The enzyme CYP2D6 can metabolize many centrally acting drugs and endogenous neural compounds (e.g. catecholamines); it can also inactivate neurotoxins such as 1-methyl-4-phenyl-1,2,3,6-tetrahydropyridine (MPTP), 1,2,3,4-tetrahydroisoquinoline (TIQ) and β-carbolines that have been associated with Parkinson’s disease (PD). CYP2D6 is ideally situated in the brain to inactivate these neurotoxins. The CYP2D6 gene is also highly polymorphic, which leads to large variation in substrate metabolism. Furthermore, CYP2D6 genetically poor metabolizers are known to be at higher risk for developing PD, a risk that increases with exposure to pesticides. Conversely, smokers have a reduced risk for PD and smokers are suggested to have higher brain CYP2D6 levels. Our studies furthered the characterization and involvement of CYP2D6 in neuroprotection against PD. METHODS: We investigated the effects of CYP2D6 inhibition on MPP+-induced cell death in SH-SHY5Y human neuroblastoma cells. We compared levels of brain CYP2D6, measured by western blotting, between human smokers and non-smokers, between African Green monkeys treated with saline or nicotine, and between PD cases and controls. In addition, we assessed changes in human brain CYP2D6 expression with age. RESULTS: Blocking CYP2D6 activity in SH-SY5Y cells with four diverse inhibitors significantly increased MPP+-induced neurotoxicity. Smokers have higher brain CYP2D6 compared to non-smokers. In monkeys, basal expression of CYP2D6 varied across brain regions and was increased by chronic nicotine treatment in select regions (notably the basal ganglia) and specific cell types. Expression of human brain CYP2D6 increased from fetal to 80 years of age in the frontal cortex; the influence of age on CYP2D6 expression was brain region specific. Compared to age-matched controls, PD cases had ~40% lower CYP2D6 levels in the frontal cortex, cerebellum and hippocampus consistent with lower CYP2D6 increasing the risk for PD. In the caudate and substantia nigra, CYP2D6 levels were similar between PD case and controls using Western blotting. This is likely due to the increase in CYP2D6-expressing astrocytes and much higher cellular CYP2D6 in PD affected areas as observed with immunocytochemical staining. CONCLUSIONS: Brain CYP2D6 can meaningfully inactivate neurotoxins, and it can be increased by nicotine in brain regions of interest to PD. These findings support the contention that higher brain CYP2D6 is protective and lower levels may contribute to increased risk for PD.

Background: A dysfunctional mesocorticolimbic dopamine system has been reported in alcohol dependence and major depressive disorder. Probing mesocorticolimbic dopamine function in severe depression using dextroamphetamine revealed an altered behavioural response and a disrupted mesocorticolimbic circuitry in behavioural and functional magnetic resonance imaging (fMRI) studies. The purpose of this study was to use a similar approach in alcohol dependence. Behavioural Study: to assess dextroamphetamine subjective effects in alcohol-dependent and depressed alcohol-dependent participants. FMRI Study: to assess how the mesocorticolimbic circuitry would respond to a dextroamphetamine challenge in alcohol-dependent participants exposed to alcohol cues. Methods: In both studies, a single oral 30 mg dose of dextroamphetamine was the pharmacological intervention. Behavioural Study: randomized, double-blind, placebo-controlled, between-subject study. Eighteen alcohol-dependent and 22 depressed alcohol-dependent participants were compared using validated self-report drug effect tools (e.g. Addiction Research Center Inventory). FMRI Study: single-blind, between-subject study. FMRI blood oxygen level–dependent (BOLD) activation was measured in 14 alcohol-dependent and 9 healthy control participants during an alcohol-cue exposure task pre- and post-drug. Results: Behavioural Study: DRUG (F1,40=18.6; p<0.001) and GROUP (F1,40=16.6; p<0.001) main effects but no GROUPxDRUG interaction effects (F1,40=0.02; p=0.88) were detected, even when only severely depressed alcohol-dependent individuals were included (F1,30=0.04; p=0.84). FMRI Study: Alcohol-dependent participants exhibited greater ventral striatal activation compared to controls pre-drug and post-drug effect (F1,40=20.1; z=3.8; p<0.001; k>10; (x=10;y=-2;z=-14)). A GROUPxDRUG interaction effect was detected in the medial orbitofrontal cortex (mOFC) (F1,40=21.5; z=4.0; p<0.001; k>10; (x=-12;y=28;z=-20). The alcohol-dependent group exhibited a negligible mOFC response across both pre- and post-drug scanning sessions. In contrast, controls exhibited attenuation of mOFC response post-drug. Conclusion: The lack of significant GROUPxDRUG interaction effects in the Behavioural Study may suggest different neurobiological mechanisms underlying alcohol dependence and depression mesocorticolimbic dysfunction. Alcohol dependence appeared to mitigate the impact of depression severity on participants’ behavioural responses to dextroamphetamine. The FMRI Study data suggest there may be ventral striatal and mOFC disruption in alcohol-dependent participants. We suggest the mOFC may be involved in the reported loss of prefrontal modulation of dopamine cell activity in alcohol dependence. This supports a key role for the mOFC in mesocorticolimbic dysfunction in alcohol dependence.

It is highly recommended for women to take multivitamin/mineral supplements during the periconceptional and prenatal periods. Studies have confirmed that taking prenatal multivitamins prevents maternal iron deficiency anemia, and reduces the risk for neural tube defects (NTDs). To date, research aimed at optimizing the use of multivitamins before and during pregnancy has been minimal. My thesis focused on two challenges of periconceptional and prenatal multivitamin supplementation. The first challenge was gastrointestinal (GI) adverse events such as nausea and constipation which may be attributed to iron content and tablet size. Pregnant women are highly susceptible to GI adverse events since 80% experience nausea and vomiting of pregnancy. A prospective, randomized, controlled, open-label study was conducted to investigate whether a low-iron, small-tablet prenatal multivitamin can reduce GI adverse events, and improve supplement tolerability and adherence, relative to a high-iron, small-tablet prenatal multivitamin. We determined that low iron dose did not produce a significant difference, while small tablet size could be considered an important factor. Moreover, our results confirmed that adherence was poor in pregnant women. We were prompted to identify determinants which could predict adherence to prenatal multivitamins. Our retrospective study determined that predictors of adherence are rooted in women’s prior experiences with multivitamin use. The second challenge we addressed was achieving adequate blood folate concentrations for prevention of NTDs. If adherence is poor, standard dosing of 0.4-1 mg folic acid may not produce the blood folate concentrations needed in women prior to conception. We investigated the pharmacokinetics of 5 mg folic acid. Our prospective, parallel, open-labeled study, comparing a single dose of 5 mg to 1.1 mg folic acid, confirmed that folic acid follows linear (proportional) pharmacokinetics. However, our prospective, randomized, controlled, open-labeled, multiple-dose study determined that repeated use of folic acid at these 2 doses followed non-linear pharmacokinetics. Nevertheless, our data confirmed that 5 mg folic acid can produce higher blood folate concentrations, with a faster rate, which can counter the effect of poor adherence. In conclusion, optimal use of prenatal multivitamins requires improvements in supplement tolerability, adherence, and pharmacokinetics which depend on supplement formulations, and individualized assessment and counseling.

M2 muscarinic receptor extracted from Sf9 cells in cholate-NaCl differs from that extracted from porcine sarcolemmal membranes. Whereas the latter has been shown to exhibit non-competitive effects in the binding of N-methylscopolamine (NMS) and quinuclidinylbenzilate (QNB), which can be explained in terms of cooperativity within a receptor that is at least tetravalent, binding to the former is essentially competitive. Levels of cholesterol in Sf9 membranes were only 5% of those in sarcolemmal membranes and were increased to about 100% by means of cholesterol-methyl-β-cyclodextrin. M2 receptors extracted from CHL-treated Sf9 membranes resembled those from heart; that is, cholesterol induced a pronounced heterogeneity detected in the binding of both radioligands, including a shortfall in the apparent capacity for [3H]NMS, and there were marked discrepancies in the apparent affinity of NMS as estimated directly and via the inhibition of [3H]QNB. The data can be described quantitatively in terms of cooperative effects among six or more interacting sites, apparently within an oligomer. Cholesterol also was found to increase the affinity of the receptor for NMS and QNB, and the effect was examined for its possible relationship to the known interconversion of cardiac muscarinic receptors between an agonist-specific (R*) and an antagonist-specific (R) state. Cholesterol and N-ethylmaleimide (NEM) were compared for their effect on the affinity of NMS, QNB and four muscarinic agonists, and the data were assessed in terms of an explicit mechanistic model for a receptor that interconverts spontaneously between two states. The data can be described equally well by an effect of cholesterol on either the distribution of receptors between R and R* or the affinity of all ligands for both states, with an accompanying effect of NEM on either the affinity or the distribution between states, respectively. Since NEM is known from other data to favor R* over R, cholesterol appears to increase affinity per se. Cholesterol therefore is a determinant of affinity and cooperativity in the binding of orthosteric ligands to the M2 receptor. Both effects are observed in solution and therefore appear to arise from a direct interaction between the lipid and the receptor.

Nausea and vomiting of pregnancy (NVP) is the most common medical condition in pregnancy, and, unfortunately, variability exists among pregnant women in the therapeutic effect of anti-emetics as well as in factors that can exacerbate NVP. Identifying and managing these sources of variability will result in significant improvements in the quality of life of pregnant woman. This dissertation addressed clinical pharmacology strategies in managing NVP by focusing on three predominant areas of variability. The first challenge addressed in this dissertation was women with pre-existing gastrointestinal (GI) conditions and adherence and tolerability to prenatal multivitamin supplementation. To identify the role of iron in reducing adherence and increasing NVP and GI symptoms, two separate studies were conducted. In the first study, women randomized to a prenatal multivitamin supplementation with higher iron content experienced more adverse GI effects and increased severity of NVP symptoms. In the second study, after discontinuing iron-containing prenatal multivitamins, two-thirds of women in a prospective cohort reported improvement in their NVP symptoms which was corroborated with validated scales to quantify NVP severity. The second challenge addressed in this dissertation was the effect of heartburn and acid reflux on the severity of NVP. In a controlled, prospective study, women experiencing heartburn and acid reflux experienced greater severity of NVP compared to women with no GI symptoms. Furthermore, treatment of heartburn and acid reflux with acid-reducing pharmacotherapy with associated with a reduction in GI symptoms and NVP severity. Therefore, histamine 2 blockers or proton pump inhibitors, which do not appear to be associated with increased fetal risks, should be administered when required. The third clinical pharmacology challenge addressed in this dissertation was to determine the pharmacokinetic variability of the active ingredients of Diclectin®, first-line pharmacotherapy for the treatment of NVP. Large variability was observed in the area under the curve for both active metabolites: a 6.5-fold difference for pyridoxal-5’-phosphate and a 2.1-fold difference for doxylamine. Whether these pharmacokinetic differences contribute to suboptimal efficacy remains to be determined. In conclusion, based on the results presented in this dissertation, several improvements in clinical pharmacology strategies can be made to enhance management of NVP.

Fetal alcohol spectrum disorder (FASD) is the leading non-genetic cause of brain damage. In an effort to reduce alcohol-exposed pregnancies, steps are needed to identify at risk women as early as possible so that appropriate intervention can occur. The objective of this dissertation was to examine screening methods validated in identifying pregnant women at risk for consuming alcohol and illicit drugs during pregnancy. A systematic review identified three main approaches including maternal self-report, use of standardized questionnaires and detection via biological markers. Since most screening tools were developed in alcoholic women, it was important to examine performance in problem drinkers. Alcohol screening tools (ASQ), currently the best method of predicting prenatal problem drinking, were not effective in a cohort representative of problem drinkers. ASQ performance improved minimally, using higher thresholds, but not enough to be used alone. Provider’s knowledge of complexities inherent in women under their care is an important component in screening. As illicit drug use is an important predictor of problem drinking, identifying maternal risk factors associated with substance use was necessary. Increased rates of STD’s, untreated psychiatric disorders, binge drinking and heavy smoking were all identified as predictors of prenatal methamphetamine (MA) use. These factors, combined with high rates of unplanned pregnancies have serious adverse implications for the fetus. The most widely used method to screen for illicit substance use is based on a practice-based approach that relies heavily on maternal self-report. Most providers do not ask about alcohol and substance use in the absence of a high index of suspicion due to the assumption that patient will deny use. But evidence suggests that maternal account can be accurate in a supportive environment. The last study examines the agreement between self-reported data, in comparison to illicit drug use based on positive hair test results. A reasonable agreement between the two approaches of identification demonstrates that maternal self-report can be reliable in women who are motivated enough to seek prenatal care. No single approach is sufficient to effectively identify at risk women. However, combining two or more methods will improve screening and help reduce the number of alcohol-exposed pregnancies.

Anthracycline- and taxane-based regimens have been the mainstay in treating breast cancer patients using chemotherapy. Yet, the genetic make-up of patients and their tumors may have a strong impact on tumor sensitivity to these agents and to treatment outcome. This study represents a new paradigm assimilating bioinformatic tools with in vitro model systems to discover novel genetic variations that may be associated with chemotherapy response in breast cancer. This innovative paradigm integrates drug response data for the NCI60 cell line panel with genome-wide Affymetrix SNP data in order to identify genetic variations associated with drug resistance. This genome wide association study has led to the discovery of 59 candidate loci that may play critical roles in breast tumor sensitivity to doxorubicin and paclitaxel. 16 of them were mapped within well-characterized genes (three related to doxorubicin and 13 to paclitaxel). Further in silico characterization and in vitro functional analysis validated their differential expression in resistant cancer cell lines treated with the drug of interest (over-expression of RORA and DSG1, and under-expression of FRMD6, SGCD, SNTG1, LPHN2 and DCT). Interestingly, three and six genes associated with doxorubicin and paclitaxel resistance, respectively, are involved in the apoptotic process in cells. A constructed interactome suggested that there is cross-talk at the Nrf-2 oxidative stress pathway between genes associated with resistance to doxorubicin and paclitaxel. This unique GWA approach serves as a proof-of-principle study and systematically investigates targets responsible for variable response to chemotherapy in breast tumor cells and possibly the tumors of breast cancer patients. Overall, the model discovered novel candidate genes that have not been previously associated with doxorubicin and paclitaxel cytotoxicity. Future studies will be directed at illustrating a causative relationship between the observed genomic changes and drug resistance in breast cancer patients undergoing doxorubicin and paclitaxel chemotherapy.

The enzyme CYP2D6 can metabolize many centrally acting drugs and endogenous neural compounds (e.g. catecholamines); it can also inactivate neurotoxins such as 1-methyl-4-phenyl-1,2,3,6-tetrahydropyridine (MPTP), 1,2,3,4-tetrahydroisoquinoline (TIQ) and β-carbolines that have been associated with Parkinson’s disease (PD). CYP2D6 is ideally situated in the brain to inactivate these neurotoxins. The CYP2D6 gene is also highly polymorphic, which leads to large variation in substrate metabolism. Furthermore, CYP2D6 genetically poor metabolizers are known to be at higher risk for developing PD, a risk that increases with exposure to pesticides. Conversely, smokers have a reduced risk for PD and smokers are suggested to have higher brain CYP2D6 levels. Our studies furthered the characterization and involvement of CYP2D6 in neuroprotection against PD. METHODS: We investigated the effects of CYP2D6 inhibition on MPP+-induced cell death in SH-SHY5Y human neuroblastoma cells. We compared levels of brain CYP2D6, measured by western blotting, between human smokers and non-smokers, between African Green monkeys treated with saline or nicotine, and between PD cases and controls. In addition, we assessed changes in human brain CYP2D6 expression with age. RESULTS: Blocking CYP2D6 activity in SH-SY5Y cells with four diverse inhibitors significantly increased MPP+-induced neurotoxicity. Smokers have higher brain CYP2D6 compared to non-smokers. In monkeys, basal expression of CYP2D6 varied across brain regions and was increased by chronic nicotine treatment in select regions (notably the basal ganglia) and specific cell types. Expression of human brain CYP2D6 increased from fetal to 80 years of age in the frontal cortex; the influence of age on CYP2D6 expression was brain region specific. Compared to age-matched controls, PD cases had ~40% lower CYP2D6 levels in the frontal cortex, cerebellum and hippocampus consistent with lower CYP2D6 increasing the risk for PD. In the caudate and substantia nigra, CYP2D6 levels were similar between PD case and controls using Western blotting. This is likely due to the increase in CYP2D6-expressing astrocytes and much higher cellular CYP2D6 in PD affected areas as observed with immunocytochemical staining. CONCLUSIONS: Brain CYP2D6 can meaningfully inactivate neurotoxins, and it can be increased by nicotine in brain regions of interest to PD. These findings support the contention that higher brain CYP2D6 is protective and lower levels may contribute to increased risk for PD.

Cystic Fibrosis (CF) is a life-threatening autosomal recessive disease affecting 1:3600 children born in Canada. CF is caused by mutations in the Cystic Fibrosis Transmembrane Conductance Regulator (CFTR) chloride channel. The most common disease causing mutation is a deletion of residue F508, resulting in a structurally compromised protein which is retained in the endoplasmic reticulum and targeted for proteasomal degradation. Therapeutic strategies currently being pursued to alleviate the afflictions caused by this and other mutants include the use of corrector compounds to modify the surface expression of the channel, and potentiator compounds to increase cAMP-mediated channel activity. Despite the discovery of a number of small molecules affecting CFTR, much is still unknown about the nature of these interactions. This thesis contains the investigation of two potentiators: VRT-532 and VX-770, and two correctors VX-809 and C18. We assessed the consequences of interactions with these drugs on CFTR channel activity, ATPase activity and phosphorylation. We demonstrated that VRT-532 binds directly to mutant CFTR to modify its channel and ATPase activity. VX-770, known to bind directly to CFTR, can stimulate channel activity in the absence of cAMP stimulation in baby hamster kidney (BHK) cells. Correctors VX-809 and C18, based off the same molecular scaffold, are both capable of acutely augmenting cAMP-stimulated channel activity, providing evidence for potentiator activities in these compounds. Quantitative mass spectrometry (MS) techniques demonstrate a defect in phosphorylation at Ser-660 in the regulatory (R) domain in the major mutant. Treatment with C18 was unable to repair this defect. These novel findings regarding interactions between several small molecules and CFTR contributes to the understanding of the mechanism of action of these compounds, and will help identify how they may be modified for greater efficacy to improve the treatment of CF disease.

Cystic Fibrosis (CF) is a life-threatening autosomal recessive disease affecting 1:3600 children born in Canada. CF is caused by mutations in the Cystic Fibrosis Transmembrane Conductance Regulator (CFTR) chloride channel. The most common disease causing mutation is a deletion of residue F508, resulting in a structurally compromised protein which is retained in the endoplasmic reticulum and targeted for proteasomal degradation. Therapeutic strategies currently being pursued to alleviate the afflictions caused by this and other mutants include the use of corrector compounds to modify the surface expression of the channel, and potentiator compounds to increase cAMP-mediated channel activity. Despite the discovery of a number of small molecules affecting CFTR, much is still unknown about the nature of these interactions. This thesis contains the investigation of two potentiators: VRT-532 and VX-770, and two correctors VX-809 and C18. We assessed the consequences of interactions with these drugs on CFTR channel activity, ATPase activity and phosphorylation. We demonstrated that VRT-532 binds directly to mutant CFTR to modify its channel and ATPase activity. VX-770, known to bind directly to CFTR, can stimulate channel activity in the absence of cAMP stimulation in baby hamster kidney (BHK) cells. Correctors VX-809 and C18, based off the same molecular scaffold, are both capable of acutely augmenting cAMP-stimulated channel activity, providing evidence for potentiator activities in these compounds. Quantitative mass spectrometry (MS) techniques demonstrate a defect in phosphorylation at Ser-660 in the regulatory (R) domain in the major mutant. Treatment with C18 was unable to repair this defect. These novel findings regarding interactions between several small molecules and CFTR contributes to the understanding of the mechanism of action of these compounds, and will help identify how they may be modified for greater efficacy to improve the treatment of CF disease.