Turkiye Klinikleri Journal of Medical Sciences

.: ORIGINAL RESEARCH
Investigation of Relation Between MDR1 Gene and Ankylosing Spondylitis: Case Control Research
MDR1 Geni ile Ankilozan Spondilit Arasındaki İlişkinin İncelenmesi: Olgu Kontrol Araştırması
Fatma KURT ÇOLAKa, Arslan BAYRAMb, Keziban KORKMAZ BAYRAMc, Mehmet KIRNAPd, Munis DÜNDARe, Çetin SAATÇİe
aDepartment of Medical Genetics, Sütçü İmam University Faculty of Medicine, Kahramanmaraş, Türkiye
bClinic of Medical Genetics, Etlik Zübeyde Hanım Women's Diseases Training and Research Hospital, Ankara, Türkiye
cDepartment of Medical Genetics, Ankara Yıldırım Beyazıt University Faculty of Medicine, Ankara, Türkiye
dDepartment of Physical Therapy and Rehabilitation, Erciyes University Faculty of Medicine, Kayseri, Türkiye
eDepartment of Medical Genetics, Erciyes University Faculty of Medicine, Kayseri, Türkiye
Turkiye Klinikleri J Med Sci. 2022;42(3):213-20
doi: 10.5336/medsci.2021-87249
Article Language: EN
Full Text
ABSTRACT
 Objective: In this study, the relationship between the MDR1 gene and ankylosing spondylitis (AS) was investigated. Genetic and environmental factors are known to play an important role in the pathogenesis of AS. It is obvious that different patients have different reactions to prescribed drugs and drug dosages during standard treatment. One of these factors is the P-glycoprotein encoded by the MDR1 gene. The most widely studied alleles of this gene are rs1045642-NM_000927.4:c.3435T>C, p. Ile1145Ile (C3435T), rs2032582-NM_000927.4:c.2677T>G/A, p. Ser893Ala/Thr (G2677T/A) and silent rs1128503-NM_000927.4:c.1236T>C, p. Gly412Gly (C1236T). Material and Methods: The study group was formed from 34 patients with biological therapy, 32 patients with other treatments (66 AS patients in total) and 32 healthy individuals. DNA isolation was performed using a High Pure PCR Template Preparation Kit. RNA isolation was performed with TRIzol manual isolation. For quantitative real-time polymerase chain reaction, a Roche LightCycler FastStart DNA Master device HybProbe was used. Results: There was no statistically significant difference between groups regarding the investigated polymorphisms. In the biological therapy [tumor necrosis factor alpha (TNF-α) inhibitor] group, a significant decrease was found in MDR1 gene expression (p<0.001). Conclusion: In conclusion, we could say that there is no relation between single-nucleotide polymorphism and treatment choice and response for AS patients. Decreased MDR1 expression can be explained by the possible downregulatory effect of TNF-α inhibitors.

Keywords: Ankylosing spondylitis; MDR1; genetic polymorphisms; gene expression; anti-TNF
ÖZET
 Amaç: Bu çalışmada MDR1 geni ile Ankilozan spondilit araştırıldı. Genetik ve çevresel faktörlerin ankilozan spondilit (AS) patogenezinde önemli rol oynadığı bilinmektedir. Standart tedavi sırasında farklı hastaların, reçeteli ilaçlara ve ilaç dozajlarına karşı farklı tepkileri olduğu açıktır. Bu faktörlerden biri, MDR1 geni tarafından kodlanan P-glikoproteindir. Bu genin en çok çalışılan allelleri rs1045642-NM_0009 27.4:c.3435T>C, p. Ile1145Ile (C3435T), rs2032582- NM_ 000927. 4:c.2677T>G/A, p. Ser893Ala/Thr (G2677T/A) ve sessiz rs1128503-NM_000927.4:c.1236T>C, p. Gly412Gly (C1236T)'dir. Gereç ve Yöntemler: Otuz dört biyolojik tedavi, 32 diğer tedavileri alan toplam 66 AS hastası ve 32 sağlıklı herhangi bir ilaç kullanmayan bireyden oluşan grup karşılaştırıldı. DNA izolasyonu High Pure PCR Template Preparation Kiti kullanılarak gerçekleştirildi. RNA izolasyonu trizolle yapıldı. Kantitatif gerçek zamanlı polimeraz zincir reaksiyonu, Roche LightCycler FastStart DNA Master HybProbe cihazında gerçekleştirildi. Bulgular: Çalışmamızın sonucunda, araştırılan polimorfizmlerle ilgili gruplar arasında istatistiksel olarak anlamlı bir fark yoktu. Biyolojik tedavileri [tümör nekrozis faktör alfa (TNF-α)] kullanan AS grubunun, MDR1 gen ekspresyonu arasında anlamlı bir farklılık bulundu (p<0,001). Sonuç: Sonuç olarak AS hastalarında tek nükleotid polimorfizmi ile tedavi seçimi ve yanıt arasında bir ilişki olmadığını söyleyebiliriz. Azalan MDR1 ekspresyonu, TNF-α inhibitörlerinin olası baskılayıcı regülatör etkisi ile açıklanabilir.

Anahtar Kelimeler: Ankilozan spondilit; MDR1; genetik polimorfizm; gen ekspresyon; anti-TNF
REFERENCES:
  1. Pelechas E, Kaltsonoudis E, Voulgari PV, Drosos AA. Illustrated Handbook of Rheumatic and Musculo-Skeletal Diseases. 1st ed. Cham, Switzerland: Springer International Publishing; 2019. [Crossref] 
  2. Feldtkeller E, Khan MA, van der Heijde D, van der Linden S, Braun J. Age at disease onset and diagnosis delay in HLA-B27 negative vs. positive patients with ankylosing spondylitis. Rheumatol Int. 2003;23(2):61-6. [Crossref]  [PubMed] 
  3. Hoyle E, Laval SH, Calin A, Wordsworth BP, Brown MA. The X-chromosome and susceptibility to ankylosing spondylitis. Arthritis Rheum. 2000;43(6):1353-5. [Crossref]  [PubMed] 
  4. Sharip A, Kunz J. Understanding the pathogenesis of spondyloarthritis. Biomolecules. 2020;10(10):1461. [Crossref]  [PubMed]  [PMC] 
  5. Brown MA, Kennedy LG, MacGregor AJ, Darke C, Duncan E, Shatford JL, et al. Susceptibility to ankylosing spondylitis in twins: the role of genes, HLA, and the environment. Arthritis Rheum. 1997;40(10):1823-8. [Crossref]  [PubMed] 
  6. van der Heijde D, Ramiro S, Landewé R, Baraliakos X, Van den Bosch F, Sepriano A, et al. 2016 update of the ASAS-EULAR management recommendations for axial spondyloarthritis. Ann Rheum Dis. 2017;76(6):978-91. [Crossref]  [PubMed] 
  7. Ward MM, Deodhar A, Gensler LS, Dubreuil M, Yu D, Khan MA, et al. 2019 Update of the American College of Rheumatology/Spondylitis Association of America/Spondyloarthritis Research and Treatment Network Recommendations for the Treatment of Ankylosing Spondylitis and Nonradiographic Axial Spondyloarthritis. Arthritis Care Res (Hoboken). 2019;71(10):1285-99. [Crossref]  [PubMed]  [PMC] 
  8. Moon KH, Kim YT. Medical treatment of ankylosing spondylitis. Hip Pelvis. 2014;26(3):129-35. [Crossref]  [PubMed]  [PMC] 
  9. Sayitoglu M. Kanser tedavisine farmakogenetik yaklaşım [Cancer therapy and pharmacogenetic approach: scientific letter]. Turkiye Klinikleri J Med Sci. 2007;27(3):434-41. [Link] 
  10. Evans WE, Johnson JA. Pharmacogenomics: the inherited basis for interindividual differences in drug response. Annu Rev Genomics Hum Genet. 2001;2:9-39. [Crossref]  [PubMed] 
  11. Sakaeda T. MDR1 genotype-related pharmacokinetics: fact or fiction? Drug Metab Pharmacokinet. 2005;20(6):391-414. [Crossref]  [PubMed] 
  12. Jiang EZ, Chang YJ, Lee JW, Lee WK, Kim JS, Sohn SK, et al. Multi-drug resistance (MDR1) gene expression in de novo acute leukemia cells: correlations with CD surface markers and treatment outcome. J Korean Med Sci. 1998;13(6):617-22. [Crossref]  [PubMed]  [PMC] 
  13. Baran Y, Gündüz U, Ural AU. Expression of multi drug resistance (MDR1) gene in human promyelocytic leukemia cell line selected with vincristine. Turkish Journal of Cancer. 2005;35(2):88-92. [Link] 
  14. Hoffmeyer S, Burk O, von Richter O, Arnold HP, Brockmöller J, Johne A, et al. Functional polymorphisms of the human multidrug-resistance gene: multiple sequence variations and correlation of one allele with P-glycoprotein expression and activity in vivo. Proc Natl Acad Sci U S A. 2000;97(7):3473-8. [Crossref]  [PubMed]  [PMC] 
  15. Jamroziak K, Balcerczak E, Cebula B, Janus A, Mirowski M, Robak T. No influence of 3435C>T ABCB1 (MDR1) gene polymorphism on risk of adult acute myeloid leukemia and P-glycoprotein expression in blast cells. Ther Drug Monit. 2006;28(5):707-11. [Crossref]  [PubMed] 
  16. Kimchi-Sarfaty C, Marple AH, Shinar S, Kimchi AM, Scavo D, Roma MI, et al. Ethnicity-related polymorphisms and haplotypes in the human ABCB1 gene. Pharmacogenomics. 2007;8(1):29-39. [Crossref]  [PubMed]  [PMC] 
  17. Schwab M, Eichelbaum M, Fromm MF. Genetic polymorphisms of the human MDR1 drug transporter. Annu Rev Pharmacol Toxicol. 2003;43:285-307. [Crossref]  [PubMed] 
  18. Tanabe M, Ieiri I, Nagata N, Inoue K, Ito S, Kanamori Y, et al. Expression of P-glycoprotein in human placenta: relation to genetic polymorphism of the multidrug resistance (MDR)-1 gene. J Pharmacol Exp Ther. 2001;297(3):1137-43. [PubMed] 
  19. Akar S, Önen F. Ankilozan spondilit epidemiyolojisi [Epidemiology of ankylosing spondylitis]. Turkiye Klinikleri J Int Med Sci. 2007;3(27):1-12. [Link] 
  20. Siddiqui A, Kerb R, Weale ME, Brinkmann U, Smith A, Goldstein DB, et al. Association of multidrug resistance in epilepsy with a polymorphism in the drug-transporter gene ABCB1. N Engl J Med. 2003;348(15):1442-8. [Crossref]  [PubMed] 
  21. Tang K, Ngoi SM, Gwee PC, Chua JM, Lee EJ, Chong SS, et al. Distinct haplotype profiles and strong linkage disequilibrium at the MDR1 multidrug transporter gene locus in three ethnic Asian populations. Pharmacogenetics. 2002;12(6):437-50. [Crossref]  [PubMed] 
  22. Kim RB, Leake BF, Choo EF, Dresser GK, Kubba SV, Schwarz UI, et al. Identification of functionally variant MDR1 alleles among European Americans and African Americans. Clin Pharmacol Ther. 2001;70(2):189-99. [Crossref]  [PubMed] 
  23. Gümüş-Akay G, Rüstemoğlu A, Karadağ A, Sunguroğlu A. Haplotype-based analysis of MDR1/ABCB1 gene polymorphisms in a Turkish population. DNA Cell Biol. 2010;29(2):83-90. [Crossref]  [PubMed] 
  24. Schaeffeler E, Eichelbaum M, Brinkmann U, Penger A, Asante-Poku S, Zanger UM, et al. Frequency of C3435T polymorphism of MDR1 gene in African people. Lancet. 2001;358(9279):383-4. [Crossref]  [PubMed] 
  25. Poller B, Drewe J, Krähenbühl S, Huwyler J, Gutmann H. Regulation of BCRP (ABCG2) and P-glycoprotein (ABCB1) by cytokines in a model of the human blood-brain barrier. Cell Mol Neurobiol. 2010;30(1):63-70. [Crossref]  [PubMed] 

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