EFFECT OF THE -759C/T VARIANT OF THE SEROTONIN (5-HT2C) RECEPTOR GENE ON RISPERIDONEASSOCIATED WEIGHT GAIN IN CHILDREN & ADOLESCENTS

IN EXTENDED TREATMENT
Daniel Cole, BS; Chadi Calarge, MD; Vicki Ellingrod, PharmD; Del Miller, MD, PharmD; Janet Schlechte, MD
After controlling for the effect of baseline weight z score and the dose of methylphenidate/kg/day, the 5-HT2C genotype predicted a differential rate of weight z score gain after, but not before, risperidone was started (three-way interaction of time, risperidone treatment status, and 5-HT2C genotype group: F(1, 49.8)=4.40, p<0.04) (Figure 1). In fact, after risperidone was started, the T allele carriers were less likely to gain weight so that, by study enrolment, the difference in weight z score gain between the two groups was 0.84 (SE = 0.32, adjusted p=0.01).
Figure 1: Estimated Weight Z-Score over time for the two Serotonin Receptor Alleles
1.1 1 T(-); n=57 T(+); n=8

Introduction
Background: Weight gain is a common adverse event of atypical antipsychotics (AAPs) (1). Its medical sequelae are well established and concerns about its effect on self-esteem and medication adherence have been raised. While the exact mechanism for AAP-associated weight gain is not well known, significant inter-individual variability suggests a genetic contribution (1 & 2). The -759 C/T variant of the 5-HT2C receptor gene has been of special interest due to the protective potential of the T allele against obesity in the general population (3). In fact, studies have linked this allele to resistance against AAP-associated weight gain in adults with psychosis (2). Aim: To study the relationship between the -759C/T variant and weight gain during long term risperidone treatment in children and adolescents.

Figure 2: Estimated weight z-score over time for the two serotonin genotypes during psychostimulant treatment
0.6

0.5

Adjusted Weight Z-Score

0.8 0.7 0.6 0.5 0.4 0.3 0.2 0.1 -25 -20 -15 -10 -5 0 5 10 15 20 25 Time in months < Risperidone Time in months > Risperidone

Adjusted Weight Z-Score

0.9

0.4

Methods
Subjects: 7 to 17 yo patients, treated with risperidone for 6 mos, irrespective of diagnosis and indication, were recruited from outpatient clinics. Participants were excluded if they received other antipsychotic drugs, as were those with neurological disorders or chronic medical conditions. Pregnant females were not eligible. Procedures: Anthropometric measurements were collected from the medical records and measured, upon recruitment, following standard procedures. The treatment history was thoroughly documented. Tanner stage was rated by a physician and self-rating. In addition, a morning fasting blood sample was collected to measure total, HDL, and LDL cholesterol, triglycerides, glucose, total insulin, and for genetic testing. PCR and sequencing primers for the -759C/T variant (dbSNP rs3813929) were designed using Pyrosequencing SNP Primer Design Version 1.01 software (http://www.pyrosequencing.com). Genotyping was conducted with Pyrosequencing Technology (4). Statistical Analysis: All weight measurements were converted into z scores using the 2000 CDC growth charts. The sample was divided based on the presence of the T allele. Differences across genotype groups were compared using the Student t-test for continuous variables and Fishers exact test for categorical ones. The Wilcoxon Rank Sum test was used for continuous variables that were not normally distributed. To test the effect of genotype on risperidone-associated weight gain, a random coefficient regression model was fitted, having weight z score as the dependent variable and baseline weight z score (obtained within one month before risperidone initiation), genotype group, methylphenidate dose (mg/kg/day), and genotype group-time, risperidone treatment status-time, and genotype group-risperidone treatment status-time interactions as the predictor variables. Since the model included a linear and quadratic effect for time, we required a minimum of three weight measurements before or three after risperidone initiation in order for a participant to contribute to this analysis. Analysis of covariance (ANCOVA) was used to compare the fasting metabolic laboratory results across the two genetic groups after adjusting for age.

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0.2 T(-); n=56 T(+); n=8

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-0.1 -25 -20 -15 -10 -5 0 5 10 15 20 25 Time in months < MPH Time in months > MPH

In order to evaluate whether the effect of the -759C/T variant extends to other weight-altering psychotropics, we examined whether the genetic groups predicted weight loss following psychostimulant use. This analysis included 64 participants and was not significant (three-way interaction of time, stimulant treatment status, and 5-HT2C genotype group: F(1, 119)=0.08, p=0.8) (Figure 2). We then investigated whether the genetic groups were also differentially associated with metabolic abnormalities (Table 2). In fact, though the sample size was small, potentially obscuring some significant differences, the T allele carriers appeared to have lower total and LDL cholesterol concentrations.
Table 2: Concentrations of Lipids, Glucose, and Insulin in T Allele Carriers and Non-carriers who were fasting for 9 hours
Laboratory Tests: Total Cholesterol, LSMean SE, (mg/dl) HDL Cholesterol, LSMean SE, (mg/dl) LDL Cholesterol, LSMean SE, (mg/dl) Triglycerides, LSMean SE, (mg/dl) Glucose, LSMean SE, (mg/dl) Total Insulin, LSMean SE, (uIU/ml) HOMA-IR, LSMean SE, (mg/dl)
LSMeans adjusted for age. Effect size was computed by dividing the difference in LSMeans across the two genetic groups by the standard deviation of the residual in each regression model.

T(+) (N=7) 147.6 8.8 60.4 1.1 75.7 7.5 53.3 1.2 88.3 3.6 6.3 1.2 1.4 1.3

T(-) (N=49) 159 3.3 57.2 1.0 87.1 2.8 56.9 1.1 89.9 1.4 5.6 1.1 1.2 1.1

p value p=0.2 p=0.5 p<0.2 p=0.8 p=0.7 p=0.6 p=0.7

Effect Size -0.5 0.3 -0.6 -0.1 -0.2 0.2 0.1

Results

Conclusions
To our knowledge, this is the first study to evaluate the potential role of the -759C/T variant in the promoter region of the 5HT2C receptor gene in AAP-associated weight gain in a pediatric population. After accounting for baseline weight and psychostimulant treatment, we found the T allele to be protective against weight gain during extended risperidone treatment. This protective effect of -759C/T variant appears more specific to risperidone-related weight gain than to psychostimulants-induced weight loss, suggesting that these psychotropics affect different pathways of appetite regulation. Finally, the T alleles protective effect against weight gain might be associated with a more favorable lipid profile. Study limitations include restricting the study to patients treated with risperidone as the only AAP, the retrospective and naturalistic design of the study, and the small number of children with the T allele. Clinical Implications: we present initial evidence for the involvement of a variant of the 5HT2C receptor gene in predicting weight gain during chronic risperidone treatment in children and adolescents. With additional research, pharmacogenetics may eventually allow clinicians to better individualize psychiatric care.
References:
1. Allison DB, Mentore JL, Heo M, Chandler LP, Cappelleri JC, Infante MC, Weiden PJ. Antipsychotic-induced weight gain: a comprehensive research synthesis. Am J Psychiatry. 1999;156:1686-1696. 2. De Luca V, Mueller DJ, de Bartolomeis A, Kennedy JL. Association of the HTR2C gene and antipsychotic induced weight gain: a meta-analysis. Int J Neuropsychopharmacol. 2007;10:697-704. 3. Yuan X, Yamada K, Ishiyama-Shigemoto S, Koyama W, Nonaka K. Identification of the polymorphic loci in the promoter region of the serotonin 5-HT2C receptor gene and their association with obesity and Type II diabetes. Diabetologia. 2000;43:373-376. 4. Ronaghi M: Pyrosequencing for SNP genotyping. Methods Mol Biol 2003; 212:189-95

Sixty five participants (89% males), who had never received AAPs other than risperidone contributed to this analysis. Risperidone was used to target irritability/aggression in 83% of the sample. The genotype frequencies for female subjects were CC 71% (n = 5), CT 29% (n = 2), and TT 0% and for males C 90% (n = 52) or T 10% (n = 6). The demographic and clinical characteristics were not significantly different between the two genotype groups (Table 1).
Table 1: Demographic and Clinical Characteristics of the Sample Divided Based on T Allele Carrier State Characteristics:
Male, n (%) Age, median (quartiles), y Pubertal Status, % at Tanner stage I, II, III, IV, V Race/Ethnicity: % Non-Hispanic Caucasian/African American/Hispanic/Other Baseline Weight z Score, mean SD Endpoint Weight z Score, LS Means SE Baseline BMI z Score, mean SD BMI z Score Difference, mean SD T(+) (N=8) 6 (75) 13.7 (11.3-15.0) 12/12/0/64/12 88/0/12/0 0.3 1.5 0.1 0.3 0.3 1.5 0.3 1.2 0.03 (0.01-0.04) 1.2 (1.1-3.5) 5 (63) 1.2 0.4 T(-) (N=57) 52 (91) 11.5 (9.2-13.9) 48/18/4/23/7 81/15/2/2 0 1.0 0.9 0.1 0.1 1.5 0.6 0.7 0.02 (0.02-0.04) 2.4 (1.0-3.6) 40 (70) 1.3 0.5 Statistical Analysis Fishers Exact Wilcoxon S=334 Fishers Exact Fishers Exact P Value p=0.2 p=0.2 p=0.1 p=0.5

t=0.67, df=63 p=0.5 Adjusted p=0.3 t=0.49, df=61 p=0.6 t=-0.63, df=65 p=0.6 Wilcoxon S=256 Wilcoxon S=257 Fishers Exact t=-0.46, df=43 p=0.9 p=0.9 p=0.7 p=0.6

Medications:
Risp Dose, median (quartiles), (mg/kg/d) Risp Duration, median (quartiles), y MPH, n (%) MPH, mean SD, (mg/kg/d)

Adjusted for baseline weight z score, risperidone treatment duration, and dose of methylphenidate/kg/day.

Funding Support: The National Alliance for Research on Schizophrenia & Depression and by the National Institute of Health General Clinical Research Center Mechanism Contact Information: Email: chadi-calarge@uiowa.edu

Disclosures: NONE