Abstract
Introduction:
Mirtazapine is commonly administered to patients with recurrent depressive disorder. Some of these patients do not show adequate response to the therapy with mirtazapine, whereas many of them experience dose-dependent adverse drug reactions. Previous research revealed that CYP2D6 is involved in the metabolism of mirtazapine, the activity of which is highly dependent on the polymorphism of the gene encoding it.
Objective:
The objective of this study was to investigate the effect of polymorphisms of the CYP3A4, CYP2C9, CYP3A5, ABCB1, CYP2C19, SCL6A4, and 5-HTR2A genes on the concentration/dose indicator of mirtazapine and on the CYP3A expression level obtained by measuring the miR-27b plasma concentration levels in patients suffering from a recurrent depressive disorder.
Material and Methods:
Our study included 108 patients with recurrent depressive disorder (average age – 35.2 ± 15.1 years). The treatment regimen included mirtazapine in an average daily dose of 45.0 [30.0; 60.0] mg per week. Therapy efficacy was assessed using the international psychometric scales. Therapy safety was assessed using the UKU Side-Effect Rating Scale. For genotyping and estimation of the microRNA (miRNA) plasma levels, we performed the real-time polymerase chain reaction. The activity of CYP3A was evaluated using the HPLC-MS/MS method by the content of the endogenous substrate of the given isoenzyme and its metabolite in urine (6b-HC/cortisol). Therapeutic drug monitoring has been performed using HPLC-MS/MS.
Results:
Our study didn’t reveal any statistically significant results in terms of the treatment efficacy and safety of the therapy. We also didn’t reveal a statistical significance for the concentration/dose indicator of mirtazapine in patients with different genotypes. Analysis of the results of the pharmacotranscriptomic part of the study didn’t demonstrate the statistically significant difference in the miR-27b plasma levels in patients with different genotypes. At the same time, correlation analysis didn’t reveal a statistically significant relationship between the mirtazapine efficacy profile evaluated by changes in HAMD scale scores and the miR-27b plasma concentration: rs = −0.2, p = 0.46. Also, we didn’t reveal the correlation between the miRNA concentration and safety profile: rs = 0.029, p = 0.93. In addition, we didn’t reveal the relationship between the CYP3A enzymatic activity and the miR-27b plasma concentration: rs = −0,188, p = 0.85. However, the difference in the CYP3A enzymatic activity in carriers of AG and GG genotypes of the 6986A > G polymorphism of CYP3A5 gene has been revealed: (AG) 4.75 [1.28; 7.34] vs (GG) 8.83 [4.73; 13.62], p-value = 0.023.
Conclusion:
Thus, the effect of genetic polymorphism of the CYP3A4, CYP2C9, CYP2C9, CYP3A5, ABCB1, CYP2C19, CYP2C19, CYP2C19, SCL6A4, 5-HTR2A gene on the efficacy and safety profiles of mirtazapine was not demonstrated in a group of 108 patients with depressive disorder and alcohol use disorder.
Keywords: mirtazapine, pharmacogenetics, biotransformation, personalized medicine, depressive spectrum disorders, alcohol use disorder
Introduction
Depressive spectrum disorders are among the most prevalent comorbid psychiatric disorders in patients suffering from alcohol use disorder.2 Antidepressants are used to treat patients suffering from depressive disorders,10 and mirtazapine is a representative of this drug group.10 Even though selective serotonin reuptake inhibitors (SSRIs) are included in clinical guidelines for the treatment of patients with patients suffering from depressive spectrum disorders, the amount of resistant patients and patients with dose-dependent adverse drug reactions remains high.11
CYP2D6 isoenzyme participates in the pharmacokinetics of many drugs prescribed for psychopharmacotherapy of patients suffering from a recurrent depressive disorder.4 Meanwhile, gene encoding CYP2D6 is highly polymorphic, which can affect the activity of CYP2D6.9 Changes in activity may affect the rate of metabolism of xenobiotics, including substrate drugs, which, in turn, may have an impact on their efficacy and safety profiles.17 There are four groups of metabolizers distinguished by their metabolic rates: extensive metabolizers with the normal metabolic rate; poor metabolizers with mutations in the CYP2D6 gene, which may result in the decreased activity of the encoded protein along with a slowdown in the biotransformation of substrate drugs, which may lead to an increased risk of type A adverse drug reactions (type A ADRs); intermediate metabolizers having a mutation in only one of the homologous chromosomes, which reduces the activity of CYP2D6, but to a lesser degree than in poor metabolizers; ultra-rapid metabolizers having the congenital increased activity of CYP2D6, which leads to the accelerated elimination of substrate drugs and the reduced treatment efficacy.1 So, changes in the profiles of the efficacy and safety of mirtazapine may depend on, inter alia, the changes in genes encoded pharmacodynamics and pharmacokinetics elements and, inter alia, CYP2D6.
Concerning the pharmacotranscriptomic part of the study, the in vitro studies showed the correlation between the plasma concentration of microRNA hsa-miR-370-3p and CYP2D6 activity.16
The objective of this study was to investigate the effect of polymorphisms of the CYP3A4, CYP2C9, CYP2C9, CYP3A5, ABCB1, CYP2C19, CYP2C19, CYP2C19, SCL6A4, 5-HTR2A genes on the concentration/dose indicator of mirtazapine, on CYP3A expression level obtained by measuring the miR-27b plasma concentration levels in patients suffering from a recurrent depressive disorder.
Material and Methods
Clinical Characteristics of the Study Subjects
The study involved 108 male patients (average age—35.2 ± 15.1 years). The inclusion criteria were the existence of two diagnoses: “Depressive episode (F32.x, according to ICD-10)”, and “Mental and behavioral disorders due to use of alcohol. Dependence syndrome. Currently abstinent but in a protected environment (F.10.212)”; signed informed consent and 8-weeks mirtazapine monotherapy. Exclusion criteria were the presence of any other mental disorders; the presence of severe somatic disorders (except alcoholic hepatitis and toxic encephalopathy); the presence of any other psychotropic medications in treatment regimen; creatinine clearance values <50 mL/min, creatinine concentration in plasma >1.5 mg/dL (133 mmol/L), bodyweight less than 60 kg or greater than 100 kg, age of 75 years or more and presence of any contraindications for mirtazapine use.
Therapy Efficacy and Safety Evaluation
To evaluate mirtazapine efficacy, several international psychometric scales were used: Hospital Anxiety and Depression Scale (HADS),5 The assessment3,6,18 of depression states by rating (HAMD).6 The safety profile was evaluated using the UKU Side-Effect Rating Scale (UKU).8 Patients were examined on weeks 1, 4 and 8 of mirtazapine therapy.
Genotyping
For genotyping, venous blood samples were collected into VACUETTE® (Greiner Bio-One, Austria) vacuum tubes during the week 8 of mirtazapine therapy. The DNA amplifiers “Dtlite” by DNA Technology (Moscow, Russia), CFX96 Touch Real-Time System with CFX Manager software by Bio-Rad Laboratories Inc. (Hercules, CA, USA) and the “SNP-screen” sets by “Syntol” (Moscow, Russia) were used to perform the real-time polymerase chain reaction in order to determine the single-nucleotide polymorphisms (SNPs) CYP3A4 (rs35599367), CYP2C9 (rs1799853), CYP2C9 (rs1057910), CYP3A5 (rs776746), ABCB1 (rs1045642), CYP2C19 (rs4244285), CYP2C19 (rs4986893), CYP2C19 (rs12248560), SCL6A4 (rs25531), and 5-HTR2A (rs1928040). We used two allele-specific hybridizations in every “SNP-screen” set, which have enabled us to determine separately two alleles of the studied SNP on two fluorescence channels.
Phenotyping
CYP3A enzymatic activity was evaluated on the weeks 1 and 8 by determining the urinary concentration of endogenous substrate of the enzyme and its metabolite, 6b-HC/cortisol,7,14,12 using high-performance liquid chromatography-mass spectrometry (HPLC-MS/MS). Results of the isoenzyme activity evaluation are demonstrated in arbitrary units.
Therapeutic Drug Monitoring
For TDM, venous blood samples were collected on the week 8th of mirtazapine therapy. The plasma calibration standards (St) and quality control samples (QC) were made from a stock solution prepared by consistent dissolving of substantial amounts in methanol with subsequent dilution to the relevant concentrations. Calibration curve was created using 5, 10, 20, 50, 100, 200, 500, 1000, 2000 ng/mL calibration standards along with 5 ng/mL (LLOQ), 15 ng/mL (Low QC), 1000 ng/mL (Medium QC), and 1500 ng/mL (High QC) quality control samples (QC). Diazepam (250 ng/mL in acetonitrile) was used as the internal standard.
Sample Preparation
Samples were prepared using a protein precipitation method. A 1.5 mL tube was filled with 200 mcL of analyzed plasma sample and 600mcL of acetonitrile containing the internal standard. The mixture was shaken on Vortex for 10 minutes, and then samples were centrifuged at 14,500 g for 10 minutes at 4°C. Then the supernatant was transferred to an autosampler vial. Samples were analyzed using the HPLC system Agilent 1260 (Agilent Technologies, California, USA) and tandem mass selective detector Agilent 6460 (Agilent Technologies, California, USA) with Jet Stream Electrospray Ionization Source.
Conditions of Chromatographic Analysis
Stationary phase: column Agilent Poroshell 120 EC-C18 (2.7 μm, 3.0 mm × 50 mm) with the precolumn InfinityLab Poroshell 120 EC-C18 (2.7 μm, 3.0 mm × 5.0 mm) (Agilent Technologies, California, USA). The column temperature was 50°C. The mobile phase consisted of the A eluent (10 mM ammonium formate in 0.1% formic acid) and B eluent (methanol in 0.1% formic acid). The flow rate was 0.4 mL/min. Gradient elution process was performed; the gradient of the mobile phase is presented in Table 1. The analysis time was 9.0 minutes for every sample. The volume of the inserted sample was 2 mcL. Retention time under the given conditions was 4.75 min for mirtazapine and 4.84 min for diazepam.
Table 1. The Results of Genotyping.
| Gene | RS | AA* (N, %) | AB (N, %) | BB (N, %) | HWE** (Chi2, p-value) |
|||||
| CYP3A4 | rs35599367 | 107 (99.1%) | 1 (0.9%) | 0 (0.0%) | 0.002; 0.96 | |||||
| CYP2C9 | rs1799853 | 87 (80.6%) | 21 (19.4%) | 0 (0.0%) | 1.25; 0.26 | |||||
| CYP2C9 | rs1057910 | 96 (88.9%) | 12 (11.1%) | 0 (0.0%) | 0.37; 0.54 | |||||
| CYP3A5 | rs776746 | 0 (0.0%) | 8 (7.4%) | 100 (92.6%) | 0.16; 0.69 | |||||
| ABCB1 | rs1045642 | 16 (14.8%) | 60 (55.6%) | 32 (29.6%) | 2.00; 0.16 | |||||
| CYP2C19 | rs4244285 | 99 (91.7%) | 9 (8.3%) | 0 (0.0%) | 0.20; 0.65 | |||||
| CYP2C19 | rs4986893 | 106 (98.1%) | 2 (1.9%) | 0 (0.0%) | 0.009; 0.92 | |||||
| CYP2C19 | rs12248560 | 60 (55.6%) | 46 (42.6%) | 2 (1.9%) | 4.27; 0.05 | |||||
| SCL6A4 | rs25531 | 53 (49.1%) | 51 (47.2%) | 4 (3.7%) | 3.53; 0.06 | |||||
| 5-HTR2A | rs1928040 | 25 (23.1%) | 59 (54.6%) | 24 (22.2%) | 1.53; 0.21 |
Note: *A: minor allel; B: major allel; **HWE: Hardy–Weinberg equilibrium.
Conditions of Mass-Spectrometry Determination
We used positive mode electrospray ionization for mass-selective detection. Detector registered following MRM-transitions: from 349.0 m/z [M+H+] to 206.1 m/z (collision cell energy 40 V) and from 349.0 m/z [M+H+] to 184.0 m/z (collision cell energy 32 V) for mirtazapine; from 285.1 m/z [M+H+] to 193.1 m/z (collision cell energy 32 V) and from 285.1 m/z [M+H+] to 154.1 m/z (collision cell energy 24 V) for diazepam (the internal standard). The voltage on phragmentor for mirtazapine and diazepam was 156V and 166V, respectively. The voltage on capillary was 3.5 kV, the temperature of desiccant gas was 350°C, nitrogen flow was 6 L/min. Nebulizers pressure was 45 psi, sheath gas temperature was 375°C, sheath gas flow was 11 L/min.
Method Validation
The methodology used in the study met FDA Guidance for Industry: Bioanalytical method validation. Calibration dependence was linear for diapason at 0.5–200 ng/mL. Correlation coefficients were normal (at least 0.99). We evaluated the intra- and inter-cycles precision and accuracy rates. Precision and accuracy rates were normal (no more than 20% at LLOQ, no more than 15% for other points). The matrix effect had no influence.
Determination of the miRNA Levels
Blood was collected into sterile tubes containing EDTA. A closed tube with blood was turned over several times to mix blood with anticoagulant. To obtain plasma, the tube was centrifuged for 10 minutes at an acceleration of 2000 g, after which supernatant was transferred to sterile 2 or 1.5 mL tubes and stored before use at −80°C. Total RNA, including miRNA, was isolated using Trizol (Life Technologies, Carlsbad, USA) and a set of miRNeasy Mini Kit (Qiagen, Hilden, Germany) following the protocol of manufacturers with small modifications. Trizol was added to 500 μl of plasma in a volume ratio of 2:1. After chloroform was added to the tube and then centrifuged to separate phases, the aqueous phase was transferred to a new tube, and 1.5 times the volume of 100% ethanol was added to it. The solution containing RNA was loaded into the miRNeasy column and further washed according to the manufacturer’s instructions. The final volume of elution was 15 μl. Concentration and purity of the obtained RNA were estimated on the NanoDrop 2000 microvolume spectrophotometer (Thermo Fisher Scientific, New York, USA). The extraction process was repeated for each sample until a sufficient amount of RNA was obtained for the next steps. Reverse transcription was performed using the MiScript II RT Kit (Qiagen) under the recommended protocol. To obtain cDNA, 300 ng of total RNA extracted from each sample was used, which was added to the reaction mixture (4 μl 5× 5× miScript HiFlex Buffer, 2 μl 10× miScript Nucleics Mix, 1 μl of Reverse Transcriptase Mix miScript and RNAz-free water up to 20 μl) and was incubated for 60 minutes at 37°C, followed by an increase in temperature up to 95°C for 5 minutes to inactivate transcriptase. Real-time PCR was performed with three repetitions for each of the analyzed miRNAs, as well as endogenous control of RNU6B, using the MiScript SYBR Green PCR Kit (Qiagen) and presynthesized miScript Primer Assay (Qiagen) primers in the volume of the reaction mixture of 12 μl (2 μl of cDNA obtained), 5 μl 2× QuantiTect SYBR Green PCR Master Mix, 1 μl 10× 10× miScript Universal Primer, 1 μl 10× miScript Primer Assay to the studied microRNA and RNAz-free water up to 12 μl). Real-time PCR was performed on the CFX96 Real-Time PCR Detection System (Bio-Rad, Hercules, USA) according to the manufacturer’s recommended program (15 minutes at 95°C to activate the HotStarTaq DNA Polymerase and 40 three-step cycles (94°C – 15 seconds, 55°C – 30 seconds, 70°C – 30 seconds)).
Local Ethical Committee
The local ethical committee of the Russian Medical Academy of Continuous Professional Education of the Ministry of Health of the Russian Federation approved the research (The protocol No. 6 from 5/16/2017).
Statistical Analysis
Statistical analysis of the results was performed with non-parametric methods using the “Statsoft Statistica v. 10.0” (Dell Statistica, Tulsa, OK, USA). The normality of sample distribution was evaluated using the W-Shapiro-Wilk test and taken into account when choosing a method. The differences were considered statistically significant at p < 0.05 (power above 80%). Two samples of continuous independent data were compared using the Mann-Whitney U-test, which takes into account the abnormal nature of data distribution, with further correction of the obtained p-value using the Benjamin-Hochberg test, due to the multiple comparison procedure. Several samples of continuous data were analyzed using the Kruskal-Wallis H-test. Correlation analysis was performed using the Spearman nonparametric test, taking into account the abnormal nature of sample distribution. Pearson’s Chi2 test for the evaluation of the sampling distribution of the alleles (Hardy Weinberg equilibrium) has been used. Research data are presented in the form of the median and interquartile range (Me [Q1; Q3]), or in case of their normal distribution, as the arithmetic mean and standard deviation (Mean ± SD).
Study Results
The results of genotyping are demonstrated in Table 1.
The results of data analysis performed for psychometric assessments, side-effect rating scale, concentration of mirtazapine and miR-27b can be found in Table 2.
Table 2. Data From the Psychometric Assessments and Side-Effect Rating Scale, Pharmacokinetic and Pharmacotranscriptomic Studies in Patients with Different Genotypes.
| Gene | RS | AA* | AB | BB | KWT** (p-value) | |||||
| HAMD | ||||||||||
| CYP3A4 | rs35599367 | 15.0 [13.0;16.0] | 13.0 [11.0;15.0] | 15.0 [13.0;16.0] | 0.56 | |||||
| CYP2C9 | rs1799853 | 13.0 [10.0;14.0] | 13.0 [12.0;14.0] | 13.0 [12.0;14.0] | 0.97 | |||||
| CYP2C9 | rs1057910 | 14.0 [12.0;16.0] | 13.0 [12.0;14.0] | 14.0 [11.0;16.0] | 0.85 | |||||
| CYP3A5 | rs77646 | 14.0 [12.0;16.0] | 13.0 [12.0;15.0] | 15.0 [12.0;18.0] | 1.00 | |||||
| ABCB1 | rs1045642 | 14.0 [13.0;15.0] | 13.0 [11.0;15.0] | 15.0 [14.0;18.0] | 0.54 | |||||
| CYP2C19 | rs4244285 | 15.0 [12.0;18.0] | 14.0 [11.0;16.0] | 13.0 [10.0;16.0] | 0.82 | |||||
| CYP2C19 | rs4986893 | 15.0 [14.0;18.0] | 14.0 [13.0;17.0] | 13.0 [12.0;15.0] | 0.51 | |||||
| CYP2C19 | rs12248560 | 15.0 [13.0;18.0] | 14.0 [13.0;15.0] | 14.0 [13.0;15.0] | 0.92 | |||||
| SCL6A4 | rs25531 | 15.0 [14.0;18.0] | 14.0 [13.0;17.0] | 14.0 [11.0;16.0] | 0.81 | |||||
| 5-HTR2A | rs1928040 | 14.0 [13.0;16.0] | 15.0 [12.0;17.0] | 13.0 [11.0;15.0] | 0.86 | |||||
| UKU | ||||||||||
| CYP3A4 | rs35599367 | 4.0 [3.0;5.0] | 4.0 [3.0;5.0] | 3.0 [2.0;4.0] | 0.98 | |||||
| CYP2C9 | rs1799853 | 4.0 [3.0;5.0] | 4.0 [3.0;5.0] | 4.0 [3.0;5.0] | 0.68 | |||||
| CYP2C9 | rs1057910 | 3.0 [2.0;4.0] | 3.0 [2.0;4.0] | 3.0 [2.0;4.0] | 0.58 | |||||
| CYP3A5 | rs77646 | 3.0 [2.0;4.0] | 4.0 [3.0;5.0] | 4.0 [3.0;5.0] | 0.81 | |||||
| ABCB1 | rs1045642 | 4.0 [3.0;5.0] | 4.0 [3.0;5.0] | 3.0 [2.0;4.0] | 0.66 | |||||
| CYP2C19 | rs4244285 | 3.0 [2.0;4.0] | 3.0 [2.0;4.0] | 3.0 [2.0;4.0] | 0.86 | |||||
| CYP2C19 | rs4986893 | 4.0 [3.0;5.0] | 4.0 [3.0;5.0] | 4.0 [3.0;5.0] | 0.91 | |||||
| CYP2C19 | rs12248560 | 3.0 [2.0;4.0] | 3.0 [2.0;4.0] | 4.0 [3.0;5.0] | 0.39 | |||||
| SCL6A4 | rs25531 | 4.0 [3.0;5.0] | 3.0 [2.0;4.0] | 4.0 [3.0;5.0] | 0.73 | |||||
| 5-HTR2A | rs1928040 | 4.0 [3.0;5.0] | 4.0 [3.0;5.0] | 4.0 [3.0;5.0] | 0.86 | |||||
| Concentration of miR-27b | ||||||||||
| CYP3A4 | rs35599367 | 24.7 [18.5;29.6] | 25.8 [20.6;31.5] | 21.0 [17.0;24.6] | 0.55 | |||||
| CYP2C9 | rs1799853 | 21.5 [17.4;25.2] | 22.1 [18.8;27.6] | 24.2 [19.1;29.5] | 0.50 | |||||
| CYP2C9 | rs1057910 | 25.0 [20.8;31.3] | 23.9 [18.6;29.2] | 25.2 [19.7;29.2] | 0.48 | |||||
| CYP3A5 | rs77646 | 25.5 [20.4;29.3] | 26.0 [19.8;29.9] | 24.1 [20.5;28.2] | 0.48 | |||||
| ABCB1 | rs1045642 | 26.0 [20.0;31.2] | 22.7 [17.9;27.7] | 21.3 [17.7;25.6] | 0.37 | |||||
| CYP2C19 | rs4244285 | 21.2 [18.0;26.5] | 24.8 [19.1;31.0] | 23.2 [17.9;27.6] | 0.30 | |||||
| CYP2C19 | rs4986893 | 22.5 [18.2;27.7] | 22.6 [17.4;27.8] | 25.2 [19.9;30.5] | 0.43 | |||||
| CYP2C19 | rs12248560 | 25.4 [19.8;29.7] | 25.2 [20.7;30.7] | 22.5 [18.2;26.8] | 0.57 | |||||
| SCL6A4 | rs25531 | 25.8 [21.9;30.2] | 23.5 [17.6;29.1] | 24.1 [18.6;29.4] | 0.60 | |||||
| 5-HTR2A | rs1928040 | 24.6 [19.7;28.8] | 22.7 [18.2;27.0] | 24.5 [20.1;28.2] | 0.37 | |||||
| Concentration of fluvoxamine, ng/mL | ||||||||||
| CYP3A4 | rs35599367 | 1.115 [0.903;1.316] | 1.173 [0.974;1.431] | 1.153 [0.899;1.384] | 0.36 | |||||
| CYP2C9 | rs1799853 | 1.083 [0.910;1.354] | 1.109 [0.865;1.309] | 1.134 [0.885;1.372] | 0.90 | |||||
| CYP2C9 | rs1057910 | 1.122 [0.842;1.358] | 1.154 [0.981;1.443] | 1.142 [0.971;1.370] | 0.89 | |||||
| CYP3A5 | rs77646 | 1.165 [0.885;1.398] | 1.165 [0.885;1.340] | 1.170 [0.959;1.369] | 0.48 | |||||
| ABCB1 | rs1045642 | 1.058 [0.857;1.301] | 1.171 [0.878;1.417] | 1.159 [0.904;1.344] | 0.96 | |||||
| CYP2C19 | rs4244285 | 1.157 [0.972;1.354] | 1.066 [0.842;1.301] | 1.054 [0.801;1.307] | 0.93 | |||||
| CYP2C19 | rs4986893 | 1.063 [0.882;1.286] | 1.089 [0.828;1.307] | 1.114 [0.880;1.281] | 0.68 | |||||
| CYP2C19 | rs12248560 | 1.169 [0.924;1.391] | 1.103 [0.871;1.268] | 1.176 [0.882;1.435] | 0.98 | |||||
| SCL6A4 | rs25531 | 1.124 [0.854;1.315] | 1.091 [0.906;1.298] | 1.098 [0.824;1.340] | 0.31 | |||||
| 5-HTR2A | rs1928040 | 1.137 [0.955;1.376] | 1.168 [0.969;1.448] | 1.126 [0.923;1.385] | 0.72 | |||||
Note: *A: minor allel; B: major allel; **KWT: Kruskal-Wallis H-test.
The results of phenotyping is shown in Table 3.
Table 3. The Results of Phenotyping in Carriers of Different Allels of the 6986A > G Polymorphism of CYP3A5 Gene.
| Parameter | AG genotype | GG genotype | MWT (p-value) | |||
| 6b-HC/cortisol ratio (units) | 4.75 [1.28; 7.34] | 8.83 [4.73; 13.62] | 0.023 | |||
| Cortisol (ng/mL) | 485.53 [132.75; 693.25] | 573.51 [410.42; 719.42] | 0.249 | |||
| 6b-HC (ng/mL) | 937.63 [319.39; 3849.42] | 3947.43 [1749.82; 5739.82] | 0.032 |
The correlation analysis didn’t show any statistical significant correlations between plama concentration of miR-27b, mirtazapine efficacy and safety rates and the phenotyping results (Table 4).
Table 4. The Results of Correlation Analysis Between Plama Concentration of Mir-27b, Mirtazapine Efficacy and Safety Rates and the Phenotyping Results.
| Parameter | rs | p-value | ||
| 6b-HC/cortisol ratio (units) | −0,188 | 0,85 | ||
| Cortisol (ng/mL) | 0,139 | 0,55 | ||
| 6b-HC (ng/mL) | −0,171 | 0,92 | ||
| Concentration of mirtazapine, ng/mL | 0,111 | 0,46 | ||
| Difference in HAMD scale | 0,2 | 0,34 | ||
| Difference in UKU scale | 0,029 | 0,93 |
Discussion
The findings of this study didn’t reveal a statistically significant difference between the values of mirtazapine steady-state concentration in carriers of different alleles of CYP3A4 (rs35599367), CYP2C9 (rs1799853), CYP2C9 (rs1057910), CYP3A5 (rs776746), ABCB1 (rs1045642), CYP2C19 (rs4244285), CYP2C19 (rs4986893), CYP2C19 (rs12248560), SCL6A4 (rs25531), and 5-HTR2A (rs1928040) polymorphisms. Moreover we didn’t reveal any statistical significant correlations between plama concentration of miR-27b, mirtazapine efficacy and safety rates and the phenotyping results.
Thus, based on the results obtained that CYP3A4 (rs35599367), CYP2C9 (rs1799853), CYP2C9 (rs1057910), CYP3A5 (rs776746), ABCB1 (rs1045642), CYP2C19 (rs4244285), CYP2C19 (rs4986893), CYP2C19 (rs12248560), SCL6A4 (rs25531), and 5-HTR2A (rs1928040) genetic polymorphisms do not affect the efficacy and safety rates of mirtazapine therapy in patients with recurrent depressive disorder, it is possible to assume that before prescribing mirtazapine to such patients it is not necessary to take into account the results of genotyping by the loci of this gene. According to the results of our earlier studies, it was also shown that polymorphism of the CYP2D6 gene should be taken into account when administering mirtazapine, as this may have an impact on the efficacy and safety profile of mirtazapine in this category of patients.12–15
Conclusion
Thus, the effect of genetic polymorphisms of the CYP3A4, CYP2C9, CYP3A5, ABCB1, CYP2C19, SCL6A4, and 5-HTR2A gene on the efficacy and safety profiles of mirtazapine was not demonstrated in a group of 108 patients with depressive disorder and alcohol use disorder.
Footnotes
Funding
This work was financially supported by the project 16-15-00227 entitled “Fundamental research and exploratory research in priority areas of research” of the Russian Science Foundation.
Conflict of Interest
The authors declare that there is no conflict of interest regarding the publication of this article.
Funding Source
This work was supported by the grant of the Russian Science Foundation (project No. 18-75-10073).
Disclosure
The authors report no conflicts of interest in this work.
References
- 1.Bertilsson L, Dahl ML, Dalen P, Al-Shurbaji A. Molecular genetics of CYP2D6: clinical relevance with focus on psychotropic drugs. Br J Clin Pharmacol. 2002;53(2):111–122. doi: 10.1046/j.0306-5251.2001.01548.x. doi: [DOI] [PMC free article] [PubMed] [Google Scholar]
- 2.Boschloo L, Vogelzangs N, Smit JH, van den Brink W, Veltman DJ, Beekman AT, Penninx BW. Comorbidity and risk indicators for alcohol use disorders among persons with anxiety and/or depressive disorders: findings from the Netherlands Study of Depression and Anxiety (NESDA) J Affect Disord. 2011;131(1–3):233–242. doi: 10.1016/j.jad.2010.12.014. [DOI] [PubMed] [Google Scholar]
- 3.Busner J, Targum SD. The clinical global impressions scale: applying a research tool in clinical practice. Psychiatry (Edgmont) 2007;4(7):28–37. [PMC free article] [PubMed] [Google Scholar]
- 4.D Empaire I, Guico-Pabia CJ, Preskorn SH. Antidepressant treatment and altered CYP2D6 activity: are pharmacokinetic variations clinically relevant. J Psychiatr Pract. 2011;17(5):330–339. doi: 10.1097/01.pra.0000405363.95881.01.. doi: [DOI] [PubMed] [Google Scholar]
- 5.Flannery BA, Volpicelli JR, Pettinati HM. Psychometric properties of the Penn Alcohol Craving Scale. Alcohol Clin Exp Res. 1999;23(8):1289–1295. [PubMed] [Google Scholar]
- 6.Hamilton M. A rating scale for depression. J Neurol Neurosurg Psychiatry. 1960;23:56–62. doi: 10.1136/jnnp.23.1.56. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 7.Jiang XL, Shen HW, Yu AM. Pinoline may be used as a probe for CYP2D6 activity. Drug Metab Dispos. 2009;37(3):443–446. doi: 10.1124/dmd.108.025056. doi: Epub 2008 Dec 18. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 8.Lingjaerde O, Ahlfors UG, Bech P, Dencker SJ, Elgen K. The UKU side effect rating scale. A new comprehensive rating scale for psychotropic drugs and a cross-sectional study of side effects in neuroleptic-treated patients. Acta Psychiatr Scand Suppl. 1987;334:1–100. doi: 10.1111/j.1600-0447.1987.tb10566.x. [DOI] [PubMed] [Google Scholar]
- 9.Neafsey P, Ginsberg G, Hattis D, Sonawane B. Genetic polymorphism in cytochrome P450 2D6 (CYP2D6): Population distribution of CYP2D6 activity. J Toxicol Environ Health B Crit Rev. 2009;12(5–6):334–361. doi: 10.1080/10937400903158342. doi: [DOI] [PubMed] [Google Scholar]
- 10.Shiv G, Akhilesh J, Manaswi G. Guidelines for the Pharmacological Management of Depression. Indian J Psychiatry. 2017;59(1):34–50. doi: 10.4103/0019-5545.196973. doi: [DOI] [Google Scholar]
- 11.Spear BB, Heath-Chiozzi M, Huff J. Clinical application of pharmacogenetics. Trends Mol Med. 2001;7(5):201–204. doi: 10.1016/s1471-4914(01)01986-4. PMID:11325631. [DOI] [PubMed] [Google Scholar]
- 12.Sychev DA, Zastrozhin MS, Smirnov VV, Grishina EA, Savchenko LM, Bryun EA. The correlation between CYP2D6 isoenzyme activity and haloperidol efficacy and safety profile in patients with alcohol addiction during the exacerbation of the addiction. Pharmgenomics Pers Med. 2016;14(9):89–95. doi: 10.2147/PGPM.S110385. eCollection 2016. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 13.Zastrozhin MS, Grishina EA, Denisenko NP, Skryabin VY, Markov DD, Savchenko LM, Bryun EA, Sychev DA. Effects of CYP2D6 genetic polymorphisms on the efficacy and safety of mirtazapine in patients with depressive disorder and comorbid alcohol use disorder. Pharmgenomics Pers Med. 2018;29(11):113–119. doi: 10.2147/PGPM.S160763. doi: eCollection 2018. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 14.Zastrozhin MS, Skryabin VY, Smirnov VV, Grishina EA, Ryzhikova KA, Chumakov EM, Bryun EA, Sychev DA. Effects of CYP2D6 activity on the efficacy and safety of mirtazapine in patients with depressive disorders and comorbid alcohol use disorder. Can J Physiol Pharmacol. 2019;97(8):781–785. doi: 10.1139/cjpp-2019-0177. doi: Epub 2019 May 17. [DOI] [PubMed] [Google Scholar]
- 15.Zastrozhin MS, Sorokin AS, Agibalova TV, Grishina EA, Antonenko AP, Rozochkin IN, Duzhev DV, Skryabin VY, Galaktionova TE, Barna IV, Orlova AV, Aguzarov AD, Savchenko LM, Bryun EA, Sychev DA. Using a personalized clinical decision support system for bromdihydrochlorphenylbenzodiazepine dosing in patients with anxiety disorders based on the pharmacogenomic markers. Hum Psychopharmacol. 2018;33(6):e2677. doi: 10.1002/hup.2677. doi: Epub 2018 Oct 25. [DOI] [PubMed] [Google Scholar]
- 16.Zeng L, Chen Y, Wang Y et al. MicroRNA hsa-miR-370-3p suppresses the expression and induction of CYP2D6 by facilitating mRNA degradation. Biochem Pharmacol. 2017;140:139–149. doi: 10.1016/j.bcp.2017.05.018. doi: [DOI] [PMC free article] [PubMed] [Google Scholar]
- 17.Zhou SF. Polymorphism of human cytochrome P450 2D6 and its clinical significance: Part I. Clin Pharmacokinet. 2009;48(11):689–723. doi: 10.2165/11318030-000000000-00000. doi: [DOI] [PubMed] [Google Scholar]
- 18.Zigmond AS, Snaith RP. The hospital anxiety and depression scale. Acta Psychiatr Scand. 1983;67(6):361–370. doi: 10.1111/j.1600-0447.1983.tb09716.x. [DOI] [PubMed] [Google Scholar]