Amonafide and irinotecan are anticancer drugs representative of the clinica
l relevance of N-acetyltransferase (NAT) and uridine diphosphate glucuronos
yltransferase (UGT) polymorphisms in cancer chemotherapy, respectively. Amo
nafide, a substrate for the polymorphic NAT2, has an active metabolite, N-a
cetyl-amonafide. Using caffeine as a probe, slow and rapid acetylators of a
monafide were identified. Fast acetylators experienced greater myelosuppres
sion than did slow acetylators, and a reduced dose of amonafide for fast ac
etylators has been recommended. A pharmacodynamic model based on acetylator
phenotype, pretreatment white blood cell count, and gender has been propos
ed for dose individualization. The strategy adopted for amonafide is a mode
l for future investigations in pharmacogenetics, although amonafide is no l
onger in clinical development. SN-38, the active metabolite of irinotecan,
is glucuronidated to the inactive SN-38 glucuronide by UGT1A1, the isoform
catalyzing bilirubin glucuronidation. Genetic defects in UGT1A1 determine C
rigler-Najjar and Gilbert's syndromes characterized by unconjugated hyperbi
lirubinemia. Gilbert's syndrome often remains undiagnosed and occurs in up
to 19% of individuals. Gilbert's syndrome is due to a homozygous TA inserti
on in the TATAA promoter of UGT1A1, leading to the mutated (TA)(7) allele.
Irinotecan toxicity depends on the individual glucuronidation rate of SN-38
. Decreased SN-38 glucuronidating activity has been found in livers obtaine
d from individuals carrying the (TA)(7) allele. A phenotyping procedure for
UGT1A1 has not been identified and genotyping of the UGT1A1 promoter in pa
tients receiving irinotecan may identify patients at increased risk of toxi
city. A clinical trial at the University of Chicago is ongoing to demonstra
te the predictive significance of UGT1A1 genotyping for irinotecan pharmaco
dynamics.