Advanced Lectures on "Gene Regulation, Epigenetics & Genome Stability"

EPIGENETICS IN THE CONTEXT OF HEALTH AND

MEDICINEProf. Leszek Wojnowski

Advanced Lectures on "Gene Regulation, Epigenetics & Genome Stability"

Learning objectives

1) What are the main phases of the clinical drug and marker development? 2) Which epigenetic markers are currently used in patient management?3) Which epigenetic drugs are currently used in the clinics?4) What are my interests in epigenetics?

Prospective validation of new drugs and treatments

3

Benefit in*:

• healing

• survival

• life quality

• treatment costs

R

Study population Placebo? Standard?

Verum

Patient population

Inclusion

exclusion

1. Randomized (non-randomized)

2. Prospective (retrospective)

3. Controlled (uncontrolled)

4. Interventional (observational; all drugtrials are interventional)

Nurses- vs. WHI-Study

Also: lesshomicides,

suicides, caraccidents

„healthy user bias“

keine HT

HTCAD

infrequent

CAD

frequent

Randomisationreduces the risk ofbiased selection

HT, no HT

keine HTR

HTno HT

CAD

infrequent

CAD

frequent

1. Primary – most reliable, determines the study design

2. Secondary, tertiary… – less reliable

The risk of false-positive findings increases with the number of statistical tests – „the more you search, the more you will find“.

The sequence of tests must be set prior to study onset.

What is the primary (preferentially clinical) end-point of the study?

*Publication bias

EH Turner et al. NEJM 358:252-260 (2008)

Published antidepressant studies

51

48 3

Positive effect

Negative or questionable effect

48/51 = 94%

Publication bias

EH Turner et al. NEJM 358:252-260 (2008)

Antidepressant studies registered at the FDA

74

51

48 3

23

22 1

37 11

Positive effect

Negative or questionable effect

38/74 = 51%

As a result, best journals require prior registration of trials. Nevertheless, industry-sponsoredstudies are currently less trusted than tax payer-sponsored studies (Kesselheim, NEJM, Sept20, 2012)

The life cycle of a drug

Pre-clinical clinical

Phase I Phase III

ToxDose

escalation 50-100

probandsor

patients

Phase II

Efficacy, toxDose

escalation100-500patients

EfficacySide-effects500-5000patients

Randomized Controlled Trials (RCT)

(hospital, multicenter)

Cohort studies

Case reports

(population-based)

Phase IV

Rare side-effectsPot. allpatients

Candidateidentificationoptimizationvalidation

(cells, animals)

Cohort studies

(specialized companies)

Approvalwithdrawal of rosiglitazone

(2010)

Avastin in gastric

cancer (2010)

Epigenetic modifiers as cancer drugs

9Dawson and Kouzarides, Cell 2012; Jones PA, Issa JJ and Baylin S, Nat Rev Genet 2016; Ahuja N, Sharma AR and Baylin SB, Annu Rev Med 2016

FDA and EMA approved: • DNMT: Azacitidine (myelodysplastic syndrome- FDA and EMA), Decitabine (AML in adults- EMA,

myelodysplastic syndrome- FDA)• HDAC: Belinostat (peripheral T cell lymphoma- FDA), Panobinostat (multiple myeloma- FDA),

Romidepsin, Vorinostat (cutaneous T cell lymphoma- FDA)

20122016

Expected impact of epigenetics on disease management

10

New drugs

Markers- detection- diff. diagnosis- classification- prognosis- therapy

Detection of colorectal cancer – Septin9 methylation

11

Markers*- detection- diff. diagnosis- classification- prognosis- therapy

New drugs

In October 2009, the Septin9 test was approved as a CE-marked test in Europe.

US approval history

12

(…) need for additional data demonstrating that the blood-based Epi proColon® test will increase compliance to CRC screening in the intended use population, i.e. in those patients who today do not undergo CRC screening by guideline recommended methods such as colonoscopy or FIT.

Gut, 2014, 63: 317-25Sensitivity 48%; 35% in Stage I“(…) the utility of the test for population screening for CRC will require improved sensitivity for detection of early cancers and advanced adenomas.”

13

Prospective validation of colorectal cancer detection

14

RBenefit in*:

• survival

• life quality

• treatmentcosts

colonoscopy

markers + colonoscopy

Institut für Pharmakologie

CAR- and PXR-mediated defence against xenobiotics

Drugs:Glucocorticoids,

Antibiotics,Antimycotics,

Statins,Antiretrovirals, Barbiturates,

etc.

Environmental:Bisphenol A,

DEHP, Pesticides, etc.

15

RXR

RE RE

CAR/PXR

+ + +

CYP3ACYP2BCYP2C

Phase I:Enzyms

UGTsSULTsGSTs

Phase II:Enzyms

MRP2OATP2MDR1

Phase III:Transporters

renal, biliaryexcretion

IOH

IOSO3H

metabolicdisturbances

Endobiotics:Steroids,

Bile acids, Lipids

IOH

IOSO3H

Institut für Pharmakologie

12 Wochen

F0

F0

F1

Transmission of induction to F1

TCPOBOP

40 -

fach

5400

-fa

ch

750-

fach

540-

fach

10 -

fach

190

-fac

h

16Ergebnisse von Dr. Marianne Mathäs

Cross-generational Cyp2b10 inductionmediated by the mCAR ligand TCPOBOP

17

F0 F1F1F0F0

birthconception1 week

injection

ABC

Mechanism of cross-generational transfer

18

A. preconceptional exposition

B. postconceptional / intrauterine exposition

adipose tissue

TCPOBOP

TCPOBOP

ET

MaiskeimölTCPOBOP

F1 (6 Tage alt)

F0ET

TCPOBOP

F1 (6 Tage alt)

F0

MaiskeimölMaiskeimöl

ET ET

TCPOBOP is detectable in the adipose tissueof the adult F1 generation

19

conc

entr

atio

n of

TC

POB

OP

in 1

20 µ

l mel

ted

fat (

nM)

0 3 0,6 0,3 0,03

0,006

0,003 0 3

0 (F0)

3 (F0)

0

2

4

6

8

10

12

14

100

300

500

700

900

1100

3 days 12 weeks 1 week prior to mating (F0)12 weeks old (F1)

injected TCPOBOP(mg/kg)

F0 F1Generation

Time after Injection

n=4

HPLC/MS measurements were conducted in cooperation with the Institute of Molecular Biology by Dr. Michael Musheev

Sicherheit von Arzneimitteln

20

birthconception

F0 F1

lactationpregnancy

• Maternal drug exposure is considered during pregnancy and lactation• Teratogenic effects right after birth get reported

pre-pregnancy exposure? delayed F1-effects?termination 6-24month prior to pregnancycytostatics, radioiodine, retinoids, vitamin K antagonists,amiodarone, leflunomidemethotrexate

Outlook

22