Individualized Medication Study Of Voriconazole Basing On Genetic Polymorphisms Of CYP2C19、CYP2C9、CYP3A4、ABCB1

BackgroundAn increasing incidence of invasive fungal infections(IFIs)has been observed.And IFIs are important reasons of mortality in nosocomial infections.Voriconazole(VRC)is a secondary-generation triazole antifungal agent with superior target site affinity and broad-spectrum activity against yeasts and moulds,it has been regarded as primary treatment or prophylactic for IFIs.VRC is extensively metabolized by CYP2C19,CYP3A4,CYP2C9.And ABCB1 is one of the important transporters Genetic polymorphisms of the main metabolic enzymes and ABCB1 may leads to discrepancies of the metabolic activity.The trough concentration is regarded as a good measurement of VRC exposure,and it is associated with efficacy of antifungal and adverse reactions.However,the treatment remains intractable,there are still several challenges in individualized medication of VRC at present;And the challenges are as following: a narrow therapeutic range,inter-and intra-individual variability,remarkable adverse reactions,expensive fees.The treatment of VRC is influenced by genetic and non-genetic factors.However,up to now,the factors has not been clarified.The research aim to study the factors which result in considerableinter-and intra-individual variability of VRC treatment,and to be applied to individualized medication of VRC.Objectives1.Mornitor voriconazole initial steady serum trough concentration [(Css)min],and study the charicteristics of(Css)min;2.Study gentic polymorphisms of CYP2C19,CYP3A4,CYP2C9 and ABCB1 of Chinese Han hematological patients in Henan Provincial People’s Hospital;3.Study the effects of CYP2C19,CYP3A4,CYP2C9 and ABCB1 genetic polymorphisms on(Css)min of Chinese Han hematological patients in Henan Provincial People’s Hospital;4.Study the effects of non-genetic factors on(Css)min of Chinese Han hematological patients in Henan Provincial People’s Hospital.Methods1.This retrospective study was performed in the Henan Provincial People’s Hospital.Hematological patients who conformed with diagnostic criteria of IFD and were prescribed VRC for either antifungal treatment or prophylaxis of IFIs,and underwent therapeutic drug monitoring(TDM)of VRC between March 2015 and September 2016 were eligible;2.The serum concentrations of VRC in the blood samples were measured by a validated reverse-phase high performance liquid chromatography(HPLC)method;DNA was extracted from blood samples.The quantity and quality of DNA extracted from the blood samples was tested by BioSpectrometer.Then the DNA samples were stored in-40℃ untill genotype detection.3.MassARRAY system was utilized to perform SNPs genotyping by means of matrix assisted laser desorption ionization-time of flight mass spectrometry method(MALDI-TOF)according to the manufacturers instructions.Primers of PCR and extension were designed by Assay Designer.Genotype calling was performed in real time with MassARRAY RT software version 3.0.0.4 and analyzed using theMassARRAY Typer software version 3.4.4.We retrospectively reviewed the electronic medical records of the patients,and extracted the information which may concerning VRC therapy.Demographic data,administration routes,underlying diseases,concomitant medications,transaminase and albumin(ALB)levels,SNPs genotyps,and(Css)min is collected.5.Statistical analyses were performed by SPSS Statistics 19.0.The Hardy-Weinberg equilibrium test was performed on each alleles by chi-square test.Pairwise linkage disequilibrium(LD)analysis among the selected alleles was performed by the SHEsis software platform.Non-parametric tests(Mann-Whitney U test for two groups,Kruskal-Wallis Test for three and more groups)were used to perform comparisons between groups,and a Spearman rank test was used to investigate correlation between quantitative data.Optimal Scaling Regression analysis was choose to confirm the determinants which contributes to the variability of(Css)min.A p value of <0.05 was set to consider statistical significance.Results1.A total of 106 blood samples from 86 patients were included in the analysis.3patients were diagnosed as Proven IFD,11 patients were diagnosed as Probable IFD,32 patients were diagnosed as Possible IFD,40 patients were diagnosed as Undetermined IFD.And the coefficient of(Css)min was 65.8%.2.Minor allele frequency(MAF)of the 21 SNPs in the study was different with Global MAF.And mutation was not observed or the MAF were particularly low in rs17882687,rs12248560,rs1799853,rs2740574,rs35599367,rs10264272 and rs41303343.3.Genetic polymorphisms of CYP2C19 is an important factor of the variability of(Css)min;Patients with mutation of rs4244285 or rs4986893 showed higher(Css)min/D,and age is positively correlated with(Css)min/D;4.While BMI was confirmed as a factor of(Css)min/D in patients of extensive metabolizers(EMs),for patients of intermediate or poor metabolizers,mutation T allele of rs4646437(CYP3A4)combined with older age(P=0.002)were associatedwith higher(Css)min/D.Conclusions1.VRC showed considerable inter-individual variability with high variability of(Css)min;2.CYP2C19 genetic polymorphisms is an important factor of the variability of(Css)min;3.In individualized medication of voriconazole of hematological patients,genetic polymorphisms of CYP3A4,and non-genetic factors as BMI,age should also be taken into account,especially for IMs or PMs patients.