930391

Q J Med 2000; 93:391–423
Review
QJM
Impact of genomics on drug discovery and clinical medicine
G. EMILIEN1, M. PONCHON2, C. CALDAS3, O. ISACSON4 and
J.-M. MALOTEAUX1,5
From the 1Laboratory of Pharmacology, 2Diabetes and Nutrition Unit, and 5Department of
Neurology, Université Catholique de Louvain, Brussels, Belgium, 3Department of Oncology,
University of Cambridge, Addenbrookes’s Hospital, Cambridge, UK, and 4Neuroregeneration
Laboratories, Harvard Medical School, McLean & Massachusetts General Hospital,
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Belmont MA, USA
Summary
Genomics, particularly high-throughput sequencing medicine is that disease could be treated according
and characterization of expressed human genes, has to genetic and specific individual markers, selecting
created new opportunities for drug discovery. medications and dosages that are optimized for indi-
Knowledge of all the human genes and their func- vidual patients. The possibility of defining patient
tions may allow effective preventive measures, and populations genetically may improve outcomes by
change drug research strategy and drug discovery predicting individual responses to drugs, and could
development processes. Pharmacogenomics is the improve safety and efficacy in therapeutic areas
application of genomic technologies such as gene such as neuropsychiatry, cardiovascular medicine,
sequencing, statistical genetics, and gene expression endocrinology (diabetes and obesity) and oncology.
analysis to drugs in clinical development and on Ethical questions need to be addressed and guide-
the market. It applies the large-scale systematic lines established for the use of genomics in clinical
approaches of genomics to speed the discovery of research and clinical medicine. Significant achieve-
drug response markers, whether they act at the level ments are possible with an interdisciplinary
of the drug target, drug metabolism, or disease approach that includes genetic, technological and
pathways. The potential implication of genomics and therapeutic measures.
pharmacogenomics in clinical research and clinical
Introduction
Genome research centers worldwide are engaged in region of the genome. In September of 1996, this
the Human Genome Project (HGP) with the ultimate number was 3868 genes—a more than two-fold
goal of elucidating and characterizing the complete increase. As of June 1996, 62 human genes linked
sequence of the 3×109 base pairs (bp) arranged in to human diseases had been isolated by genomic
about 85 000 genes of the human genome. An even technologies and, of these, 51 (82%) were available
greater task is to determine their function and inter- in the public domain as clones or as DNA sequences.
play. The genomic approach to mapping and sequen- Moreover, biomedical research is rapidly defining
cing the genome project has accelerated the rate of the molecular mechanisms of pharmacological
gene discovery. In 1990, 1772 human genes were effects, genetic determinants of disease pathogenesis,
identified and mapped to a specific chromosome or and functionally important polymorphisms in genes
Address correspondence to Dr G. Emilien, 127 rue Henri Prou, 78340 Les Clayes Sous Bois, France.
e-mail: Gemilien@aol.com
© Association of Physicians 2000
392 G. Emilien et al.
that govern drug metabolism and disposition. A these genetic disorders are candidates for gene
radical new, but complementary, approach to drug therapy because the expression of the transduced
development is now emerging which promises dra- gene need not be strictly regulated. In contrast, it is
matic improvements in the efficiency and speed of not always necessary to correct the genetic lesion in
drug development. This approach uses the emerging the cell type that shows the defect. In such cases, a
technological expertise from pharmacogenetics, therapeutic gene may be introduced into another
pharmacogenomics and functional genomics to dis- cell type so that the genetically modified cells
sect, predict and monitor the nature of the individual functionally replace the defective cell type.
response to medications. Ultimately, this may lead This paper discusses the impact of genomic sci-
to smaller and faster clinical studies and to individu- ence on drug discovery and clinical medicine and
ally tailored pharmacological treatments, in which provides examples of treatment interventions in neur-
patients are screened to identify which therapeutic opsychiatry (migraine, neurological channelopathies
option most suits their genetic and physiological and neurodegenerative disorders), cardiovascular
makeup and accurately monitored for their response. medicine, endocrinology (diabetes and obesity) and
This approach is likely to have radical consequences oncology.
in the planning, conduct of clinical trials and medical

treatment of diseases.
One important outgrowth of molecular medicine
is the development of technologies for the transfer Genomics
of therapeutic genes to cells in culture and tissues Molecular genetics reached human genetics
in vivo, with potential applications both to medical about 1976, when the first human genes were
research and the practice of clinical medicine. The cloned.2 Transgenic methods, ‘knock-outs’ and
use of genomic databases to find new targets for ‘knock-ins’ began in about 1986, and in about 1996,
drug discovery and the rapid accumulation of human database searching became a fruitful way to do
gene sequences is promising for clinical medicine, genomic research.3 The term ‘genome’ refers to an
if the molecular level can be translated into improved organism’s complete set of genes and chromosomes.
interventions. If it can, therapeutic agents with The term ‘genomics’ describes the scientific discip-
specific molecular functions can be produced, be line of mapping, sequencing, and analysing
they gene products which are deficient or abnormal
genomes.4
in the patients, or drugs with direct transcriptional
Genome analysis may be divided into structural
or molecular effects. Individual genetic testing, with
and functional genomics. Structural genomics is an
knowledge of disease genes, will help early diagnosis
initial phase of genome analysis, and has a clear
and early treatment. For example, recent advances
in the genetics of complex traits (for example, endpoint which is the construction of high-resolution
diabetes, coronary heart disease and Alzheimer’s genetic, physical, and transcript maps of an organism
disease) have to some extent reshaped disease pheno- (its complete DNA sequence). This genotypic
typic descriptions. The techniques developed for approach focuses on understanding how genotypic
automated sequencing and analysis of DNA may variation gives rise to phenotypic variation, relying
eventually allow inexpensive screening of multiple on physical and genetic maps and easily-typed DNA
loci for polymorphisms. sequence polymorphisms. The expression approach
Molecular genetic techniques may also translate (functional genomics) relies on the large collection
into gene therapy. The ability to clone and manip- of partially-sequenced cDNA clones. The benefits of
ulate genes responsible for human disease and to the information arising from the accumulation of
re-introduce functional copies of normal genes into human gene sequences includes developing system-
living cells and tissues is one such therapeutic atic ways of finding genes of interest, and their
objective. The potential clinical applications of gene functions; hence ‘functional genomics’. The genes
therapy are numerous, and a number of specific cloned and their corresponding DNA sequences
human genetic or environmentally-induced diseases provide the tools for comprehensive characterization
that result from a lesion in a single gene have been of the expression patterns of this entire set of genes,
proposed as candidates for gene therapy (Table 1). and for systematic experimental investigations of the
For some of these diseases, the introduction of a functional properties of their products. Thus, func-
functional homologue of the defective gene and the tional genomics, which represents a new phase of
production of even small amounts of the missing genome analysis, makes use of the structural genom-
gene product would have a beneficial effect; for ics information. The investigation is primarily a
example 10–20% production of the normal levels of systematic approach to elucidate the genome and its
factor IX can alleviate severe haemophilia B.1 At the functions.
same time, overexpression of the gene product would The fact that most diseases do not follow a simple
not be expected to have deleterious effects. Thus, inheritance patterns has led to a significant challenge
Table 1 Some examples of genetic diseases
Genetic disease Deficient gene product Cell type References
Lesch-Nyhan syndrome Hypoxanthine phosphoribosyl transferase Basal ganglia 239, 240

Duchenne muscular dystrophy Dystrophin Muscle 241
Parkinson’s disease Dopamine Substantia nigra 242
Neurological channelopathies
Voltage-gated
Paramyotonia congenita a1 subunit of the sodium channel (SCN4A) Muscle
Genomics
Thomsen’s disease (Autosomal dominant myotonia congenita) Allelic disorders associated with mutations in a gene Muscle
Becker’s disease (Autosomal recessive myotonia congenita) coding for skeletal muscle chloride channel (CLCN1) Muscle
Familial hyperkalaemic periodic paralysis a1 subunit of the sodium channel (SCN4A) Muscle
Familial hypokalaemic periodic paralysis a1 subunit of a skeletal muscle calcium channel Muscle
(CACNL1A3)
Episodic ataxia type 1 Potassium channel genes Cerebellum and peripheral nerve
Episodic ataxia type 2 a1 subunit of a brain specific calcium channel Brain 243
Ligand-gated
Familial startle disease a1 subunit of the glycine receptor 82
Nocturnal frontal lobe epilepsy a4 subunit of the nicotinic acetylcholine receptor 83
Familial paroxysmal choreoathetosis Chromosome 1p where a cluster of potassium channel 84
genes is located
Familial hypercholesterolemia Low-density lipoprotein receptor Liver cells 244
393
in the genetic dissection of the complex traits of used to select out adverse effects before drugs enter
diseases such hypertension, Alzheimer’s disease, the clinic. For example, the gene-expression pattern
schizophrenia and diabetes.5 Four major approaches for the liver of an animal administered a drug can
have been developed: linkage analysis, allele-sharing indicate whether gene pathways related to toxicity
methods, association studies in human populations, have been turned on. Variations in gene expression
and polygenic analysis of experimental crosses in levels may prove just as useful as genetic variation
model organisms such as mouse and rat. The gold- in predicting drug response at any stage in the clinic
standard tests for human genes should include associ- and as a diagnostic. Pharmacogenetic data are vital
ation studies demonstrating a clear correlation during the development of a compound with a
between functionally relevant allelic variations and narrow therapeutic index or which is metabolized
the risk of disease in humans, and transgenic studies from a prodrug, as such information may influence
demonstrating that gene addition or gene knockout decision of whether to discontinue development or
in animals produces a phenotypic effect. If these design trials to study clinical responses in individual
genetic approaches are successful, they may have polymorphic for the relevant enzyme.
significant relevance on drug research and clinical Significant issues at the preclinical level usually
medicine. need to be addressed. Problems of medicinal chem-

istry, developing drugs with the appropriate absorp-
tion, metabolism, distribution, and elimination
Pharmacogenomics profiles still have an empirical basis. Nonetheless,
small molecule drugs directed toward targets disco-
Pharmacogenomics has its roots in pharmacogenet- vered by genomics may soon account for a great
ics. Whereas pharmacogenetics is the study of the majority of drugs introduced into the marketplace.
linkage between an individual’s genotype and that Pharmacogenomics may benefit many stages of
individual’s ability to metabolize a foreign com- clinical drug development. It will significantly affect
pound, pharmacogenomics is quite broad in scope, trial design, primarily through improved inclusion/
and is similar to molecular medicine, aiming to exclusion criteria and more effective assessment of
detect, monitor and treat the molecular causes of patient responses. Genes linked with drug metabol-
disease. Pharmacogenomics involves the application ism in preclinical studies could be genotyped in
of genomics technologies such as gene sequencing, patients recruited for phase I trials. Any genotype
statistical genetics and gene expression analysis to that correlates with adverse effects could then be
drugs in clinical development and trials. Since many used to screen out relevant patients in subsequent
diseases develop as a result of a network of genes trials. Furthermore, if efficacy data are collected
failing to perform correctly, pharmacogenomics can during phase I trials, polymorphisms in the drug
identify the genes or loci which are involved in target gene could be typed in phase I participants to
determining the responsiveness to a given drug. In assess whether they are linked with side-effects or
this way, genetic characterization of patient popula- with variations in drug response. That analysis could
tions is becoming an integral part of the drug obviously be further refined in phase II trials, enabling
discovery and development process. Pharmaco- companies to undertake phase III trials in a subgroup
genomics may aim to capitalize on these new mol- of patients that responds well and exhibits fewer
ecular insights to discover new therapeutic targets side-effects. The resultant drugs would be expected
and interventions and to elucidate the constellation not only to have better efficacy, but also a better
of genes that determine the efficacy and toxicity safety profile.
of specific medications. At the clinical level, while the disease symptoms
might appear to be uniform, individual-to-individual
variations in these polygenic networks may make
Impact on drug discovery and clinical drugs healing for certain individuals while toxic for
others. Pharmacogenomics can sometimes correlate
research gene variations with differential responses to the
Applying pharmacogenomics in the preclinical set- same drug leads, thereby hoping to accelerate novel
ting, one may start screening compounds with the drug discovery dramatically, by defining specific
least variation across individuals. If the target gene populations that will benefit from a drug. While this
is selected, the compound that works best overall approach may maximize the medical utility of
against all its subtypes may be chosen. Thus, drug existing pharmaceuticals, it could also rescue dead
selection is substituted for patient selection, decreas- drugs. Several products that have failed in recent
ing the uncertainties that patient stratification intro- years in late stage clinical trials may on retrospective
duces at the FDA and in marketing, as well as the analysis be effective in subsets of patients, although
need for a genetic screening. Genomics may also be at the time, there was no clear way of recognizing
Genomics 395
such subsets clinically. A study of the genetic differ- therapeutic drugs. The best studied metabolizing
ences between the individuals could provide an enzymes are the cytochrome P450 (CYP450) isoen-
answer. Consequently, traditional approaches that zymes, the N-acetyl transferase (NAT) isoenzymes,
focus on broad groups of patients with a diagnosis the UDP-glucuronosyl transferases, and the methyl
(e.g. Alzheimer’s disease) may need to be much transferases. Of these enzymes, the CYP450s are
more precisely divided into subsets of patients who very important because they metabolize drugs into
may have a traditionally defined disease amenable products that are readily excreted into the urine and
to treatment based on a particular molecular target. faeces. In humans, six different forms of CYP450
These pharmacogenomic developments should lead (CYP1A2, CYP2C9, CYP2C19, CYP2D6, CYP2E1 and
to smaller, more rapid and cost-effective trials, and CYP3A4) are largely responsible for eliminating
ultimately to more individually focused and effective drugs. The rate of metabolism by several of the
therapeutics. cytochrome CYP450 enzyme subfamilies varies, due
to genetically-determined polymorphisms in all
populations studied. Recent research using phenotyp-
Relevance to clinical medicine ing and genotyping techniques has reflected the
interest and importance of these pharmacogenetic

In summary, patient segmentation and individual factors in determining drug responses. Some of the
profiling will become increasingly important and metabolizing enzymes such as CYP1A1, 1A2, 2A6,
pharmacogenomics analysis may serve to customize 2C9, 2C19, 2D6, 2E1, NAT1, NAT2 and NQO1
the use of pharmaceuticals for specific subgroups of exhibit genetic polymorphism and alter responses to
patients. Over the past 20 years, genetic heterogen- drugs (see Table 2). These metabolic polymorphisms
eity has been increasingly recognized as a significant
are determined by gender (e.g. CYP1A2) and racial/
source of variation in drug response. Some drugs
ethnic origin.7–8 Increased CYP1A activity (an
work better in some patients than in others, and
enzyme catalysing a phase I oxidation reaction),
some drugs may even be highly toxic to certain
patients. Pharmacogenomics can be used not only coupled with slow acetylation (a phase II conjugation
to predict drug efficacy in a particular patient, but reaction), resulted in less myelosuppression from the
also the likelihood of side-effects, for example those active metabolites of the drug amonafide.9 Because
due to differences in drug metabolism. This informa- every individual represents a combination of drug-
tion could be used to rescue failed or failing drugs, metabolizer phenotypes, given the large number of
by repositioning them for a defined patient popula- enzymes involved in drug metabolism, it is apparent
tion. Pharmacogenomics is about spotting correla- that some individuals are likely to have unusual
tions between such responses to drugs and the reactions to drugs, or to combination of drugs, due
genetic profiles of patients.6 It generates data that to the coincident occurrence of multiple genetic
are relevant to a drug’s clinical performance. defects in drug-metabolizing enzymes. Such an align-
Ultimately, knowledge of the genetic basis for the ment of genotypes, particularly when coupled with
drug disposition and response should make it pos- polymorphisms in drug receptors, is likely to consti-
sible to select many medications and their dosages tute part of the mechanism for the so-called ‘idiosyn-
on the basis of each patient’s inherited ability to cratic’ drug reactions.
metabolize, eliminate and respond to specific drugs. Although no evidence to date suggests the CYP3A4
Therefore, for clinical management in general, gen- isoenzyme exhibits genetic polymorphism, in recent
etic subtyping of the patient response, whether due years there has been much discussion about the 3A4
to different disease subtypes or differential drug system because of life-threatening arrhythmic side-
effects, should make it possible gradually to replace effects that can occur as result of enzyme inhibition
the current trial-and-error-based selection of the and accumulation of the antihistamines terfenadine,
appropriate pharmacological intervention with a astemizole and cisapride.10−12 Terfenadine has been
more informed and rational strategy. This will repres- removed from the market because of its serious
ent an important advance, particularly in diseases cardiovascular drug interactions. Concerning
where it currently may require months or years of CYP2C9, recent data suggest that patients who
treatment to observe whether a positive response has require low doses of warfarin (∏1.5 mg/day) carry
occurred. point mutations (alleles CYP2C9*2 and CYP2C9*3)
at the gene coding for CYP2C9 (which could occur
at a frequency of 21% in the general population).
Genetic variations in pharmacokinetic These patients metabolized warfarin poorly, and
responded to small doses of the drug with greater
and pharmacodynamic effects lengthening of the prothrombin time and higher
Numerous factors, including genetics, affect drug international normalized ratio (INR) values than did
metabolism and thus alter the bioavailability of carriers of the wild-type allele CYP2C9*1.13
Genetically determined high-responders to warfarin
References
had bleeding complications four times more com-
7, 246
14
245
monly than did a control group stabilized on larger
doses of the drug. Knowledge of carriage of the
hyper-responsiveness alleles of CYP2C9*2 and
CYP2C9*3 might help the clinician to decide against
(Canadian Native Indians)

the use of warfarin (in favour of other coumarin
derivatives such as phenoprocoumon and acenocou-
19.1% CYP2C19*2 &

marol, the metabolism of which is less influenced
Frequency in other
0% CYP2C19*3
by CYP2C9), particularly in high-risk elderly patients.
In addition to variation in drug metabolism or
0–19% (Black)
pharmacokinetics, the genetic variations in receptor
populations
function (and thereby pharmacodynamic effects) are

important. Subtle differences in the sequences of
receptor subtypes for dopamine, serotonin and cate-
cholamines may result in individual differences in

behavior and drug responses.6 Overall, a highly
Frequency in
complex picture emerges in which genetic variation

Orientals
in both pharmacodynamic and pharmacokinetic fac-

10–18%
15–23%
<1%
tors contributes to drug responses. Some patients do

50%
7%
not respond to a given drug because it is not

processed efficiently; other patients do not respond
because the disease gene defects or its pathway is
Table 2 Frequency of polymorphism in some important drug metabolism genes in different ethnic groups
Frequency in
not targeted by the drug.

Caucasians
Great progress has been made in understanding

2.5–6%
>28%
>5%
the molecular genetics of acetylation as well as the

20%
3%
clinical consequences of being a rapid or slow

acetylator. Inborn errors (several different alleles) at
the hepatic arylamine N-acetyltransferase-2 (NAT2)
Poor-metabolizer (mild)
locus are responsible for the traditional acetylator

polymorphism.14 Rapid and slow acetylators reflect
Poor-metabolizer
Poor-metabolizer
the genetically determined variation in the elimina-

Rapid acetylator
Slow acetylator
tion of xenobiotics, as well as in NAT2 activity in

Phenotypes
the liver and other tissues.15 The human NAT2 gene

contains an 870 bp intronless protein-coding
region.16 To date, one allele with a code for fast
acetylation (wild-type) and several mutated alleles
with codes for impaired acetylation activity have
been discovered.17−18 Of all the NAT2 allelic variants
Mutation/allele
C282T/G857A
C188T (P34S)
that had been identified, three (NAT*5, NAT*6

m1 and m2
and NAT*7) account for majority of the slow

T341C
NAT2 acetylator genotype in White subjects.18

N-acetylation status seems to be associated with
4
several kinds of diseases, such as colon cancer,

rheumatoid arthritis, and systemic lupus erythem-
atosus.19−21 The independent genetic feature as a
Cytochrome P450 2C19 (CYP2C19)
Cytochrome P450 2D6 (CYP2D6)
rate of acetylation was shown to be related to the

immunological system dysfunction. It may be one of
N-acetyl transferase (NAT-2)
the factors that makes an individual susceptible to

the development of an atopic disease, and one study
showed that up to 80% of individuals with chronic
allergic rhinitis had a slow acetylation phenotype.22
A recent study which assessed the influence of NAT2
polymorphism on the risk of development of atopic
disease also suggests that the risk of development of
Gene
atopic diseases was five-fold greater for homozygous

slow acetylators compared to healthy subjects, and
Genomics 397
that slow acetylation genotype may be an important and plasma levels of gastrin, omeprazole and its
factor of individual susceptibility to atopic diseases.23 metabolites were observed among the three groups
This group of patients may also be at increased risk of volunteers (homozygous extensive metaboli-
of adverse reactions after using drugs which are zers, heterozygous extensive metabolizers and poor
mainly metabolized by acetylation reaction. Among metabolizers), whereas no significant differences
them, the mechanism of hypersensitivity to sulfonam- in these parameters were observed with the placebo
ides typical for slow acetylators seems to be of administration.26 Both the individual omeprazole
particular importance. AUC and mean intragastric pH values were greater
Studies have revealed variant alleles at the NAT1 in the poor metabolizer group compared with those
locus as well. The consequences of pharmacogenetic in the homozygous extensive metabolizer and hetero-
variation in these enzymes include altered kinetics zygous extensive metabolizer groups. The results
of specific drug substrates, drug–drug interactions confirmed that the effects of omeprazole on intra-
resulting from altered kinetics, and idiosyncratic gastric pH significantly depends on CYP2C19 geno-
adverse drug reactions. The latter have been extens- type status, and also suggest that the genotyping test
ively investigated for the arylamine-containing sul- of CYP2C19 may be useful for an optimal prescrip-
fonamide antimicrobial drugs. Individual differences tion of omeprazole.

in multiple metabolic pathways can increase the Low metabolic activity of the CYP2D6 enzymes
likelihood of covalent binding of reactive metabolites is inherited as an autosomal recessive gene and
of the drugs to cell macromolecules with resultant although CYP2D6 represents only about 1.5% of the
cytotoxicity and immune response to neoantigens. total liver enzymes, it is involved in the metabolism
This can result clinically in an idiosyncratic hyper- of a number of commonly used drugs.7 There are
sensitivity reaction manifested by fever, skin rash now more than 20 identified variant CYP2D6 alleles
and variable toxicity to organs including liver, bone which contribute to the variation in CYP2D6 meta-
marrow, kidney, lung, heart and thyroid. bolism. The most common allelic variations associ-
Consideration of the genetic characteristics leads ated with poor-metabolizers in Caucasians are
to population segmentation into groups, the slow CYP2D6*4 (75%), *3 (5%) and the gene deletion *5
metabolizers (having a slow metabolism) and fast (15%).27 For drugs in which CYP2D6 plays a predom-
metabolizers (having a normal metabolism). For inant role in metabolism, poor-metabolizers will
example, in some Asian populations the incidence have high plasma concentrations and report the most
of poor metabolizers of the gastrointestinal drug severe adverse reactions.28 Studies in Caucasian
omeprazole (due to polymorphism in CYP2C19) is extensive-metabolizers and poor-metabolizers have
15–23%, compared to 2.5–6% in Caucasians.24 In uniformly demonstrated a 2- to 5-fold difference in
individuals with a poor-metabolizer genotype for the capacity to metabolize CYP2D6 substrates, such
CYP2C19, the therapeutic efficacy of omeprazole (a as antidepressants and neuroleptics.29 On the other
proton-pump inhibitor widely used as acid inhibitory hand, non-Westerners (Asians and Indians) may
agent for the treatment of upper gastrointestinal require lower doses of several classes of psycho-
diseases and metabolized by CYP2C19) may be tropics that are metabolized by CYP2D6 (e.g. con-
increased.25 In patients with a poor-metabolizer ventional neuroleptics and tricyclic antidepressants)
phenotype or genotype of CYP2C19, the area under than do Westerners.30 The poor-metabolizers lack
the plasma concentration-time curve of omeprazole this enzyme as a result of an autosomal recessively
is markedly increased, and the clinical effect of transmitted defect in its expression. When drugs are
omeprazole is greater. Acid secretion in patients with converted to an active metabolite by 2D6 (e.g.
a poor metabolizer status of CYP2C19 who are conversion of codeine to morphine), the drug may
undergoing an omeprazole therapy is therefore be ineffective in poor-metabolizers. Although signi-
assumed to be more strongly inhibited than those ficant interactions between 2D6-metabolized drugs
with the extensive metabolizer status. Cure rates for with the well-known inducers rifampin and antiepi-
Helicobacter pylori were noted to be 28.6%, 60% leptics have been described, specific inducers of 2D6
and 100% in the rapid-, intermediate-, and poor- have yet to be clearly identified. Administration of
metabolizer groups, respectively. The results of the dextromethorphan followed by measurement of
genotyping test for CYP2C19 seem to predict the O-demethylated metabolite excretion in urine is an
cure of Helicobacter pylori infection and peptic ulcer accurate and non-invasive way of phenotyping indi-
in patients who receive dual therapy with omepra- viduals as either extensive-metabolizers or poor-
zole and amoxicillin. A recent study designed to metabolizers for 2D6 activity.
determine whether the effects of omeprazole on Many opioid analgesics are activated by CYP2D6,
intragastric pH depends on CYP2C19 genotype status rendering the 2–10% of the population who are
confirmed that after omeprazole administration, sig- homozygous for non-functional CYP2D6 mutant
nificant differences in mean intragastric pH values alleles relatively resistant to opioid analgesic
effects.31 It is thus not surprising that there is remark- Affymetrix is already marketing a CYP2C6/CYP2C19
able interindividual variability in the adequacy of genechip for identifying potential poor drug metab-
pain relief when uniform doses of codeine are used. olizers. The recent development of a simple mouth-
Nothing is known about any particular advantage wash method for obtaining genomic DNA clinical
or disadvantage of any CYP2D6 variant. Because studies appears promising.40 Using this cheap and
CYP2D6 occurs not only in the liver but also in the simple-to-perform approach, subjects were success-
brain, it might affect some personality traits: this fully genotyped by PCR-based assays for polymorph-
might affect fitness and thereby frequency of the isms in the CYP1A1, CYP2E1 and NQO1 genes,
variants.32–33 confirming that the quality of DNA isolated from
Thiopurine methyltransferase (TPMT) is a cytosolic mouthwash samples was sufficient to support PCR
enzyme that catalyses the S-methylation of aromatic amplification reliably. This mouthwash procedure
and heterocyclic sulfhydryl compounds, including may be suitable for large community-based studies
the thiopurine drugs 6-mercaptopurine (6-MP) and of genetic susceptibility to disease in which samples
6-thioguanine.34 Thiopurines are used to treat can be collected by the participants themselves.
patients with neoplasia and autoimmune disease as However, there should be agreed standards for the
well as recipients of transplanted organs. The TPMT reproducibility and robustness of such systems.

genetic polymorphism may represent a striking The pharmacodynamics of drug action may be
example of the potential clinical importance of subject to genetic variation with respect to the
pharmacogenetic variation in expression of a drug- sensitivity of the drug’s target to its action (e.g. due
metabolizing enzyme.35 Individuals with genetically to subtle conformational variations at the drug’s
very low levels of TPMT activity are at a greatly binding site). Most drugs interact with specific target
increased risk for potentially life-threatening toxicity proteins to exert their pharmacological effects, such
when exposed to standard doses of thiopurines, as receptors, enzymes, or proteins involved in signal
while those with very high levels of this enzyme transduction, cell cycle control, or many other cellu-
activity may be undertreated with the same dosages lar events. Molecular studies have shown that many
of these drugs.36,37 Recent genetic data suggest that of the genes encoding these drug targets exhibit
the active gene for the TPMT enzyme is ~34 kb in genetic polymorphism, which in many cases alters
length, consists of 10 exons and has been localized their sensitivity to specific pharmacological treat-
to chromosome band 6p22.3.38 The wild-type allele ments. Such examples include polymorphisms in
for high TPMT activity has been designated TPMT*1, b-adrenergic receptors and their sensitivity to
and to date eight variants for very low TPMT activity b-agonists in asthmatics, sulfonylurea receptor
have been reported.38,39 The most common of these and responsiveness to sulfonylurea hypoglycaemic
in Caucasians, TPMT*3A, represents 55–70% of all agents, and 5-hydroxytryptamine receptor and
variant alleles for very low activity.39 TPMT*3A response to neuroleptics such as clozapine.41,42 In
contains two point mutations, G460A and addition, genetic polymorphisms that underlie dis-
A719G, resulting in Ala154Thr and ease pathogenesis can also be major determinants
Tyr240Cys amino acid substitutions, respect- of drug efficacy, such as mutations in the apolipo-
ively.38 However, because of the clinical significance protein E (ApoE) gene and responsiveness of patients
of inherited variation in levels of TPMT activity, with AD to tacrine therapy.43 Finally, the risk of
characterization of as many variant alleles respons- adverse drug effects has been linked to genetic
ible for very low TPMT activity as possible will be polymorphism that predispose to toxicity, such as
necessary so that DNA-based diagnostic tests can be dopamine D3 receptor polymorphism and the risk
compared with the phenotypic test presently used to of drug-induced tardive dyskinesia, potassium chan-
individualize therapy with thiopurine drugs. The nel mutations and drug-induced dysrhythmias and
ultimate aim is to minimize toxicity and improve the polymorphism in the ryanodine receptor and
therapeutic efficacy of this important class of pharma- anesthesia-induced malignant hyperthermia.44
cotherapeutic treatments. Bronchodilator responsiveness to b -adrenergic
2
Besides helping delineate such biological differ- receptor agonists in patients with asthma varies
ences, genetic markers could also be used in considerably and several missense mutations in
selecting patients for clinical trials either for screening the coding region of the b -adrenergic receptor
2
out individuals with genotypes that react adversely gene have been identified.45,46 Among the general
or for selecting patients who are more likely to population (including patients with asthma), b -
2
respond well. The advent of DNA chip technology adrenergic receptor alleles are distributed in the
presents the opportunity not only to rapidly genotype following approximate proportions: homozygous Arg
individuals to provide information on polymorphic (Arg16/Arg16), 15%; heterozygous (Arg16/Gly16)
drug metabolism genes, but also to identify genes 38%; homozygous Gly 16 (Gly 16/Gly 16),
differentially expressed in response to a drug. 45%; homozygous Gln27 (Gln27/Gln27), 26%;
Genomics 399
heterozygous (Gln27/Glu27), 49%; and homozygous that 15100 children have a serious genetic defect,
Glu27 (Glu27/Glu27), 22%.45−48 The Gly6 allele and the possibility now exists of introducing engine-
has been associated with enhanced agonist-promoted ered genes, with the protein product supplementing
b -receptor down-regulation, whereas the Glu27 the defective gene. Ideally, the treatment should
2
allele showed minimal down-regulation compared include replacing the defective gene with a function
with the Arg16 and Gln27 alleles.49,50 Although gene for a complete elimination of the disease-
asthma is primarily an inflammatory disease of the provoking gene.
airways, mutations in the b -adrenergic receptor may The primary problem in gene therapy is the
2
be risk factors in certain asthma phenotypes.45 They method of gene delivery. Successful gene therapy
may also be factors in determining responsiveness depends on the availability of reliable methods for
to b -agonists.46 In a study of 269 children with delivering a gene into the nuclei of selected target
2
asthma, a glycine/arginine polymorphism at amino cells and subsequently ensuring the regulation of
acid 16 was noted to be associated with a difference gene expression. Genes can be delivered (transfected)
in responsiveness to albuterol.51 Individuals homozy- into cells by various systems.52 These fall into two
gous for the arginine variant were over five times main categories: gene delivery using recombinant
more likely to respond to albuterol than individuals viral vectors, and physical gene delivery. Somatic

homozygous for the glycine variant. In another recent transfer of single genes is being attempted at the
study determined to assess whether genetic poly- present time for terminal diseases such as cystic
morphisms of the b -adrenergic receptor gene affect fibrosis and Duchenne muscular dystrophy, for which
2
the relationship between albuterol, plasma concen- there is no effective treatment.53,54 Understanding
trations and the forced expiratory volume in 1 s polygenic diseases represents a more difficult chal-
(FEV ) in patients with moderate asthma, it was lenge, and another problem is presented by diseases
1
reported that the albuterol-evoked FEV was higher such as diabetes mellitus in which feedback control
1
and the response was more rapid in Arg16 homozy- of gene expression is important. The problem with
gotes compared with the cohort of carriers of the some of the delivery systems is the size of the DNA
Gly16 variant (maximal percentage increase in FEV that can be introduced. In the course of a typical
1
was 18% vs. 4.9%, p<0.03).41 The results of this infection, viruses insert their genetic material into
study confirm that b -adrenergic receptor gene poly- cells of the victim, where this added genetic code
2
morphism is a major determinant of bronchodilator directs the synthesis of various molecules needed to
response to albuterol and that future pharmacodyn- make new viral particles. Although natural viruses
amic studies of b -agonists should include determina- can be destructive, it is possible to tame and convert
2
tion of b -adrenergic receptor genotype. some of them so that they can carry a therapeutic
2
The variation in cytochrome drug-metabolizing gene and quietly deposit it inside a cell without
genes that correlates with patients’ adverse response causing damage. All ‘gene therapy’ that is reported
or non-response in clinical trials need to be consid- in the literature is gene addition rather than replace-
ered. This information could be used to stratify ment. Gene replacement is straightforward in yeast
clinical trials, leading to higher efficacy and limiting and is feasible in mammalian cell lines, but remains
adverse reactions. Ultimately, detailed information a long way from effective clinical applications.
about each patient’s genetic variants relevant to drug Two general strategies have been developed for
treatments might eliminate the use of ineffective or gene therapy: the in vivo approach and the ex vivo
even dangerous treatments. Prognosis of patients will approach. These two approaches each have potential
be more informed, because more precise information advantages and disadvantages which render them
on the aetiology of the illness, its pathophysiology appropriate under different conditions. The in vivo
and the effectiveness of therapeutic interventions will approach is conceptually and technically more
be available. Thus, the incorporation of pharmaco- direct, involving the introduction of a gene directly
genetic information into trials as early as possible is into the tissues of an affected individual. In principle,
recommended and appears very useful for effective it does not depend on the success of cell culture or
drug development. subsequent survival of transplanted cells. The ex vivo
approach, on the other hand, is technically more
demanding. First, a suitable cell type is harvested
from a donor and grown in tissue culture. Since
Gene therapy mature neurons and glia are notoriously difficult to
Gene therapy in the broadest sense is the introduction grow and genetically manipulate in culture, alternat-
of foreign genetic material into a cell with therapeutic ive cell types such as fibroblasts and myoblasts have
intent. For deficiency states such as haemophilia, the been used.55 Next the gene is introduced into the
aim is to add a normal gene to that cell to comple- cells in vitro and cells expressing the transgene are
ment an abnormal counterpart. It has been estimated amplified. The genetically altered cells are then
harvested and reimplanted into an affected host. This and cystic fibrosis (8%).61 The key vectors used
approach is labor-intensive and time-consuming, and remain retroviruses (56%), but this high percentage
it requires the growth of suitable cells in vitro and is decreasing.
their subsequent survival after implantation. On 18 December 1997, Human Genome Sciences
However, one advantage of the ex vivo approach is (HGS) announced the filing of its first investigational
that it does not require a highly efficient method for new drug (IND) application and was preparing to
gene transfer, because genetically altered cells may begin clinical testing of a chemokine called myeloid
be amplified in vitro prior to implantation. progenitor inhibitor factor-1 (MPIF-1) for the treat-
Gene therapy is today a robust scientific discipline ment of cancer patients to allow more potent doses
with several new reagents which are being released of chemotherapy. According to HGS, MPIF-1 is the
for specific clinical applications. Transgenic techno- first genomics-derived therapeutic product to enter
logy/transgenic animal models are continuously help- clinical trials. Among more than 50 candidate pro-
ing to set the stage for somatic gene therapy in teins tested in an extensive range of high-throughput
humans. Encouraging results have been reported cellular assays, MPIF-1 showed the greatest selectiv-
from long-term animal studies of gene transfer and ity, the least inflammatory properties, and the best
expression by direct injection of vector into brain, protective activity against a wide range of chemother-

muscle and liver.56,57 These data have led to an apeutics in over 100 primary human cell lines.
increased interest in adeno-associated virus and MPIF-1 moved into animal testing with excellent
expanded its use in human gene therapy trials. To results. In mouse models, it reduced the severity of
date, clinical gene therapy has been attempted in neutropenia, prolonged stem-cell survival, and
only two central nervous system disorders, namely rapidly reverted white blood cell counts to normal
brain tumours and Canavan disease (an autosomal following successive rounds of chemotherapy. For
recessive leukodystrophy associated with spongiform the development of MPIF-1, HGS will be the sole
degeneration of the brain and is characterized by sponsor of the phase I/IIa trial, and on completion,
mutations in the aspartoacylase gene, resulting in first Schering-Plough and then SmithKline will have
loss of enzyme activity).58,59 Most early phase I an option to co-develop the protein in later trials.
clinical studies that have been performed were trials Clinical trials are currently addressing a very broad
not designed to demonstrate efficacy at all, but range of potential delivery systems and disease
instead to assess the safety of transferring cloned
targets. Of the 313 clinical studies listed in the
genes into humans. The results suggest that these
public database maintained by the US National
approaches were safe; remarkably little morbidity
Institute of Health, 70% are involved in the treatment
and no deaths have been noted. Therefore with the
of cancer. This preponderance of cancer-related trials
advance of the engineering of new vectors including
may be surprising if one considers gene therapy as
the adenoviruses, adeno-associated viruses and lenti-
viruses which promise to greatly enhance the effici- a treatment for genetic diseases, but in the broader
ency of in vivo gene delivery and to simultaneously context, gene therapy could be considered as another
reduce the immunogenicity of both vectors and form of drug delivery, and this accounts for the wide
transgenes, prospects for the clinical application of variety of applications of this approach. Therefore,
gene therapy appear good. Obviously, the cloning clinical gene therapy applications include treatments
and sequencing of large numbers of new human aimed at a diverse list of disorders such as
genes and a better understanding of the genetic arthritis, HIV infection, several types of cancers and
bases of human diseases have greatly increased the extremely rare genetic diseases. Often, the number
scope of diseases that may be amenable to treatment of patients enrolled in these trials is small (fewer
by gene therapy. than 20 patients) and this is mainly because of the
necessity for ex vivo manipulation of the individual’s
patient’s cells.
One of the more encouraging results in recent
First genomic products in clinical trials reports comes from the use of injections of DNA
The number of clinical trials involving human gene encoding vascular endothelial growth factors to pro-
therapy has dramatically increased since the initiation mote angiogenesis in tissues affected by vascular
of the first approved trial in the US to treat adenosine insufficiency.62
deaminase deficiency (ADA, a hereditary deficiency One of the most exciting applications of the use
of an enzyme essential to the immune system) of viral vectors is adeno-associated vector injection
in 1990.60 Since then, >2100 patients have been into muscle. A clinical trial was recently initiated to
enrolled in trials worldwide, with >1700 inject factor IX expressing adeno-associated vectors
in the US.61 The majority of active trials involve into the muscles of patients with haemophilia B, and
gene therapy for malignancy (68%), AIDS (18%) similar approaches have been suggested for retinitis
Genomics 401
pigmentosa, familial hypercholesterolemia, and mus- studying the core symptoms of an illness, the clinical
cular dystrophy. phenotype will be more aetiologically homogeneous.
The extent to which genetic mapping is simplified
by restriction of the phenotype redefinition can be
The impact of genetic advances on assessed by measuring the recurrence risk for a
relative of an affected person, divided by the risk in
clinical medicine the general population.5
These genetic advances have greatly enhanced Factors such as genetic polymorphisms, age at
understanding of disease mechanisms and have onset, disease severity and family history can be
begun to explain why the clinical course of common helpful in the identification of homogeneous sub-
disorders such as diabetes is so variable. In future, types. Early onset is associated with increased familial
presymptomatic population-based genetic testing for risk in schizophrenia, bipolar affective disorder,
common late-onset disorders such as Alzheimer’s major depressive disorder and obsessive-compulsive
disease may become widespread and bring important disorder.66–68 The study of associated symptoms and
health benefits.63 Genotyping may become part of co-morbid conditions has also proved helpful in the
routine investigations to help clinicians tailor drug identification of subgroups. Increased familial risk

treatment effectively. Soon medical prescriptions may can also provide a key in the identification of
be personalized to our genotype, along with specific subgroups that have a genetic basis. In schizophrenia,
neutraceutical foods. Some vaccines will be delivered a study of genetic polymorphism for drug metabolism
through foods such as raw potatoes or bananas.64 (CYP2D6) and tardive dyskinesia suggests that hetero-
However, there are issues which need to be better zygous carriers of 2D6 mutated alleles may show an
understood. Even in the simple Mendelian disorders, increased susceptibility to developing dyskinesia.69
the relation between the DNA sequence of a gene In Alzheimer’s disease, point mutations in the gene
and the corresponding phenotype is far from clear. encoding the amyloid precursor protein (chromo-
In late-onset conditions, such as coronary heart some 21), the gene encoding presenilin 1 (chromo-
disease and diabetes, where genetic, social, biolo- some 14) and the gene encoding presenilin 2
gical and environmental factors interact over time, (chromosome 1) were identified only after early-
predicting the clinical importance in a given patient onset familial cases that showed an autosomal dom-
of several different mutations of low penetrance inant pattern of inheritance were recognized.
genes is very difficult.65 Whether testing will inevit- Furthermore, subdivision according to age at onset
ably become widespread as more tests become and mode of inheritance has been particularly useful
available is uncertain. Much depends on the severity in the clarification of genetic heterogeneity in demen-
of the disease and the scope for effective treatment tias of the Alzheimer type.
or prevention. Readiness to undergo testing also
depends on how testing is offered and on personal, Migraine
social, and psychological factors. Rigorous assess-
ment of the benefits and costs, both economic and Molecular genetics offers a novel approach to the
psychosocial is essential, not least because informa- understanding and management of migraine, since
tion from genetic screening tests carry implications the disorder is known to have a strong genetic
for families as well as individuals. component. In a recent study, a Nocardia corallina-I
(NcoI) polymorphism in the gene encoding dopamine
D receptor was evaluated in a group of 250
Neuropsychiatry 2
unrelated individuals.70 The major findings of the
Psychiatrists must usually rely on complex clinical study was that susceptibility to migraine with aura
symptoms and diagnostic schemes that although is modified by dopamine D NcoI alleles. However,
2
highly reliable, have no obvious biological criteria. it is also clear that since not all individuals with the
Thus, the question of whether our modern definitions dopamine D NcoI A1/A1 genotype suffer from
2
of clinical syndromes (considered as phenotypes) migraine with aura, multiple additional genes are
accurately reflect underlying genetic substrates (geno- involved in the pathogenesis of migraine.
types) remains. Genetic analysis of some psychiatric A gene for familial hemiplegic migraine (FHM, a
disorders might be improved by the identification of rare subtype of migraine with aura inherited as an
basic phenotypes for which a more homogeneous autosomal dominant trait), has been assigned to
aetiology might be expected. The identification of chromosome 19.71 This gene codes for a brain-
these phenotypes could be achieved by two comple- specific calcium channel, and is responsible for FHM
mentary strategies: the description of the affected in 55% of the FHM families. Other FHM families
subjects and the identification of vulnerability traits have been linked to two different locations on
in non-affected relatives of affected individuals. By chromosome 1. The identification of the genes
for FFM may be a key to the identification of the different mutations of the same gene can give rise to
genes for migraine with and without aura. such different phenotypes. A CACLN1A4 mutation
in a case of ‘non-hemiplegic’ migraine suggests also
that such mutations may associate with commoner
Neurological channelopathies forms of migraine.80 The abnormalities on EEG which
Disorders of ion channels (channelopathies) are are noted in patients with familial hemiplegic
increasingly being identified, making this a significant migraine and episodic ataxia type 2 together with
expanding area of neurology. Ion channel function the recent observations of mouse models have led
may be controlled by changes in voltage (voltage- to the question of whether the gene CACLN1A4 is
gated), chemical interaction (ligand-gated), or by relevant to epilepsy in humans.81 In the case of
mechanical perturbation and it has become obvious myotonia congenita and familial hyperrekplexia,
that genetic defects of both ligand- and voltage-gated point mutations in the same gene can result in either
ion channels can cause diverse neurological dis- autosomal recessive or dominant inheritance.
ease.72–74 A channelopathy may cause an abnormal Ligand-gated channelopathies that have recently
gain of function (e.g. myokymia, myotonia, and been described include familial startle disease, which
epilepsy) or an abnormal loss of function (e.g. is due to mutations of the a1 subunit of the glycine

weakness or numbness) depending on whether receptor, and dominant nocturnal frontal lobe epi-
change of channel function leads to excessive mem- lepsy, which is due to mutations of the a4 subunit
brane excitability or inexcitability. The impact of of the nicotinic acetylcholine receptor.82,83 A gene
these recent discoveries is that it is now understood for familial paroxysmal choreoathetosis has been
that genetic channelopathies could affect nerves as mapped to a region of chromosome 1p where a
well as muscles, and that they may also represent cluster of potassium channel genes is located.84
rare forms of more common disorders such as The benefits of recent genetic findings are an
migraine and epilepsy.75 improved classification of these neurological dis-
The first diseases recognized as channelopathies orders and the availability of DNA-based diagnosis.
were the voltage-gated channelopathies causing Such findings will certainly bring novel treatment
inherited muscle diseases (the non-dystrophic interventions issued from pharmacogenomics
myotonias and familial periodic paralyses). research with the likely possibility of linking treat-
Paramyotonia congenita is due to mutations in the ments to specific genotypes and modes of ion
gene coding for the a1 subunit of the sodium channel channel impairment.
(SCN4A), while Thomsen’s disease (autosomal dom-
inant myotonia congenita) and Becker’s disease
(autosomal recessive myotonia congenita) are allelic
Huntington’s disease
disorders associated with mutations in a gene coding Huntington’s disease (HD) is an autosomal dominant
for skeletal muscle chloride channel (CLCN1). genetic disorder caused by a mutated gene found on
Familial hyperkalaemic periodic paralysis is due to chromosome 4.85,86 Efforts continue to determine
mutations in the same sodium channel gene (SCN4A) how this genetic mutation leads to the symptoms
as that affected in paramyotonia congenita, while of HD and recent investigations have provided further
familial hypokalaemia periodic paralysis results from understanding of its genetics. It has been shown that
mutations in the gene coding for the a1 subunit of a triplet mutation in a gene (IT15) on chromosome
a skeletal muscle calcium channel (CACNL1A3). 4 p16.3 results in a protein with an expanded
DNA-based diagnosis of periodic paralyses is now polyglutamine tract caused HD.86 The HD gene
decreasing the need for time-consuming and hazard- transcript has been denoted IT15 and the protein it
ous provocative testing.76 Malignant hyperthermia is encodes has been termed ‘huntingtin’.87 The CAG
now known to be a disorder of regulation of skeletal repeat number in the normal IT15 gene varies, but
muscle calcium and that mutations in the ryanodine typically ranges between 10 to 36. In contrast, in
receptor gene (RYR1) may cause malignant hyper- patients with HD, the number of CAG repeats range
thermia in some families.77,78 Ryanodine receptor from 37 to 121 repeats. The number of diseases
gene mutation analysis can now be used to identify identified as caused by (CAG) continues to grow,
n
those at risk of malignant hyperthermia in families and a common mechanisms could underlie these
with a known mutation in this gene. diseases. To date, eight such inherited neurological
One of the most intriguing recent discoveries in disorders have been identified to be caused by
genetic channelopathies is that mutations in the same CAG-repeat expansion in their respective genes
gene (CACNL1A4) can cause three different (Huntington’s disease, dentatorubral pallidoluysian
autosomal dominant disorders such as familial hemi- atrophy, spino-bulbar muscular atrophy and spino-
plegic migraine, episodic ataxia type 2 and spinocer- cerebellar ataxia types 1, 2, 3, 6 and 7).88−90 Most
ebellar degeneration type 6.79 It is unclear how of the diseases caused by expanded CAG repeats
Genomics 403
share common features which include neurodegener- and hippocampal neurons. Cholinergic neurons in
ation, a dominant pattern of inheritance and genetic the basal forebrain which project to cortex and
anticipation (earlier onset and increased severity in hippocampus appear to be particularly vulnerable,
successive generations).91–93 Of these diseases, HD and to an extent, so are serotonergic and noradren-
is the most prevalent, occurring in 4–10 per 100 000 ergic afferents to cortical regions. The extracellular
individuals of Caucasian origin, so that a knowledge deposition of peptide fragments (amyloid-beta) from
of the neuropathological events that lead to HD will the larger membrane precursor protein (APP) is
probably provide insights into the disease mechan- typical in affected brain tissue. Intracellular accumu-
isms of the other triplet-repeat disorders. lations of tau-proteins (tangles) are present in many
Symptoms of HD typically appear in adult life cortical and cortico-limbic regions.99
between the ages of 30 and 50, and the disease is Genetic studies have led to the identification of
most often characterized by chronic progressive three genes in which mutations can cause AD: the
chorea (quick, jerking, uncontrollable movements of b-amyloid precursor protein gene located on chro-
the limbs, trunk and face) and dementia without mosome 21, presenilin 1 (PS1) located on chromo-
remissions. An individual with HD often has problems some 14, and presenilin 2 (PS2) located on
in control of most bodily movements, intellectual chromosome 1.100−102 In addition, the E4 allele of

functioning (poor short-term memory and judgment) the apolipoprotein E (ApoE) gene is a risk factor
and emotional control (depression, irritability and for AD. While mutations associated with APP are
apathy). The intensity and number of the above extremely rare, the 50 or so mutations associated
symptoms, however, varies with each HD patient. with PS1 may explain up to half of all cases of early-
The neuropathology of HD is most pronounced onset AD. A study which investigated the association
in the caudate and putamen forebrain region. Its of two candidate genes (PS1 and a -antichymotrypsin
pathogenesis is unknown, although roles for glutam- 1
(ACT)) with the risk of sporadic Alzheimer’s disease
ate-receptor activation and deteriorations in mito- on chromosome 14 reported that the frequency of
chondrial energy metabolism have been proposed as the ACT*A allele was significantly higher in AD
co-factors.94,95 patients than in controls and the stratification of
There is no cure for HD; medication can alleviate the ACT data by PS1 genotypes showed that the risk
some of the involuntary movements and emotional associated with the ACT*A allele was confined to
disorders for some HD patients. However, novel PS1*1 carriers only.103 The two-site haplotype data
therapies in the near future may include interference for PS1 and ACT indicated that the A1 haplotype,
with RNA splicing, blockade of the deleterious carrying the ACT*A and PS1 alleles, was more
protein’s effect or physiological interventions by frequent in Alzheimer’s disease patients, and these
pharmacological tools or neural transplants. At results may also suggest that there is a possible
the RNA level of intervention, it may be possible to
synergistic effect of these two loci on the risk of AD.
integrate viral or non-viral vectors carrying catalytic
In contrast to early-onset AD, there is to date only
antisense RNAs or ribozymes that bind to, and
one genetic factor indisputably linked with late-onset
irreversibly cleave, abnormal mRNA molecules.96,97
forms of this disorder; the E4 allele of apolipoprotein
Antisense RNA has been used to hamper transcrip-
tion, processing or translation of mRNAs in a variety E.104 Differences in ApoE genotyping appear to
of cell types. However, the results from animal explain differences in patients’ responses to drug
studies suggest that although the antisense oligo- therapy. With tacrine, a better response was seen in
deoxynucleotide targeted against the initiation codon patients with the ApoE E2 or ApoE E3 allele than in
of IT15 gene had penetrated several striatal cells and those carrying the ApoE E4. The ApoE E4 allele has
that they were not toxic to the brain, no significant an inverse relationship with residual brain choline
decrease in levels of huntingtin was detected acetyltransferase (the acetyl-choline synthesizing
by immunostaining or Western blot analysis.97 enzyme) activity, and it appears that patients with
Therefore, improved methods for molecular modi- this genotype may not have sufficient acetylcholine
fications of IT15 may be needed for therapeutic to benefit from a drug which acts as an inhibitor of
initiatives. Considering the feasibility of gene therapy acetylcholinesterase. However, patients with the
for HD, a recent study suggests that encapsulated ApoE E4 genotype appear to have a better response
human ciliary neurotrophic factor producing than other AD patients to treatment with another
fibroblasts may prevent behavioral deficits and striatal drug, Servier’ s S12024 (morpholinyl-2 methoxyl-8
degeneration in models of HD.98 tetrahydro-1,2,3,4 quinoline) which is currently in
phase II clinical trials. In fact, this drug had no
detectable effect in patients with the other ApoE
Alzheimer’s disease genotypes. S12024 does not appear to affect the
Pathologically, Alzheimer’s disease (AD) is associated cholinergic system, but rather to facilitate brain
with generalized degeneration of the cerebral cortical noradrenergic and vasopressinergic activity, and
increases vasopressin synthesis and release in a dose- rons in the basal forebrain from their normal supply
dependent manner. There may be a balance between of nerve growth factor (NGF) in the cortex.107,108 In
cholinomimetic and vasopressinergic pathways, the absence of a constant supply of NGF, the
according to ApoE E4 allele presence or absence.105 cholinergic neurons degenerate. Early studies had
With relevance to design of clinical trials, the import- documented that the dying neurons could be rescued
ant observation may be that alleles that appear to by the intracerebral delivery of purified NGF via
be conclusively associated with a therapeutically artificial mini-pumps.
relevant phenotype can be used to select a subgroup The appropriateness of NGF administration as
of patients for clinical trials. A polymorphic site need treatment for AD and other neurodegenerative dis-
not be part of the target for the drug; it only needs orders remains a matter of debate. However, the
to be associated with a response to the treatment. In animal experiments demonstrate the principle that
responsive patients, the selective treatment could be gene therapy may be applied to prevent neurodegen-
more effective, and associated with fewer or less eration by directing constant local production of a
severe side effects. Furthermore, pre-emptive geno- growth factor either by grafts of growth factor-
typing aimed at drug-associated genes could mean producing cells, or direct introduction of growth
that fewer drug candidates would fail to reach the factor genes.

market place because of poor toxicity/efficacy pro-
files in the general population. For example, genotyp-
ing of early-onset AD is likely to include the two PS1
Amyotrophic lateral sclerosis
and PS2 genes involved in this disease. Predictive Amyotrophic lateral sclerosis (ALS) is an adult-onset,
and diagnostic tests for PS1 mutations and diagnostic chronic neuromuscular disorder, characterized by
tests for ApoE alleles are already commercially selective degeneration of cortical and spinal/bulbar
available and other tests are being developed. Thus, motor neurons. The discovery that 15–25% of
genetic testing for AD exists for clinical use, and is familial ALS patients have mutated Cu2+/Zn2+
likely to be used more often to stratify patients in superoxide dismutase (SOD1) links ALS to toxicity
Alzheimer’s disease research, both in trials of pre- by reactive oxygen species.109 SOD1 is thought to
ventive products and in tests of new pharmacological protect against cellular damage induced by oxygen
treatments. Therefore, predictive and diagnostic gen- radicals but the mechanism(s) through which muta-
etic testing for these highly penetrant mutations such tions in SOD1 lead to late-onset motor neuron
as PS1 or PS2 may be appropriate for adults from degeneration remains unidentified.110 Two mutations
families with a clear autosomal dominant pattern or which have been successfully used to generate
inheritance, particularly those with a family history transgenic mice that develop an ALS-like syndrome
of early onset of symptoms. Testing is an option that are glycine 85 to arginine (G85R) and glycine 93 to
could be discussed and that could reasonably be alanine (G93A) with the mutant SOD1 allele overex-
accepted or declined by the patients. However, the pressed in a normal mouse genetic background.111
application of the ApoE test raises concerns, because Recent data assessing the axonal transport in animal
although the E4 allele is associated with an increased models suggest that an important aspect of toxicity
risk of AD, its predictive value for individuals is may arise from damage to transport, and that reduced
quite limited.106 The small increase in diagnostic transport of selective cargoes of slow transport,
confidence provided by ApoE genotyping does not especially tubulin, arises months before neurodeneg-
justify the burdens of testing; such testing may have eration.112 Therefore, damage to the machinery of
value in AD research, but its widespread clinical use slow transport may be an early feature of toxicity
is premature until practical benefits outweigh its mediated by mutant SOD1.
costs. Ciliary neurotrophic factor (CNTF) and glial-cell-
A successful treatment approach might be the line-derived neurotrophic factor (GDNF) have been
delivery of neurotrophic factors which prevent neur- shown to rescue motor neurons from axotomy-
onal degeneration. Gene therapy may provide an induced cell death and to slow the degeneration of
effective alternative to traditional methods for deliv- motor neurons in a mouse mutant with progressive
ery of trophic factors. For example, genes encoding motor neuropathy (animal models of ALS), so neuro-
trophic factors can be introduced into cells in tissue trophic factors may be of therapeutic importance for
culture. Subsequent intracerebral implantation of the treatment of neurodegenerative disease such
these cells effectively produces a biological mini- as ALS.113,114 A phase I clinical trial designed as an
pump for constant local delivery of a trophic factor. open-label safety study using intrathecal delivery of
The effectiveness of this approach has already been human CNTF has been performed in six patients
demonstrated in several animal models of neurodeg- suffering from ALS.115 Baby hamster kidney (BHK)
eneration. In the first model, surgical lesions of the cells transfected with the CNTF gene were loaded
fimbria-fornix in rodents interrupts cholinergic neu- in 5-cm long polyethersulfone fibres and surgically
Genomics 405
placed within the lumbar intrathecal space. erated or dead dopamine cells for PD, experiments
According to the protocol, the implant was retrieved using heterologous donor tissue have mainly focused
after 3–4 months. The results of this small study on tissue derived from the embryonic mesencephalon
showed that significant doses of CNTF can be harvested at a time point when the cells start
delivered directly into the central nervous system, differentiating into dopaminergic neurons. Embryonic
and that no limiting adverse effects in any of the cells survive in the striatum after grafting and display
patients exposed to low intrathecal doses of CNTF a TH-immunoreactive phenotype.120,121 One of the
were noted. Further long-term studies may therefore main advantages of the use of fetal tissue over
be conducted to assess efficacy and safety of this genetically engineered cells may lie in its potential
gene therapy approach for the treatment of ALS. to form functional synapses with the host brain and
release dopamine in a regulated fashion.122,123
Unfortunately, large amounts of tissue have been
Parkinson’s disease necessary to achieve behavioural recovery, and even
In Parkinson’s disease (PD), patients display cog- with optimized techniques, only a minimal fraction
wheel rigidity, resting tremor, and an impairment in of the transplanted cells will survive as TH-IR neu-
the initiation and speed of movements. Although rons. Several clinical trials using fetal donor tissue

familial PD has been reported, most cases are thought have had various degrees of success, possibly due
to be acquired. The cause of the disease is unknown, to significant differences in patient history and tech-
but environmental toxins, metabolic derangements, nical details.124,125 So far, fetal tissue shows the
infectious processes, and normal aging have all been greatest potential, but it may be difficult to obtain
hypothesized to play a role.116 Pathologically, this the significant amount of tissue to obtain the neces-
disorder arises because a part of the brain known as sary amount of tissue for a great number of patients
the substantia nigra degenerates over time. This and ethical considerations have to be balanced with
region helps to regulate motor control, and destruc- safety and efficacy issues. Progenitor cell or xenog-
tion makes it hard for a person to initiate movements enetically-derived dopamine cells may provide useful
or execute complex coordinated motion. sources for clinical cell implantation in PD.126,127
Epidemiological studies have shown that positive To genetically engineer cells, because of the
family history and exposure to environmental toxins limitations of established cell lines, retroviral-
are considered risk factors for PD. Recent evidence mediated gene transfer has been used to transduce
indicated that there is a significant association primary fibroblasts and astrocytes.108,128 The applica-
between the slow acetylator genotype of tion of gene transfer techniques for the treatment
N-acetyltransferase 2 and familial PD.117 The propor- of PD has been explored in animal models as a
tion of slow acetylators was significantly higher potential therapeutic intervention. Since the loss of
among patients with familial PD (69%) than among striatal dopamine is thought to underlie the motor
normal controls (37%, p<0.001) and this difference disturbances in PD, gene therapy strategies have
remained significant after correction for multiple focused on replacement of dopamine levels by
comparison ( p=0.002). It is hypothesized that this genetically engineering cells to produce tyrosine
difference may be due to the impaired ability to hydroxylase (TH), the enzyme necessary for the
metabolize neurotoxic substances in patients with conversion of tyrosine to L-DOPA. Local production
slow acetylation, resulting in the increased metabolic of L-DOPA in the affected area may diminish the
predisposition to familial PD. unwanted side-effects observed with systemic admin-
With the recent identification of mutations in the istration. It is clear from behavioural analysis that
a-synuclein gene or linkage to a region on chromo- grafted, genetically-engineered, non-neuronal cells
some 2 in families with PD, it appears that genetic can have significant effects as a biological L-dopa
factors are important when the disease begins at or pump system. However, in contrast to fetal dopamine
before age 50 years.116, 118,119 Mutations in the alpha- neurons, these cells are unable to make connections
synuclein gene may cause early-onset PD by acceler- with host cells. The importance of functional cellular
ating the formation of Lewy bodies. This findings integration in the restoration of finer motor control
could lead to a novel treatment for PD. It was tasks remains to be determined.
observed that a mutant form of alpha-synuclein, A second strategy for treatment of PD is to prevent
known as A53T, formed fibrils characteristics of dopaminergic neurons from dying. Brain-derived
Lewy bodies more quickly when concentrated and neurotrophic factor (BDNF), has been used to prevent
encouraged to aggregate than either wild-type alpha- cell death in either cell culture models of dopa-
synuclein or another mutant, A30P. The making of minergic toxicity or animal models of PD.129–131 The
a new drug which targets inhibition of fibril formation neurotrophin BDNF has been shown to have effect
should be possible. on damaged dopaminergic neurons in vivo. Although
In a strategy for therapeutic replacement of degen- infusions of recombinant BDNF into the parenchyma
failed to protect dopaminergic neurons from tailor the treatment of patients who have the syn-
axotomy, delivery of BDNF by genetic engineering drome according to their genotype; LQTS is caused
of nonneuronal cells has shown promising effects.132 by defective ventricular repolarization leading to
These data suggest that this strategy may be a viable prolongation of QT interval, and predisposes to
approach for enhancing the survival and function of ventricular tachyarrhythmias, largely associated with
dopamine neurons grafted into parkinsonian patients. stressful settings. The prolonged pauses can cause
cardiac syncope, and additionally serve as
Cardiology arrhythmogenic substrates, allowing ectopic beats to
occur. Patients with LQTS may be asymptomatic or
In pre-clinical studies of potential gene therapies for experience recurrent fainting spells, palpitations, tor-
cardiovascular disease, methods are being examined sade de pointes, and ventricular arrhythmias leading
for genetically modifying cellular constituents of the to sudden death. The observation of an increased
vessel wall and the heart. Ex vivo approaches have lethality of cardiac events in patients with SCN5A
included attempts to resurface specific arterial vessel mutation may suggest the need for more aggressive
segments with genetically modified endothelial cells treatment of these patients. It also appears that gene-
or smooth muscle cells. The resurfacing of prosthetic specific therapy with class Ib sodium-channel block-

vascular grafts with genetically modified cells has ers may be more adequate treatment for these
also been examined.133 patients.136–138 This approach of linking a defective
Most of the work indicating that gene therapy can gene to clinical outcome and treatment is an import-
show real clinical benefits in patients with heart ant major direction in clinical medicine.
disease has been done with the gene for vascular Many areas of research are opened up by the
endothelial growth factor (VEGF). This approach is exciting new molecular genetic findings in LQTS.
based on the idea that injection of the VEGF gene Examples include the identification of drug therapies
into the area where atherosclerotic plaques have that might correct the defects in these mutations and
caused the most blockade to the arteries will allow studies to determine the relationship between clinical
new blood vessels to grow which can by-pass the phenotypes and underlying genetic defects.137
blockage. This approach is being tested in both Preliminary data suggest a role for sodium-channel
peripheral artery disease (who have blockages in the blockers such as mexiletine in LQT3, linked to late-
blood vessels in their legs) and those with coronary opening sodium channels.137 In patients with this
heart disease (in whom the arteries supplying the defect, blockers of the late-opening sodium channels
heart have become blocked). Many different groups might entirely reverse all the manifestations of the
have reported initial clinical trials in which the gene syndrome. Use of sodium-channel blockers in
for VEGF induced the formation of new blood patients with other defects might theoretically also
vessels. While most of the studies to date have been shorten the QT interval by reducing inward current
conducted in patients with peripheral vascular dis- during the plateau.139 However, they would not be
ease, several groups have now reported preliminary expected to reverse the ion channel defect underlying
evidence of success in patients with coronary heart the syndromes. In patients with LQTS due to abnor-
disease. If such research continues to progress well, mal potassium-channel function, therapies directed
the use of gene therapy could become an alternative at altering the function of the abnormal channels to
to angioplasty or bypass surgery in coronary heart create outward current (e.g. potassium-channel
disease patients, and may even do away with the openers) might achieve the latter effect. While these
need for some drug therapies. are interesting suggestions for future therapy after
evaluation in vitro and in controlled trials, b-blockers
Cardiovascular risk factors remain the current mainstay of therapy.
Genome-wide linkage scans have revealed multiple Familial hypertropic cardiomyopathy affects about
quantitative trait loci contributing to susceptibility 1 in 500 of the general population.140 Most cases
for several major cardiovascular risk factors. The are inherited in an autosomal dominant manner with
challenge that remains, however, is how to improve variable clinical expression.141 To date, disease-
these studies in order to narrow the genetic interval causing mutations have been described in genes for
and find susceptibility genes. seven cardiac sarcomeric proteins; b-myosin heavy
The clinical course of the congenital long QT chain (chromosome 14q11), cardiac troponin T
syndrome (LQTS), a hereditary arrhythmic disorder, (chromosome 1q3), cardiac troponin 1 (chromosome
can be predicted through genotypic analysis and 19p13.2-q13.2), a-tropomyosin (chromosome 15q2),
that LQTS should no longer be excluded on purely cardiac myosin-binding protein C (MyBPC, chromo-
clinical grounds134,135 (see Table 3). The finding of a some 11p11.2), and the essential and regulatory
link between variations in genotype and differential myosin light chains (chromosomes 3 and 12,
clinical disease expression may allow clinicians to respectively).142−143 Mutations in the genes encoding
Genomics 407
Table 3 Genotype of long QT syndrome (from data in reference 134)
Mutant Chromosome locus Abnormal characteristics Clinical course

genes
KVLQT1 LQT1 locus on chromosome 11 Encodes an abnormal potassium- The frequency of cardiac events
(11p15.5) channel protein (a subunit) was higher among subjects
that, when expressed with a with mutations at the LQT1
protein from the min K gene, locus (63%) or the LQT2 locus
reduces the current of the (46%) than among subjects
slowly activating, delayed with mutations at the LQT3
inwardly rectifying potassium locus (18%). However, the
channel. likelihood of dying during
HERG LQT2 locus on chromosome 7 Encodes an abnormal potassium- a cardiac event was
(7q35–36) channel protein that reduces significantly higher among
the current of the rapidly families with mutations at the
activating, delayed inwardly LQT3 locus (20%) than among
rectifying potassium channel. those with mutations at the

SCN5A LQT3 locus on chromosome 3 Encodes an abnormal sodium- LQT1 locus (4%) or the LQT2
(3p21–24) channel protein that does not locus (4%).
allow the complete inactivation
of sodium inflow, resulting in
continued entry of sodium into
the myocardial cell during
repolarization.
KCNE1 LQT5 locus on chromosome 21 Encodes b subunits that assemble
with KVLQT1
a subunits to form slowly
activating delayed inwardly
rectifying potassium channels.
b-myosin heavy chain, troponin T and cardiac identified.145 Hypertension due to single-gene abnor-
MyBPC account for over 50% of all reported cases. malities is very rare, and it appears that high blood
However, most published genetic studies are rather pressure is, in general, a complex final phenotype
small and in highly selected populations; therefore that involves many control systems operating at each
this prevalence of different mutations may be impre- level of biological organization. The blood pressure
cise. The discovery of mutations in genes for sarcom- difference between a hypertensive individual and a
eric proteins in patients with hypertrophic normotensive control has been attributed to the
cardiomyopathy has raised the possibility of gene influence/interaction of 2–6 genetic loci.146 In par-
testing in clinical care. Unfortunately, the genetic ticular, through the candidate gene approach or
heterogeneity of this disease has made routine gen- random genome scanning, some specific genes have
etic testing impracticable, and testing is performed been identified such as angiotensinogen (AGT),
in research centers and limited to particular circum- angiotensin-1 converting enzyme (ACE) and adducin.
stances (e.g. patients with incomplete expression and In humans, the problem of the association between
a strong family history of sudden death). If the a given genetic trait and hypertension can be
association between late-onset hypertrophy and approached both with case-control and linkage stud-
MyBPC gene mutations is confirmed, genetic screen-
ies. Only two genes, adducin and AGT were found
ing in children of affected individuals may become
to be involved in human essential hypertension when
appropriate.
both types of studies were considered.147,148
Considering hypertension due to single gene
Essential hypertension abnormalities, glucocorticoid-remediable aldosteron-
Molecular genetics applied to essential hypertension ism (GRA) is an autosomal dominant form of moder-
has allowed the identification of some quantitative ate-to-severe hypertension associated with both an
trait loci or genes that influence blood pressure.144 excess of cerebral haemorrhage and Celtic ances-
A polymorphism of the genes for the cytoskeletal try.149 The hypertension is caused by excessive
protein, adducin, which is linked to both rat and secretion of aldosterone, and possibly additional
human hypertension, sodium sensitivity and to the adrenal mineralocortocoid hormones, where aldos-
pressor responsiveness to diuretic therapy has been terone secretion is regulated by corticotrophin rather
than by angiotensin II. Kindreds with GRA demon- response to sodium depletion and long-term therapy
strate a novel gene on chromosome 8 that represents with a thiazide than those who were homozygous
duplication arising from unequal crossover between for the glycine variant. Confirmation of these data
the aldosterone synthase and 11 b-hydroxylase would indicate a way of predicting a diuretic-
genes, such that the regulatory sequences of 11 b- responsive form of hypertension.
hydroxylase are fused with coding sequences of Considering the AGT genotype, an association has
aldosterone synthase.150 Aldosterone synthase gene been reported between the T235 allele and both
expression and enzymatic activity are therefore plasma AGT concentration and elevated blood pres-
brought under the control of ACTH, which results in sure variation.147,156 AGT genotype was also strongly
ectopic production of aldosterone, with hypertension associated with blood pressure reduction after 5
due to increased salt and water retention. This type weeks’ ACE inhibition, and the best blood pressure
of hypertension responds to administration of response was associated with the T235 allele.157
physiological doses of glucocorticoids which These data suggest that a variation in the regulatory
suppress ACTH secretion and thereby suppress sequence of AGT may be more important in evaluat-
expression of the mutant gene.150 It is now possible ing the response to blood-pressure-lowering treat-
to define these individuals using a simple genetic ment. It also appears that genetic understanding

test. This is an example of an approach in clinical of hypertension will be used to develop predictions
practice to identify hypertensive individuals who of pharmacological response and the development
should be treated with glucocorticoids as antihyper- of new novel pharmacological therapeutic strategies.
tensive therapy. It is important that in the assessment of drug treat-
Patients with autosomal-dominant monogenic ment, study designs include tests as to whether new
hypertension who tended to metabolic alkalosis with diagnostics can predict treatment responses. This
hypokalaemia were described by Liddle (Liddle syn- might provide an opportunity to focus on specific
drome). The patients had low-renin and low- hypertensive subtypes and provide the most effective
aldosterone values; however, they did not respond antihypertensive drugs to such defined hypertensive
to spironolactone, while thiazides and triamterene individuals.
decreased the blood pressure. The responsible gene A study which analysed data on the efficacy of
in a family with Liddle syndrome was localized to specific drugs in individual patients concluded that
chromosome 16 and that the gene encodes the b- 10–59% of patients failed to respond to diuretics,
subunit of the epithelial sodium channel (ENaC).151 12–86% failed to respond to b-blockers, some
The channel is amiloride- and triamterene-sensitive, patients exhibited heterogeneous responses to ACE
explaining the efficacy of these drugs in treating the inhibitors and calcium antagonists, and a small
syndrome. The channel remains inappropriately per- percentage of patients even showed an increase in
meable even in high salt intake, thereby leading to blood pressure.158 The variation in the individual
salt-sensitive hypertension. Another mutation in the response to antihypertensive drugs may be due to
c-subunit of ENaC has also been reported which can the heterogeneity of the mechanisms underlying
result in Liddle syndrome.152 hypertension, to interindividual variations of the
Evidence for association and genetic linkage of pharmacokinetics of the drugs, or both. Although the
the ACE gene with hypertension and blood pressure choice of a proper therapeutic strategy through
in men, but not in women, was reported when data pharmacogenomics approach is complex, and target-
for over 3000 patients in a study were analysed.153 ing the disease gene itself may not be sufficient for
Animal studies suggest that mutations in the a- the selection of the optimal therapeutic target, the
adducin gene may account for 50% of the observed gene identification involved in essential hypertension
differences in blood pressure between hypertensive should provide clarification on the regulatory path-
and normotensive strains.154 A study in human hyper- ways triggered by the primary genetic defect and
tensive sibling pairs also revealed support for linkage therefore lead to the identification of the optimal
of the chromosomal region containing the a-adducin point of therapeutic intervention.
gene to high blood pressure.154 A polymorphism
which exchanges tryptophan for glycine at posi-
tion 460 (G460T) in the gene product associates
Diabetes
with hypertension, and evidence suggests that this Diabetes can arise from a number of mutations in
polymorphism may influence the response of blood either the nuclear or mitochondrial genomes, and the
pressure to sodium loading or depletion. It also search for diabetes-associated genes is an important
appears that the G460T polymorphism may influence area of intense scientific investigation. In almost all
response to long-term therapy with a thiazide diur- cases of type 1 diabetes (insulin-dependent diabetes
etic.155 Patients who were heterozygous for the mellitus, IDDM), the disease has an autoimmune
polymorphism exhibited a greater blood pressure component, whereby the system of insulin produc-
Genomics 409
tion by pancreatic b cells is slowly and irreversibly early age of onset (usually <25 years) and autosomal
eroded by the body’s own misdirected immune dominant inheritance.162 Mutation in the gene for
attack. The major histocompatibility complex on insulin, the genes for insulin processing enzymes,
chromosome 6 has been shown to contain one or and the genes for the insulin receptor have also been
more major genetic determinants of disease suscepti- detected and associated with the early-onset forms
bility.159 At least 40% of the familial aggregation of of the disease.163,164 Linkage studies have identified
type 1 diabetes is accounted for by the human genes that are mutated in different MODY pedigrees
leucocyte antigen (HLA) genes: in particular, the HLA on chromosomes 20 (MODY1 locus, hepatocyte
class II genes DQ and DR. In Caucasians, high-risk nuclear factor-4a [HNF-4a] gene, 7 (MODY2 locus,
class II molecules include DQA1*0501-DQB1*0201 glucokinase gene), and 12 (MODY3 locus, HNF-1a
(associated with DR3) and DQA1*0301-DQB1*0302 gene) and clinical studies indicate that mutations in
(associated with DR4). Dominant protection is these genes are associated with abnormal patterns
apparently conferred by the DQ molecule of glucose-stimulated insulin secretion165–168
DQA1*0102-DQB1*0602, which is carried on DR2 (Table 4). Regarding the identification of genes
haplotypes.160 responsible for the more common forms of late-onset
As yet there is no way to halt the destruction of type 2 diabetes, recent data suggest that the region

insulin-producing b-cells in pancreatic islets, and by of chromosome 12q close to MODY3 harbors a
the time type 1 diabetes is diagnosed in children novel susceptibility gene or genes for type 2
and young adults, the damage has been done, and diabetes.169
the only treatment is daily insulin injections. Current The maternal inheritance pattern of diabetes has
evidence suggests that the age at diagnosis of type led researchers to look for genetic defects in the
1 diabetes is genetically determined, and that pairs mitochondrial genome (mtDNA; mtDNA is mater-
of siblings tend to develop clinical diabetes at a nally inherited, because the mitochondria contrib-
similar age because of a common effect, such as uted to the embryo by the sperm is much less than
puberty.161 One gene at fault is on chromosome 6p, that present in the egg at the time of fertilization;
within the HLA complex, but other genes can make the ratio is around 151000. Therefore mtDNA muta-
additional contributions to the susceptibility of the tions are transmitted to the progeny via maternal
insulin system to such immune attack. The only one lineage). To date, more than 42 different mtDNA
noted so far is on chromosome 11p, and codes for
mutations (point mutations, deletions and duplica-
insulin itself: it has two alleles, one (dominant) that
tions) have been found to associate with the type 2
is protective against type I diabetes and another
diabetes phenotype, and many are also associated
(recessive) that is susceptible to disease development.
with other disturbances such as central nervous
So far, up to 20 additional genetic loci have been
system as well as disturbed muscle and renal func-
mapped by investigators looking for other contribut-
ory mutations; in every family with type 1 diabetes, tion.170,171 Patients with type 2 diabetes associated
a different number or selection of genes is implicated with mtDNA mutations generally are not obese, and
in its development. It is believed that identifying the they exhibit hyperglycaemia that is due to a signific-
faulty genes at an early age would provide clinicians antly reduced insulin secretory capacity that pro-
with the opportunity to target prophylactic therapies gresses with age.172,173 These patients develop a fatty
at those likely to be susceptible to the disease. liver, which is not an uncommon feature of diabetes
Obviously, a knowledge of the genes’ function and mellitus. Beta-cell loss is seen, as well as defects in
how they are disrupted will provide clues to new glucose-induced signaling of insulin release.174 Any
therapies or even cures. However, evidence is easier mutation of the mtDNA affects the synthesis of ATP
to gather in a single-gene disorder with a Mendelian and therefore the supply of energy. The discovery
pattern of inheritance; in a multigenic disorder, the that mutations in the mtATPase 6 and 8 genes
case for linkage of markers is weaker. associate with type 2 diabetes has led to better
Type 2 diabetes (formerly known as non-insulin- understanding of this disorder, and to date five
dependent diabetes mellitus or NIDDM) is a poly- mutations that associate with type 2 diabetes have
genic disease characterized by insulin-resistance in been reported in the genes for ATPase 6 and 8.175,176
muscle, fat and liver followed by a failure of pancre- Animal models such as the BHE-Cdb rat mimic
atic b-cells to adequately compensate for this resist- the human with type 2 diabetes.177,178 It develops
ance despite increased insulin secretion. It is a moderate hyperglycaemia and impaired glucose tol-
genetically and clinically heterogeneous disorder and erance as it ages, as well as a number of diabetic
can be divided into early-and late-onset forms. The complications. With this animal model, hypothesis
early-onset forms includes maturity-onset diabetes of about the roles of age, diet and drugs in the pathology
the young (MODY), a genetically heterogeneous of type 2 diabetes may be studied. The usefulness of
monogenic form of type 1 diabetes characterized by the BHE/Cdb rat as a tool to develop appropriate
Table 4 Nuclear DNA mutations associated with type 2 diabetes
Gene Chromosome Comment Reference

location
Glucokinase (MODY 2) 7 Uncommon; heterogeneous 247

Insulin cleavage enzyme ? Results in excessive amounts of proinsulin in the blood 248
MODY 3 12q Encodes transcription factor 1a 249
MODY 1 20 Encodes transcription factor 4a 250
Glycogen synthase 19q 13.3 Two forms (liver and muscle); Highly polymorphic 251
FAD-glycerol 3 phosphate 3 Associates with type 2 diabetes in the GK rat 252
dehydrogenase
Glucagon receptor ? Associates with type 2 in French & Sardinian patients but 253
not Japanese patients
CCKBR 11p 15.4 Associates with type 2 diabetes in French patients 254
IRS 1 ? Plays a role in downstream insulin signaling. When 255
mutated, the signal pathway is aberrant

CCKBR, cholecystokinin B receptor; IRS 1, insulin receptor substrate 1.
pharmacotherapies and nutriceuticals for the treat- obesity and syndrome X may be fully expressed, and
ment of human mt diabetes should be recognized. by early adulthood apparently healthy men with
increased central fat may already have cardiac
Obesity pathology.187,188
Visceral obese male individuals heterozygous for
Obesity, a common multifactorial disorder, affects the apolipoprotein B-EcoRI polymorphism are more
approximately one-third of the United States popula- prone to develop the dense LDL phenotype, and
tion and 20% of Europeans. It predisposes to type 2 increased risk of coronary disease also occurs with
diabetes, hypertension and coronary heart disease, some lipoprotein lipase gene variants.189,190 Genetic
and is a major cause of morbidity and mortality. The studies also suggest that there may be specific genes
evidence for genetic factors in human obesity has responsible for visceral obesity. Genetic variations
become increasingly strong, with studies of twins in the glucocorticoid receptor (bclI restriction frag-
and families with and without obesity. All mutant ment length polymorphism) and the fatty acid binding
genes responsible for animal obesities have now protein 2 (Ala54Thr FABP2) gene were associated
been identified, and strong homology exists between with visceral adiposity in lean men.191,192 Defects in
the rodent genes and human genes. The investigation
the ob gene or receptor appear to be unlikely
of the mutant genes as well as the peptides (e.g.
candidates, particularly because leptin levels correl-
neuropeptide Y) with which they interact to determine
ate with total body fat rather than visceral
treatment of obesity is important. Leptin protein and
its functions appear to play a significant role in the adiposity.136,193
organization of energy control and obesity. Studies Genes which appear to be implicated in obesity
have also shown consistently that about 40–70% of include agouti-related transcript (ART), neuropeptide
the variation in obesity-related phenotypes, such as Y (NPY) and its receptors (NPY Y5R and Y6R), pro-
body mass index (BMI), skinfold thickness, fat mass, opiomelanocortin (POMC), uncoupling protein 2
and leptin levels, is heritable.179,180 (UCP2), and the melanocortin-4 receptor (MC4-R).
Abdominal obesity is a heterogeneous phenotype The agouti gene modulates melanocortin signaling
with metabolic disturbance associated more closely in the hypothalamus and inhibits the anorexogenic
with altered regional adiposity than obesity per se. effect of melanocyte-stimulating factor (MSH) in this
Studies using precise measures of regional obesity brain region.194 The fat and tubby mutations also
(dual energy X-ray absorptiometry, computed tomo- appear to alter the neural circuits that regulate
graphy and magnetic resonance imaging) indicate weight. The fat gene encodes carboxypeptide (CPE),
that visceral adipose tissue, independent of obesity, an enzyme involved in neuropeptide processing, and
is a major determinant of insulin resistance and the tubby gene is expressed in the paraventricular
dyslipidaemia (syndrome X).181–183 The phenotypic nucleus of the hypothalamus, a brain region known
expression of adult obesity can be identified in to play a role in the regulation of body weight. NPY
children from the age of 6–10 years and increases is one of the most potent appetite stimulators in
in abdominal and hepatic fat probably begin at the animals and it also appears to be one of the mediators
same time.184–186 By the time of adolescence, visceral of ob gene in the brain.195,196 Mice deficient in
Genomics 411
MC4-R develop late-onset obesity and alterations in gene at 17q21, a tumour suppressor gene, which
their peripheral metabolism.194 Brain administration when mutated dramatically increases a woman’s risk
of glucagon-like peptide 1 (GLP-1) to rats reduces for developing breast or ovarian cancer.200 In addi-
food intake and GLP-1 receptor agonists may be tion to BRCA-1, another breast cancer susceptibility
useful for reducing food intake.197 In general, these gene has been cloned, BRCA-2, which is located at
data suggest that body fat is controlled by a lipostat 13q12.3.201 With regard to BRCA-1, each of the 1
mechanism in which leptin is the afferent signal; the in 200 women who carry a mutation in this gene
hypothalamus serves as an integrator and activates will have an estimated 85% lifetime risk of develop-
an output loop that modulates feeding behavior, ing breast cancer. The fact that 15% of women who
energy expenditure, and fat and glucose carry such a defect never develop breast cancer is
metabolism.198 an intriguing point which needs resolution. It is
Genetic testing may play a role in assisting the becoming clear that BRCA-1 mutation screening
clinician to predict, monitor and prevent this prob- could have a useful role in familial and early-onset
lem, which is reaching epidemic proportions in cases, but is unlikely to have a major impact on
Western society. There are many new therapeutic breast and ovarian cancer in the general population.
targets, and combinations of drugs with different While the risk of ovarian cancer among women in

modes of action may be necessary. The next genera- general is less than 2%, women with BRCA-1 have
tion of medicines to treat obesity may target the a risk of developing ovarian cancer in their lifetimes
ob/leptin pathway. A drug that activates the ob as high as 45%. The risk is 25% among women with
pathway may have multiple therapeutic benefits such BRCA-2. Since there is not yet a preventive thera-
as suppressing appetite, increasing metabolic rate peutic drug, screening for breast cancer may be of
and reducing the amount of body fat. Leptin is an uncertain value in young women. Extensive clinical
obvious choice, and trials of recombinant human trials will need to address these issues before the
leptin are in phase II. The development of new, benefits of BRCA-1 and BRCA-2 mutation testing can
highly specific and effective centrally-acting agents be determined. It is likely that within the next few
remains an attractive possibility. Therefore, this years, genetic testing and identification of cell popu-
approach may include agonists of GLP-1, MC4-R lations that share specific genetic alterations from
and specific neuropeptide receptor (e.g. NPY Y1, Y5) samples obtained non-invasively (saliva, sputum,
antagonists. However, for Y5-receptor selective ant- urine, stool, mucosal washings) will become a
agonists, side-effects related to epileptogenesis, drug method of screening populations for common
withdrawal symptoms, gut motility, sodium retention cancers.202
and the metabolic system must be investigated very Several studies have also shown that alterations
carefully, as recent observations suggest that the Y5 of the p53 gene may be involved in breast cancer
receptor may not be very specific for chronic reduc- aetiology and pathogenesis. The dysfunction of the
tion of food intake.199 p53 protein is associated with tumour progression,
since an association between p53 abnormalities and
accumulation of genetic lesions (measured as overall
Oncology allelic imbalance, homogeneously staining regions,
Critical and specific genetic events involving onco- and strong ErbB2 overexpression) was observed.203
genes, tumour suppressor genes, DNA repair A recent meta-analysis of studies involving over 2000
enzymes have been characterized in many tumours, patients has confirmed that somatic mutations of the
and these molecular flags of malignancy can be p53 gene in the primary tumour are associated with
exploited for screening and treating cancers. A worse prognosis.204
number of genetic aberrations have been identified The erbB oncogene family provides an important
and the molecular prognostic factors include example of how we can translate advances from
BRCA-1, BRCA-2, p53, erbB oncogenes, loss of basic research into clinically relevant tumour markers
heterozygosity (LOH), chromosomal aberrations, that may also serve as new therapeutic targets.205
microsatellite instability, transforming growth factor This oncogene family encodes four different mem-
a (TGFa), and the multiple resistance (MDR) gene. brane-bound growth factor receptors: erbB-1 (epi-
Genetic heterogeneity has been shown or is sus- dermal growth factor, EGFR), erbB-2 (HER 2/neu),
pected in inherited forms of melanoma, as well as erbB-3 and erbB-4. The EGFR gene is localized on
colorectal, breast and prostate cancer (Table 5). chromosome 7 and encodes a 170 kDa glycoprotein
Case-control studies have shown that breast cancer which possesses tyrosine kinase activity.206 EGFR is
aggregates in familial patterns along with ovarian expressed at detectable levels in 20–58% of the
cancers and sometimes other cancers (male breast breast cancer specimens studied.207 The human
cancer, prostate cancer, and pancreas cancer, for proto-oncogene c-erbB-2, also known as neu or
example). The inherited defects include the BRCA-1 HER2/neu, is localized on chromosome 17 and the
Table 5 Some examples of tumours, their chromosome location and the genes cloned
Tumours Chromosome location Cloned gene and its proposed function
Retinoblastoma 13q14.3 RB1; cell cycle and transcriptional regulation

Sarcomas, breast cancer 17p13.1 p53 (TP53); transcriptional factor; response to
DNA damage and stress
17q21 BRCA-1; interacts with Rad51 protein; repair of
double-strand breaks
13q12 BRCA-2; interacts with Rad51 protein
Breast cancer, thyroid cancer 10q23 PTEN (MMAC1); dual-specificity phosphatase with
(follicular type) similarity to tensin
Colorectal cancer 5q21 APC; regulation of b-catenin; microtubule binding
2p16, 3p21, 2q32, 7p22 MSH2, MLH1, PMS1, PMS2; DNA mismatch
repair
Neurofibromas 17q11.2 NF1; GAP for p21 ras proteins
Acoustic neuromas, meningiomas 22q12.2 NF2
Renal cancer (papillary type) 7q31 MET; transmembrane receptor for HGF

Medullary thyroid cancer 10q11.2 RET; transmembrane receptor tyrosine kinase for
GDNF
Lymphoma 11q22 ATM, DNA repair
Exostoses (cartilaginous 8q24.1, 11p11-13, 19p EXT1, EXT2, EXT3
protuberances on bones)
GAP, GTPase-activating protein, a negative regulator of the p21 ras guanine nucleotide-binding proteins; APC, adenomatous
polyposis coli; NF1, neurofibromatosis type 1.
oncogenic effects of erbB-2 are manifested when the rigorous methods has refuted this association.
protein is overexpressed rather than mutated.208,209 Regarding the use of drug to prevent breast cancer,
Overexpression of c-erbB-2 may be associated with the approval of tamoxifen for reducing the incidence
resistance to hormone therapy. Pharmacogenomic of breast cancer in healthy women with an increased
applications of array-based transcript profiling risk of developing the disease is still being debated.216
include analysis of patient tissues in response to In an effort to guide the transition from clinical
therapy during clinical trials. Expression-based stud- research to clinical application, the American Society
ies appear to be especially appropriate in cancers, of Clinical Oncology has recommended that clinical
because RNA can be obtained from biopsies and predisposition testing be offered when the prior
surgical specimens. This technology readily detects probability of a positive result is high because of a
the somatic changes associated with the development strong family history of cancer or very early age of
of some tumours and their response to chemotherapy. onset of cancer, the test can be adequately inter-
Somatic changes linked to therapeutic outcomes preted and the results will influence medical manage-
include the amplification of the oncogene erb-B2, ment of the patient or a family member.217
which predicts good response to cyclophosphamide- Knowledge of molecular characteristics of certain
methotrexate-5-fluorouracil (CMF) adjuvant therapy cancers has made it possible to identify patients who
of breast cancer.210 One study has proposed that could benefit from therapies that target those features.
overexpression of HER-2/neu in ER-positive patients For example, leukaemic cells in the majority of
is associated with a relative resistance to tamoxifen, patients with chronic myelogenous leukaemia have
while ER-positive HER-2 negative patients were more a telltale chromosomal abnormality.218 This abnor-
likely to respond.211,212 From a clinical perspective, mality, a swapping of genetic material between
the assessment of c-erbB-2 overexpression in breast chromosome 9 and 22, results in the production of
cancer might become a useful tool in the future an abnormal enzyme thought to be related to the
treatment of patients by chemotherapy, since patients development and proliferation of leukaemic cells in
whose tumours show overexpression may benefit patients with chronic myelogenous leukaemia.
from higher doses of chemotherapy.213 Therefore, effective pharmacological intervention
Two large epidemiological studies have clearly may be designed to target and specifically to inhibit
demonstrated the increased risk of breast cancer this faulty enzyme. Concerning breast cancers, only
among blood relatives of patients with the ataxia- women whose breast cancers overexpress a gene
telangiectasia (ATM) gene.214,215 The evidence sup- called HER2 are offered the medication herceptin, a
porting the association between mutations at the ATM drug that binds to the product of that gene, a growth
locus and breast cancer is strong, and no study with factor receptor.219 Women with breast cancers are
Genomics 413
also not treated with tamoxifen, if their cancers do cells blocking the establishment of MDA-MB-468
not express the gene for the oestrogen receptor.220 tumours. A variety of other tumour cell lines that
Therefore, genotyping may help for treatment strat- were also tested could be blocked with 1–10% of
egies and in some drug treatment choice, genotyping IFN-b transduced cells. This dramatic regression of
may be an absolute necessity. The adenoviral agent, tumours appeared to be primarily the result of the
ONYX-015 (Onyx Pharmaceutical), for instance, direct antiproliferative or cytotoxic activity of IFN-b,
aims to combat tumours caused by mutations in the as the IFN-b gene used in this study was of human
tumour suppressor gene p53. As part of the clinical origin, and human IFN-b gene does not cross-react
trials, Onyx is providing genotyping of patients for appreciably with the host mouse cells. Therefore,
p53 mutations. This drug will require the develop- local IFN-b gene therapy may provide a promising
ment of an accompanying diagnostic tool to stratify strategy for the treatment of some solid tumours in
the populations. humans. Another preclinical study which showed
A number of gene therapy approaches have been that intramuscular injection of plasmid DNA encod-
taken in clinical trials for cancer therapy, including ing murine IFN-a leads to potent antitumour effects
the delivery of tumour-suppressing genes, notably in mice, suggests that a novel type of in vivo cancer
p53, cytokines and the herpes simplex virus- gene therapy may be used to treat primary tumours

thymidine kinase gene plus gancyclovir treat- as well as to prevent the development of metastases
ment.221–223 A phase I clinical trial of wild-type p53 in advanced cancer patients.228
(p53wt) gene therapy of patients with hepatocellular Several of the approved clinical gene therapy
carcinoma (HCC) in the UK has already produced protocols that involve cancer patients concern ther-
objective tumour responses in 50% of the patients apies designed to treat brain tumours.229 Factors that
treated.224 The principle behind using p53 for gene promote the use of gene therapy for gliomas include
therapy is well established. A number of groups have the failure and toxicity of conventional treatments,
demonstrated that p53wt inhibits the growth of HCC and the identification of the genetic abnormalities
cells in vitro; while others have shown that if p53 is that contribute to the malignancy of gliomas. During
injected into nude mice pretreated with human the malignant progression of astrocitic tumours, sev-
cancer cells, their tumours get smaller. This study is eral tumour suppressor genes are inactivated, and
the first to attempt gene therapy with p53 of HCC many growth factors and oncogenes are increasingly
patients. However, with all the above, a major overexpressed. Therefore, in principle brain tumours
limitation is the inefficiency of delivery into the could be treated by targeting their fundamental
tumour cells and the relatively inefficient killing of molecular defects, if the gene drug can be delivered
neighbouring untransduced cells by bystander effects. to a sufficient number of malignant cells. Further
A recent preclinical study suggests that improvement in the gene delivery systems would
interferon-b gene therapy inhibits tumour formation probably help to make significant progress in the
and causes regression of established tumours in successful clinical application of gene therapy in the
immune-deficient mice, and it was argued that local treatment of brain tumour. Results obtained to date
interferon-b gene therapy with replication-defective in this field suggest that gene therapy strategies for
adenoviral vectors might be an effective treatment brain tumour are quite promising, provided more
for some solid tumours.225 The type 1 interferons clinical research is performed, particularly in the
(IFNs), the IFN-a family and IFN-b execute diverse vector field.
biological functions including growth inhibition and Because of the discovery of large amount of new
immune cell stimulation, and have been shown to genes involved in cancer, the National Cancer
be inhibitors of angiogenesis (sprouting of new Institute is launching a major effort aimed to revolu-
vessels from pre-existing blood vessels), and therefore tionize how tumours are classified, a project that
could inhibit tumour growth by blocking tumour may have huge impact on how doctors in the future
vascularization.226,227 This study demonstrated that will diagnose and treat cancer.230 Pathologists tradi-
ex vivo IFN-b gene transduction by a replication- tionally have relied on tumour pathology as the basis
defective adenovirus in as few as 1% of implanted for classifying tumours, and the weakness of such
cells blocked tumour formation. Direct in vivo IFN-b approach is that it is not possible to distinguish
gene delivery into established tumours generated between tumours that have similar histopathological
high local concentrations of IFN-b and inhibited features but vary in clinical course and response to
tumour growth, and the results show a remarkable treatment. The Cancer Genome Anatomy Project
ability of IFN-b gene therapy to block the formation (CGAP) which has been compiling a comprehensive
of tumours de novo and to cause regression of record of all genes involved in human cancer indi-
established tumours. The ex vivo transduction results cates a record of more than 40 500 genes that are
confirmed the potential bystander effects of a potent directly or indirectly active in one or more cancers,
secreted cytokine, with as few as 0.3–1% transduced and it is believed that recognizing the detailed
‘tumour signatures’ and fully understanding how they social and political norms. Increasingly, however,
correlate with their key clinical criteria will doctors may feel obliged to offer tests to healthy
immensely improve cancer diagnostics and drug patients, including tests for future diseases to which
development. A recent study has examined the the patient may never have thought about.
possibility of developing a more systematic approach As studies to correlate genetic predisposition with
to cancer classification based on the simultaneous clinical disease increase, issues of confidentiality
expression monitoring of thousands of genes using and informed consent warrant more attention.233
DNA microarrays.231 The class discovery procedure Informed consent to undergo a predictive genetic
automatically discovered the distinction between test requires that the patient be aware of the possibil-
acute myeloid leukaemia and acute lymphoblastic ity of false-positive and false-negative findings, and
leukaemia without previous knowledge of these that treatment options after a positive finding may
classes, and an automatically-derived class predictor lack proved safety and efficacy, or may not be
was able to determine the class of new leukaemia known. Respect for the privacy of the individual and
cases. 231 These preliminary results tend to indicate for the confidentiality of genetic information is cru-
the feasibility of cancer classification based solely cial, and some guidelines would prohibit any com-
on gene expression monitoring and suggest a general munication to all third parties without consent of the

strategy for discovering and predicting cancer classes person concerned.234–236 In the area of justice, the
for other types of cancer, independent of previous international community is united in its concern for
biological knowledge. vulnerable populations such as incompetent adults
or minors and for future generations. Some argue
that the intention of much genetic research is eugenic
by implication, and legislation in China which has
Ethical issues made this explicit has provoked much controversy.237
Scientific and industrial enthusiasm for the promises A recent ‘official’ survey on ethical issues in genetic
of genetic engineering have generated widespread testing and screening in China shows that the major-
concern about the potential dangers of their careless ity of respondents favor offering genetic testing in
application, which have led to the suggestion of the workplace for predisposition of executives to
issuing regulations covering what could be done, heart disease, cancer, and diabetes (94%) and testing
and under what conditions. It is clear that the ability children for genes for late-onset disorders such
to modify the human germline may open vast med- as hypercholesterolemia (84%), alcoholism (69%)
ical possibilities, with unprecedented potential for and AD (61%).238 There are serious concerns about
reducing human suffering. However, consideration the purely moral dimensions of deliberate interven-
should be also be paid to the unforeseen hazards tion in the human germ line intended primarily to
that might emerge from tampering with the human enhance culturally desirable characteristics. Several
genome, and that are likely to be avoided only by countries (e.g. Austria, France, Germany, Norway
careful monitoring. There is also the difficult task of and Switzerland) prohibit germline alteration by
establishing a boundary between acceptable and statute. Furthermore, in the absence of treatment or
unacceptable applications. The ability to know who prevention, the presymptomatic testing of children
carryies which disease genes will bring about ethical, for late-onset disease has not been recommended.
legal and social implications. It appears that five The quality issue has also been underlined so that
basic principles (autonomy, privacy, justice, equity specific criteria for laboratory test sensitivity, specifi-
and quality) need to be considered in order to city and effectiveness has been recommended. Before
harmonize eventual national regulation.232 a genetic test becomes clinically available for predict-
Considering the concept of autonomy, it is argued ive purposes, the test developer must collect informa-
that genetic testing and the resulting information is tion regarding the test’s validity. Therefore, there is
highly personal. Since most genetic information is an important responsibility that such developments
only predictive and probabilistic, this imprecise and application take place in an acceptable manner.
nature of genetic information may necessitate further Both scientific and ethical considerations should be
protection against social pressures and a reaffirmation carefully weighed. The codification of these prin-
of informed consent procedures. An exception to ciples in an international instrument is probably
this principle may be applied to newborn screening imminent.
programs for immediately treatable disorders. There
also seems to be a consensus to limit genetic testing
(including prenatal testing) to tests that are medically
therapeutic and that decisions as to what tests are
Discussion and conclusions
considered to be therapeutic remains the decision of New gene targets for therapeutic intervention only
individual countries with respect to their cultural, provide a starting point in the long and difficult
Genomics 415
process of drug discovery. However, genomics will similar ways. Pharmacogenomics will not only
have an important impact in the later stages of drug enable companies to target drugs more precisely,
development, especially in providing an understand- but will also lead to customization. This should
ing of the molecular nature of diseases and of the reduce the number of patients needed in any trial,
responses, both desirable and adverse to drugs. but it would also bring about an increase in the
Modern genetics will bring about significant improve- number of trials needed. The creation of populations
ments in the provision and practice of healthcare by of ‘software people’ and ‘virtual trials’ should reduce
redefining disease and targeting treatment. It will the amount of clinical resources required.
also lead to the discovery of novel targets and The therapeutic industry will soon be entering a
effective treatments and the provision of more effect- time when solutions to therapeutic problems can be
ive preventative healthcare. It is estimated that within targeted to the individual. Using knowledge of gene
the relatively short time frame of 7–10 years, func- functions and commercially available genomics
tional genomics will begin to have a real impact on tools, a genomics consumer will be able to employ
clinical medicine. The major targets of industrial focused, high-speed technologies that will produce
R&D are, and will continue to be, the most common an individualized treatment in a short period of time.
disease such as osteoporosis, diabetes, schizo- This is a fundamental change in research and clinical

phrenia, asthma, AD, arthritis, obesity, bipolar affect- medicine. Instead of blockbuster drugs, there will be
ive disorders and atherosclerosis. It should become blockbuster therapeutic approaches that will be
possible to combine genetic information with more widely applicable to different populations. One way
conventional risk factors, such as smoking or lack of in which this approach might function would be that
exercise, to determine quite accurately an indi- a patient who is not feeling well might initially go
vidual’s chance of developing serious heart or neur- to a diagnosis centre, where a series of diagnostic
opsychiatric disease. These developments will have tests would be run. These tests would focus on
important implications for the pharmaceutical indus- measuring not crude approximations of gene func-
try. By identifying those patients most likely to tion, but on the gene functions themselves. Massively
respond to novel drugs, it will be easier to demon- parallel testing would rapidly provide a clinician
strate efficacy and safety. This would lead to smaller, with a map of the patient’s current pattern of gene
more effective clinical trials with corresponding cost expression. Sophisticated bioinformatics tools would
savings, in addition to a focused approach in which match the gene function map to a particular therapy
a suitably efficacious drug will be administered to regimen, substantially reducing or even eliminating
the right patient. side-effects, and provide the patient’s doctor with
Pharmacogenomics has major implications both detailed suggestions about continued therapy.
for drug development and clinical management. In linkage and association of genetic polymorph-
Pharmacogenomics aims to complement the current isms and disease, it is important at first to convince
‘one-medicine-fits-all’ scenario with drugs that are ourselves that putative associations are real.
based on a deeper understanding of gene variations Consideration of the ethnic backgrounds of patients
and the effect of such variations on drug responses. and the use of multiple, independent populations
Drugs that are more specific, not only in terms of can help avoid this problem. An association that is
the particular molecule they target, but also in the not confirmed should be regarded as provisional,
populations they affect, will be much more widely pending alternate proof of causality.
accepted and used in the future. In the short term, However, some important clinical issues will
pharmacogenomics will be strategically used for require to be quickly and adequately resolved. The
clinical development of particular compounds with pharmacokinetic and pharmacodynamic parameters
potential efficacy or toxicity issues. Pharmaco- of gene delivery vectors are largely uncharacterized
genomics may also be applied to approved drugs in humans. Estimation of risk-to-benefit ratio and
with restricted market share because of limited actual healthcare costs for gene therapy is not well
efficacy or high toxicity. As our molecular under- documented. Undoubtedly, gene therapy will not be
standing of both human populations and preclinical cheap, and requires resources and vigilance as trials
models of disease and toxicity develops, pharmaco- become approved for human use. Although the
genomic information will optimize predictions of current ethical, legal and social issues include some
drug effects in humans. Perhaps a more certain educational projects, a distinct and expanded pro-
outcome from the pharmacogenomics approach is a gram should be launched that is aimed for students,
redefinition of what a disease is at the molecular the general public, clinicians and genetic counselors.
level. There is little doubt that many of our current Failure to appreciate the complexity and limita-
disease definitions such as diabetes, and heart disease tions of genetic tests and the fact that testing may
are actually very different diseases at the molecular provoke rather than allay uncertainty must be
level that manifest themselves phenotypically in tackled. It will be the responsibility of clinicians to
deal with the public’s hopes and fears. Therefore, it acetylator phenotype and gender. Pharmacogenetics 1996;
is important to define and clarify service needs and 6(1):93–101.
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Q J Med 2000; 93:391–423

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Genetic disease Deficient gene product Cell type References

Lesch-Nyhan syndrome Hypoxanthine phosphoribosyl transferase Basal ganglia 239, 240

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Genetically determined high-responders to warfarin

(Canadian Native Indians)

19.1% CYP2C19*2 &

function (and thereby pharmacodynamic effects) are

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complex picture emerges in which genetic variation

in both pharmacodynamic and pharmacokinetic fac-

tors contributes to drug responses. Some patients do

not respond to a given drug because it is not

not targeted by the drug.

Great progress has been made in understanding

the molecular genetics of acetylation as well as the

clinical consequences of being a rapid or slow

locus are responsible for the traditional acetylator

the genetically determined variation in the elimina-

tion of xenobiotics, as well as in NAT2 activity in

the liver and other tissues.15 The human NAT2 gene

that had been identified, three (NAT*5, NAT*6

and NAT*7) account for majority of the slow

NAT2 acetylator genotype in White subjects.18

several kinds of diseases, such as colon cancer,

rate of acetylation was shown to be related to the

the factors that makes an individual susceptible to

atopic diseases was five-fold greater for homozygous

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Table 3 Genotype of long QT syndrome (from data in reference 134)

Mutant Chromosome locus Abnormal characteristics Clinical course

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Table 4 Nuclear DNA mutations associated with type 2 diabetes

Gene Chromosome Comment Reference

Glucokinase (MODY 2) 7 Uncommon; heterogeneous 247

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Tumours Chromosome location Cloned gene and its proposed function

Retinoblastoma 13q14.3 RB1; cell cycle and transcriptional regulation

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that had been identified, three (NAT5, NAT6