1. Introduction
Drug treatments are characterized by substantial difference in terms of efficacy and/or safety in different patients. Adverse drug reactions (ADR), including allergic, pseudo-allergic, and exaggerated pharmacological reactions to medications, are a relatively common result of drug treatment, accounting for at least 5% of hospital admissions, with an overall fatality of 0.15% and an annual cost of >500 M
$, only for the UK National Health Service [
1,
2]. These data highlight the social and economic costs of ADRs and the urgent need to find effective strategies to ameliorate drug efficacy and reduce ADR.
The same drug, once other parameters are fixed, can have different therapeutic effects in different people due to causal genetic variants [
3]. The analysis of the genetic variability modulating the individual’s drug response (pharmacogenetics, PGx) has, thus, received great attention for its capacity to provide a new way to optimize drug therapies in terms of optimal dosing to improve drug efficacy and reduce toxicity risk [
4]. As a result, a patient may receive the right drug at the right dose the first time they consult their doctors such that efficacy is guaranteed, and the risk of ADR is reduced. From a pharmaceutical point of view, PGx variants can influence pharmacokinetics and pharmacodynamics drugs, thus influencing dosing, formulation sensitivity and drug-hypersensitivity reactions.
An individual’s drug response can be assessed through the identification, by genotyping arrays or sequencing, of well-characterized genetic variants and specific haplotypes in key genes implicated in drug processing. For example, the gene CYP2D6 is characterized by the presence of over 100 haplotypes, which share SNPs and include gene duplications and deletions, strongly influencing the metabolism and/or bioactivation of many clinically used drugs and, thus, determining a phenotype. In this example, phenotypes are assigned to haplotypes that contains specific and relevant SNPs to differentiate CYPD6 functions [
5].
The interest in ameliorating drug efficacy, while reducing ADR, promotes the development of tools to properly analyze the correlation between variability in the genome and individual’s drug response. For example, The Pharmacogenomics Knowledge Base (PharmGKB:
http://www.pharmgkb.org (accessed on 22 March 2022) [
6,
7]) covers much information about pharmacogenomics and provides a convenient approach for researchers. The Pharmacogenetics of Membrane Transporters (PMT) database is another tool focused on the effect of genetic variation in the response to drugs that interact with membrane transport proteins [
8,
9].
Furthermore, the increasing availability of accurate classifications of pharmacogenetic variants and haplotypes, together with guidelines for their clinical translatability, allow analysis of the potential impact of pharmacogenetics programs in many populations for which large-scale genomic resources exist [
10,
11]. The analysis of the prevalence of PGx-risk variants in target populations, in combination with actual data on drug usage, make it possible to predict the proportion of the population for which genetics could lead therapy decision. Overall, the following axes could support a coordinate pharmacogenetic program in the European healthcare systems: (i) the analysis of PGx variant prevalence, (ii) the results of clinical trials evaluating patient outcomes and cost-effectiveness of PGx-markers [
12] and (iii) outcomes of implementation strategies [
13,
14].
Sardinians, a population for which large-scale genomic data are available, is particularly well suited for genetic studies. Sardinians are the contemporary human population that has retained the highest degree of inheritance from early European farmers who lived in the Neolithic period along with significant ancestry from western hunter gatherers who lived in the late Paleolithic period [
15,
16]. This is due to founder effects during the initial settlement of the island and the scarcity of gene flow from other populations during later periods [
15,
16]. As a result of its past evolutionary history the Sardinians are now a reservoir of ancient European genetic variants that are currently very rare elsewhere and may have relevant clinical consequences [
17,
18,
19,
20]. Genetic factors and the distinct genetic structure of the Sardinians thus present an excellent opportunity to also look for new pharmacogenetic information.
Here, we profiled pharmacogenetic variation in fourteen clinically relevant genes in 1577 unrelated sequenced Sardinians. We used PGxPOP [
21], a PGx allele caller, based on the guidelines created by the Clinical Pharmacogenetics Implementation Consortium (CPIC), to identify the main phenotypes associated with the PGx alleles most represented in Sardinians. We estimated that 99.43% of Sardinian individuals might potentially respond atypically to at least one drug, and that, on average, each individual is expected to have an abnormal response to about 17 drugs. Furthermore, we highlighted differences in haplotype and diplotype frequencies of star alleles as compared to other populations and estimated that for 27 drugs the fraction of the population at risk of atypical responses to therapy is more than 40%. These findings represent the foundation for further large-scale and more detailed pharmacogenomic investigations in Sardinia, and, at the same time, underline the importance of the pharmacogenomic characterization of ethnically diverse European populations, as exemplified by Sardinians.
3. Discussion
We estimated the potential impact of the large-scale introduction of pharmacogenetic practices in the Sardinian population by evaluating the prevalence of clinically relevant pharmacogenetic variants in a core set of 1577 unrelated sequenced individuals, representative of the entire population (Sardinia has 1.5 M residents on the island and a similar number of individuals of Sardinian descent spread across the world). To this end, we used PGxPOP [
21], a PGx matching engine that is based on PharmCAT and uses its PGx allele definitions, to characterize PGx allele and phenotype frequencies. Using this analysis, it was possible to estimate the theoretical number of Sardinian individuals exposed to adverse reactions to a range of drugs. In more detail, the frequencies of two phenotypes (“Decreased warfarin dose” and “Possibly decreased warfarin dose”) involving warfarin, a widely used anticoagulant drug, were among the most interesting findings from this analysis. The two atypical phenotypes are determined by diplotypes of the
VKORC1 gene [
24] and affected a total of 1192 individuals in our cohort (i.e., about 3 of 4 individuals). Overall, common genetic variants in this gene, but also in
CYP2C9,
CYP4F2, and the CYP2C cluster (e.g., rs12777823), plus known nongenetic factors, account for 50% of warfarin dose variability [
24].
Other phenotypes potentially affecting a large proportion of the population were the “Intermediate Metabolizer” and “Poor Metabolizer” phenotypes, which are determined by cytochrome
CYP2C9 diplotypes and affected a total of 650 individuals in our cohort (about 41% of the cohort analyzed). These phenotypes have important effects on the ADME-Tox of Nonsteroidal Anti-Inflammatory Drugs, such as celecoxib, flurbiprofen, lornoxicam, and ibuprofen. According to CPIC guidelines [
25], the diplotypes involved may result in a higher-than-normal risk of adverse events, especially in individuals with other factors affecting clearance of these drugs, such as hepatic impairment or advanced age. The same guidelines suggest a reduced dosage of these drugs and monitoring of adverse effects. The same cautions can be extended to other drugs, such as meloxicam, piroxicam and tenoxicam.
An important finding concerned two atypical phenotypes related to the
SLCO1B1 gene (“Decreased Function”, N = 324 individuals, and “Poor function”, N = 51), which globally affect almost 1 in 4 individuals, and are important for the metabolism of important drugs, such as Atorvastatin (second among the top thirty active drugs both for consumption and expenditure in Italy) [
26], and Fluvastatin, Lovastatin, Pitavastatin, Pravastatin, Rosuvastatin and Simvastatin. According to CPIC guidelines [
27], these phenotypes can impact the starting dose and suggest an adjustment of doses based on disease-specific guidelines. According to suggestions in the same guidelines, prescribers should be aware of possible increased risk for myopathy.
We could then hypothesize that an important impact on the frequency of adverse effects could be caused by the high diffusion of atypical phenotypes (“Intermediate metabolizer”, N = 450, “Poor metabolizer”, N = 32, “Rapid metabolizer”, N = 343 and “Ultrarapid Metabolizer”, N = 37) attributable to diplotypes of the gene
CYP2C19, involved in the metabolism of some of the most widely used antidepressants in Italy, including escitalopram and sertralin. According to the guidelines [
28], among the problems caused by an incorrect dosage are increased risk for adverse cardiac and cerebrovascular events.
Special attention should be paid to the 103 individuals (approximately 6.5%) who are at high risk of severe toxicity due to antineoplastic drugs, such as azathioprine, mercaptopurine, and thioguanine, because of atypical phenotypes determined by diplotypes of the TPMT gene.
In a second phase of analysis, we aimed to identify the variants of pharmacogenetic interest that were more differentiated in Sardinia than in the general European population (taking as reference the genetic data of gnomAD version 2.1). In this analysis, we distinguished highly relevant PGx variants (levels of evidence 1A, 1B, 2A and 2B) from those of lower relevance (levels 3 and 4).
The strongest difference in terms of allele frequency was seen for the rs396991 variant located in the
FCGR3A gene and which could be relevant for patients treated with Rituximab, according to a 2B level of evidence documented by PharmGKB [
29]. In fact, the C allele of the rs396991 variant had a frequency 1.5 times higher in Sardinia (AF = 0.528) than in the rest of Europe (AF = 0.344) This difference may significantly affect the efficacy of Rituximab, used in the treatment of certain types of cancer and autoimmune disorders, including Rheumatoid Arthritis and Neuromyelitis Optica. Indeed, patients with a CC genotype may have an increased response to the drug compared to patients with AA and AC genotypes.
Another variant of special interest was rs8050894, for which the frequency of the G allele was 1.34 times higher in Sardinia (AF = 0.523) than in the general European population (AF = 0.389). This variant has a role, supported on a type 1B level of evidence, in influencing warfarin dosage. According to the guidelines, patients with the GG genotype may require a lower dose of warfarin as compared to patients with the CC genotype. The variant is part of a haplotype of variants in the VKORC1 gene, all of which are associated with warfarin dosing. Among them, the one with the strongest level of evidence was rs9923231, whose T allele was 1.309 times more frequent in Sardinians (AF = 0.509 versus 0.389). This last variant was also relevant for the pediatric population and had relevance not only for the dosage of Warfarin, Acenocoumarol and Phenprocoumon, but also for the resultant efficacy and toxicity of these drugs. Of note, the genotypes of VKORC1-1639G > A (rs9923231) are mentioned in the FDA Label of Warfarin.
Warfarin inhibits
VKORC1 to prevent regeneration of a reduced form of vitamin K necessary for clotting factor activation [
30]. The common variants, noted in our analysis, are located in the 5′UTR and introns of the
VKORC1 gene and are associated with reduced gene expression and related effects on warfarin dosage. Warfarin and Acenocoumarol are common oral anticoagulant prescribed for the treatment and prevention of thromboembolic events for which genetic variants in several genes (
CALU, calumenin;
CYP, cytochrome P450 family members;
GGCX, gamma-glutamyl carboxylase;
NQO1, NAD(P)H quinone dehydrogenase 1;
VKORC1, vitamin K epoxide reductase) have been associated with the need for carefully calibrated dosage to prevent bleeding episodes.
The influence of
VKORC1 polymorphisms on vitamin K antagonist dose requirements provides a remarkable example of pharmacogenomic diversity worldwide. This is documented by the International Warfarin Pharmacogenomic Consortium (IWPC) datasets, comprising 5700–6200 patients recruited from four continents, and ascribed to three ‘racial’ groups, namely Asians, Blacks (mainly African Americans) and Whites [
31].
Furthermore, considering the 19 HLA alleles associated with adverse events to the therapy with the highest level of evidence, mention should be made of HLA-B*58:01, which has been shown to have a strong effect on the development of severe cutaneous adverse reactions (SCARs), including Stevens—Johnson syndrome and toxic epidermal necrolysis after treatment with allopurinol, the common treatment for hyperuricemia and gout. However, the frequency of HLA-B*58:01 significantly differs between different ethnic groups. The frequency of HLA-B*5801 is the highest in Han-Chinese (20%), Korean (12%), and Thai (13%), but is much less frequent in Japanese (0.1%) The same allele, however, is also much more frequent in Sardinians (11%) than in other European populations (France 1.5%) [
32]. We believe that this evidence is of particular relevance, given that Sardinia has the highest percentage of reports of adverse events [
26] following allopurinol administration of the total number of adverse reports registered in Italy (1.9% compared to an average of 0.41% in the other Italian regions).
Among the most differentiated variants with lower levels of evidence, two independent variants rs3815087 (allele A) and rs3131003 (allele A) located in
PSORS1C1 region, were of particular interest. Both variants were highly frequent in Sardinians compared to European populations (delta frequency > 29%), have been associated with epidermal necrolysis and Stevens-Johnson syndrome [
33,
34] after allopurinol therapy (evidence levels 3 and 4, respectively) and show coincident, strong association with psoriasis (
p = 1.2 × 10
−294, OR = 2.93;
p = 1.4 × 10
−105, OR = 1.64) [
https://genetics.opentargets.org (accessed on 22 March 2022); rs3815087 and rs3131003 variants respectively]. They were very common in Sardinia (AR 50% and 74.6%), and, thus, screening for these variants before therapy could be important. It is, thus, not surprising that the variant rs2233945, localized in the same
PSORS1C1 gene, modulates the response to etanercept, a TNF inhibitor used for psoriasis and other autoimmune disorders, including rheumatoid arthritis. Allele A in that locus has been associated with increased etanercept efficacy in comparison to allele C: and at the same time allele A has been associated with protection from psoriasis. This variant has been in linkage disequilibrium with one canonically described for allopurinol adverse events, rs9263726, the variant tag for HLA-B*58:01.
5. Conclusions
In this work, we have completed what is, to date, the most extensive characterization of pharmacogenetic variability in an Italian population, specifically that of Sardinia. The analysis of the prevalence of PGx risk variants presented here may stimulate initiatives to implement large-scale pharmacogenetic strategies in Italy.
The impact of pharmacogenetic variation on health is, thus, patently obvious; in a future analysis it may be useful to consider that the impact falls disproportionally with age and it may be stronger on the elderly. The effects of aging result first from the relatively high usage of pharmaceutical drugs in the elderly (
https://www.kff.org/health-reform/issue-brief/data-note-prescription-drugs-and-older-adults/ (accessed on 22 March 2022);
https://hpi.georgetown.edu/rxdrugs/ (accessed on 22 March 2022)) and second from the relatively greater sensitivity to drugs in the elderly, so that the dosages, which are determined on younger adults, are often excessive for them, increasing the risk of side effects.
Variants in pharmacogenes can then further exacerbate the problems. Concerning germ-line mutations, we have dealt here with the effect of single variants on single drugs, but we know little about the effect of genetics on combinations of multiple drugs. This is again especially important for the elderly, who, compared to the middle-aged individuals who normally participate in clinical trials, are more frequently simultaneously prescribed multiple drugs (often in a ‘therapeutic cascade’, in which the side effects of one drug are treated with another drug). Correspondingly, additive or synergistic incidence of side effects and intensification of genetic variant effects can be expected. Furthermore, with age each individual accumulates new somatic mutations, and the liver—in which the majority of the genes relevant to ADME-Tox are expressed—is one of the tissues most exposed to environmental mutagens. It, therefore, tends to accumulate somatic mutations that can potentially further alter the function of pharmacogenes [
37,
38], although the extent to which this occurs has not been quantified. Further analyses should define more precisely the relative load of genetic risk as a function of age and the measures, like lower doses and substitution of drugs by others with different genetic risk profiles, that may mitigate it.
There are some limitations to this study that could be met in the future. First, only by using high coverage sequencing data on the exome or genome will it be possible to define with certainty the existence and prevalence of rarer variants with important effects specific to the Sardinian population. Second, we did not assess structural variants, but for example, CYP2D6 is well-known to have structural variants including copy number variability and gene rearrangements between CYP2D7-CYP2D6 known as hybrid tandems. Third, our analysis was limited to 14 genes, that could be analyzed with PGxPOP at the time this work was prepared; this limitation could be overcome by future analysis, that uses new available information on drug-gene pairs (unfortunately not implemented in PGxPOP). Two other limitations currently preclude estimation of the potential economic cost of non-stratification of patients based on genetic characteristics. The absence of personal data on drug prescriptions (which would allow us to understand how many people, and which individuals, are really at risk of adverse reactions to the drugs they use) and global data on consumption in Sardinia (which would allow us to make pharmacoeconomic estimates).
Nevertheless, the findings demonstrate the value of characterizing allele frequencies in diverse populations and highlights the need for more PGx research on understudied populations, an important step in the corresponding refined implementation of modern personalized medicine.