BCH 421: XENOBIOTICS (2 CREDIT UNITS)

(By Dr. Faoziyat Adenike Sulaiman)

Induction and inhibition of enzymes of drug biotransformation

Enzyme induction is a process in which a drug induces or enhances the expression of an enzyme.
It is also the phenomenon of increased drug metabolizing ability of the enzymes by several drugs
and chemicals. A drug may reverse or stop the action of a previous drug, For example Rifampicin
if taken by female patients that were taking contraceptives, it can cause decreased therapeutic
effect, leading to pregnancy. Similarly, Phenobarbitone if administered to patients taking
warfarin, may cause its therapeutic failure.
Auto induction is the phenomenon in which a drug induces metabolism of other drugs as well as
its own metabolism, an example is seen in carbamazepine-antiepileptic drug combination. A
number of drugs can cause an increase in liv3ner enzyme activity over time. This in turn can
increase the metabolic rate of the same drug or that of other drugs. For example, phenobarbitone
will induce the metabolism of itself and phenytoin. Carbamazepine is another drug which can
induce its own metabolism. Rifampin has been shown to cause up to twenty times increase in
midazolam metabolism. Cigarette smoking can cause increased elimination of theophylline (two
fold increase) and other compounds. Dosing rates may need to be increased to maintain effective
plasma concentration.

If the molecule induces enzymes that are responsible for its own metabolism, this is called auto-
induction (or auto-inhibition if there is inhibition). These processes are particular forms of gene
expression regulation. These terms are of particular interest to pharmacology, and more
specifically to drug metabolism and drug interactions.
Metabolism based drug-drug and with other drug-interactions, can have a significant influence on
the use of and safety of many drugs. Induction of drug metabolism can lead to unexpected drops
in drug concentration or in the build-up of metabolites. The reverse can occur when there is
inhibition of drug metabolism. The major organ involved in metabolism is the liver and the
major enzyme system, involved in drug metabolism is CY P450, the well-known family of oxidative
hemo-proteins. Induction of CY P450 enzymes in the liver is responsible for induction of
metabolism of many drugs.
Enzyme inducers may alter the biotransformation of xenobiotics and endogenous compounds. The
consequence of faster conversion is therapeutic insufficiency or too-high exposure to an active
drug formed from its prodrug.
Enzyme inhibition: is the phenomenon of decreased drug metabolizing ability of the enzymes by
several drugs and chemicals. The process of inhibition may be of two types, Direct and indirect
inhibition.
Direct inhibition may result from the interaction of +- enzymes active site, the outcome been a
change in the enzyme activity. Direct inhibition can occur by competitive inhibition, which
occurs when normal substrate and the inhibitor substrate share structural similarities. Many
enzymes have multiple substrates that can compete with each other, for the same active site. For
example, Metacholine (inhibitor) inhibits the metabolism of Acetylcholine (real substrate) by
competing with it for cholinesterase (enzyme).

Indirect inhibition: it is brought about one of the two mechanisms: Repression or Altered
physiology.
Repression: is defined as the decrease in enzyme content concentration. It may be due to fall in
the rate of enzyme synthesis as affected by ethlonine, puromycin and actinomycin-D or
because of rise in the rate of enzyme degradation, such as by carbon-tetrachloride,
carbon disulphide, Disulphiram, etc.
Altered Physiology: this occurs due to nutritional deficiency or hormonal balance. Enzyme
inhibition is more important clinically, than enzyme induction, especially for drugs with
narrow therapeutic index, for example anticoagulants, antiepileptics, hypoglycemics, etc,
since it results in prolonged pharmacological action with increased possibility of
precipitation of toxic effects.
 Enzyme induction and inhibition involves:
1 Inhibitors usually prolong the activity of co-administered drugs
2 It also increases the toxic effects of unchanged drugs, if any
3 Drug metabolism varies in smokers and alcoholics (in human patients)
4 In case of combined administration, alteration of dose may be required
The inhibition of metabolic enzymes is a frequent underlying cause of drug-drug
interactions. Assessment of the inhibitory potential of NCEs is a focus of ADME
property screening in drug discovery. The prediction of in vivo drug-drug
interactions based on in vitro-generated enzyme kinetic constants is a challenging
task.

The role of cytochrome P450 in drug-metabolizing enzymes

Induction of drug-metabolizing enzymes has been shown in several instances to alter
the efficacy of some therapeutic agents. Induction of various species of cytochrome
P450 is also known to increase the rate at which potentially toxic reactive metabolic
intermediates are formed from drugs or environmental chemicals.
 Drug interactions: major mechanisms of drug-drug interaction and drug-
nutrient interaction
Drug Interaction:

DRUG INTERRACTIONS: Drug interaction is defined as the pharmacological activity that

occurs when one drug’s activity is altered by the concomitant use of another drug or by the
presence of some other substance. The Drug whose Activity is affected by such an Interaction is
called as the “Object drug.” The agent which precipitates such an interaction is referred to as the
“Precipitant”.

➢ Types of drug Interactions

1. Drug-drug interactions. 2. Drug-food interactions. 3. Chemical-drug interactions.
4. Drug-laboratory test interactions. 5. Drug-disease interactions.

➢ The Net effect of a Drug Interaction is:

•Generally quantitative i.e., Increased or decreased effect
• Seldom qualitative i.e., Rapid or slower effect.
•Precipitation of newer or increased adverse effect.

➢ Drug interactions are thus-:

• Mostly undesirable or • Rarely desirable (beneficial): for e.g., enhancement of activity of
penicillin when administered with probenecid.
 ➢ Factors contributing to drug interactions include:
1. Multiple drug therapy. 2.Multiple prescribers. 3.Multiple pharmacological effects of
drug. 4. Multiple diseases/predisposing illness. 5. Poor patient compliance. 6. Advancing
age of patient. 7. Drug-related factors.

Different types of drug interactions:

Drug interactions are usually considered in terms of three broad classes of underlying
mechanisms:
pharmacodynamic,
pharmacokinetic and
pharmaceutical incompatibility.

Pharmacokinetic interactions occur when one drug alters the absorption, distribution,
metabolism or excretion of the other drug. This type of response varies between patients without
any particular drug pattern and can be difficult to predict. Pharmacokinetic interaction effects are
generally common to related drugs.

Pharmacodynamics describes the relationship between drug concentration and drug response.

Nutrient-drug interactions:
Nutrient-Drug Interactions can alter metabolism of drugs; eg, high-protein diets can accelerate
metabolism of certain drugs by stimulating cytochrome P450, while eating grapefruit can inhibit
cytochrome P450 34A, slowing metabolism of some drugs (eg, amiodarone, carbamazepine,
cyclosporine, certain calcium channel blockers).

Applications of Nutrient-Drug Interactions:

1). In nutrient and food interactions, some drugs are known to significantly alter fluid or electrolyte
balance.
2). The interaction has been used to prevent vitamin deficiencies related to drug therapy.
3). It has been used to recognize the multiple causes of diarrhea associated with drug therapy.
4). It has been used to describe many nutrient-drug interactions involving certain food types such
as grapefruit juice.
5). It has been used to discuss means of identifying and appropriately treating clinically important
drug-nutrient interactions.
6). It has been used to list drug vehicles that provide clinically important doses or calories and
those that provide an insignificant amount of calories.

DRUG - FOOD / NUTRIENTS INTERACTIONS

• Drug-food/beverage interactions result from drugs reacting with foods or beverages.
• For example, mixing alcohol with some drugs may cause you to feel tired or slow down your
reactions.
• A lack of standardization and contamination will further contribute negatively to these
interactions.

Drug – Nutrient Interactions: How Drugs and Nutrients Interact

A drug-nutrient interaction is the effect of a medication on food or a nutrient in food. Medications
interact with foods and nutrients in several ways. Medications can decrease appetite or change the
way a nutrient is absorbed, metabolized, or excreted.

A food-drug interaction is the effect of food or a nutrient in food on a medication. Dietary nutrients
can affect medications by altering their absorption or metabolism. The food you eat could make
the medications you take work faster, slower, or even prevent them from working at all. Both
prescription and over-the-counter medications can affect the way your body uses nutrients in food.
In addition, certain foods or nutrients in food can affect the action of medications.

Such interactions raise concerns that medications may lead to nutritional deficiencies or that your
diet may change how a medication works. This does not mean that if you are taking a medication
you need to use a vitamin and or mineral supplement. There is little chance that taking a medication
for a short time, such as a ten-day treatment, will affect your nutritional status. However, use of
some medications for months or years may affect your nutritional health.

Children, older adults, pregnant women, people who are poorly nourished, and people with a
chronic disease are at greater risk of medications affecting their nutritional health. Changing the
diet to include more foods rich in vitamins and minerals is preferred to taking vitamin or mineral
supplements. In fact, vitamin and/or mineral supplements taken in excess can affect how a
medication works. Medications, both prescription and over-the-counter, can affect how the body
uses nutrients. For individuals taking medications for long periods of time drug-nutrient
interactions may lead to vitamin or mineral deficiencies.

➢ Medications can decrease appetite or cause nausea, vomiting, an unpleasant taste, or dry
mouth. This can affect nutritional health by causing poor food intake.
Example: Appetite suppressants are medications that directly affect food intake by
depressing appetite.
 Example: Several cancer medications and treatments may cause nausea, vomiting, sore, or
dry mouth resulting in poor food intake.

➢ Medications can decrease nutrient absorption.

Example: Laxatives can decrease the absorption of many vitamins and minerals. Laxatives
cause food to move rapidly through the body causing poor nutrient absorption.
Example: Some anticonvulsants can decrease folate absorption.

➢ Medications can slow down nutrient production.

Example: Vitamin K is produced by bacteria in the intestines. Antibiotics kill harmful
bacteria, but they can also kill helpful bacteria, including bacteria that produce vitamin K
in the intestine.

➢ Medications can interfere with the body’s ability to metabolize nutrients.

Example: Some anticonvulsants alter the activity of liver enzymes, causing increase
metabolism of folate, vitamin D and vitamin K.

➢ Medications can increase the loss of a nutrient.

Example: Diuretics remove excess fluid from the body. Some diuretics may also increase
loss of potassium along with fluids. Potassium is very important in proper functioning of
the heart and other muscles.

Food and nutrients can also alter a medication’s effectiveness in many ways.
➢ Food can increase or decrease the absorption of a drug. Absorbing less than the intended
dose may decrease the effect of the drug. Absorbing more than the intended dose increases
the chance for an overdose effect.
Example: Dietary calcium can bind to the antibiotic tetracycline. As a result the body does
not absorb the amount of antibiotic intended.
Example: Drugs are absorbed more quickly into the body when the stomach is empty.
Having food in the stomach will slow down a medication’s absorption. Sometimes a
medication should be taken with food. Other medications should be taken on an empty
stomach, one hour before or two hours after eating. It is important to read the directions to
see if a medication should be taken with or without food.

➢ Foods or nutrients may interfere with a drug’s metabolism or a drug’s action in the body.
Example: Aged and fermented foods contain a chemical called tyramine that interacts with
a medication, monoamine oxidase inhibitor. This interaction can result in dangerously high
blood pressure.
Example: Vitamin K can decrease the effectiveness of certain anticoagulant medications.

➢ Foods or nutrients may be needed for the removal of a medication from the body.
Example: Liver enzymes prepare medications for removal from the body. These enzymes
require nutrients to work properly. If required nutrients are not present, medications may
stay active in the body longer than they are supposed to.
Alcohol and Drugs
Alcohol and medications do not mix well. Alcohol can adversely affect medications as well as
nutrients. Alcohol can slow down the body’s metabolism. As a result, medications can stay active
in the body longer than they were supposed to. In some cases, mixing alcohol and medications can
be fatal. A rule of thumb is to avoid alcoholic beverages when taking prescription or over-the-
counter medications.

Nutrient Supplements
Nutrient supplements themselves can result in drug-nutrient interactions. In excessive amounts,
vitamins and minerals act like drugs instead of nutrients. Nutrients in excessive amounts may
interact with other nutrients or may even be toxic. For example: large amounts of zinc can interfere
with copper and iron absorption. Similarly, large amounts of iron can interfere with zinc
absorption.

The Importance of Following each drug’s usage direction

It is important to follow the directions on how to take a medication. Many people do not take
prescription or over-the-counter medications properly. Following the directions on how to take a
medication can affect how or if a medication works.

How to Lower the Risk of Drug-Nutrient Interactions

• Eat a healthy diet following the recommended daily servings.
• Follow directions on how to take medication (both prescription and over-the-counter
drugs).
• Read warning labels on both prescription and over-the-counter medications.
• Do not share medications with others or take other peoples’ medications.
• Do not take over-the-counter medications frequently on your own.
• Tell your physician about everything and every drug you are taking, including over-the-
counter medications, alcohol, and herbal products.
• Tell your physician and pharmacist about any new or intensified symptoms that develop
when taking a medication.
• Keep a list of all medications (prescription and over-the-counter) that you use.
• If you have questions, ask your pharmacist, physician, or dietitian for answers.

Questions to Ask Your Physician When You Get a Prescription

• What is the medication for? (medication name, medication purpose).
• How should I take the medication? (how often, how long, storage recommendations,
recommendations on consuming food and/or beverages with the medication).
• What should I expect? (expected outcomes, precautions, side effects).
Specie differences in the metabolism of xenobiotics/genetic polymorphism
Genetic polymorphisms, through multiple alleles at individual loci, provide a mechanism to tag a
gene or a piece of DNA, providing a powerful tool for a variety of investigations. Genetic
polymorphisms are important contributors to inter-individual variation in medication response and
tolerability. Presently, over 30 commonly used CNS-active medications contain
pharmacogenic information in the product labeling that is relevant to drug selection, dosing, and
monitoring. Most of this information references genetic variation in drug metabolism. Notable
exceptions included markers for hypersensitivity reactions to some antiepileptic drugs.

Pharmacogenic studies of drug pharmacodynamics have yielded important information on drug

mechanisms, but the clinical utility of this information is still ongoing. We still need to better
clarify how and when pharmacogenetic test information will improve patient outcomes over
standard clinical practice. As the cost of genetic analysis continues to decline, pharmacogenetic
testing will become more accessible, requiring clinicians to better understand the underlying
science and clinical relevance of specific drug–gene pairs. Neurologic and psychiatric
disorders are challenging to treat and often require the long-term use of medications.
Pharmacogenetics is one way to better understand potential sources of variability in response that
has growing potential to increase the quality of life for patients and help clinicians weigh the
benefits and risks of treatment options. The goal of xenobiotics metabolism is to make
xenobiotics less poisonous or convert it to non-toxic metabolites.
The role of NAT2 genetic polymorphism in susceptibility to cancer: The epidemiological data
on the role of NAT2 genetic polymorphism, in susceptibility to various cancers, suggest that the
role of this polymorphism varies both with the specific carcinogen and with the organ site

How many genetic polymorphisms are there in arylamine NAT2?

More than 20 genetic polymorphisms have been identified in these NAT genes; these
polymorphisms can affect the catalytic activity of NATs toward AAs and HAAs. In humans, a
common genetic polymorphism is seen in arylamine NAT2, giving rise to rapid and slow acetylator
phenotypes.
Uses of Polymorphisms:
Genetic polymorphisms, whether studied in the form of allozymes, RFLP, mini- and
microsatellite variation, or DNA sequences, have become useful tools in a variety of research
fields, such as population genetics, evolutionary genetics, systematics and molecular phylogeny,
human genetics, agricultural genetics, and forensics. Genetic polymorphisms, through multiple
alleles at individual loci, provide a mechanism to tag a gene or a piece of DNA, providing a
powerful tool for a variety of investigations. These investigations cover a wide berth of objectives,
including:

i). identification of genotypes in paternity and forensic studies,

ii). tracking the movement of individuals in field studies,
iii). following the progression of selection experiments in laboratory populations,
iv). mapping of quantitative loci affecting economical traits in plants and animals,
v). mapping of disease genes in humans, and evolutionary comparisons of DNA sequences and
chromosomal organization between related species. The uses of genetic polymorphisms are
almost endless.
vi). Within a mere 50-year period, our picture of genetic variation in natural populations has moved
from near monomorphism to ubiquitous polymorphism in all organisms whose populations have
not gone through severe bottlenecks in their recent evolutionary history.

Dopamine and Other Receptor Polymorphisms as an example:

Genetic polymorphisms in dopamine receptors have been associated with drug abuse liability
and the reinforcing effects of alcohol, cocaine, and nicotine. Genetically variant dopamine
receptors are also associated with increased incidence of tardive dyskinesias following long-
term treatment of schizophrenia with dopamine receptor antagonists. Schizophrenia is itself a
complex set of diseases that is not adequately managed in many patients. Accordingly, both typical
and atypical antipsychotic drugs have been found to be effective in some but not all patients with
schizophrenia. Genetic polymorphisms in antipsychotic medication receptor targets
(dopaminergic, adrenergic, serotoninergic, and/or histaminergic receptor subtypes) have been
associated with different clinical responses. Combinations of drug target polymorphisms and drug
metabolism variants may eventually form the basis for targeting genetic subgroups of patients with
schizophrenia for effective treatment with both typical antipsychotics and newer atypical
antipsychotic drugs.

Regulation by Genetic Polymorphisms

Genetic polymorphisms, most commonly occurring as single-nucleotide substitutions in the
genomic DNA sequence (also known as SNPs), are heritable genetic differences among
individuals; SNPs with frequencies equal to or greater than 5% are regarded as common,
whereas those with frequencies lower than 1% are regarded as rare.

Other types of genetic variations include insertion or deletion of nucleotides, ranging from a single
base to >1 kilobase, gene copy number variations (deletion, duplication, or multi-duplications,
which affect the amount of enzyme produced), and gene conversion, as a result of chromosomal
recombination.
Genetic variations can give rise to enzymes with altered substrate specificity and/or catalytic
activity, through non-synonymous changes (i.e., changes associated with an amino-acid change
in the encoded protein) in DNA sequences in the coding region of a gene, polymorphisms can also
affect the expression of the enzymes, by altering sequences important for various transcriptional
and post-transcriptional regulatory events.
Furthermore, changes in gene copy number can have a gene-dosage effect on the level of an
enzyme produced, as well as potential disruptive effects on chromosomal structure and the
expression of neighboring genes. The extent of genetic variation for
various biotransformation enzymes is usually quite high. For example, the number of unique
alleles (i.e., different forms of the gene that exist at the same chromosomal locus in various
individuals) for a human P450 gene can be >100 (for CYP2D6; Table 1).

For some CYP genes, such as CYP2S1, the small number of identified alleles may either be a mere
reflection of the fact that the gene has not been studied extensively, or alternatively an indication
of the gene’s evolutionary conservation. It is also clear from the information in Table 1 that not
all alleles encode altered protein sequences; for example, two alleles that differ only in the
promoter region would produce the same protein, albeit in differing amounts. Notably, many
SNPs or other types of mutations appear to have no detectable effects on either enzyme activity or
expression, and a major challenge for pharmacogenetics is to identify those genetic variations
that lead to changes in the expression or function of the gene.

Table 1: Examples of the various types of genetic variations that affect the expression

of human P450 enzymes

Polymorphism Affected allele Mechanism identified Consequence

Coding region CYP3A7*3 Shift in reading frame, No expression
mutations protein truncation
Coding region CYP1B1*4 Amino acid change Decreased protein
SNP half-life
Polymorphism Affected allele Mechanism identified Consequence
Coding region CYP2B6*28 Premature stop codon, No expression
SNP protein truncation
Gene conversion CYP2A6*1B gene conversion in the 3′- Increased mRNA
flanking region with stability
CYP2A7
Gene deletion CYP2D6*5 Gene deletion No expression
Gene deletion CYP2A6*4 Gene deletion No expression
Gene duplication CYP2D6*1 × N Up to 13 copies Increased
expression
Promoter region CYP1A2*1K Loss of a functional element Decreased
SNP expression
Promoter region CYP3A4*1B Decreased nuclear protein Decreased
SNP binding promoter activity
Promoter region CYP2C19*17 Gain of a functional element Increased promoter
SNP activity
SNP affecting CYP2D6*4 Defective splicing No expression
splicing
SNP affecting CYP3A5*3, *6 Truncated protein; No or little
splicing nonsense-mediated mRNA expression
decay
Mechanisms and Consequences of Drug-Drug Interactions

Medications used to treat human immunodeficiency virus (HIV) and hepatitis C virus (HCV)
infections present a special challenge with respect to the management of potential and actual drug-
drug interactions (DDIs). The HIV and HCV treatments may interact with each other, and also
interact with drugs of abuse and/or with medications used to treat substance abuse. Possible
mechanisms of these DDIs generally include induction or inhibition of activity/expression of
human cytochromes P450, glucuronosyl transferases, or energy-dependent transport
proteins. These DDIs can be complex and time-dependent in nature. Because time and resources
available for new drug development are necessarily limited, not all potential DDIs can be evaluated
via clinical pharmacokinetic studies in the course of development of HIV, HCV, and substance
abuse treatments. Strategies are needed to refine existing in vitro models and screening techniques
to allow more efficient targeting of resources to those clinical studies having the highest impact in
terms of enhancing medication effectiveness and patient safety.

Genetic polymorphism of xenobiotic metabolising enzymes, diet and cancer susceptibility

There is increasing evidence identifying the crucial role of numerous dietary components in
modifying the process of carcinogenesis. The varied effects exerted by nutrient and non-nutrient
dietary compounds on human health and cancer risk are one of the new challenges for nutritional
sciences. Many reviews has been done for the most recent epidemiological data on interactions
between dietary factors and metabolic gene variants in terms of cancer risk. The majority of case-
control studies indicate the significant relationship between cancer risk and polymorphic
xenobiotic metabolising enzymes in relation to dietary components. The risk of colorectal cancer
is associated not only with CYP2E1 high-activity alleles, but also GSTA1 low-activity alleles,
among consumers of red or processed meat.

Genetic polymorphisms of NAT1 and NAT2 may be also a breast-cancer susceptibility factor
among postmenopausal women with a high intake of well-done meat. On the other hand,
phytochemicals, especially isothiocyanates, have a protective effect against colorectal and lung
cancers in individuals lacking GST genes. Moreover, polymorphism of GSTM1 seems to be
involved in the dietary regulation of DNA damage. The European Prospective Investigation into
Cancer and Nutrition study shows a significant inverse association between the polycyclic
aromatic hydrocarbon-DNA adduct level and dietary antioxidants only among GSTM1-null
individuals. However, the absence of a modulatory effect of polymorphic xenobiotic
metabolising enzymes and diet on the development of cancer has been indicated by some
epidemiological investigations. Studies of interactions between nutrients and genes may have
great potential for exploring mechanisms, identifying susceptible populations/individuals and
making practical use of study results to develop preventive strategies beneficial to human
health.

The importance of cytochrome P450 isoforms to species differences in the metabolism of foreign
compounds and activation of procarcinogens has been identified. The possible range of P450
isozymes in significant variations in toxicity exhibited by experimental rodent species may have a
relevance to chemical risk assessment, especially as human P450s are likely to show changes in the
way they metabolize xenobiotics. Consequently, in the safety evaluation of chemicals, we should
be cautious in extrapolating results from experimental animal models to humans. Species
differences in P450s may lead to significant alterations in carcinogenic response, there are
now current procedures for toxicity screening, with an emphasis on short-term tests.

Xenobiotic metabolism, genetic polymorphisms and male infertility

Male reproductive function may be impaired by various occupational and environmental chemical
agents. The majority of these xenobiotics, however, require metabolic activation in order to exert
adverse effects via covalent interactions between intermediate metabolites and cellular
macromolecules such as DNA or protein. In addition, metabolization may alter endocrine-
disrupting properties of xenobiotics. Thus tissue-specific expression and regulation of multiple
xenobiotic-metabolizing enzymes are likely to play an important role in chemically induced
disorders of male reproductive organs. Recent studies suggest that genetic polymorphisms
underlying inter-individual and inter-ethnic variability of xenobiotic metabolism modulate
susceptibility to male reproductive disorders. For cytochrome P450 1A1 (CYP1A1), a key
enzyme in extra-hepatic metabolic activation of lipophilic xenobiotics, increased frequencies of
two genetically linked polymorphisms have been found among infertile men.