Influence of the CYP2C9 AND CYP2C19 polymorphisms on phenytoin hydroxylation in healthy individuals from south India.

BACKGROUND AND OBJECTIVES: Phenytoin, a widely used anti-epileptic drug, is metabolized mainly by CYP2C9 (90%) and partly by CYP2C19 (10%) to its major metabolite 5-(para-hydroxyphenyl)-5- phenylhydantoin (p-HPPH). The CYP2C9 and CYP2C19 genes encoding these enzymes are polymorphically expressed and most of the variants result in decreased metabolism of the respective substrates. The present study was undertaken to investigate the influence of the CYP2C9*2 and *3 as well as CYP2C19*2 and *3 variant genotypes on phenytoin hydroxylation in healthy subjects from south India. METHODS: A total of 27 healthy, unrelated, subjects were administered a single oral dose of 300 mg phenytoin. Four hours later, 5 ml of blood was collected and genotyped for CYP2C9*1, *2, *3, CYP2C19*1, *2 and *3 by polymerase chain reaction-restriction fragment length polymorphism (PCR-RFLP) method. Phenytoin and the major metabolite p-HPPH were estimated by reverse phase HPLC. The metabolic ratio was calculated as concentration of phenytoin/p-HPPH. RESULTS: A significant correlation was observed between the CYP2C9 genotype and metabolic ratio of phenytoin/p-HPPH (r = 0.472, 95% CI 0.100 to 0.728; P = 0.01). While no association was found with CYP2C19 alone, a significant correlation was observed between the combined CYP2C9 and CYP2C19 genotypes and phenytoin metabolic ratio (r = 0.507, 95% CI 0.146 to 0.749; P< 0.01). INTERPRETATION AND CONCLUSION: CYP2C9*2 and *3 mutant alleles caused decreased hydroxylation of phenytoin in vivo, whereas the mutant alleles of CYP2C19 played only a minor role in the metabolism of phenytoin in subjects of our study. The results of present preliminary study needs to be confirmed with a larger sample.

The effect of the CYP2C19 genotype on the hydroxylation index of omeprazole in South Indians.

To investigate the relationship between CYP2C19 genotypes and the hydroxylation index (HI) of omeprazole in the South Indian population. Healthy unrelated South Indian subjects (n=300) were separated into three groups based on their CYP2C19 genotypes. They were administered a single oral dose of 20 mg omeprazole, and venous blood was collected 3 h later. Plasma was assayed using reversed-phase high-performance liquid chromatography, and the omeprazole HI was calculated. The means of HIs in individuals with CYP2C19*1/*1 (n=124), *1/*2 (n=129) and *2/*2,*2/*3 (n=47) were 2.4, 5.3 and 22.5, respectively, and were found to be significantly different between any two groups (P<0.0001). A good correlation was established between CYP2C19 genotype and omeprazole HI (r=0.54, 95% CI 0.45-0.62; P<0.0001). Of the 300 subjects, 42 (14.0%; 95% CI 10.1-17.9) were phenotypic poor metabolizers (PMs), but only 33 of them had two mutant alleles and the remaining 9 PMs had at least one wild-type allele. Among the 258 extensive metabolizers, 14 had two mutant alleles. The prevalence of PMs in the South Indian population was 14.0%, which is similar to that in North Indians and Orientals but significantly higher than in Caucasians and Africans. A genotype-phenotype relationship was established between the CYP2C19 genotype and HI of omeprazole, but 7.7% of subjects deviated from expected genotype-phenotype associations. This could be due to an additional mutation, either in the exons/introns or in the 5'-regulatory region of the CYP2C19 gene.

Glutathione S-transferase M1 and T1 null genotype distribution in South Indians.

OBJECTIVE: To investigate the distribution of the homozygous null genotypes of GSTM1 and GSTT1 in the South Indian population. METHODS: Five hundred and seventeen unrelated natives of the South Indian states of Tamilnadu and Pondicherry (n=170), Kerala (n=122), Karnataka (n=110) and Andhra Pradesh (n=115) were analyzed for homozygous deletions of GSTM1 and GSTT1. A multiplex polymerase chain reaction method simultaneously detected both GSTM1 and GSTT1 homozygous null genotypes. The observed frequencies from the four groups were compared statistically with each other and the combined frequencies were compared with frequencies of other major populations previously reported in the literature. RESULTS: In South India, 30.4% (95% CI 26.4-34.3) lacked the GSTM1 gene, 16.8% (13.6-20.1) lacked the GSTT1 gene and 4.6% (3.0-6.8) lacked both the GSTM1 and GSTT1 genes. The highest frequency of GSTM1 null was observed in Karnataka (36.4%, 27.4-45.4), while Andhra Pradesh had the lowest frequency of the GSTM1 and GSTT1 combined double-null genotypes (1.7%, 0.21-6.2). CONCLUSION: The prevalence of the GSTM1 null genotype differed within India. The frequency of GSTM1 null in South Indians was significantly lower than that in Caucasians. The frequencies of both GSTM1 and GSTT1 null genotypes in South Indians were significantly lower than in the Japanese.

Formalin assay parameters differ in confirming the antinociceptive mechanism of domperidone in mice.

Domperidone, a prokinetic drug with minimal extrapyramidal side-effects was investigated for its antinociceptive response in mice using formalin assay procedure. Two parameters namely the pain score and the time spent by the animal in licking/biting the formalin injected paw were considered. Domperidone (1, 2.5 or 5 mg/kg; ip) injected 15 min prior to formalin effectively reduced the pain score bringing it to zero at the 15th minute and was also effective till 30 min but to a lesser degree. This effect of domperidone (2.5 mg/kg) was significantly attenuated in naloxone pretreated mice indicating a partial role for opioid pathways. In the other parameter i.e. time spent in licking/biting, domperidone in all the doses employed failed to modify significantly the same by the animal in the early phase. In contrast, a dose related inhibition of the time spent was recorded in the late phase. Besides, a trend towards the enhancement of the inhibitory effect of domperidone (2.5 mg/kg) in the late phase was noticed in naloxone pretreated mice. Possibly, the peripheral analgesic mechanisms may play a role in this response since the late phase was considered akin to inflammation. The results confirm the antinociceptive effect of domperidone and suggest that caution be exercised while selecting the parameters when formalin assay is employed.

Allele and genotype frequency of CYP2C9 in Tamilnadu population.

OBJECTIVES: To identify the frequency of CYP2C9*1, *2 and *3 alleles and the genotype of CYP2C9 gene in the Tamilian population. METHODS: The study was conducted on 135 unrelated healthy human volunteers. DNA was extracted from the peripheral leukocytes samples and was analyzed using the polymerase chain reaction (PCR)-restriction fragment length polymorphism (RFLP) protocol. The PCR products were digested with AvaII, KpnI or NsiI restriction enzymes. The digested products were separated using 8% polyacrylamide gel and stained by ethidium bromide. Genotyping of the subjects was done based on DNA fragment size. RESULTS: The frequencies of CYP2C9*1, *2 and *3 alleles in the Tamilian population were 0.907, 0.026 and 0.067, respectively. The distribution of CYP2C9*1/*1, *1/*2, *1/*3 and *2/*3 genotypes were 0.823, 0.044, 0.126 and 0.007, respectively. CONCLUSION: CYP2C9*3 is the most frequent mutant allele found in the Tamilian population. The distribution of this mutant allele in the Tamilian population was found to be lesser than in Caucasians but higher than in Chinese.

Genotype and allele frequency of CYP2D6 in Tamilian population.

OBJECTIVE: To assess the frequency of CYP2D6 *3, *4, *5 and *10 allelic variants in a South Indian population and compare the frequencies with other major populations. METHODS: Polymerase chain reaction (PCR) or PCR-restriction fragment length polymorphism (RFLP)-based methods were used to identify the CYP2D6 genotypes of 106 healthy unrelated male and female volunteers of Tamilian origin. The allele and genotype frequencies observed were compared with other major populations. RESULTS: The *10 allele was the most frequent mutant allele in Tamilians (20.3%). The *5 allele occurred at 0.9% and the *3 allele was not detected. The most frequent allele causing enzyme inactivation was *4 allele in Tamilians (6.6%), which is significantly higher than that reported in Japanese (0%). CONCLUSIONS: The *10 allele is the most common mutant allele in Tamilians. The CYP2D6*4 and CYP2D6*5 alleles are distributed in a significantly different way in the Tamil population relative to Oriental populations.

Allele and genotype frequency of CYP2C19 in a Tamilian population.

AIMS: To investigate the frequencies of CYP2C19*1, CYP2C19*2 and CYP2C19*3 alleles and CYP2C19 genotypes in a Tamilian population. METHODS: The study was conducted in 112 unrelated healthy human volunteers. DNA was extracted from leucocytes and analyzed by the PCR-RFLP protocol. The PCR product was digested with restriction enzymes (SmaI and BamH1) and then separated electrophoretically using polyacrylamide gel. RESULTS: The frequencies of the CYP2C19*1, *2 and *3 alleles were 0.598 [95% confidence interval (CI) 0.507, 0.689], 0.379 (95% CI, 0.350,0.407) and 0.022 (95% CI -0.005, 0.049), respectively. The distribution of CYP2C19*1/*1,*1/*2, *1/*3, *2/*2 and *2/*3 genotypes were 0.295 (95% CI, 0.210, 0.379), 0.580 (95% CI, 0.488, 0.671), 0.027 (95% CI -0.003, 0.057), 0.080 (95% CI 0.030, 0.130) and 0.018 (95% CI -0.006, 0.042), respectively. CONCLUSIONS: The distribution of CYP2C19*1/*1 in the Tamilian population is lower than that in Caucasians, Africans and the North Indian population. The CYP2C19*1/*2 is significantly higher in Tamilians when compared with other populations. The CYP2C19*1/*3 allele, which was not reported in the North Indian and Caucasian populations has been identified in 2.7% of the Tamilian population.

Relative efficacy of some prokinetic drugs in morphine-induced gastrointestinal transit delay in mice.

AIM: To study the relative efficacy of cisapride, metoclopramide, domperidone, erythromycin and mosapride on gastric emptying (GE) and small intestinal transit (SIT) in morphine treated mice. METHODS: Phenol red marker meal was employed to estimate GE and SIT in Swiss albino mice of either sex. The groups included were control, morphine 1 mg/kg (s.c. 15 min before test meal) alone or with (45 min before test meal p.o.) cisapride 10 mg/kg, metoclopramide 20 mg/kg, domperidone 20 mg/kg, erythromycin 6 mg/kg and mosapride 20 mg/kg. RESULTS: Cisapride, metoclopramide and mosapride were effective in enhancing gastric emptying significantly (P<0.001) whereas other prokinetic agents failed to do so in normal mice. Metoclopramide completely reversed morphine induced delay in gastric emptying followed by mosapride. Metoclopramide alone was effective when given to normal mice in increasing the SIT. Cisapride, though it did not show any significant effect on SIT in normal mice, was able to reverse morphine induced delay in SIT significantly (P<0.001) followed by metoclopramide and mosapride. CONCLUSION: Metoclopramide and cisapride are most effective in reversing morphine-induced delay in gastric emptying and small intestinal transit in mice respectively.

Influence of honey on orally and intravenously administered diltiazem kinetics in rabbits.

Effect of honey on plasma concentration of diltiazem after oral and intravenous administration in rabbits, has been studied. For oral study, single dose of diltiazem (5 mg/kg, p.o.) along with saline was administered to New Zealand white rabbits (n=8). Blood samples were collected at 0, 0.25, 0.5, 0.75, 1, 1.5, 2, 3, 4, 6 and 8 hr after drug administration from marginal ear vein. After a washout period of one week, diltiazem was administered with honey (2.34 ml/kg; p.o.) and the blood samples were collected as above. To the same animals honey (2.34 ml/kg; p.o.) was continued once daily for 7 days. On 8th day, honey and diltiazem were administered simultaneously and blood samples were collected at similar time intervals as mentioned above. For intravenous study the pharmacokinetic was done in each animal on two occasions. The first study was done after single dose administration of diltiazem (5 mg/kg; i.v.) along with saline (2.34 ml/kg; p.o.). Blood samples were collected at 0, 0.083, 0.25, 0.5, 0.75, 1, 1.5, 2, 3, 4 and 6 hr after i.v. diltiazem administration. The same animals were treated with honey (2.34 ml/kg; p.o.) for seven days. On day 8, the second study was carried out with single dose i.v. administration of diltiazem along with honey (2.34 ml/kg; p.o.) and blood samples were collected. In the oral study, single dose administration of honey decreased the AUC and Cmax of diltiazem associated with significant increase in clearance and volume of distribution when compared to saline treated group. After one week administration of honey, diltiazem kinetic data showed further reduction in AUC and Cmax and increase in clearance and volume of distribution. In the i.v. study also, multiple dose administration of honey significantly reduced the AUC and increased the clearance value of diltiazem. The results suggest that honey may decrease the plasma concentration of diltiazem after its oral or i.v. administration in rabbits.

Effect of honey on carbamazepine kinetics in rabbits.

The study was undertaken to determine the effect of honey on carbamazepine kinetics in rabbits. The study was done on three occasions in each animal. Study 1 was carried out after single dose administration of carbamazepine (80 mg/kg, po), along with saline (2.34 ml/kg, po). After a wash out period of one week, the second study was carried out by co-administration of carbamazepine with honey (2.34ml/kg, po). After this, the animals continued to receive honey (2.34ml/kg, po), once daily, for 7 days. On the eighth day of honey treatment, the carbamazepine kinetics was studied again. Pharmacokinetic analysis revealed that single as well as multiple dose honey treatment showed a significant decrease in area under the plasma time concentration curve (AUC) when compared with saline treated control. A significant increase in the clearance (CL/F) rate of carbamazepine was observed only after multiple dose honey treatment. Both single and multiple dose honey treatment did not show any significant effect on other pharmacokinetic parameters like t1/2, Cmax, Tmax and Vd when compared with saline treated group. Data thus obtained suggested that honey decreases the bioavailability of carbamazepine.

Effect of two types of Indian breakfast on bioavailability of cefuroxime axetil.

BACKGROUND & OBJECTIVES: The oral bioavailability of cefuroxime axetil is enhanced by food. This study was done to compare the effect of two types of Indian breakfast on the bioavailability of cefuroxime axetil in healthy volunteers. METHODS: Eight healthy male volunteers participated in the crossover study. Subjects were randomized to receive either one of the two types of breakfast, Diet-A or Diet-B, 10 min before single dose of 500 mg cefuroxime axetil. After a washout period of one week the study was repeated with the other type of diet. Diet-A included idly with chutney. Diet-B included poori and dal-fry. Blood samples for pharmacokinetic analysis were obtained prior to dosing and at 0.25, 0.50, 0.75, 1.0, 1.5, 2.0, 2.5, 3.0, 4.0, 5.0, 6.0 and 8.0 h following dosing and urine collections were done for 8 h. The serum and urine samples were assayed by using HPLC. RESULTS: The AUC and Cmax were significantly increased after oral administration of cefuroxime axetil with Diet-B, when compared to Diet-A (P < 0.01 and P < 0.02 respectively). The values of apparent absorption rate constant, lag-time, Tmax and t1/2 beta for the two regimens were not significantly different. The volume of distribution and plasma clearance for cefuroxime were significantly lower (P < 0.02, P < 0.001 respectively) in the regimen with Diet-B. The 8 h urinary recovery of cefuroxime was 16.59 and 28.44 per cent (P < 0.005) with Diet-A and Diet-B respectively. INTERPRETATION & CONCLUSIONS: The administration of cefuroxime axetil with poori and dal-fry may enhance the bioavailability when compared with idly and chutney.

Effect of hyoscine butylbromide and atropine on heart rate during nocturnal sleep.

This is a single blind crossover study designed to test the effects of hyoscine butylbromide (HBB), an anticholinergic which does not cross the blood brain barrier (BBB), on the temporal changes in heart rate during nocturnal sleep. The effects were compared with atropine sulphate which is known to cross the BBB. Ten healthy male volunteers slept in the JIPMER sleep disorders laboratory for three nights and received either saline, atropine sulphate (0.4 mg, i.v.) or HBB (10 mg, i.v.) just prior to sleep onset. All night polysomnography recording was done to monitor heart rate during the specific stages of sleep. The normal physiological fall in heart rate is blunted by both drugs during slow wave sleep whereas only HBB prevented the fall in rapid eye movement sleep. Therefore, HBB may be a better choice as pre-anaesthetic medication for patients with cardiac abnormalities since it does not alter heart rate during both slow wave sleep and rapid eye movement sleep.

Ascorbic acid delays the development of tolerance to amphetamine induced anorexia but does not affect the reverse tolerance which develops to the locomotor activity.

Ascorbic acid (1 g/kg) accentuated anorectic and locomotor effects of amphetamine (5 mg/kg) and delayed development of tolerance to anorectic effect. On the contrary, it did not alter the pattern of reverse tolerance to increased locomotor activity. The results suggest that modulation of dopamine receptor sensitivity by ascorbic acid may be the reason for the delay in development of tolerance to amphetamine induced anorexia.

Pharmacokinetics of single dose oral digoxin in patients with uncomplicated type II diabetes mellitus.

Digoxin pharmacokinetics was studied in eight patients with uncomplicated type II diabetes mellitus and seven healthy volunteers. After a single oral dose of digoxin (1 mg), the drug concentration was measured in the serum collected at different time intervals, using a radioimmunoassay method. The diabetics had a higher serum concentration of drug when compared to control. The clearance rate of digoxin was significantly reduced in diabetics when compared to healthy volunteers. The elimination half-life of about 22 hours in both groups is much less than that reported in Western data. Possible reasons for this discrepancy are discussed.

Altered pharmacokinetics of lignocaine after epidural injection in type II diabetics.

The pharmacokinetics of lignocaine has been compared after epidural anaesthesia in diabetics and non-diabetic patients. Epidural lignocaine 8 mg.kg-1 was given to 8 well controlled Type II diabetic and 8 non-diabetic patients and the plasma drug concentration in serial blood samples were measured by HPLC. The plasma level of lignocaine was lower in diabetics compared to non-diabetics. The peak level was attained at 20 min in both groups. The clearance of the drug was significantly higher, (39.9 vs 16.7 ml.min-1.kg-1) associated with a decreased elimination half-life and mean residence time. The study suggests that the rate of absorption of lignocaine is not altered after epidural administration and that its hepatic metabolism is increased in diabetics compared to non-diabetics.

Drug utilization at primary health care level in southern India.

Primary health centres provide health care to the majority of the population in developing countries. A drug utilization study was conducted for 1 y at two primary health centres in Pondicherry, India. Information on complaints, diagnosis and drugs prescribed was collected. From the 2953 prescriptions studied, it was found that on an average each patient received 2.71 drugs. Vitamins, antibiotics, analgesics and antihistamines were the most commonly used, accounting for more than 80% of the drugs prescribed. The antimicrobials which constituted one fourth of the drug consumption, comprised sulphonamides, tetracycline and cotrimoxazole. About half of the patients received injections, particularly of the vitamin B Complex and antibiotics. The results will be used to plan intervention strategies for the promotion of rational drug use.

PIP: Records from 2 of the 8 primary health care clinics (PHCs) in Pondicherry, India, were surveyed one day per month in 1988 by medical graduates to determine drug utilization. 2953 patients treated during the morning hours received 8021 prescriptions, an average of 2.71 each. The most commonly prescribed drugs were vitamins (24.7% of total drugs), antimicrobials (24.3% of drugs, 66.2% of patients), analgesics (19.9% of drugs) and antihistamines (10.3%). The most prevalent diagnoses were would infection (20.5%), myalgia (11.3%), urinary tract infections (10.2%), pain, skin diseases, cold and diarrhea. Asthma, worms and fever of unknown origin were found in 5% or fewer patients. Among antimicrobials, the most commonly prescribed were sulfonamides, tetracycline, and cotrimoxazole. Children received more antibiotics than adults. Chloramphenicol was given to 42 patients, 28 of them children. Penicillin made up only 6.4% of the antibiotics given. 32.8% of the antibiotics were administered intramuscularly, including 355 tetracycline injections. B-vitamin complex was also injected intramuscularly in 474 patients. Both consumers and practitioners in developing locales must be informed that injections, particularly of agents such as tetracycline and vitamins which are safer and cheaper to give orally, are not the administration route of choice for all medications. A safer antibiotic than chloramphenicol should be chosen for serious infections, especially in pediatrics.

Influence of type I and type II diabetes mellitus on phenytoin steady-state levels.

Phenytoin kinetics was studied in male type I and type II diabetic patients, ten in each group. Age and sex matched epileptic patients receiving phenytoin alone served as control groups. Steady-state concentration of phenytoin was significantly lower in both types of diabetics compared to respective controls. The Vmax and Vmax/Km of phenytoin were significantly increased in type I diabetics. The Vmax was unaltered in type II diabetics but the Vmax/Km was higher in them. Protein binding of the drug was decreased in both groups. It is concluded that phenytoin kinetics is increased in both types of diabetics which may be responsible for the lower steady-state concentration of the drug.