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Association Analysis of Drug Metabolizing Enzyme Gene Polymorphisms in AIDS Patients with Cutaneous Reactions to Sulfonamides

2005; Elsevier BV; Volume: 125; Issue: 5 Linguagem: Inglês

10.1111/j.0022-202x.2005.23939.x

1523-1747

P. Wolkenstein, Marie‐Anne Loriot, Antoine Flahault, Michel Cadilhac, Éric Caumes, M. Eliaszewicz, Philippe Beaune, Jean‐Claude Roujeau, O. Chosidow,

Pharmacogenetics and Drug Metabolism

Variation in the bioactivation and the detoxification may determine the susceptibility of AIDS patients to cutaneous reactions to sulfonamides. We undertook a genotyping study to evaluate glutathione S-transferase P1, cytochrome P450 2C9, NAD(P)H: quinone oxidoreductase, and myeloperoxidase genetic polymorphism as risk factors. One hundred and thirty-six AIDS patients treated with sulfonamides were prospectively followed up. Patients with and without a cutaneous drug reactions were compared as a function of their genotype. To increase the power of study, we pooled our data with those of a similar study. We identified in the pooled data a significant association between sulfonamides cutaneous reactions and glutathione S-transferase P1* A/A compared with glutathione S-transferase P1* A/B and B/B (p=0.003). To conclude, most of the polymorphisms in drug metabolism investigated do not act as predisposing factors for sulfonamides reactions. The role of glutathione S-transferase P1 variants requires further in vitro and in vivo studies. Variation in the bioactivation and the detoxification may determine the susceptibility of AIDS patients to cutaneous reactions to sulfonamides. We undertook a genotyping study to evaluate glutathione S-transferase P1, cytochrome P450 2C9, NAD(P)H: quinone oxidoreductase, and myeloperoxidase genetic polymorphism as risk factors. One hundred and thirty-six AIDS patients treated with sulfonamides were prospectively followed up. Patients with and without a cutaneous drug reactions were compared as a function of their genotype. To increase the power of study, we pooled our data with those of a similar study. We identified in the pooled data a significant association between sulfonamides cutaneous reactions and glutathione S-transferase P1* A/A compared with glutathione S-transferase P1* A/B and B/B (p=0.003). To conclude, most of the polymorphisms in drug metabolism investigated do not act as predisposing factors for sulfonamides reactions. The role of glutathione S-transferase P1 variants requires further in vitro and in vivo studies. cutaneous drug reactions confidence interval cytochrome P450 2C9 glutathione S-transferase P1 NAD(P)H:quinone oxidoreductase odds ratio polymerase chain reaction The use of anti-infectious sulfonamides is complicated by the unusually high rate of cutaneous drug reactions (CDR) (Eliaszewicz et al., 2002Eliaszewicz M. Flahault A. Roujeau J.C. et al.Prospective evaluation of risk factors of cutaneous drug reactions to sulfonamides in patients with AIDS.J Am Acad Dermatol. 2002; 47: 40-46Abstract Full Text Full Text PDF PubMed Scopus (59) Google Scholar). Theoretically, variation in the bioactivation of sulfonamides and the detoxification of the hydroxylamine and nitroso- may determine this susceptibility (van der Ven et al., 1991van der Ven A.J. Koopmans P.P. Vree T.B. van der Meer J.W. Adverse reactions to co-trimoxazole in HIV infection.Lancet. 1991; 338: 431-433Abstract PubMed Scopus (135) Google Scholar). Following this hypothesis, drug-metabolizing enzyme gene polymorphisms were evaluated as markers for CDR to sulfonamides in AIDS. Glutathione S-transferase M1 and glutathione S-transferase T1 null genotypes, slow N-acetyl-transferase 2 (NAT2) genotypes, a slow acetylator phenotype, and glutathione deficiency were not shown to be major predisposing factors (Pirmohamed et al., 2000Pirmohamed M. Alfirevic A. Vilar J. Stalford A. Wilkins E.G. Sim E. Park B.K. Association analysis of drug metabolizing enzyme gene polymorphisms in HIV-positive patients with co-trimoxazole hypersensitivity.Pharmacogenetics. 2000; 10: 705-713Crossref PubMed Scopus (79) Google Scholar; Wolkenstein et al., 2000Wolkenstein P. Loriot M.A. Aractingi S. Cabelguenne A. Beaune P. Chosidow O. Prospective evaluation of detoxification pathways as markers of cutaneous adverse reactions to sulphonamides in AIDS.Pharmacogenetics. 2000; 10: 821-828Crossref PubMed Scopus (33) Google Scholar; O'Neil et al., 2002O'Neil W.M. MacArthur R.D. Farrough M.J. et al.Acetylator phenotype and genotype in HIV-infected patients with and without sulfonamide hypersensitivity.J Clin Pharmacol. 2002; 42: 613-619Crossref PubMed Scopus (35) Google Scholar; Alfirevic et al., 2003Alfirevic A. Stalford A.C. Vilar F.J. Wilkins E.G. Park B.K. Pirmohamed M. Slow acetylator phenotype and genotype in HIV-positive patients with sulphamethoxazole hypersensitivity.Br J Clin Pharmacol. 2003; 55: 158-165Crossref PubMed Scopus (49) Google Scholar). Glutathione S-transferase P1 (GSTP1) and cytochrome P450 2C9 (CYP2C9) were also investigated (Pirmohamed et al., 2000Pirmohamed M. Alfirevic A. Vilar J. Stalford A. Wilkins E.G. Sim E. Park B.K. Association analysis of drug metabolizing enzyme gene polymorphisms in HIV-positive patients with co-trimoxazole hypersensitivity.Pharmacogenetics. 2000; 10: 705-713Crossref PubMed Scopus (79) Google Scholar). The GSTP1*A/A and CYP2C9*2/*3 genotypes were over-represented in the hypersensitive group without reaching significance. Given the power of the study, a minor effect of these enzymes could not be excluded. We undertook a new genotyping study in our previously established Epitox cohort of AIDS patients to evaluate GSTP1, CYP2C9, and NQO1, myeloperoxidase genetic polymorphism as risk factors for CDR to sulfonamides (London et al., 1997London S.J. Lehman T.A. Taylor J.A. Myeloperoxidase genetic polymorphism and lung cancer risk.Cancer Res. 1997; 57: 5001-5003PubMed Google Scholar; Harth et al., 2000Harth V. Donat S. Ko Y. Abel J. Vetter H. Bruning T. NAD(P)H quinone oxidoreductase 1 codon 609 polymorphism and its association to colorectal cancer.Arch Toxicol. 2000; 73: 528-531Crossref PubMed Scopus (44) Google Scholar; Eliaszewicz et al., 2002Eliaszewicz M. Flahault A. Roujeau J.C. et al.Prospective evaluation of risk factors of cutaneous drug reactions to sulfonamides in patients with AIDS.J Am Acad Dermatol. 2002; 47: 40-46Abstract Full Text Full Text PDF PubMed Scopus (59) Google Scholar). Twenty-nine females and 107 males were included, 76 with Pneumocystis jirovecii pneumonia and 60 with cerebral toxoplasmosis. Their mean age was 37±8 y old. At inclusion, the mean CD4+ cell count was 56±78 cells per mm3. During the follow-up, 48 patients among the 136 (35%) developed a CDR to sulfonamide (maculo-papular rash (n=41), severe pruritus (n=4), urticaria (n=1), exfoliative dermatitis (n=1), Stevens–Johnson syndrome (n=1)). The frequencies of the genotypes of these different enzymes in the patients with or without CDR to sulfonamides and the suspected associations with CDR are shown in Table I. The genotyping was limited by DNA samples consummation but these subgroups of patients were not different from the whole cohort for their main characteristics (data not shown).Table IGSTP1 and 2C9 variant alleles in hypersensitive and non-hypersensitive AIDS patients (our data and pooled data of the literature)VariableOur study: Epitox cohortaCDR tended to be more frequent in the GSTP1*A/A patients than in the GSTP1*B/B group (p=0.06, OR=8.1, 95% CI=0.9–70.4). CDR were significantly more frequent in the CYP 2C9*1/*2 patients than in the CYP 2C9*1/*1 group (p=0.01, OR=4.4, 95% CI=1.3–14.5). For other enzymes, myeloperoxidase, NQ01, there was no difference in the frequencies of genotypes between patients with or without CDR (p>0.1) (Wald test, two-tailed).Pirmohamed et alPooled datap-valueCDR+ (n) (%)CDR− (n) (%)CDR+CDR−CDR+CDR−GSTP1 genotyping36 (100)62 (100)56 (100)89 (100)92 (100)151 (100)0.003bPooling of the data showed that there was a significant association between sulfonamides hypersensitivity and the GSTP1*A/A versus GSTP1*A/B and B/B (p=0.003). GSTP1*A/A19 (53)21 (34)38 (68)43 (48)57 (62)64 (42) GSTP1*A/B16 (44)32 (52)13 (23)35 (39)29 (32)67 (44) GSTP1*B/B1 (3)9 (14)5 (9)11 (12)6 (6)20 (13)CYP 2C935 (100)47 (100)56 (100)89 (100)91 (100)136 (100)0.13cPooling of the data did not confirm a significant association between hypersensitivity and the 2C9 *1/*2 versus 2C9*1/*1 (p=0.13).CDR, cutaneous drug reactions; GSTP1, glutathione S-transferase P1; OR, odds ratio; CI, confidence interval. CYP 2C9*1/*119 (54)38 (81)33 (59)61 (69)52 (57)99 (73) CYP 2C9*1/*211 (31)5 (11)10 (18)19 (21)21 (23)24 (18) CYP 2C9*1/*35 (14)4 (8)8 (14)8 (9)13 (14)12 (9) CYP 2C9*2/*30 (0)0 (0)5 (5)1 (1)5 (5)1 (1)a CDR tended to be more frequent in the GSTP1*A/A patients than in the GSTP1*B/B group (p=0.06, OR=8.1, 95% CI=0.9–70.4). CDR were significantly more frequent in the CYP 2C9*1/*2 patients than in the CYP 2C9*1/*1 group (p=0.01, OR=4.4, 95% CI=1.3–14.5). For other enzymes, myeloperoxidase, NQ01, there was no difference in the frequencies of genotypes between patients with or without CDR (p>0.1) (Wald test, two-tailed).b Pooling of the data showed that there was a significant association between sulfonamides hypersensitivity and the GSTP1*A/A versus GSTP1*A/B and B/B (p=0.003).c Pooling of the data did not confirm a significant association between hypersensitivity and the 2C9 *1/*2 versus 2C9*1/*1 (p=0.13).CDR, cutaneous drug reactions; GSTP1, glutathione S-transferase P1; OR, odds ratio; CI, confidence interval. Open table in a new tab Variables with a p≤0.2 including those of our previous study were included in a multivariate analysis: age <36 y, previous history of CDR, absence of prophylaxis, CD4+ cells 460 per mm3, GSTP1, and CYP 2C9 polymorphisms. The results of the multivariate analysis are shown in Table II.Table IIMultivariate analysis of predictors of cutaneous reaction to sulfonamides in AIDS patientsOR (95% CI)p-valueHistory of drug eruption2.5 (0.7–9.7)0.18No prophylaxis8.0 (2.0–32.5)0.003CD8+ cells >460 per mm33.0 (0.9–10.1)0.08GSTP1*A/B versus GSTP1*B/B4.3 (0.4–46.3)0.23GST P1*A/A versus GST P1*B/B10.1 (0.9–108.4)0.06CYP 2C9*1/*2 versus CYP 2C9*1/*17.7 (1.6–38.2)0.01CYP 2C9*1/*3 versus CYP 2C9*1/*14.1 (0.7–24.4)0.12Hosmer—Lemeshow, p=0.91.OR, odds ratio; CI, confidence interval. Open table in a new tab Hosmer—Lemeshow, p=0.91.OR, odds ratio; CI, confidence interval. The study ofPirmohamed et al., 2000Pirmohamed M. Alfirevic A. Vilar J. Stalford A. Wilkins E.G. Sim E. Park B.K. Association analysis of drug metabolizing enzyme gene polymorphisms in HIV-positive patients with co-trimoxazole hypersensitivity.Pharmacogenetics. 2000; 10: 705-713Crossref PubMed Scopus (79) Google Scholar and ours showed a trend, although not significant (p<0.10, two sided), in the association between sulfonamides hypersensitivity and the GSTP1*A/A and CYP 2C9*1/*2 genotypes, respectively. The data were pooled together. We identified a significant association between sulfonamides CDR and GSTP1*A/A compared with GSTP1*A/B and B/B (p=0.003). On the other hand, CYP 2C9*1/*2 compared with CYP 2C9*1/*1 was no more significantly associated with sulfonamides CDR (p=0.13). In our study we confirmed the high frequency of CDR during the treatment with sulfonamides in AIDS. We ruled out the role of myeloperoxidase and NQO1 polymorphisms. We also investigated the role of CYP 2C9 and GSTP1. CYP 2C9 metabolizes sulfonamides to the hydroxylamine (Cribb et al., 1995Cribb A.E. Spielberg S.P. Griffin G.P. N4-hydroxylation of sulfamethoxazole by cytochrome P450 of the cytochrome P4502C subfamily and reduction of sulfamethoxazole hydroxylamine in human and rat hepatic microsomes.Drug Metab Dispos. 1995; 23: 406-414PubMed Google Scholar). The amino acid substitutions Arg144 to Cys (CYP2C9*2) and Ile359 to Leu (CYP2C9*3) affect activity of CYP2C9 toward drugs. Microsomes prepared from cell lines expressing the allelic variants CYP2C9*2 and CYP2C9*3 display a 3- and 20-fold decrease in intrinsic clearance for sulfamethoxazole, respectively, when compared with wild type (Gill et al., 1999Gill H.J. Tjia J.F. Kitteringham N.R. Pirmohamed M. Back D.J. Park B.K. The effect of genetic polymorphisms in CYP2C9 on sulphamethoxazole N-hydroxylation.Pharmacogenetics. 1999; 9: 43-53Crossref PubMed Scopus (43) Google Scholar). In our cohort, contrary to what would have been expected, the CYP 2C9*1/*2 patients were found to be over-represented in the CDR group (7.7, 95% confidence interval (CI) 1.6–38.2; p=0.01). This association between CYP2C9 genotypes and CDR was not confirmed when the data of the literature were pooled in (Pirmohamed et al., 2000Pirmohamed M. Alfirevic A. Vilar J. Stalford A. Wilkins E.G. Sim E. Park B.K. Association analysis of drug metabolizing enzyme gene polymorphisms in HIV-positive patients with co-trimoxazole hypersensitivity.Pharmacogenetics. 2000; 10: 705-713Crossref PubMed Scopus (79) Google Scholar) (Cochran–Mantel–Haenszel test, p=0.13), leading to the conclusion that CYP 2C9 does not play a major role. The GSTP1*A/A patients were over-represented in the CDR group without reaching statistical significance (p=0.06, odds ratio (OR)=8.1, 95% CI=0.9–70.4). A similar finding was previously published (Pirmohamed et al., 2000Pirmohamed M. Alfirevic A. Vilar J. Stalford A. Wilkins E.G. Sim E. Park B.K. Association analysis of drug metabolizing enzyme gene polymorphisms in HIV-positive patients with co-trimoxazole hypersensitivity.Pharmacogenetics. 2000; 10: 705-713Crossref PubMed Scopus (79) Google Scholar), but the authors suspected that their results could be because of a type I statistical error. As the trend was identical in both studies we pooled the data without performing multitesting correction. Pooling of the data identified a significant association between sulfonamides reactions and the GSTP1 genotypes (p=0.003). The lower GSTP1*B allele frequency in the CDR group counters what would be expected according to the reactive metabolites hypothesis. Increased toxicity would have been expected from the altered specific activity and affinity of the GSTP1*B allele for electrophilic substrates. How could variant GSTP1 alleles be protective against CDR to sulfonamides? Either the wild-type GSTP1 enzyme has the ability to generate more reactive metabolites than the GSTP1 variant, or the mutant protein displays higher affinity for sulfonamides (Hu et al., 1997Hu X. Ji X. Srivastava S.K. et al.Mechanism of differential catalytic efficiency of two polymorphic forms of human glutathione S-transferase P1-1 in the glutathione conjugation of carcinogenic diol epoxide of chrysene.Arch Biochem Biophys. 1997; 345: 32-38Crossref PubMed Scopus (73) Google Scholar,Hu et al., 1998Hu X. Xia H. Srivastava S.K. Pal A. Awasthi Y.C. Zimniak P. Singh S.V. Catalytic efficiencies of allelic variants of human glutathione S-transferase P1-1 toward carcinogenic anti-diol epoxides of benzo[c]phenanthrene and benzo[g]chrysene.Cancer Res. 1998; 58: 5340-5343PubMed Google Scholar; Sundberg et al., 1998Sundberg K. Seidel A. Mannervik B. Jernstrom B. 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Do arylhydroxylamine metabolites mediate idiosyncratic reactions associated with sulfonamides?.Chem Res Toxicol. 2003; 16: 1035-1043Crossref PubMed Scopus (24) Google Scholar). Most of the polymorphisms in drug metabolism investigated in the literature including our study do not act as predisposing factors for sulfonamides reactions: NAT2, glutathione S-transferase T1, glutathione S-transferase M1, myeloperoxidase and NQO1. GSTP1 acts paradoxically. Our pharmacogenetic finding adds to the complexity of CDR. The respective role of parent compound, reactive intermediates, free radicals, or nitroso derivatives, their way to act, haptens, danger signals (Pirmohamed et al., 2002Pirmohamed M. Naisbitt D.J. Gordon F. Park B.K. The danger hypothesis—potential role in idiosyncratic drug reactions.Toxicology. 2002; 181–182: 55-63Crossref PubMed Scopus (131) Google Scholar; Svensson, 2003Svensson C.K. Do arylhydroxylamine metabolites mediate idiosyncratic reactions associated with sulfonamides?.Chem Res Toxicol. 2003; 16: 1035-1043Crossref PubMed Scopus (24) Google Scholar), or something else in the context of different CDR in HIV-positive and -negative populations need to be clarified. The role of GSTP1 variants requires further in vitro and in vivo studies. Between August 1995 and January 1997, 136 AIDS patients treated with sulfamethoxazole plus trimethoprim (co-trimoxazole) for P. jirovecii pneumonia or sulfadiazine plus pyrimethamine for cerebral toxoplasmosis were prospectively included and followed-up for sulfonamide CDR (Eliaszewicz et al., 2002Eliaszewicz M. Flahault A. Roujeau J.C. et al.Prospective evaluation of risk factors of cutaneous drug reactions to sulfonamides in patients with AIDS.J Am Acad Dermatol. 2002; 47: 40-46Abstract Full Text Full Text PDF PubMed Scopus (59) Google Scholar). Genomic DNA from peripheral leukocytes was obtained. All patients gave their written informed consent to the study, which had been approved by the Ethical committee (CCPPRB Créteil-Henri-Mondor). The study was conducted according to the Declaration of Helsinki Principles. The determination of the GSTP1, 2C9, myeloperoxidase, NQO1 genotypes was performed as previously described (Stubbins et al., 1996Stubbins M.J. Harries L.W. Smith G. Tarbit M.H. Wolf C.R. Genetic analysis of the human cytochrome P450 CYP2C9 locus.Pharmacogenetics. 1996; 6: 429-439Crossref PubMed Scopus (281) Google Scholar; Traver et al., 1997Traver R.D. Siegel D. Beall H.D. Phillips R.M. Gibson N.W. Franklin W.A. Ross D. Characterization of a polymorphism in NAD(P)H: Quinone oxidoreductase (DT-diaphorase).Br J Cancer. 1997; 75: 69-75Crossref PubMed Scopus (279) Google Scholar; Nedelcheva et al., 1998Nedelcheva K.V. Andersen T.I. Erikstein B. Geitvik G. Skovlund E. Nesland J.M. Borresen-Dale A.L. Single tube multiplex polymerase chain reaction genotype analysis of GSTM1, GSTT1 and GSTP1: Relation of genotypes to TP53 tumor status and clinicopathological variables in breast cancer patients.Pharmacogenetics. 1998; 8: 441-447Crossref PubMed Scopus (81) Google Scholar; Morin et al., 2001Morin S. Loriot M.A. Poirier J.M. et al.Is diclofenac a valuable CYP2C9 probe in humans?.Eur J Clin Pharmacol. 2001; 56: 793-797Crossref PubMed Scopus (52) Google Scholar; Chevrier et al., 2003Chevrier I. Stucker I. Houllier A.M. Cenee S. Beaune P. Laurent-Puig P. Loriot M.A. Myeloperoxidase: New polymorphisms and relation with lung cancer risk.Pharmacogenetics. 2003; 13: 729-739Crossref PubMed Scopus (39) Google Scholar). Patients with and without a CDR were compared as a function of their genotype using a non-conditional univariate logistic regression (Wald test, two-tailed). Variables that differed between the two groups at a p≤0.2 were subjected to a multivariate non-conditional logistic regression model with a stepwise ascending procedure. Two-tailed α values of 0.05 were chosen. Predictors of CDR were presented as OR with 95% CI. All the computations were done with the BMDP statistical package (Statistical Software Inc., Los Angeles, California). Only one study reported enzymatic polymorphism genotypes investigated in our study in HIV-positive sulfonamides-hypersensitive patients compared with non-hypersensitive patients (Pirmohamed et al., 2000Pirmohamed M. Alfirevic A. Vilar J. Stalford A. Wilkins E.G. Sim E. Park B.K. Association analysis of drug metabolizing enzyme gene polymorphisms in HIV-positive patients with co-trimoxazole hypersensitivity.Pharmacogenetics. 2000; 10: 705-713Crossref PubMed Scopus (79) Google Scholar). To increase the power of our study, we analyzed the pooled data using the Cochran–Mantel–Haenszel test. We are indebted to Agnes Bazelly for technical assistance. This work was supported by the following grants: SIDACTION, Fondation pour la Recherche Médicale, Délégation à la Recherche Clinique de l'AP-HP (EMUL 940703), Agence Française de Sécurité Sanitaire des Produits de Santé, Ligue Nationale contre le Cancer. This work was presented in part at the Journées Dermatologiques de Paris 2003, December 2–6.