cause the -cell to be unresponsive to glucose and therefore are a cause of neonataldiabetes mellitus(NDM) TCF7L2:直接影响SU的疗效; CYP2C9,CYP2C19:SU的代谢; HNF1 &HNF1:直接影响SU的疗效; IRS1:直接影响SU的疗效; NOS1AP:降低SU的疗效.Acta Pharm 2010;60:387406,41,两种最重要的CYP2C9基因多态性,CYP2C9*2: 是单核苷酸中的外显子 3位由C T),其活性仅是正常功能者的40%左右; CYP2C9*3:是单核苷酸中的外显子 7位由A C), 其活性仅是正常功能者的10%左右;,42,CYP2C9基因多态性显著降低磺脲类的疗效,A recent population-based study of incident sulfonylurea users found that Type 2 diabetes patients with CYP2C9*2/*2, *2/*3 or *3/*3 genotypes were 3.4-times more likely to achieve a treatment HbA1c of less than 7% compared with CYP2C9 wild-type homozygotes . Furthermore, patients with at least one copy of the CYP2C9*2 or *3 allele were less likely to experience sulfonylurea monotherapy treatment failure Clin. Pharmacol. Ther. 2009;87(1):5256,43,CYP2C9基因多态性显著增加磺脲类的ADR,CYP2C9 polymorphisms may also serve as useful predictors of adverse effects. For example, a different study showed that sulfonylurea-treated patients who possessed the CYP2C9*3/*3 or *2/*3 genotype had 5.2-times the odds of a severe hypoglycemic event than the other CYP2C9 genotype groups .Br. J. Clin. Pharmacol. 2005;60(1):103106.,44,CYP2C9基因多态性影响磺脲类的疗效,携带杂合子CYP2C9*1/*2的患者可轻度减少格列本脲的肾清除,较携带纯合子CYP2C9*2/*2 者降低10%; 携带杂合子CYP2C9*1/*3 和 CYP2C9*2/*3的患者可减少甲苯磺丁脲肾清除率50%; 携带纯合子CYP2C9*3/*3的患者可显著减少格列本脲的肾清除。Acta Pharm 2010;60:387406,45,携带杂合子CYP2C9*1/*2和 纯合子CYP2C9*3/*3的患者,与携带野生型CYP2C9*1/*1的患者相比,可分别减少甲苯磺丁脲、格列本脲以及格列吡嗪的肾清除率16%、50%和20%, 携带纯合子CYP2C9*2/*2的患者,与携带野生型CYP2C9*1/*1的患者相比,可分别减少甲苯磺丁脲、格列本脲的肾清除率75%和90%。,CYP2C9基因多态性影响磺脲类的疗效,46,为什么有些国人应用磺脲类易发生ADR?,Br.J. Clin. Pharmacol.2007, 64, 67-74.,因为亚洲人的PM占10-25%,而白人仅有2-6% 。如携带CYP2C19 PM的中国男性患者,服用格列齐特后的AUC ,与携带野生型CYP2C9*1/*1的患者相比增加3.4-fold 95% CI 2.5, 4.7; P0.01 ; 其半衰期也从15.1h延长至44.5 h (P0.01);相似的差别,在多剂量研究时也同样存在,携带CYP2C19 PM的患者与携带野生型CYP2C9*1/*1的患者相比,AUCss, AUC0 and Cmax 分别增加 3.4倍 (95% CI 2.9, 4.0)、4.5倍 (95% CI 3.8, 5.4) 和 2.9 倍(95% CI 2.4, 3.4) ,(P0.01) ,其半衰期也从13.5 h延长至24.6h (P1/2, 依此给患者调整剂量极为重要。 Acta Pharm. 2010; 60 : 387406近期Zeller等提岀将格列苯脲淘汰岀局,因显著增加AMI死亡率。是否与患者基因变异相关?JCEM 2010;95;49935002,48,CYP2C9基因多态性与磺脲类等的清除率,49,相关生物标记物的基因多态性对磺脲类作用的重要影响,There are several other KCNJ11 variants (which include F333I, F35V, R201H, R201C, Q52R, I296L, L164P, G53S,G53R) and ABCC8 variants (which include I182V, H1023Y, I1424Y, F132L),Pharmacogenomics and Personalized Medicine 2009:2 7991,50,CYP2C19基因多态性对格列齐特PK的影响(单剂量),Br.J. Clin. Pharmacol.2007, 64, 67-74,51,CYP2C19 基因多态性对格列齐特PK的影响(多剂量),Br.J. Clin. Pharmacol.2007, 64, 67-74,52,磺脲类与TCF7L2变异 GoDARTS (Genetics of Diabetes Audit and Research Tayside)study,方法:1997 July 2006 ,901例口服磺脲类,945例口服二甲双胍,研究转录因子7-相似物2 (Transcription factor 7-like 2 ;TCF7L2) 的等位基因 rs12255372 和rs7903146是否影响两类药物的作用;无效指标是用药312个月后HbA1C 7%。Diabetes 56:21782182, 2007,53,磺脲类与TCF7L2的变异,结果:携带rs12255372 T/T等位基因的患者与携带rs12255372 G/G的患者相比,无效率的Odds ratio (OR) 为1.95 (95% CI 1.233.06; P 0.005), 如以基线HbA1C相比,则OR为 2.16 95% CI 1.213.86, P = 0.009); 携带rs7903146等位基因的患者其结果相似; 在二甲双胍组未见此相关性。Diabetes 56:21782182, 2007,54,涉及格列奈类/二甲双胍/ 噻唑烷二酮的基因多态性,Acta Pharm. 60 (2010) 387406,55,涉及格列奈类的基因多态性,CYP2C9其基因变异有CYP2C9*3CYP2C8其基因变异有CYP2C8*3SLCO1B1: solute carrier organic anion transporter family,member 1B1)其基因变异有521TT, 521TC,521CCOATP:其基因变异有OATP 1B1IGF2BP2(insulin-like growth factor 2 mRNA binding protein 2 )Pharmaceuticals (Basel). 2010 August 1; 3(8): 26102646Pharmacogenomics and Personalized Medicine 2009:2 7991,56,Pharmacogenomics and Personalized Medicine 2009:2 7991,转运体/药酶基因多态性影响格列奈类的疗效,57,2C9基因多态性影响格列奈类的清除,研究表明 CYP2C9*3可减少格列奈类的清除, 而CYP2C8*3 则增加格列奈类的清除。 Mol Diagn Ther. 2007;11(5):291-302,58,2C9基因多态性影响格列奈类的疗效,携带CYP2C9*3的患者,可显著降低那格列奈的清除率;而携带CYP2C9*2的患者,其药动学参数与携带野生型CYP2C9*1的患者却相似; 携带CYP2C9*3 /*3的患者与携带野生型CYP2C9*1/*1的患者相比,可增加低血糖的风险,特别是那格列奈剂量超过120 mg时!Mol Diagn Ther. 2007;11(5):291-302,59,SLCO1B1基因多态性对格列奈类的影响,SLCO1B1 有三个等位基因:521TT, 521TC,521CC; 携带杂合子521TC和纯合子 521CC的患者与携带纯合子521TT相比,可分别显著增加那格列奈的血浓度 83%和76%;半衰期延长78% ,(p = 0.036) ; 提示SLCO1B1基因多态性可显著增加那格列奈血浓度, 可能是减少了肝细胞的摄取所致。,60,涉及噻唑烷二酮类的基因多态性,PPAR- gene:过氧化物体增殖激活受体-基因变异有 PPAR- heterozygous genotype (rs1801282; Pro12Ala)和 homozygous genotype (Pro12Pro).lipoprotein lipase gene: 其基因变异有 S447S和S447XCYP2C8 gene:其基因变异有 CYP2C8*1/*3 CYP2C8*3/*3 ACDC gene:adipocyte C1q and collagen domain-containing (ACDC) gene,编码adiponectin其基因变异有SNP45, SNP276,SNP11377 SLCO1B1 : solute carrier organic anion transporter family,member 1B1)其基因变异有521TT, 521TC,521CCADIPOQ:其基因变异有 rs1501288 和 rs2241766PGC-1(PPAR-coactivator):其基因变异有Thr394和Gly482 Pharmaceuticals (Basel). 2010 August 1; 3(8): 26102646Pharmacogenomics and Personalized Medicine 2009:2 7991,61,为什么有些患者TZDs无效?,TZDs未达标率:罗格列酮(2mg/bid ;26week) 45.8%罗格列酮(4mg/bid ;26week) 36.1%吡格列酮(45 mg/d ;26 weeks) 25.0%(空腹血糖降低不超过10%; 12%患者HbA1c仅降低0.5%1.0%)The Journal of Clinical Endocrinology & Metabolism 2001 86: 280-288 Diabetes Care 2003;26:825831,62,ACDC/S447S基因多态性对TZDs的影响,Pharmacogenomics and Personalized Medicine 2009:2 7991,63,脂蛋白酯酶(LDL)基因多态性对TZDs的影响,研究发现,中国T2D患者服用吡格列酮,如携带纯合子S447S,其达标率较携带其他基因多态性者更高,反之如携带S447X,则达标率较携带S447S患者降低 1/2, 提示检测LPL基因多态性可预测吡格列酮的疗效。,64,脂联素ADIPOQ等位基因 对罗格列酮疗效的影响,Pharmaceuticals (Basel). 2010 Aug 1;3(8):2610-2646.,65,PGx与噻唑烷二酮类的疗效,首先,过氧化物体增殖激活受体-( PPAR-)基因变异有 heterozygous genotype (rs1801282; Pro12Ala)和 homozygous genotype (Pro12Pro). 如携带Pro/Ala者,较携带 Pro/Pro者显著降低罗格列酮的禁食血糖水平和HbA1c水平;如携带Pro12Ala, 则PPAR-增加 7.2倍Mol Diagn Ther. 2007;11(5):291-302Pharmacogenomics 2007;8:917931,66,CYP2C8/SLCO1B1基因多态性 对罗格列酮疗效的影响,研