key: cord-0713634-1y8qj3xh
authors: Cacabelos, Ramón; Carril, Juan C.; Corzo, Lola; Fernández-Novoa, Lucía; Pego, Rocío; Cacabelos, Natalia; Cacabelos, Pablo; Alcaraz, Margarita; Tellado, Iván; Naidoo, Vinogran
title: Influence of Pathogenic and Metabolic Genes on the Pharmacogenetics of Mood Disorders in Alzheimer’s Disease
date: 2021-04-15
journal: Pharmaceuticals (Basel)
DOI: 10.3390/ph14040366
sha: 312dc0301f6d68d4f44a5da6f9f0f6102151220c
doc_id: 713634
cord_uid: 1y8qj3xh

Background: Mood disorders represent a risk factor for dementia and are present in over 60% of cases with Alzheimer’s disease (AD). More than 80% variability in drug pharmacokinetics and pharmacodynamics is associated with pharmacogenetics. Methods: Anxiety and depression symptoms were assessed in 1006 patients with dementia (591 females, 415 males) and the influence of pathogenic (APOE) and metabolic (CYP2D6, CYP2C19, and CYP2C9) gene variants on the therapeutic outcome were analyzed after treatment with a multifactorial regime in a natural setting. Results and Conclusions: (i) Biochemical, hematological, and metabolic differences may contribute to changes in drug efficacy and safety; (ii) anxiety and depression are more frequent and severe in females than males; (iii) both females and males respond similarly to treatment, showing significant improvements in anxiety and depression; (iv) APOE-3 carriers are the best responders and APOE-4 carriers tend to be the worst responders to conventional treatments; and (v) among CYP2D6, CYP2C19, and CYP2C9 genophenotypes, normal metabolizers (NMs) and intermediate metabolizers (IMs) are significantly better responders than poor metabolizers (PMs) and ultra-rapid metabolizers (UMs) to therapeutic interventions that modify anxiety and depression phenotypes in dementia. APOE-4 carriers and CYP-related PMs and UMs deserve special attention for their vulnerability and poor response to current treatments.

Over 50 million people suffer dementia and it is expected that 75 million people will be affected in 2030 and 145 million in 2050, at an increasing rate of 7.7 million new cases per year. The global economic cost for dementia is over US$604 billion, equivalent to 1% of the global gross domestic product. Alzheimer's disease (AD) is the most frequent form of dementia (>50%), followed by vascular (VD) and mixed dementia (MXD) (30-40%) and other phenotypic presentations of neurocognitive disorders (NCDs) [1] . In patients over 70-75 years of age, MXD is the most prevalent form of dementia (>70%) [2] .

Genomic defects, epigenetic aberrations, cerebrovascular damage, and environmental inducers are the major risk factors that precipitate pathogenic cascades leading to the clinical phenotype of dementia. Dementia is characterized by progressive cognitive deterioration, behavioral changes, functional decline, and classical neuropathological hallmarks represented by extracellular Aβ deposition in senile plaques, intracellular neurofibrillary tangles, aberrant dendritic morphology, and neuronal loss in critical regions of the central nervous system (CNS) [3] [4] [5] [6] [7] . dementia. Early-onset AD patients exhibit greater prevalence of all BDs, especially anxiety, irritability, and sleep disorders [48] .

In this retrospective study, we investigate the presence of anxiety and depression in a well-characterized sample of AD patients and analyzed the influence of APOE variants and CYP2D6, CYP2C19, and CYP2C9 geno-phenotypes on the frequency and severity of anxiety and depression as well as the effect that different APOE single nucleotide polymorphisms (SNPs) and CYP phenotypes exert on the evolution of mood disorders after treatment with multifactorial therapy.

Age was almost identical in females and males ranging from 50-96 years. However, globally, biochemical, hematological, metabolic, psychometric, and anthropometric parameters were significantly different between females and males ( Table 1 ). The electrocardiogram (EKG) was abnormal in 47.82% of cases (43.36% in females and 54.35% in males, p < 0.001). Systolic and diastolic pressure values were higher in males than females (p < 0.001); however, heart rate was faster in females than males (p < 0.001). Total cholesterol, HDL-cholesterol, and LDL-cholesterol levels were also higher in females than males (p < 0.001), and triglycerides were higher in males than females (p < 0.005). Glucose levels were much higher in males than females (p < 0.001). Other important differences were found in kidney function, liver function, creatine phosphokinase (CK), alkaline phosphatase (ALP), and electrolytes (K + ). Red blood cell, hematocrit, and hemoglobin values were higher in males than females whereas platelets were more elevated in females than males. White blood cell number was also higher in males than females, especially leukocytes, monocytes, basophils, and eosinophils, while lymphocytes were slightly more abundant in females. Iron and ferritin values were higher in males; in contrast, folic acid and vitamin B12 values were higher in females (Table 1) . 

Anxiety was present in nearly 60% of patients (anxiety-free cases: 37.18%) and was significantly more frequent in females than males (p < 0.001). In the global sample, 48.88% of cases showed mild-anxiety (females: 52.79%; males: 43.13%; p < 0.001); moderate-anxiety appeared in 12.33% of the cases (females: 15.05%; males: 7.47%; p < 0.001); and severeanxiety was only observed in 1.69% of the cases (females: 3.21%; males: 0.48%; p < 0.001) (Figures 1-3) . The baseline Hamilton Anxiety Rating Scale (HARS) score was 11.44 ± 5.41 in the total sample, 12.49 ± 5.63 in females, and 9.94 ± 4.69 in males (p < 0.001); and a significant improvement was observed following one month of multifactorial treatment in both sexes (T: 9.79 ± 4.33, p < 0.001; F: 10.53 ± 4.55, p < 0.001; M: 8.52 ± 3.70, p < 0.001) (Figures 2 and 3 ).

Depressive symptoms were present in almost 70% of the cases (depression-free cases: 33.70%), and depression was also more frequent in females than males (p < 0.05). In the global sample, 42.34% of the patients showed mild-depression (females: 38.62%; males: 42.89%; p = 0.28); 18.19% moderate-depression (females: 22.46%; males: 13.73%; p < 0.001); 3.78% severe-depression (females: 5.51%; males: 1.69%; p < 0.001); and 1.99% very severedepression (females: 2.85%; males: 1.45%; p = 0.07) (Figures 1 and 3) .

The baseline Hamilton Depression Rating Scale (HDRS) score was 10.11 ± 5.21 in the total sample, 10.85 ± 5.33 in females, and 9.05 ± 4.85 in males (p < 0.001). One month later, a significant improvement was observed in the total group (8.57 ± 4.25, p < 0.001), and in both females (9.12 ± 4.39) and males (7.79 ± 3.93, p < 0.001) (Figures 2 and 3 ).

APOE-E. The distribution and frequency of APOE genotypes were the following: APOE-2/2 0.20%, APOE-2/3 8.54%, APOE-2/4 1.44%, APOE-3/3 61.83%, APOE-3/4 24.49%, and APOE-4/4 3.50% (Tables 2 and 3) . Baseline values of anxiety (HARS-0) were significantly different between APOE-2/3 and 2/4 (p < 0.007); APOE-2/4 vs. 3/3 (p < 0.01), vs. 3/4 (p < 0.002), and vs. 4/4 (p < 0.001); and APOE-3/3 vs. 3/4 (p < 0.005) and vs. 4/4 (p < 0.02) (Table 2; Figure 4 ). Improvement in anxiety symptoms was observed in most APOE variants; however, the best responders to multifactorial intervention were APOE-3/3 (p < 0.001), APOE-3/4 (p < 0.001), and APOE-2/4 carriers (p < 0.006) (Table 2; Figure 4 ). Baseline HDRS values for depression were significantly different between APOE-2/3 and 3/4 (p < 0.05) and 2/3 vs. 4/4 (p < 0.05); and also between APOE-2/4 and 4/4 (p < 0.05) and between APOE-3/3 and 4/4 (p < 0.05) ( Table 3 ; Figure 4 ). The best responders to treatment were APOE-3/3 (p < 0.001) and APOE-3/4 carriers (p < 0.003) (Table 3; Figure 4 ). , and ultra-rapid metabolizer (UM) (6.06%) phenotypes. Baseline HARS scores were similar among CYP2D6 geno-phenotypes, except between CYP2D6-NM and PM (p < 0.03) and between CYP2D6-IM and PM (p < 0.05). All CYP2D6 geno-phenotypes responded similarly to treatment; however, the best responders were CYP2D6-NM (p < 0.001) and IM (p < 0.001) (Table 2; Figure 5 ). Baseline HDRS scores did not show any difference among CYP2D6 geno-phenotypes. Although all variants improved with treatment, only CYP2D6-NM and IM showed significant differences as compared with basal HDRS score values, following a similar yet more modest pattern to that observed for anxiety (Table 3; Figure 5 ). Figure 6 ). No differences have been found among baseline HARS scores for anxiety, and only CYP2C19-NM (p < 0.001) and IM (p < 0.01) significantly responded to treatment. CYP2C19-PM and UM showed a mild, non-significant improvement in anxiety symptoms (Table 2; Figure 6 ). Basal HDRS scores showed differences between CYP2C19-NM and IM (p < 0.05) and between CYP2C19-NM and PM (p < 0.05). Improvement in depression HDRS scores were observed in CYP2C19-NM (p < 0.001) and IM (p < 0.02), with no response in CYP2C19-PM and minimum improvement in CYP2C19-UM (Table 3; Figure 6 ). Figure 7 ). No differences in either basal HARS and HDRS scores were found. Both CYP2C9-NM and IM responded to treatment with a significant improvement in anxiety and depression symptoms (p < 0.001), and CYP2C9-PM experienced a mild, non-significant improvement in both depression and anxiety HDRS and HARS scores, respectively (Table 3; Figure 7 ). 

Mood disorders in dementia are the result of a number of factors, either endogenous or exogenous. Our study clearly shows substantial sex-related differences in the frequency and intensity of anxiety and depression in AD patients (Tables 2 and 3 ; Figures 1 and 3) , as well as striking differences in anthropometric, biochemical, hematological, metabolic, and psychometric parameters between both sexes (Tables 1-3 ) that directly and/or indirectly may affect cognition and emotional status. Although mood disorders appear to be an intrinsic component of the dementia behavioral phenotype, in our sample of well-characterized patients, with a clinical follow-up for two decades, the improvement observed in both anxiety and depression cannot be exclusively attributed to psychotropic treatment, but also to the multifactorial intervention, covering concomitant problems, which were present in over 60% of the patients. Mood disorders in our sample appear to be unrelated to cardiovascular factors; and, apparently, both anxiety and depression present with greater frequency, with higher intensity, in females with lower red blood cell parameters and poorer metabolic conditions. Mood disorders are also unrelated to hyperglycemia in dementia (Table 1) .

Major determinants of the pharmacological outcome in dementia include age, gender, race, nutritional status, drug properties (chemistry, pharmaceutical category, biopharmaceutical properties, drug source: Synthetic, natural), route of administration, dose, pharmacokinetics, pharmacodynamics, drug target(s), disease stage, concomitant treatments, compliance rate, pharmacogenomics, and pharmacoepigenomics [24, 25] .

Our study corroborates the assertion that APOE is a major, but not exclusive, pathogenic determinant of the pharmacogenetic outcome in AD and that APOE-4 carriers are at biological disadvantage with respect to patients harboring the APOE-3 allele, as previously documented [2, 4, 6, 18, [34] [35] [36] [37] [49] [50] [51] . Most studies, where AD patients were treated with multifactorial combinations, revealed that APOE-3/3 carriers are the best responders and APOE-4/4 carriers are the worst responders. Concerning CYP-related pharmacogenomic outcomes, CYP2D6-EMs are the best responders, CYP2D6-PMs are the worst responders, and CYP2D6-IMs and UMs show an intermediate response. Many other pathogenic genes [50] and genes encoding components of the epigenetic machinery [51] also influence the pharmacogenetic outcome. Genome-wide association studies (GWAS) identified 31 genes located in 19 risk loci for major depressive disorder (MDD). Common and rare variants of L3MBTL2 are associated with AD. Transcript (mRNA) expression levels of SORCS3 and OAT are differentially expressed in AD brain tissues, and 13 MDD risk genes may interact with core AD genes such as HACE1, NEGR1, and SLC6A15 [52] .

Anxiolytics and antidepressants act as substrates, inhibitors, or inducers of enzymes encoded by metabolic genes. Among the 307 most frequently used CNS drugs, anxiolytics represent 11.40%, hypnotics and sedatives 21.17%, antidepressants 20.53%, and anti-dementia drugs 1-2%. About 90% of CNS drugs use CYP enzymes as major metabolic pathways. CNS drugs are major substrates of CYP3A4 (71%), CYP3A5 (37%), CYP2D6 (60%), CYP2C19 (45%), and CYP1A2 enzymes (44%); inhibitors of CYP3A4 (22%), CYP2D6 (23%), CYP2C19 (20%), CYP1A2 (17%), and CYP2C9 (15%); and inducers of CYP2C9 (9%), CYP2D6 (7%), CYP3A4 (5%), CYP1A2 (4.5%), CYP2A6 (4.5%), and CYP2B6 (3.7%). Major transporters of CNS drugs are ABCB1 (29%), SLCA1 (20%), SLC6A4 (20%), CLCNs (15%), SLC6A3 (12%), and SLC6A2 (11%) [26] .

CYP2D6 variants are associated with 217 diseases, and 995 drugs are CYP2D6related (218 major substrates, 174 minor substrates, 75 strong inhibitors, 183 moderate inhibitors, 32 weak inhibitors, and 18 inducers) [25] . Significant sex-related differences in the CYP2D6*4A/*41, *5/*5, *5/*6A, *41/*41 and *1A/*1xN genotypes have been identified in the Caucasian population. The number of CYP2D6-UMs is higher in males (6.16%) than in females (4.48%). These differences may contribute, in approximately 5-10% of the cases, to sex-related variability in the pharmacogenetic outcome and in the occurrence of DDIs and ADRs, as well [6, 25, 53, 54] .

The integration of CYP2D6-CYP2C9-CYP2C19 variants in trigenic clusters yields 134 genotypes and 33 phenotypes. The top five most frequent trigenic genotypes in the Iberian population are 1/1-1/1-1/1 (22.91%), 1/1-1/2-1/1 (10.45%), 1/1-1/1-1/2 (9.42), 1/4-1/1-1/1 (8.82%), and 1/4-1/2-1/1 (4.81%). Over 115 genotypes exhibit a frequency below 1%, with significant differences between females and males. Approximately 55% of trigenic phenotypes show a frequency below 1%, and only 23.55% of the subjects are extensive metabolizers for the three (2D6-2C9-2C19) enzymes [4, 23] .

About 25% of our patients with moderate-to-severe depression were treated with fluoxetine, paroxetine, or sertraline. Over 80% of these patients showed a net improvement in their depressive condition. However, these positive results cannot only be attributed to the effect of antidepressants, but also to the complementary treatments for their concomitant ailments. Meta-analyses of double-blind randomized controlled trials comparing antidepressants vs. placebo for depression in AD revealed inefficacy in most cases with different drugs (sertraline, mirtazapine, imipramine, fluoxetine, and clomipramine) [55] .

The mechanisms underlying depression in dementia remain unclarified [56] . Genetic and environmental factors are potentially involved [44, [57] [58] [59] [60] [61] [62] . For instance, an increase in depression and anxiety symptoms have been reported in nursing homes during the coronavirus pandemic [63] . About 60% of depressive patients are receiving an inappropriate medication according to their pharmacogenetic background [64, 65] , and community psychiatrists and pharmacists are more accurate in their psychotropic prescriptions when they know the CYP profile of their patients [65] [66] [67] .

Antidepressants are associated with the pharmacogenetic activity of over 600 genes. The different pharmacological categories of antidepressants (non-selective monoamine reuptake inhibitors, selective serotonin reuptake inhibitors, non-selective monoamine oxidase (MAO) inhibitors, and other chemical modalities) are substrates, inhibitors, or inducers of 40, 22, and 9 enzyme/protein gene products, respectively, and are transported by 13 different protein transporters. Antidepressants are major substrates of CYP2D6 (86%), CYP3A4 (72%), CYP2C19 (60%), CYP1A2 (57%), CYP2C9 (34%), UGT1A4 (29%), and UGT1A3 (25%); inhibitors of CYP2D6 (69%), CYP3A4 (55%), CYP1A2 (45%), CYP2C19 (45%), CYP2C9 (34%), SLC6A4 (32%), MAOA (29%), MAOB (29%), and ABCB1 (25%); and inducers of CYP3A4 (5%), CYP1A2 (5%), CYP2B6 (5%), CYP2C9 (3%), CYP2C19 (3%), CYP2D6 (3%), and ABCB1 (3%). Major transporters of antidepressants are SLC6A4 (62%), ABCB1 (55%), and SLC6A2 (40%). For instance, Sertraline is associated with 31 pharmagenes and Fluoxetine with 28 genes potentially involved in the pharmacogenetic outcome [25, 26] .

Fluoxetine is a major substrate of CYP2D6 and CYP2C9; a minor substrate of CYP1A2, CYP2B6, CYP2E1, and CYP3A4; a strong inhibitor of CYP2D6, a moderate inhibitor of CYP1A2 and CYP2C19, and a weak inhibitor of CYP2B6, CYP2C9, and CYP3A4 [25, 54] . Paroxetine is a major substrate of CYP2D6; a strong inhibitor of CYP2D6; a moderate inhibitor of CYP2B6 and a weak inhibitor of CYP1A2, CYP2C8, CYP2C9, CYP2C19, and CYP3A4 [25, 54] . Sertraline is a major substrate of CYP2D6 and CYP2C19; a minor substrate of CYP2A6, CYP2B6, CYP2C9, and CYP3A4; a moderate inhibitor of CYP2C19, CYP2D6, and CYP3A4; and a weak inhibitor of CYP1A2, CYP2C8, and CYP2C9 [25, 54] . CYP2C19 and CYP2D6 variants affect the occurrence of ADRs in patients treated with selective serotonin reuptake inhibitors (SSRIs)(citalopram, escitalopram, sertraline, fluvoxamine, fluoxetine, paroxetine), including anxiety associated with CYP2D6, and ECG prolonged QT intervals associated with CYP2C19 [68] . The serotonin receptor 1A (HTR1A) rs878567 and CYP2C19 rs12248560 gene variants are associated with depression severity [69] . Angiotensin-converting enzyme (ACE) variants influence mood in AD [49] . The co-administration of ACE inhibitors and statins with antidepressants may affect therapeutic outcomes [70] . In our case, we did not observe any ADRs in the patients treated with small doses of enalapril, atorvastatin, and SSRIs.

The neurochemical mechanisms of anxiety in dementia are unknown. Subjective cognitive decline and neuropsychiatric symptoms are associated with brain structural alterations and APOE-4 [71, 72] . Benzodiazepines are commonly prescribed for ameliorating anxiety symptomatology; however, benzodiazepines contribute to cognitive and psychomotor dysfunction [73, 74] . CYP enzymes participate in the metabolism of over 92% of benzodiazepines. About 70% of these drugs are major substrates of CYP3A4, followed by CYP2C19 (41%), CYP3A5 (38%), CYP2D6 (36%), CYP2C9 (30%), CYP1A2 (27%), CYP2B6 (19%), UGT1A4 (14%), UGT2B15 (11%), and UGT1A1, UGT1A3, UGT1A6, UGT1A10, and UGT2B7 (8%); only 10% are inhibitors of CYP3A4 and CYP2C9; 8% are inducers of CYP3A4, and about 5% are inducers of CYP1A2, CYP2A6, CYP7A1, and ABCC2. Over 50% of these drugs are transported by proteins of the CLCN family, 16% are transported by ABCB1, 9% by NQ1I2, and 5% by ABCC2, KCNE1, KCNH2, and SLCO1B1 [2, 26] . Alprazolam and Lormetazepam are major substrates of CYP3A4/4 and minor substrates of CYP1A1, CYP1A2, CYP2B6, CYP2C9, CYP2C19, and CYP2D6 [25] . In our study, they show benefit with small doses by alleviating anxiety without significant disturbance in cognitive and psychomotor functions. There is unnecessary over-prescription of psychotropic drugs in patients with dementia, which contribute to accelerated cognitive decline and increased accidentality and mortality. Pharmacogenomics of AD has proven to be useful for the prediction of therapeutic outcome, discrimination of responders vs. non-responders, and prevention of ADRs and unwanted DDIs [2, 23, 26, 27] .

Our study demonstrates that a multifactorial regime, covering biochemical and metabolic deficiencies, together with neuroprotectants and adjusted psychotropic medication, can be beneficial for emotional stability in AD patients, and that APOE-4 carriers and CYP-related PMs and UMs, representing over 40% of the AD population, deserve special attention for their vulnerability and poor response to current treatments.

Patients for this retrospective study were recruited from the CIBE database at the International Center of Neuroscience and Genomic Medicine (period: 2000-2010; followup: 2000-2020). This cohort includes patients (N = 1006; age: 67.71 ± 9.62 years; range: 50-96 years) of both sexes (591 Females; age: 67.52 ± 9.68 years; range: 50-96 years; 415 Males; age: 67.50 ± 9.54) with the diagnosis of neurocognitive disorder (NCD)-AD (331.0 (G30.9) (DSM-V/NINCDS-ADRDA criteria). All patients underwent the following protocol: (i) Clinical examination, (ii) blood and urine analyses, (iii) neuropsychological assessment (MMSE [75] , ADAS [76] , HARS [77] , HDRS [78] ), (iv) cardiovascular evaluation (EKG), (v) structural neuroimaging (brain MRI), (vi) functional neuroimaging (brain mapping, brain optical topography), (vii) genetic assessment, and (viii) pharmacogenetic profiling, as reported in previous pharmacogenetic studies [50, 51] .

The patients received, for one year, a multifactorial therapy integrated by CDP-choline (500 mg/day, p.o.) (choline donor and intermediate metabolite in DNA synthesis and repair), Piracetam (1600 mg/day, p.o.) (nootropic drug), Sardilipin (E-SAR-94010) (250 mg, t.i.d.)(nutraceutical with lipid-lowering effects and anti-atherosclerotic properties), and Animon Complex ® (2 capsules/day)(a nutraceutical compound integrated by a purified extract of Chenopodium quinoa (250 mg), ferrous sulphate (38.1 mg equivalent to 14 mg of iron), folic acid (200 µg), and vitamin B12 (1 µg per capsule). About 5% of patients received Donepezil (5 mg/day). Patients with chronic deficiency of iron (<35 µg/mL)(4.55%), folic acid (<3 ng/mL)(5.60%), or vitamin B12 (<170 pg/mL) (4.85%) received an additional supplementation of iron (80 mg/day), folic acid (5 mg/day), and B complex vitamins (B1, 15 mg/day; B2, 15 mg/day; B6, 10 mg/day; B12, 10 µg/day; nicotinamide, 50 mg/day), respectively, to maintain stable levels of serum iron (50-150 µg/mL), folic acid (5-20 ng/mL), and vitamin B12 levels (500-1000 pg/mL) in order to avoid the negative influence of these metabolic factors on cognition and mood. Patients with hypertension (>150/85 mmHg) (35%) received enalapril (5-20 mg/day, p.o.); patients with hypercholesterolemia (>220 mg/dL) (46%) received atorvastatin (10-20 mg/day); patients with diabetes (glucose >105 mg/dL) (28%) received metformin (850-1700 mg/day, p.o.); and patients (<3%) with other ailments (e.g., hypothyroidism and hyperuricemia) received the appropriate treatment according to their medical condition. Patients with moderateto-severe depression (25%) received Fluoxetine (20 mg/day), Paroxetine (20 mg/day), or Sertraline (50 mg/day); and patients with agitation and/or moderate-to-severe anxiety (18%) received Alprazolam (0.5-1.0 mg/day) or Lorazepam (1-2 mg/day) for one month. Less than 3% of patients required neuroleptics (Risperidone, Quetiapine, Levomepromazine, Haloperidol) for the treatment of severe BDs. Blood pressure, psychometric assessment (Mini-Mental State Examination, MMSE; Alzheimer's Disease Assessment Scale, ADAS; Hamilton Rating Scale-Depression, HAM-D; Hamilton Rating Scale-Anxiety, HAM-A), and blood parameters (Table 1) were evaluated prior to treatment (baseline) and after 1, 3, 6, 9, and 12 months of treatment. In this study, we analyzed parameters at baseline and after one month of treatment. Results on the pharmacogenetics of cognition for one year can be found elsewhere [4, [49] [50] [51] . All patients and/or their legal representatives provided informed consent for genotyping, clinical assessment, and treatment before they participated in the study. The study was conducted in accordance with the Declaration of Helsinki, and the protocol was approved by the Ethics Committee of the EuroEspes Biomedical Research Center (Project identification code: CDN-AD-DEP-01-99-10).

DNA was extracted from peripheral blood using Qiagen extraction columns (Qiagen, Hilden, Germany). SNPs in 18 genes encoding for proteins associated with AD pathogenesis and a panel of 113 SNPs and 3 copy number variations (CNVs) in 60 genes encoding for pharmacogenetics-related genes (metabolic, transporter, mechanistic, pleiotropic genes) were genotyped (Tables 4 and 5 ). Genes of interest for this study were the following: (i) APOE (rs7412, c.4070C > T, Cys158Arg (*2); rs429358, c.3932T > C, Cys112Arg (*4); (ii) CYP2C19 (Cytochrome P450 family 2 subfamily C member 19) (rs4244285, c.681G > A (*2A); rs12248560, g.-806C > T (*17)); (iii) CYP2C9 (Cytochrome P450 family 2 subfamily C member 9)(rs1799853, c.430C > T (*2A); rs1057910, c.1075A > C (*3A); rs28371686, c.1080C > A (*5A); rs9332131, c.817delA (*6A); rs7900194, c.449G > T (*8A); rs28371685, c.1003C > T (*11A); and (iv) CYP2D6 (Cytochrome P450 family 2 subfamily D member 6)(rs35742686, g.2549delA (*3A); rs3892097, g.1846G > A (*4A); rs5030655, g.1707T>del (*6A); CNV, CYP2D6 indel (*5, *1 × N); rs28371725, g.2988G > A (*41). Real-Time Polymerase Chain Reaction (RT-PCR) amplification was performed using TaqMan assays for SNPs using StepOne Plus Real -Time PCR System (Life Technologies) and/or TaqMan ® OpenArray ® DNA microchips for QuantStudioTM 12K Flex Real-Time PCR System. OpenArray ® genotyping analysis was performed using the Genotyper software (Thermo Fisher Scientific, Waltham, MA, USA).

Data were analyzed by using IBM SPSS Statistics 20 (IBM Corp., Armonk, NY, USA) and SigmaPlot 10.0 (SYSTAT Software Inc., San Jose, CA, USA). Comparisons between groups were studied by t-Test, Mann-Whitney Rank Sum Test, Chi Square without Yates correction and Fisher exact, and Pearson Correlation Analysis (Nonlinear Regression, Durbin-Watson Statistic, Normality Test, Constant Variance Test, 95% Confidence), when appropriate. In studies of correlation analysis, all cases have been ordinated from the lowest to the highest values for maximum differentiation in the figures. All values are expressed as mean ± SD, and the degree of significance is considered when p < 0.05. 

Major conclusions from this study include the following: (i) Biochemical, hematological, and metabolic differences may contribute to changes in drug efficacy and safety (tentative contribution: 5-20% that depends on the number of drugs involved); (ii) anxiety and depression are more frequent and severe in females than males with dementia; (iii) cardiovascular disorders and associated risk factors are more frequent in males than females; however, vascular problems appear to be unrelated to mood disorders in dementia; (iv) both females and males respond similarly to a multifactorial regime, showing significant improvements in anxiety and depression; (v) APOE-3 carriers are the best responders and APOE-4 carriers tend to be the worst responders to conventional treatments in combination regimes; (vi) among CYP2D6, CYP2C19, and CYP2C9 geno-phenotypes, NMs and IMs are significantly better responders than PMs and UMs to therapeutic interventions that modify anxiety and depression phenotypes; and (vii) APOE-4 carriers and CYP-related PMs and UMs deserve special attention for their vulnerability and poor response to current treatments.

The main conclusions related to pharmacogenetics should be interpreted with caution taking into account the polypharmacy received by dementia patients and assuming that the pharmacogenetic response depends on many more genes than those discussed in this study. Informed Consent Statement: All patients and/or their legal representatives provided informed consent for genotyping, clinical assessment, and treatment before they participated in the study.

Data Availability Statement: Data supporting reported results can be found in the CIBE Database at EuroEspes International Center of Neuroscience and Genomic Medicine. www.euroespes.com.

The authors declare no conflict of interest.

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Impact of CYP1A2, CYP2C19, and CYP2D6 genotype-and phenoconversion-predicted enzyme activity on clozapine exposure and symptom severity

The epigenetic machinery in the life cycle and pharmacoepigenetics

Pharmacoepigenetic processors: Epigenetic drugs, Drug resistance, Toxicoepigenetics, and Nutriepigenetics

Future trends in the pharmacogenomics of brain disorders and dementia: Influence of APOE and CYP2D6 variants

Pharmacogenomics of Alzheimer's and Parkinson's diseases

Genomics of dementia: APOE-and CYP2D6-related pharmacogenetics

Donepezil in Alzheimer's disease: From conventional trials to pharmacogenetics

The prevalence of depression in Alzheimer's disease: A systematic review and meta-analysis

Prevalence of Depression, Anxiety and PTSD in People with Dementia: A Systematic Review and Meta-Analysis

Psychological Predictors of Memory Decline in a Racially and Ethnically Diverse Longitudinal Sample of Older Adults in the United States

Depression and dementia: Cause, consequence or coincidence? Maturitas

Sex-specific depressive symptoms as markers of pre-Alzheimer dementia: Findings from the Three-City cohort study

Association between brain amyloid accumulation and neuropsychological characteristics in elders with depression and mild cognitive impairment

Understanding the effect of cognitive/brain reserve and depression on regional atrophy in early Alzheimer's disease

Examining the Link Between Cardiovascular Risk Factors and Neuropsychiatric Symptoms in Mild Cognitive Impairment and Major Depressive Disorder in Remission

Anxiety as a risk factor of Alzheimer's disease and vascular dementia

Updating the evidence for an association between anxiety and risk of Alzheimer's disease: A meta-analysis of prospective cohort studies

Prevalence and Severity of Neuropsychiatric Symptoms in Early-Versus Late-Onset Alzheimer's Disease

Molecular pathology and pharmacogenomics in Alzheimer's disease: Polygenic-related effects of multifactorial treatments on cognition, anxiety and depression

APOE-TOMM40 in the Pharmacogenomics of demetia

Sirtuins in Alzheimer's Disease: SIRT2-Related GenoPhenotypes and Implications for PharmacoEpiGenetics

The GWAS Risk Genes for Depression May Be Actively Involved in Alzheimer's Disease

Pleiotropy and promiscuity in pharmacogenomics for the treatment of Alzheimer's disease and related risk factors

Pharmacogenomics of antidepressants

Efficacy of Antidepressants for Depression in Alzheimer's Disease: Systematic Review and Meta-Analysis

Pharmacological Treatment of Depression in Alzheimer's Disease: A Challenging Task

Late-life depression and risk of vascular dementia and Alzheimer's disease: Systematic review and meta-analysis of community-based cohort studies

Association of Late Life Depression, (Non-) Modifiable Risk and Protective Factors with Dementia and Alzheimer's Disease: Literature Review on Current Evidences, Preventive Interventions and Possible Future Trends in Prevention and Treatment of Dementia

Neuropathology of depression in Alzheimer's disease: Current knowledge and the potential for new treatments

Ehrenthal, I.C. Risk factors for adult depression: Adverse Childhood experiences and personality functioning

Genetics of Depression: Progress at Last. Curr. Psychiatry Rep

Genome-wide meta-analysis of depression identifies 102 independent variants and highlights the importance of the prefrontal brain regions

High depression and anxiety in people with Alzheimer's disease living in retirement homes during the COVID-19 crisis

Trial-and-Error versus Personalized Treatment in Depression: The Power of

Optimization of antidepressant use with pharmacogenetic strategies

Impact of Pharmacogenomics on Clinical Outcomes for Patients Taking Medications With Gene-Drug Interactions in a Randomized Controlled Trial

The Three Ps: Psychiatry, Pharmacy, and Pharmacogenomics

Optimizing drug selection in psychopharmacology based on 40 significant CYP2C19-and CYP2D6-biased adverse drug reactions of selective serotonin reuptake inhibitors

A pharmacogenetic risk score for the evaluation of major depression severity under treatment with antidepressants

Pharmacogenetic analyses of variations of measures of cardiovascular risk in Alzheimer's dementia

Anxiety correlates with cortical surface area in subjective cognitive decline: APOE ε4 carriers versus APOE ε4 non-carriers

Neuropathologic Correlates of Psychiatric Symptoms in Alzheimer's Disease

Benzodiazepine use and risk of Alzheimer's disease: Case-control study

Is Benzodiazepine Use Associated with the Risk of Dementia and Cognitive Impairment-Not Dementia in Older Persons? The Canadian Study of Health and Aging

Mini-Mental State" a Practical Method for Grading the Cognitive State of Patients for the Clinician

A new rating scale for Alzheimer's disease

The assessment of anxiety states by rating

A rating scale for depression

We would like to thank our collaborators, administration staff, technicians and patients who made possible the performance of this study at the International Center of Neuroscience and Genomic Medicine, Bergondo, Corunna, Spain.

Pharmaceuticals 2021, 14, 366