HHS Public Access

Author manuscript
Pharmacogenet Genomics. Author manuscript; available in PMC 2017 September 01.
Author Manuscript

Published in final edited form as:

Pharmacogenet Genomics. 2016 September ; 26(9): 436–444. doi:10.1097/FPC.0000000000000232.

PharmGKB Summary: Isoniazid Pathway, Pharmacokinetics (PK)

Daniel J. Kleina,c, Sotiria Boukouvalad, Ellen M. McDonagha, Scott R. Shuldinera, Nicola
Laurierie, Caroline F. Thorna, Russ B. Altmana,b, and Teri E. Kleina
aDepartment of Genetics, Stanford University, California, USA
bDepartment of Bioengineering, Stanford University, California, USA
cKeck School of Medicine of University of Southern California, California, USA
Author Manuscript

dDepartment of Molecular Biology and Genetics, Democritus University of Thrace,

Alexandroupolis, Greece
eDepartment of Pharmacology, University of Oxford, Oxford, UK

Keywords
Isoniazid; pharmacokinetics; anti-tuberculosis drug-induced hepatotoxicity; NAT2; CYP2E1;
GSTT1; GSTM1

Background
Author Manuscript

Isoniazid (isonicotinic acid hydrazide, INH; PubChem ID 3767) [1] is a first-line anti-
mycobacterial agent used to treat active or latent tuberculosis (TB) infections generated by
Mycobacterium tuberculosis [2–4]. INH has been in clinical use for over 60 years [1] and
standard regimens for active TB infections include two months treatment with INH,
rifampicin, pyrazinamide and ethambutol or streptomycin, followed by an additional four
months of INH and rifampicin treatment [2, 4, 5]. Management of latent TB infections
typically involves administration of INH alone (for 6 or 9 months) or in combination with
rifapentine (for 3 months) to individuals at high risk of developing active TB [6, 7].
Although effective, current therapeutic regimens are very lengthy and difficult to implement
[8], and TB remains a major global health problem with more than 9 million new cases and
1.5 million deaths reported in 2013 [9].
Author Manuscript

INH formulations are available as tablets (50, 100, or 300 mg) or solution (50 mg/5 ml) for
oral administration, or as injection solution (100 mg/ml) for intramuscular use. Two
combination formulations have additionally been approved for anti-TB therapy: Rifamate®
(capsules with 150 mg INH and 300 mg rifampin) and Rifater® (tablets with 50 mg INH,
120 mg rifampin and 300 mg pyrazinamide) [10]. All drug labels begin with a boxed

Correspondence to Dr. Teri E. Klein, PhD, Department of Genetics, Stanford School of Medicine, Shriram Center, 443 Via Ortega,
Room 213, Stanford, CA 94305-4125, USA. Tel: +1 650 736 0156; fax: +1 650 725 3863; [email protected].
Conflicts of Interest
RBA is a stockholder in Personalis, Inc. TEK is a paid scientific advisor to Rxight Pharmacogenetics. All other authors declare no
conflicts of interest.
 Klein et al. Page 2

warning regarding hepatotoxicity associated with INH therapy; peripheral neuropathy is

Author Manuscript

another common adverse reaction that can be avoided by co-administration of pyridoxine

supplements to susceptible individuals (e.g. malnourished, pregnant/breastfeeding, etc.) [2,
4, 5]. Treatment-induced hepatotoxicity and other serious adverse reactions cause
discontinuation in up to 10% of patients treated with standard regimens of first-line anti-TB
drugs, including INH [7, 11, 12]. Patients who develop INH-induced hepatotoxicity present
with symptoms such as abdominal pain, jaundice, nausea and vomiting, whereas features of
drug hypersensitivity (e.g. fever, rash, arthralgia, eosinophilia) are rare [4, 12, 13]. Although
extensively studied, the underlying mechanisms for INH-induced hepatotoxicity remain
unclear [14]. This is partly due to the complexity of these mechanisms, but also to the
difficulty in distinguishing between drug-specific and patient-related factors that may
determine susceptibility to INH toxicity [15]. This manuscript outlines the basic aspects of
INH absorption, distribution, metabolism and excretion (ADME) in humans, with special
Author Manuscript

emphasis on the influence of genetic polymorphisms in genes encoding xenobiotic-

metabolizing enzymes that modulate INH pharmacokinetics and, consequently, their
association with INH-induced hepatotoxicity.

ADME/Pharmacokinetics
Few studies have been conducted investigating the in situ intestinal permeability of INH
alone, though studies have been performed showing that INH has low permeability in the
stomach and high permeability in the three segments of the small intestine (duodenum,
jejunum, ileum) of rats [16, 17]. While the apparent permeability of the intestines and
intestinal absorption rate constant of INH appears to decrease upon simultaneous perfusion
with pyridoxine, no significant effects were concomitantly observed on INH
pharmacokinetics [18]. It is of note that the bioavailability of INH was not significantly
Author Manuscript

affected in tuberculosis patients who had undergone surgical procedures involving resection
of the stomach or parts of the intestinal tract [19, 20]. Absorption may be reduced by
concomitant administration of sugar or following food intake. This is likely due to the
conversion of INH to a hydrazone species, making it less available for absorption [21–23].
INH seems to be widely distributed to all fluids and tissues, according to the apparent value
of distribution volume (0.6 L/kg on average), with the largest accumulation in the liver; the
pharmacological model for INH seems to follow first-order kinetics [24].

In the liver and intestines, INH is predominantly metabolized (50–90%) via N-acetylation of
its hydrazine functionality by arylamine N-acetyltransferase 2 (NAT2; E.C. 2.3.1.5) to N-
acetylisoniazid (AcINH) (Figure 1) [14, 25–29]. INH can also be hydrolyzed to hydrazine
(Hz) by amidase with concomitant formation of isonicotinic acid (INA); it can also be
Author Manuscript

metabolized into oxoacid hydrazone species [14, 26–30]. In turn, AcINH may be
enzymatically hydrolyzed by amidase to form acetylhydrazine (AcHz) and INA [14, 27–32].
Additionally, AcHz can be deacetylated to Hz via hydrolysis by amidase or be further
acetylated by NAT2 to diacetylhydrazine [14, 27–30, 33]. Hz can be broken down to
ammonia or acetylated to AcHz by NAT2 [27–29]. None of the metabolites have known
antitubercular properties, apart from the hepatotoxic AcHz [23].

Pharmacogenet Genomics. Author manuscript; available in PMC 2017 September 01.

 Klein et al. Page 3

INH, AcHz, and Hz are likely oxidized, in part, by cytochrome P450 2E1 (CYP2E1) into
Author Manuscript

potentially hepatotoxic intermediates, however explicit evidence of this has not yet been
found [33–35]. These intermediates can then be dehydrated into compounds that covalently
bind with macromolecules in hepatocytes causing necrosis and, possibly, autoimmunity [14,
28, 36]. The glutathione S-transferase (GST) enzyme family can conjugate these potentially
harmful metabolites with glutathione, effectively removing these toxic metabolites [26, 35,
37]. Similar to CYP2E1, there have not been any studies explicitly detailing the metabolism
of INH accomplished by the GST enzymes [37].

Urinary excretion is the primary elimination route (approximately 80%) of most INH
metabolites (AcINH, AcHz, diacetylhydrazine) [38]; INA may be excreted as a free acid
metabolite or a conjugated species with glycine (isonicotinyl glycine) [27–29]. Less than
10% of the oral INH dose is excreted in the feces [39].
Author Manuscript

INH and toxicity

Anti-tuberculosis treatment drug-induced liver injury (ATT-DILI) is an adverse reaction that
may lead to poor compliance or interruption of treatment, and thus has implications for the
control of TB infections [13, 40]. INH treatment is associated with increased activity of liver
enzymes in 20% of patients and also with severe hepatotoxicity in 1–2% of patients [41–44].
INH thus constitutes the leading cause of hepatotoxicity in many countries [41–44]. A better
understanding of the risk factors and mechanisms behind INH-induced hepatotoxicity may
help in the prevention and mitigation of this complex drug reaction [42]. Reported possible
risk factors include advanced age, female sex/pregnancy, low body weight/malnutrition,
alcoholism, pre-existing abnormal liver function/liver transplantation, co-administration with
other hepatotoxic agents, chronic hepatitis B and C infection, AIDS, and genetic factors [13,
Author Manuscript

42]. No consistent associations between race and INH-induced hepatotoxicity are evident
[13]. Despite these postulated associations, the precise mechanism underlying INH-induced
hepatotoxicity remains unclear; numerous different mechanisms are likely to be involved
and influenced by multiple factors [13, 15, 42].

INH-induced hepatotoxicity has traditionally been attributed to the cytotoxic effects of INH
metabolites, particularly AcHz and Hz [14, 29]. However, several features of this
hepatotoxicity, such as a delay in liver injury after drug onset or the activation of
macrophages by INH, are indicative of an immune response (see recent review by Metushi
and colleagues for a thorough account of possible immune-related components of INH
DILI) [14]. A recent study also reported detection of covalent INH adducts with CYP2E1,
CYP3A4 and CYP2C9 in the serum of INH-treated patients developing ATT-DILI, pointing
to immunological response as the underlying mechanism of hepatotoxicity [45].
Author Manuscript

As previously discussed, INH, AcHz, and Hz can be oxidized, potentially by CYP2E1, to

hydroxyl-hydrazine intermediates that are then dehydrated to more damaging metabolites.
These metabolites have the capacity to covalently bind macromolecules, causing liver injury
[14, 15, 28, 36]. Hz and ammonia may also contribute to toxicity [14, 26, 29]. AcINH is less
toxic than INH, but is not a potential therapeutic alternative due to its 100-fold less anti-
mycobacterial activity and its ability to be hydrolyzed to hepatotoxic AcHz [14, 26–29].

Pharmacogenet Genomics. Author manuscript; available in PMC 2017 September 01.

 Klein et al. Page 4

Mitochondrial abnormalities have been linked to the toxicity of an array of drugs [46]. With
Author Manuscript

respect to INH-induced hepatotoxicity, mitochondrial dysfunction appears to be caused by

Hz, support for which comes from the observation that rat liver cells develop
megamitochondria upon exposure to this particular metabolite prior to apoptosis. This
finding is consistent with adaptive responses to oxidant stress and/or reduced oxygen
consumption rates [47]. Mechanistically, the finding that Hz inhibits the succinate
dehydrogenase enzyme in a dose-dependent manner suggests that complex II and/or the
tricarboxylic acid cycle may also be affected, but the nature of this effect is unclear [48]. The
various postulated mechanisms underlying the toxicological hazard posed by INH on liver
cells have been extensively discussed recently [12] and include oxidative stress and
disruption of energy homeostasis attributable to mitochondrial damage.

It is also worth noting that INH is rarely administered alone and some of the toxic effects
seen in patients treated with INH may be due to, or exacerbated by, drug-drug interactions
Author Manuscript

[7, 12, 13, 49–54].

Pharmacogenetics
As ATT-DILI remains unpredictable, even when environmental factors and drug regimen are
considered, polymorphisms within genes involved in the INH pharmacokinetic pathway
have been investigated in order to identify possible biomarkers for hepatotoxicity risk. These
associations and the possible reasons behind a lack of consensus between studies are
discussed below and summarized in Table 1.

NAT2
Studies unraveling the genetic basis of N-acetylation first appeared around 1990; an
Author Manuscript

exhaustive review of INH acetylation pharmacogenetics in the NAT2 pre-genotyping era was
published by Weber and Hein [55] and the subject has subsequently been reviewed by many
authors, more recently by McDonagh and colleagues [56]. When examining plasma
concentrations of INH over time after an oral dose, a bimodal pattern was originally
observed; higher plasma levels and reduced clearance of the drug were seen in slow
acetylators compared to rapid acetylators. More refined phenotypic analysis further
demonstrated a trimodal population distribution pattern; subjects can be divided into rapid,
intermediate or slow acetylators [55]. Following the development of genotyping techniques
for the NAT2 gene, prediction of the acetylator phenotype has become possible through
genetic testing. There are many different alleles described for the NAT2 gene (NAT Gene
Nomenclature website) and an individual’s genotype can be predictive of rapid, slow or
intermediate acetylator phenotype, depending on the presence of two “rapid” alleles, two
Author Manuscript

“slow” alleles or one of each, respectively [57]. The reference NAT2*4 allele is the most
common NAT2 allele conferring the rapid acetylator phenotype and is associated with
increased metabolism and clearance of INH [56, 58, 59]. Conversely, the polymorphic NAT2
alleles of the main allelic groups *5, *6, *7 and *14 encode for slow acetylator enzyme
variants that may compromise the drug-metabolizing ability of individuals [56].

An investigation of NAT2 genotype as a pharmacogenetic biomarker for personalization of

INH therapeutic dosage demonstrated a linear relationship between clearance of the drug

Pharmacogenet Genomics. Author manuscript; available in PMC 2017 September 01.

 Klein et al. Page 5

and the number (0 in slow, 1 in intermediate or 2 in rapid acetylators) of NAT2*4 alleles;

Author Manuscript

this specific parameter accounted for 88% of the INH clearance variability observed in the
Caucasian population studied [60]. Similar conclusions were drawn by another study with
Japanese TB patients treated with INH and rifampicin. Genotyped NAT2 slow acetylators
(no *4 allele) exhibited significantly decreased acetylation of INH and Hz, resulting in
increased serum concentrations of INH compared to intermediate (one *4 allele) or rapid
(two *4 alleles) acetylators [26]. Rapid acetylators display higher levels of AcINH and
AcHz in serum and clear AcHz more quickly when compared to slow acetylators, whereas
slow acetylators have higher exposure to AcHz and excrete more unchanged INH in urine
[13, 26].

Apart from INH acetylation, NAT2 also catalyzes the acetylation of AcHz to non-toxic
diacetylhydrazine [55], and thus slow acetylator status causes accumulation of both Hz and
AcHz to potentially hepatotoxic levels [15, 61]. Consequently, the NAT2 slow acetylator
Author Manuscript

phenotype and genotype have been associated with an increased risk of INH-induced
hepatotoxicity in the majority of published pharmacogenetic studies (Table 1); the patient
cohorts genotyped are of various geographic origins, mainly from South America [62–66],
East Asia [35, 67–75], South Asia [40, 76–78], Iran [79], Turkey [80] and Tunisia [81]. The
labels of all INH-containing drug formulations currently approved by the FDA inform that
slow acetylators may have increased blood levels of the compound, which results in an
increased risk of hepatotoxicity and peripheral neuropathy [10]. The NAT2 gene is included
in the pharmacogenomic biomarkers list of the FDA in relation with INH, but no specific
actions are recommended on the basis of this information.

Contradictory results regarding the acetylator status and risk of INH hepatotoxicity have also
been reported in the literature. An early study [36] attributed INH hepatotoxicity to the
Author Manuscript

NAT2 rapid acetylator phenotype, presumably associated with increased plasma levels of
AcHz. However, a series of ensuing pharmacological studies (reviewed by Weber and Hein
[55]) showed the opposite or no association between the acetylator phenotype and INH
hepatotoxicity. A small number of recent studies have also reported no association between
the acetylator genotype and INH-induced hepatotoxicity [82–86] (Table 1).

A recent clinical trial reported a significantly lower relative risk of unfavorable events in
patients treated with an INH dose based on NAT2 genotype, compared to those treated with
the standard dose, supporting a clinically-relevant association between NAT2 variants and
INH pharmacokinetics [87]. Importantly, in the genotype-based treatment group, efficacy of
treatment in NAT2 slow acetylators was not reduced despite the lower doses administered.
Also, incidence of INH-induced liver injury was not increased in rapid acetylators when
Author Manuscript

INH was given in higher doses [87]. More independent studies are required to verify these
results.

With regard to individual NAT2 single nucleotide polymorphisms (SNPs), rs1799930

(NM_000015.2:c.590G>A, signature SNP for the NAT2*6 allelic group) has been associated
with decreased acetylation of INH and clearance of the drug, which correlated with an
enhanced risk of drug-induced hepatitis [64, 75, 77]. The NAT2*6 signature polymorphism
has been reported to confer an ultra-slow acetylator phenotype [88, 89], and this could

Pharmacogenet Genomics. Author manuscript; available in PMC 2017 September 01.

 Klein et al. Page 6

explain the higher risk of INH-induced hepatotoxicity in slow acetylators carrying this
Author Manuscript

particular SNP. A slow acetylator haplotype composed of rs4646244

(NM_00015.2:c.-1144T>A) allele A, rs4646267 (NM_000015.2:c.-949A>G) allele A,
rs1799930 allele A, and rs1799931 (NM_000015.2:c.857G>A, signature SNP for the
NAT2*7 allelic group) allele G, has been associated with an increased risk of hepatotoxicity.
Patients with this haplotype had significantly decreased acetylation and clearance of INH, as
compared to the other haplotypes examined, and this is likely attributed to the presence of
the ultra-slow NAT2*6 signature SNP [75]. Another study has correlated genotype AA of
rs1495741 (NC_000008.10:g.18272881G>A, a tag SNP located about 14 kb downstream of
NAT2) with increased risk of INH hepatotoxicity [69]. This association is indirect, as the A
allele of rs1495741 is likely to be in linkage disequilibrium with a slow NAT2 variant [90].

CYP2E1
Author Manuscript

CYP2E1 is involved in the oxidation of INH, AcHz, and Hz, resulting in likely hepatotoxic
intermediates that undergo further dehydration to potentially harmful products [14, 26, 28,
33–35, 68]. Polymorphisms of the CYP2E1 gene have been examined in association with
risk of INH-mediated ATT-DILI, mainly by investigators in South [40, 76–78, 84] and East
[26, 35, 67, 68, 71, 74, 75, 91–93] Asia and South America [62, 63, 65, 66]. Although some
studies have reported higher risk of ATT-DILI in INH-treated patients who bear high-activity
alleles of CYP2E1, particularly *1A and *6 [76, 84, 85, 91, 92], other studies have found no
association [35, 62, 63, 65–68, 71, 74, 75, 77, 78, 86, 93, 94] and, therefore, a direct role for
CYP2E1 in INH-induced hepatotoxicity remains widely controversial (Table 1). Evidence
suggests that CYP2E1 polymorphisms may be associated with increased severity of INH
related ATT-DILI, rather than enhanced susceptibility to it [71]. Studies also report increased
risk of ATT-DILI in INH-treated patients who combine high-activity CYP2E1 and slow
Author Manuscript

NAT2 genotypes [66, 67, 76, 91, 95].

Since the generation of many INH metabolites does not depend exclusively on CYPs,
attention has somewhat shifted away from CYP2E1 as a major predictor of hepatotoxicity
[12, 34]. Nonetheless, the observation that CYP2E1 is expressed in mitochondria and is one
of the CYP forms that generates relatively high levels of reactive oxygen species may point
to a role for CYP2E1 in increasing the extent of oxidative stress [96, 97]. Moreover, anti-
INH and anti-CYP2E1 antibodies have been found in the serum of patients with INH-
induced liver failure; INH-CYP2E1 covalent adducts were also detected, as well as
antibodies against them [45]. Such auto-antibodies are considered markers of CYP2E1-
directed autoimmunity, which may lead to liver injury [98]. INH has been shown to induce
CYP2E1 enzyme activity [99] and experiments with animal models support CYP2E1-
mediated hepatotoxicity when INH is administered [100].
Author Manuscript

GSTM1 and GSTT1

The GSTs are involved in the detoxification of numerous drugs and oxidative stress
products; due to this role, polymorphisms of the GSTM1 and GSTT1 genes have also been
investigated in risk of ATT-DILI [101]. GSTs are known to be involved in the metabolism of
anti-TB drugs via conjugation of potentially harmful metabolites; however, the specifics
about this interaction are unknown [35, 37]. Deficiencies in GST activity due to

Pharmacogenet Genomics. Author manuscript; available in PMC 2017 September 01.

 Klein et al. Page 7

homozygous null mutations in GSTM1 and GSTT1 may have the potential to modulate
Author Manuscript

susceptibility to INH-induced hepatotoxicity [15]. Indeed, several published studies have

reported an association between GSTM1 homozygous null genotype and increased risk of
ATT-DILI [26, 37, 102, 103], although the majority of studies report no association found
[35, 63, 65, 74, 92, 93, 104–106] (Table 1). A similar pattern is seen for the GSTT1
homozygous null genotype, with one study from Spain describing an association with
increased risk of ATT-DILI [106], but the majority of studies (in Asia or Brazil) reporting no
association [35, 37, 63, 65, 74, 93, 102–105] (Table 1). Studies have also shown an additive
effect of combined GSTM1 and GSTT1 null genotypes on risk of INH hepatotoxicity [40,
103], as well as of combined NAT2, CYP2E1, GSTM1 and/or GSTT1 polymorphic
genotypes [63]. There does not seem to be a consistent pattern of factors that indicate why
these contradictory results have been observed.

Other genes
Author Manuscript

It is likely that multiple genetic factors and gene-gene interactions are involved in INH-
induced hepatotoxicity risk, as is the case for other hepatotoxic drugs [107]. Indeed,
significant associations with risk have been reported for genotypes of other genes [102, 108]
(Table 1), which further complicates the assessment of possible risk factors. INH liver injury
was associated with certain major histocompatibility complex (MHC) class II alleles,
including human leukocyte antigen (HLA) haplotypes, which supports the role of the
immune system in INH toxicity [14]. The absence of the HLA-DQA1*0102 allele and the
presence of the HLA-DQB1*0201 allele were reported to be independently associated with
increased risk of ATT-DILI in 331 TB patients [109]; however, the Bonferroni correction
introduced to compare the distribution of both alleles in ATT-DILI and non-ATT-DILI
patients could only confirm the negative association of DQA1*0102 with ATT-DILI, but was
Author Manuscript

not clearly explained. Generally, only some cases of ATT-DILI associated with INH are
suggested to be immune-mediated and HLA-associated, which may explain the discrepancy
observed in some studies [14]. Overall, a direct association of ATT-DILI with HLA alleles
may be difficult or not possible to establish at this stage [110].

One study in Japanese patients found associations between INH-induced hepatotoxicity and
particular polymorphisms in the genes involved in one of the antioxidant pathways. Among
these positive correlations, one polymorphism in NOS2A, which encodes inducible nitric
oxide synthase, causes an increase in nitric oxide production. Polymorphisms in BACH1
(encoding basic leucine zipper transcription factor 1) and MAFK (encoding v-maf avian
musculoaponeurotic fibrosarcoma oncogene homologue K) result in suppression of the
nuclear factor erythroid 2-like 2 (Nrf2) pathway [108] (Table 1). However, it remains
mechanistically unclear how these mutations may contribute to ATT-DILI.
Author Manuscript

Meta-analyses of NAT2, CYP2E1, GSTM1 and GSTT1 genotypes

Several meta-analyses have been published to examine the association between ATT-DILI
and genetic variants of drug metabolizing enzymes. A large meta-analysis of 38 studies
found NAT2 slow acetylator genotype to be significantly associated with risk of ATT-DILI
[111]. A meta-analysis of 4 studies found an association between increased risk of ATT-

Pharmacogenet Genomics. Author manuscript; available in PMC 2017 September 01.

 Klein et al. Page 8

DILI and NAT2 slow acetylator status (defined as non-carrier of the *4 allele, as opposed to
Author Manuscript

rapid acetylator status defined as heterozygous or homozygous for *4) in TB patients of

Asian ethnicity (OR=2.52, CI=1.49–4.26, p-value not provided) [112]. However, in another
larger meta-analysis with some overlapping studies, a significant association between ATT-
DILI and NAT2 slow acetylator status was observed in both Asian and non-Asian patients
[113]. The same meta-analysis, which also analyzed different treatment combinations, found
a significantly increased risk of ATT-DILI with NAT2 slow acetylator status compared to the
rapid status in patients treated with INH, rifampicin, pyrazinamide and ethambutol (9
studies, OR=4.09, 95% CI=2.78–6.03, p<0.001), or INH and rifampicin (3 studies,
OR=34.30, 95% CI=10.41–113.00, p<0.001), but not with INH only (2 studies, OR=2.36,
95% CI=0.52–10.73, p<0.266) [113].

One meta-analysis showed that the CYP2E1*1A/*1A high-activity genotype is significantly

associated with risk of ATT-DILI, but only in East Asian patients [111]. CYP2E1*1A/*1A
Author Manuscript

genotype was significantly associated with increased risk of ATT-DILI compared to all other
genotypes in a meta-analysis of 4 studies (OR=2.22, 95% CI=1.06–4.66, p=0.03) [112].
Finally, the CYP2E1*1A/*1A genotype was determined to be a risk factor for ATT-DILI,
particularly when combined with the slow acetylator NAT2 genotype (OR=3.10, 95%
CI=1.83–5.26. p<0.0001) [95].

While two meta-analyses have shown significant associations of the GSTM1 null genotype
with risk of ATT-DILI, neither meta-analysis found such an association for the GSTT1 null
genotype [111, 112]. A recent large-scale meta-analysis of GST variants, which included 13
and 12 case-control studies for the GSTM1 and GSTT1 null genotypes, respectively
(approximately 900 cases and 1900 controls for each gene), found evidence that the null
genotype of GSTM1, but not GSTT1, was associated with marginally increased
Author Manuscript

susceptibility to ATT-DILI [114], which was consistent with the previous meta-analyses
[111, 112].

Conclusion
The current consensus among the literature is that one mechanism is unlikely to explain
INH-induced hepatotoxicity and that numerous pathways are probably involved. Different
drug-specific mechanisms have been suggested, but most supporting data have been
generated from cellular and animal models and thus do not account for the multitude of
factors that may contribute to susceptibility to INH-induced hepatotoxicity in clinical
settings. Variants of enzymes involved in the INH metabolic pathway have been associated
with ATT-DILI, particularly the slow acetylator variant of NAT2. However, upon comparing
studies in Table 1, there does not seem to be an obvious underlying factor that explains why
Author Manuscript

some studies found an association and others did not; it is likely that many factors, such as
inconsistent genotyping and phenotyping methods, study design, anti-TB drug regimen and
the overall condition of patients, may contribute to risk of INH-induced hepatotoxicity.
Future investigations that utilize DNA sequencing may lead to further identification of
variants contributing to ATT-DILI. Large-scale, robust analyses of these underlying genetic
and environmental risk factors in clinical settings will help uncover the full picture of these
important and complex adverse reactions.

Pharmacogenet Genomics. Author manuscript; available in PMC 2017 September 01.

 Klein et al. Page 9

Acknowledgments
Author Manuscript

This work is supported by the NIH/NIGMS (R24 GM61374).

Abbreviations
INH Isoniazid

AcINH N-acetylisoniazid

INA isonicotinic acid

AcHz acetylhydrazine

Hz hydrazine
Author Manuscript

ATT-DILI anti-tuberculosis treatment drug-induced liver injury

References
1. Isoniazid. Tuberculosis (Edinb). 2008; 88:112–116. [PubMed: 18486045]
2. Blumberg HM, Burman WJ, Chaisson RE, Daley CL, Etkind SC, Friedman LN, Fujiwara P,
Grzemska M, Hopewell PC, Iseman MD, et al. American Thoracic Society/Centers for Disease
Control and Prevention/Infectious Diseases Society of America: Treatment of Tuberculosis. Am J
Respir Crit Care Med. 2003; 167:603–662. [PubMed: 12588714]
3. Migliori GB, Zellweger JP, Abubakar I, Ibraim E, Caminero JA, De Vries G, D’Ambrosio L, Centis
R, Sotgiu G, Menegale O, et al. European Union Standards for Tuberculosis Care. Eur Respir J.
2012; 39:807–819. [PubMed: 22467723]
4. World Health Organization. Treatment of Tuberculosis: Guidelines. 4th. Geneva: World Health
Organization; 2010. Stop TB Initiative (World Health Organization).
5. Migliori GB, Raviglione MC, Schaberg T, Davies PD, Zellweger JP, Grzemska M, Mihaescu T,
Author Manuscript

Clancy L, Casali L. Tuberculosis Management in Europe. Task Force of the European Respiratory
Society (Ers), the World Health Organisation (Who) and the International Union against
Tuberculosis and Lung Disease (Iuatld) Europe Region. Eur Respir J. 1999; 14:978–992. [PubMed:
10573254]
6. Chapman HJ, Lauzardo M. Advances in Diagnosis and Treatment of Latent Tuberculosis Infection. J
Am Board Fam Med. 2014; 27:704–712. [PubMed: 25201941]
7. Forget EJ, Menzies D. Adverse Reactions to First-Line Antituberculosis Drugs. Expert Opin Drug
Saf. 2006; 5:231–249. [PubMed: 16503745]
8. Handbook of Anti-Tuberculosis Agents. Introduction. Tuberculosis (Edinb). 2008; 88:85–86.
[PubMed: 18486036]
9. World Health Organization. Global Tuberculosis Report 2014. Geneva: World Health Organization;
2014.
10. U.S. FDA. Drugs@Fda Database. https://www.accessdata.fda.gov/scripts/cder/drugsatfda/
11. Schaberg T, Rebhan K, Lode H. Risk Factors for Side-Effects of Isoniazid, Rifampin and
Author Manuscript

Pyrazinamide in Patients Hospitalized for Pulmonary Tuberculosis. Eur Respir J. 1996; 9:2026–
2030. [PubMed: 8902462]
12. Boelsterli UA, Lee KK. Mechanisms of Isoniazid-Induced Idiosyncratic Liver Injury: Emerging
Role of Mitochondrial Stress. J Gastroenterol Hepatol. 2014; 29:678–687. [PubMed: 24783247]
13. Saukkonen JJ, Cohn DL, Jasmer RM, Schenker S, Jereb JA, Nolan CM, Peloquin CA, Gordin FM,
Nunes D, Strader DB, et al. An Official Ats Statement: Hepatotoxicity of Antituberculosis
Therapy. Am J Respir Crit Care Med. 2006; 174:935–952. [PubMed: 17021358]
14. Metushi IG, Cai P, Zhu X, Nakagawa T, Uetrecht JP. A Fresh Look at the Mechanism of Isoniazid-
Induced Hepatotoxicity. Clin Pharmacol Ther. 2011; 89:911–914. [PubMed: 21412230]

Pharmacogenet Genomics. Author manuscript; available in PMC 2017 September 01.

 Klein et al. Page 10

15. Ramappa V, Aithal GP. Hepatotoxicity Related to Anti-Tuberculosis Drugs: Mechanisms and
Management. J Clin Exp Hepatol. 2013; 3:37–49. [PubMed: 25755470]
Author Manuscript

16. Kasim NA, Whitehouse M, Ramachandran C, Bermejo M, Lennernas H, Hussain AS, Junginger
HE, Stavchansky SA, Midha KK, Shah VP, Amidon GL. Molecular Properties of Who Essential
Drugs and Provisional Biopharmaceutical Classification. Molecular pharmaceutics. 2004; 1:85–96.
[PubMed: 15832504]
17. Mariappan TT, Singh S. Regional Gastrointestinal Permeability of Rifampicin and Isoniazid
(Alone and Their Combination) in the Rat. The international journal of tuberculosis and lung
disease: the official journal of the International Union against Tuberculosis and Lung Disease.
2003; 7:797–803.
18. Zhou Y, Jiao Y, Wei YH, Zhang GR, Zhang JP, Ren JX, Zhang F, Zhang GQ, Duan HG, Wu XA.
Effects of Pyridoxine on the Intestinal Absorption and Pharmacokinetics of Isoniazid in Rats.
European journal of drug metabolism and pharmacokinetics. 2013; 38:5–13. [PubMed: 23090666]
19. Kleber FX. Absorption of Anti-Tuberculous Drugs after Gastric Surgery (Author’s Transl). Praxis
und Klinik der Pneumologie. 1979; 33:38–44. [PubMed: 760100]
20. Polk RE, Tenenbaum M, Kline B. Isoniazid and Ethambutol Absorption with Jejunoileal Bypass.
Author Manuscript

Annals of internal medicine. 1978; 89:430–431. [PubMed: 686569]

21. Lin MY, Lin SJ, Chan LC, Lu YC. Impact of Food and Antacids on the Pharmacokinetics of Anti-
Tuberculosis Drugs: Systematic Review and Meta-Analysis. The international journal of
tuberculosis and lung disease: the official journal of the International Union against Tuberculosis
and Lung Disease. 2010; 14:806–818.
22. Rao KV, Kailasam S, Menon NK, Radhakrishna S. Inactivation of Isoniazid by Condensation in a
Syrup Preparation. Indian J Med Res. 1971; 59:1343–1353. [PubMed: 5161562]
23. Becker C, Dressman JB, Amidon GL, Junginger HE, Kopp S, Midha KK, Shah VP, Stavchansky S,
Barends DM. Biowaiver Monographs for Immediate Release Solid Oral Dosage Forms: Isoniazid.
Journal of pharmaceutical sciences. 2007; 96:522–531. [PubMed: 17117431]
24. O’Neil, MJ.; Merck Research Laboratories. The Merck Index: An Encyclopedia of Chemicals,
Drugs, and Biologicals. 14th. Whitehouse Station, N.J.: Merck; 2006.
25. Windmill KF, Gaedigk A, Hall PM, Samaratunga H, Grant DM, McManus ME. Localization of N-
Acetyltransferases Nat1 and Nat2 in Human Tissues. Toxicological sciences: an official journal of
the Society of Toxicology. 2000; 54:19–29. [PubMed: 10746928]
Author Manuscript

26. Fukino K, Sasaki Y, Hirai S, Nakamura T, Hashimoto M, Yamagishi F, Ueno K. Effects of N-

Acetyltransferase 2 (Nat2), Cyp2e1 and Glutathione-S-Transferase (Gst) Genotypes on the Serum
Concentrations of Isoniazid and Metabolites in Tuberculosis Patients. J Toxicol Sci. 2008; 33:187–
195. [PubMed: 18544910]
27. Mahapatra S, Woolhiser LK, Lenaerts AJ, Johnson JL, Eisenach KD, Joloba ML, Boom WH,
Belisle JT. A Novel Metabolite of Antituberculosis Therapy Demonstrates Host Activation of
Isoniazid and Formation of the Isoniazid-Nad+ Adduct. Antimicrob Agents Chemother. 2012;
56:28–35. [PubMed: 22037847]
28. Preziosi P. Isoniazid: Metabolic Aspects and Toxicological Correlates. Curr Drug Metab. 2007;
8:839–851. [PubMed: 18220565]
29. Tostmann A, Boeree MJ, Aarnoutse RE, de Lange WC, van der Ven AJ, Dekhuijzen R.
Antituberculosis Drug-Induced Hepatotoxicity: Concise up-to-Date Review. J Gastroenterol
Hepatol. 2008; 23:192–202. [PubMed: 17995946]
30. Sarich TC, Adams SP, Petricca G, Wright JM. Inhibition of Isoniazid-Induced Hepatotoxicity in
Author Manuscript

Rabbits by Pretreatment with an Amidase Inhibitor. J Pharmacol Exp Ther. 1999; 289:695–702.
[PubMed: 10215642]
31. Ellard GA, Gammon PT. Pharmacokinetics of Isoniazid Metabolism in Man. J Pharmacokinet
Biopharm. 1976; 4:83–113. [PubMed: 950592]
32. Ellard GA, Gammon PT, Wallace SM. The Determination of Isoniazid and Its Metabolites
Acetylisoniazid, Monoacetylhydrazine, Diacetylhydrazine, Isonicotinic Acid and
Isonicotinylglycine in Serum and Urine. Biochem J. 1972; 126:449–458. [PubMed: 5075259]
33. Daly AK, Day CP. Genetic Association Studies in Drug-Induced Liver Injury. Drug Metab Rev.
2012; 44:116–126. [PubMed: 21913872]

Pharmacogenet Genomics. Author manuscript; available in PMC 2017 September 01.

 Klein et al. Page 11

34. Cheng J, Krausz KW, Li F, Ma X, Gonzalez FJ. Cyp2e1-Dependent Elevation of Serum

Cholesterol, Triglycerides, and Hepatic Bile Acids by Isoniazid. Toxicol Appl Pharmacol. 2013;
Author Manuscript

266:245–253. [PubMed: 23142471]

35. Sotsuka T, Sasaki Y, Hirai S, Yamagishi F, Ueno K. Association of Isoniazid-Metabolizing Enzyme
Genotypes and Isoniazid-Induced Hepatotoxicity in Tuberculosis Patients. In Vivo. 2011; 25:803–
812. [PubMed: 21753138]
36. Mitchell JR, Thorgeirsson UP, Black M, Timbrell JA, Snodgrass WR, Potter WZ, Jollow HR,
Keiser HR. Increased Incidence of Isoniazid Hepatitis in Rapid Acetylators: Possible Relation to
Hydranize Metabolites. Clin Pharmacol Ther. 1975; 18:70–79. [PubMed: 1149365]
37. Roy B, Chowdhury A, Kundu S, Santra A, Dey B, Chakraborty M, Majumder PP. Increased Risk
of Antituberculosis Drug-Induced Hepatotoxicity in Individuals with Glutathione S-Transferase
M1 ‘Null’ Mutation. J Gastroenterol Hepatol. 2001; 16:1033–1037. [PubMed: 11595069]
38. Baselt, RC. Disposition of Toxic Drugs and Chemicals in Man. 6th. Foster City: Biomedical
Publications; 2002.
39. Holdiness MR. Clinical Pharmacokinetics of the Antituberculosis Drugs. Clinical
pharmacokinetics. 1984; 9:511–544. [PubMed: 6391781]
Author Manuscript

40. Singla N, Gupta D, Birbian N, Singh J. Association of Nat2, Gst and Cyp2e1 Polymorphisms and
Anti-Tuberculosis Drug-Induced Hepatotoxicity. Tuberculosis (Edinb). 2014; 94:293–298.
[PubMed: 24637014]
41. Garibaldi RA, Drusin RE, Ferebee SH, Gregg MB. Isoniazid-Associated Hepatitis. Report of an
Outbreak. Am Rev Respir Dis. 1972; 106:357–365. [PubMed: 5080707]
42. Huang YS. Recent Progress in Genetic Variation and Risk of Antituberculosis Drug-Induced Liver
Injury. J Chin Med Assoc. 2014; 77:169–173. [PubMed: 24593909]
43. Scharer L, Smith JP. Serum Transaminase Elevations and Other Hepatic Abnormalities in Patients
Receiving Isoniazid. Ann Intern Med. 1969; 71:1113–1120. [PubMed: 5361410]
44. Tafazoli S, Mashregi M, O’Brien PJ. Role of Hydrazine in Isoniazid-Induced Hepatotoxicity in a
Hepatocyte Inflammation Model. Toxicol Appl Pharmacol. 2008; 229:94–101. [PubMed:
18295292]
45. Metushi IG, Sanders C, Lee WM, Uetrecht J. Detection of Anti-Isoniazid and Anti-Cytochrome
P450 Antibodies in Patients with Isoniazid-Induced Liver Failure. Hepatology. 2014; 59:1084–
Author Manuscript

1093. [PubMed: 23775837]

46. Labbe G, Pessayre D, Fromenty B. Drug-Induced Liver Injury through Mitochondrial Dysfunction:
Mechanisms and Detection During Preclinical Safety Studies. Fundam Clin Pharmacol. 2008;
22:335–353. [PubMed: 18705745]
47. Karbowski M, Kurono C, Wozniak M, Ostrowski M, Teranishi M, Nishizawa Y, Usukura J, Soji T,
Wakabayashi T. Free Radical-Induced Megamitochondria Formation and Apoptosis. Free Radic
Biol Med. 1999; 26:396–409. [PubMed: 9895232]
48. Lee KK, Fujimoto K, Zhang C, Schwall CT, Alder NN, Pinkert CA, Krueger W, Rasmussen T,
Boelsterli UA. Isoniazid-Induced Cell Death Is Precipitated by Underlying Mitochondrial
Complex I Dysfunction in Mouse Hepatocytes. Free Radic Biol Med. 2013; 65:584–594.
[PubMed: 23911619]
49. Apostolova N, Gomez-Sucerquia LJ, Moran A, Alvarez A, Blas-Garcia A, Esplugues JV. Enhanced
Oxidative Stress and Increased Mitochondrial Mass During Efavirenz-Induced Apoptosis in
Human Hepatic Cells. Br J Pharmacol. 2010; 160:2069–2084. [PubMed: 20649602]
50. Blas-Garcia A, Apostolova N, Ballesteros D, Monleon D, Morales JM, Rocha M, Victor VM,
Author Manuscript

Esplugues JV. Inhibition of Mitochondrial Function by Efavirenz Increases Lipid Content in

Hepatic Cells. Hepatology. 2010; 52:115–125. [PubMed: 20564379]
51. Guo YX, Xu XF, Zhang QZ, Li C, Deng Y, Jiang P, He LY, Peng WX. The Inhibition of Hepatic
Bile Acids Transporters Ntcp and Bsep Is Involved in the Pathogenesis of Isoniazid/Rifampicin-
Induced Hepatotoxicity. Toxicol Mech Methods. 2015:1–6.
52. Hoffmann CJ, Charalambous S, Thio CL, Martin DJ, Pemba L, Fielding KL, Churchyard GJ,
Chaisson RE, Grant AD. Hepatotoxicity in an African Antiretroviral Therapy Cohort: The Effect
of Tuberculosis and Hepatitis B. AIDS. 2007; 21:1301–1308. [PubMed: 17545706]

Pharmacogenet Genomics. Author manuscript; available in PMC 2017 September 01.

 Klein et al. Page 12

53. Li F, Lu J, Cheng J, Wang L, Matsubara T, Csanaky IL, Klaassen CD, Gonzalez FJ, Ma X. Human
Pxr Modulates Hepatotoxicity Associated with Rifampicin and Isoniazid Co-Therapy. Nat Med.
Author Manuscript

2013; 19:418–420. [PubMed: 23475203]

54. Suzuki A, Yuen NA, Ilic K, Miller RT, Reese MJ, Brown HR, Ambroso JI, Falls JG, Hunt CM.
Comedications Alter Drug-Induced Liver Injury Reporting Frequency: Data Mining in the Who
Vigibase. Regul Toxicol Pharmacol. 2015; 72:481–490. [PubMed: 25988394]
55. Weber WW, Hein DW. N-Acetylation Pharmacogenetics. Pharmacol Rev. 1985; 37:25–79.
[PubMed: 2860675]
56. McDonagh EM, Boukouvala S, Aklillu E, Hein DW, Altman RB, Klein TE. Pharmgkb Summary:
Very Important Pharmacogene Information for N-Acetyltransferase 2. Pharmacogenet Genomics.
2014; 24:409–425. [PubMed: 24892773]
57. Stanley LA, Sim E. Update on the Pharmacogenetics of Nats: Structural Considerations.
Pharmacogenomics. 2008; 9:1673–1693. [PubMed: 19018723]
58. Vatsis KP, Weber WW, Bell DA, Dupret JM, Evans DA, Grant DM, Hein DW, Lin HJ, Meyer UA,
Relling MV, et al. Nomenclature for N-Acetyltransferases. Pharmacogenetics. 1995; 5:1–17.
[PubMed: 7773298]
Author Manuscript

59. Sabbagh A, Darlu P, Crouau-Roy B, Poloni ES. Arylamine N-Acetyltransferase 2 (Nat2) Genetic
Diversity and Traditional Subsistence: A Worldwide Population Survey. PLoS One. 2011;
6:e18507. [PubMed: 21494681]
60. Kinzig-Schippers M, Tomalik-Scharte D, Jetter A, Scheidel B, Jakob V, Rodamer M, Cascorbi I,
Doroshyenko O, Sorgel F, Fuhr U. Should We Use N-Acetyltransferase Type 2 Genotyping to
Personalize Isoniazid Doses? Antimicrob Agents Chemother. 2005; 49:1733–1738. [PubMed:
15855489]
61. Timbrell JA, Scales MD, Streeter AJ. Studies on Hydrazine Hepatotoxicity. 2. Biochemical
Findings. J Toxicol Environ Health. 1982; 10:955–968. [PubMed: 7161842]
62. Chamorro JG, Castagnino JP, Musella RM, Nogueras M, Aranda FM, Frias A, Visca M, Aidar O,
Peres S, de Larranaga GF. Sex, Ethnicity, and Slow Acetylator Profile Are the Major Causes of
Hepatotoxicity Induced by Antituberculosis Drugs. J Gastroenterol Hepatol. 2013; 28:323–328.
[PubMed: 23190413]
63. Costa GN, Magno LA, Santana CV, Konstantinovas C, Saito ST, Machado M, Di Pietro G, Bastos-
Rodrigues L, Miranda DM, De Marco LA, et al. Genetic Interaction between Gstm1 Gstt1
Author Manuscript

Cyp2e1, and Environmental Factors Is Associated with Adverse Reactions to Anti-Tuberculosis

Drugs. Mol Diagn Ther. 2012; 16:241–250. [PubMed: 22788240]
64. Possuelo LG, Castelan JA, de Brito TC, Ribeiro AW, Cafrune PI, Picon PD, Santos AR, Teixeira
RL, Gregianini TS, Hutz MH, et al. Association of Slow N-Acetyltransferase 2 Profile and Anti-
Tb Drug-Induced Hepatotoxicity in Patients from Southern Brazil. Eur J Clin Pharmacol. 2008;
64:673–681. [PubMed: 18421452]
65. Teixeira RL, Morato RG, Cabello PH, Muniz LM, Moreira Ada S, Kritski AL, Mello FC, Suffys
PN, Miranda AB, Santos AR. Genetic Polymorphisms of Nat2, Cyp2e1 and Gst Enzymes and the
Occurrence of Antituberculosis Drug-Induced Hepatitis in Brazilian Tb Patients. Mem Inst
Oswaldo Cruz. 2011; 106:716–724. [PubMed: 22012226]
66. Santos NP, Callegari-Jacques SM, Ribeiro Dos, Santos AK, Silva CA, Vallinoto AC, Fernandes
DC, de Carvalho DC, Santos SE, Hutz MH. N-Acetyl Transferase 2 and Cytochrome P450 2e1
Genes and Isoniazid-Induced Hepatotoxicity in Brazilian Patients. Int J Tuberc Lung Dis. 2013;
17:499–504. [PubMed: 23394127]
Author Manuscript

67. An HR, Wu XQ, Wang ZY, Zhang JX, Liang Y. Nat2 and Cyp2e1 Polymorphisms Associated with
Antituberculosis Drug-Induced Hepatotoxicity in Chinese Patients. Clin Exp Pharmacol Physiol.
2012; 39:535–543. [PubMed: 22506592]
68. Cho HJ, Koh WJ, Ryu YJ, Ki CS, Nam MH, Kim JW, Lee SY. Genetic Polymorphisms of Nat2
and Cyp2e1 Associated with Antituberculosis Drug-Induced Hepatotoxicity in Korean Patients
with Pulmonary Tuberculosis. Tuberculosis (Edinb). 2007; 87:551–556. [PubMed: 17950035]
69. Ho HT, Wang TH, Hsiong CH, Perng WC, Wang NC, Huang TY, Jong YJ, Lu PL, Hu OY. The
Nat2 Tag Snp Rs1495741 Correlates with the Susceptibility of Antituberculosis Drug-Induced
Hepatotoxicity. Pharmacogenet Genomics. 2013; 23:200–207. [PubMed: 23407048]

Pharmacogenet Genomics. Author manuscript; available in PMC 2017 September 01.

 Klein et al. Page 13

70. Huang YS, Chern HD, Su WJ, Wu JC, Lai SL, Yang SY, Chang FY, Lee SD. Polymorphism of the
N-Acetyltransferase 2 Gene as a Susceptibility Risk Factor for Antituberculosis Drug-Induced
Author Manuscript

Hepatitis. Hepatology. 2002; 35:883–889. [PubMed: 11915035]

71. Lee SW, Chung LS, Huang HH, Chuang TY, Liou YH, Wu LS. Nat2 and Cyp2e1 Polymorphisms
and Susceptibility to First-Line Anti-Tuberculosis Drug-Induced Hepatitis. Int J Tuberc Lung Dis.
2010; 14:622–626. [PubMed: 20392357]
72. Ohno M, Yamaguchi I, Yamamoto I, Fukuda T, Yokota S, Maekura R, Ito M, Yamamoto Y, Ogura
T, Maeda K, et al. Slow N-Acetyltransferase 2 Genotype Affects the Incidence of Isoniazid and
Rifampicin-Induced Hepatotoxicity. Int J Tuberc Lung Dis. 2000; 4:256–261. [PubMed:
10751073]
73. Shimizu Y, Dobashi K, Mita Y, Endou K, Moriya S, Osano K, Koike Y, Higuchi S, Yabe S, Utsugi
M, et al. DNA Microarray Genotyping of N-Acetyltransferase 2 Polymorphism Using
Carbodiimide as the Linker for Assessment of Isoniazid Hepatotoxicity. Tuberculosis (Edinb).
2006; 86:374–381. [PubMed: 16246623]
74. Xiang Y, Ma L, Wu W, Liu W, Li Y, Zhu X, Wang Q, Ma J, Cao M, Wang Q, et al. The Incidence
of Liver Injury in Uyghur Patients Treated for Tb in Xinjiang Uyghur Autonomous Region, China,
Author Manuscript

and Its Association with Hepatic Enzyme Polymorphisms Nat2, Cyp2e1, Gstm1 and Gstt1. PLoS
One. 2014; 9:e85905. [PubMed: 24465778]
75. Kim SH, Kim SH, Bahn JW, Kim YK, Chang YS, Shin ES, Kim YS, Park JS, Kim BH, Jang IJ, et
al. Genetic Polymorphisms of Drug-Metabolizing Enzymes and Anti-Tb Drug-Induced Hepatitis.
Pharmacogenomics. 2009; 10:1767–1779. [PubMed: 19891553]
76. Bose PD, Sarma MP, Medhi S, Das BC, Husain SA, Kar P. Role of Polymorphic N-Acetyl
Transferase2 and Cytochrome P4502e1 Gene in Antituberculosis Treatment-Induced Hepatitis. J
Gastroenterol Hepatol. 2011; 26:312–318. [PubMed: 21261721]
77. Mishra S, Daschakraborty S, Shukla P, Kapoor P, Aggarwal R. N-Acetyltransferase and
Cytochrome P450 2e1 Gene Polymorphisms and Susceptibility to Antituberculosis Drug
Hepatotoxicity in an Indian Population. Natl Med J India. 2013; 26:260–265. [PubMed:
25017831]
78. Gupta VH, Amarapurkar DN, Singh M, Sasi P, Joshi JM, Baijal R, Ramegowda PH, Amarapurkar
AD, Joshi K, Wangikar PP. Association of N-Acetyltransferase 2 and Cytochrome P450 2e1 Gene
Polymorphisms with Antituberculosis Drug-Induced Hepatotoxicity in Western India. J
Author Manuscript

Gastroenterol Hepatol. 2013; 28:1368–1374. [PubMed: 23875638]

79. Khalili H, Fouladdel S, Sistanizad M, Hajiabdolbaghi M, Azizi E. Association of N-
Acetyltransferase-2 Genotypes and Anti-Tuberculosis Induced Liver Injury; First Case-Controlled
Study from Iran. Curr Drug Saf. 2011; 6:17–22. [PubMed: 21047300]
80. Bozok Cetintas V, Erer OF, Kosova B, Ozdemir I, Topcuoglu N, Aktogu S, Eroglu Z. Determining
the Relation between N-Acetyltransferase-2 Acetylator Phenotype and Antituberculosis Drug
Induced Hepatitis by Molecular Biologic Tests. Tuberk Toraks. 2008; 56:81–86. [PubMed:
18330759]
81. Ben Mahmoud L, Ghozzi H, Kamoun A, Hakim A, Hachicha H, Hammami S, Sahnoun Z, Zalila
N, Makni H, Zeghal K. Polymorphism of the N-Acetyltransferase 2 Gene as a Susceptibility Risk
Factor for Antituberculosis Drug-Induced Hepatotoxicity in Tunisian Patients with Tuberculosis.
Pathol Biol (Paris). 2012; 60:324–330. [PubMed: 21856096]
82. Leiro-Fernandez V, Valverde D, Vazquez-Gallardo R, Botana-Rial M, Constenla L, Agundez JA,
Fernandez-Villar A. N-Acetyltransferase 2 Polymorphisms and Risk of Anti-Tuberculosis Drug-
Induced Hepatotoxicity in Caucasians. Int J Tuberc Lung Dis. 2011; 15:1403–1408. [PubMed:
Author Manuscript

22283902]
83. Lv X, Tang S, Xia Y, Zhang Y, Wu S, Yang Z, Li X, Tu D, Chen Y, Deng P, et al. Nat2 Genetic
Polymorphisms and Anti-Tuberculosis Drug-Induced Hepatotoxicity in Chinese Community
Population. Ann Hepatol. 2012; 11:700–707. [PubMed: 22947533]
84. Roy B, Ghosh SK, Sutradhar D, Sikdar N, Mazumder S, Barman S. Predisposition of
Antituberculosis Drug Induced Hepatotoxicity by Cytochrome P450 2e1 Genotype and Haplotype
in Pediatric Patients. J Gastroenterol Hepatol. 2006; 21:784–786. [PubMed: 16677176]

Pharmacogenet Genomics. Author manuscript; available in PMC 2017 September 01.

 Klein et al. Page 14

85. Vuilleumier N, Rossier MF, Chiappe A, Degoumois F, Dayer P, Mermillod B, Nicod L, Desmeules
J, Hochstrasser D. Cyp2e1 Genotype and Isoniazid-Induced Hepatotoxicity in Patients Treated for
Author Manuscript

Latent Tuberculosis. Eur J Clin Pharmacol. 2006; 62:423–429. [PubMed: 16770646]

86. Yamada S, Tang M, Richardson K, Halaschek-Wiener J, Chan M, Cook VJ, Fitzgerald JM, Elwood
RK, Brooks-Wilson A, Marra F. Genetic Variations of Nat2 and Cyp2e1 and Isoniazid
Hepatotoxicity in a Diverse Population. Pharmacogenomics. 2009; 10:1433–1445. [PubMed:
19761367]
87. Azuma J, Ohno M, Kubota R, Yokota S, Nagai T, Tsuyuguchi K, Okuda Y, Takashima T,
Kamimura S, Fujio Y, et al. Nat2 Genotype Guided Regimen Reduces Isoniazid-Induced Liver
Injury and Early Treatment Failure in the 6-Month Four-Drug Standard Treatment of Tuberculosis:
A Randomized Controlled Trial for Pharmacogenetics-Based Therapy. Eur J Clin Pharmacol.
2013; 69:1091–1101. [PubMed: 23150149]
88. Patillon B, Luisi P, Poloni ES, Boukouvala S, Darlu P, Genin E, Sabbagh A. A Homogenizing
Process of Selection Has Maintained an “Ultra-Slow” Acetylation Nat2 Variant in Humans. Hum
Biol. 2014; 86:185–214. [PubMed: 25836746]
89. Selinski S, Blaszkewicz M, Ickstadt K, Hengstler JG, Golka K. Refinement of the Prediction of N-
Author Manuscript

Acetyltransferase 2 (Nat2) Phenotypes with Respect to Enzyme Activity and Urinary Bladder
Cancer Risk. Arch Toxicol. 2013; 87:2129–2139. [PubMed: 24221535]
90. Garcia-Closas M, Hein DW, Silverman D, Malats N, Yeager M, Jacobs K, Doll MA, Figueroa JD,
Baris D, Schwenn M, et al. A Single Nucleotide Polymorphism Tags Variation in the Arylamine
N-Acetyltransferase 2 Phenotype in Populations of European Background. Pharmacogenet
Genomics. 2011; 21:231–236. [PubMed: 20739907]
91. Huang YS, Chern HD, Su WJ, Wu JC, Chang SC, Chiang CH, Chang FY, Lee SD. Cytochrome
P450 2e1 Genotype and the Susceptibility to Antituberculosis Drug-Induced Hepatitis.
Hepatology. 2003; 37:924–930. [PubMed: 12668988]
92. Wang T, Yu HT, Wang W, Pan YY, He LX, Wang ZY. Genetic Polymorphisms of Cytochrome
P450 and Glutathione S-Transferase Associated with Antituberculosis Drug-Induced
Hepatotoxicity in Chinese Tuberculosis Patients. J Int Med Res. 2010; 38:977–986. [PubMed:
20819434]
93. Tang SW, Lv XZ, Zhang Y, Wu SS, Yang ZR, Xia YY, Tu DH, Deng PY, Ma Y, Chen DF, Zhan
SY. Cyp2e1, Gstm1 and Gstt1 Genetic Polymorphisms and Susceptibility to Antituberculosis
Author Manuscript

Drug-Induced Hepatotoxicity: A Nested Case-Control Study. J Clin Pharm Ther. 2012; 37:588–
593. [PubMed: 22335459]
94. Leiro-Fernandez V, Valverde D, Vazquez-Gallardo R, Constenla L, Fernandez-Villar A. Genetic
Variations of Nat2 and Cyp2e1 and Isoniazid Hepatotoxicity in a Diverse Population.
Pharmacogenomics. 2010; 11:1205–1206. author reply 1207–1208. [PubMed: 20860460]
95. Sheng YJ, Wu G, He HY, Chen W, Zou YS, Li Q, Zhong L, Huang YM, Deng CL. The
Association between Cyp2e1 Polymorphisms and Hepatotoxicity Due to Anti-Tuberculosis Drugs:
A Meta-Analysis. Infect Genet Evol. 2014; 24:34–40. [PubMed: 24607341]
96. Knockaert L, Fromenty B, Robin MA. Mechanisms of Mitochondrial Targeting of Cytochrome
P450 2e1: Physiopathological Role in Liver Injury and Obesity. FEBS J. 2011; 278:4252–4260.
[PubMed: 21929725]
97. Lieber CS. Cytochrome P-4502e1: Its Physiological and Pathological Role. Physiol Rev. 1997;
77:517–544. [PubMed: 9114822]
98. Sutti S, Rigamonti C, Vidali M, Albano E. Cyp2e1 Autoantibodies in Liver Diseases. Redox Biol.
Author Manuscript

2014; 3:72–78. [PubMed: 25462068]

99. Park KS, Sohn DH, Veech RL, Song BJ. Translational Activation of Ethanol-Inducible
Cytochrome P450 (Cyp2e1) by Isoniazid. Eur J Pharmacol. 1993; 248:7–14. [PubMed: 8339754]
100. Yue J, Peng RX, Yang J, Kong R, Liu J. Cyp2e1 Mediated Isoniazid-Induced Hepatotoxicity in
Rats. Acta Pharmacol Sin. 2004; 25:699–704. [PubMed: 15132840]
101. Daly AK. Drug-Induced Liver Injury: Past, Present and Future. Pharmacogenomics. 2010;
11:607–611. [PubMed: 20415545]
102. Huang YS, Su WJ, Huang YH, Chen CY, Chang FY, Lin HC, Lee SD. Genetic Polymorphisms of
Manganese Superoxide Dismutase, Nad(P)H:Quinone Oxidoreductase, Glutathione S-

Pharmacogenet Genomics. Author manuscript; available in PMC 2017 September 01.

 Klein et al. Page 15

Transferase M1 and T1, and the Susceptibility to Drug-Induced Liver Injury. J Hepatol. 2007;
47:128–134. [PubMed: 17400324]
Author Manuscript

103. Gupta VH, Singh M, Amarapurkar DN, Sasi P, Joshi JM, Baijal R, H RP, Amarapurkar AD, Joshi
K, Wangikar PP. Association of Gst Null Genotypes with Anti-Tuberculosis Drug Induced
Hepatotoxicity in Western Indian Population. Ann Hepatol. 2013; 12:959–965. [PubMed:
24114827]
104. Chatterjee S, Lyle N, Mandal A, Kundu S. Gstt1 and Gstm1 Gene Deletions Are Not Associated
with Hepatotoxicity Caused by Antitubercular Drugs. J Clin Pharm Ther. 2010; 35:465–470.
[PubMed: 20853551]
105. Kim SH, Kim SH, Yoon HJ, Shin DH, Park SS, Kim YS, Park JS, Jee YK. Gstt1 and Gstm1 Null
Mutations and Adverse Reactions Induced by Antituberculosis Drugs in Koreans. Tuberculosis
(Edinb). 2010; 90:39–43. [PubMed: 20036620]
106. Leiro V, Fernandez-Villar A, Valverde D, Constenla L, Vazquez R, Pineiro L, Gonzalez-Quintela
A. Influence of Glutathione S-Transferase M1 and T1 Homozygous Null Mutations on the Risk
of Antituberculosis Drug-Induced Hepatotoxicity in a Caucasian Population. Liver Int. 2008;
28:835–839. [PubMed: 18397238]
Author Manuscript

107. Daly AK. Pharmacogenomics of Adverse Drug Reactions. Genome medicine. 2013; 5:5.
[PubMed: 23360680]
108. Nanashima K, Mawatari T, Tahara N, Higuchi N, Nakaura A, Inamine T, Kondo S, Yanagihara K,
Fukushima K, Suyama N, et al. Genetic Variants in Antioxidant Pathway: Risk Factors for
Hepatotoxicity in Tuberculosis Patients. Tuberculosis (Edinb). 2012; 92:253–259. [PubMed:
22341855]
109. Sharma SK, Balamurugan A, Saha PK, Pandey RM, Mehra NK. Evaluation of Clinical and
Immunogenetic Risk Factors for the Development of Hepatotoxicity During Antituberculosis
Treatment. Am J Respir Crit Care Med. 2002; 166:916–919. [PubMed: 12359646]
110. Bothamley GH. Treatment Tuberculosis Human Leukocyte Antigen. Am J Respir Crit Care Med.
2002; 166:907–908. [PubMed: 12359643]
111. Cai Y, Yi J, Zhou C, Shen X. Pharmacogenetic Study of Drug-Metabolising Enzyme
Polymorphisms on the Risk of Anti-Tuberculosis Drug-Induced Liver Injury: A Meta-Analysis.
PLoS One. 2012; 7:e47769. [PubMed: 23082213]
112. Sun F, Chen Y, Xiang Y, Zhan S. Drug-Metabolising Enzyme Polymorphisms and Predisposition
Author Manuscript

to Anti-Tuberculosis Drug-Induced Liver Injury: A Meta-Analysis. Int J Tuberc Lung Dis. 2008;
12:994–1002. [PubMed: 18713495]
113. Wang PY, Xie SY, Hao Q, Zhang C, Jiang BF. Nat2 Polymorphisms and Susceptibility to Anti-
Tuberculosis Drug-Induced Liver Injury: A Meta-Analysis. Int J Tuberc Lung Dis. 2012; 16:589–
595. [PubMed: 22409928]
114. Li C, Long J, Hu X, Zhou Y. Gstm1 and Gstt1 Genetic Polymorphisms and Risk of Anti-
Tuberculosis Drug-Induced Hepatotoxicity: An Updated Meta-Analysis. Eur J Clin Microbiol
Infect Dis. 2013; 32:859–868. [PubMed: 23377313]
Author Manuscript

Pharmacogenet Genomics. Author manuscript; available in PMC 2017 September 01.

 Klein et al. Page 16
Author Manuscript
Author Manuscript
Author Manuscript

Figure 1.
Author Manuscript

Graphic representation of the candidate genes involved in the pharmockinetics of isoniazid.

A fully interactive version of this pathway is available online at PharmGKB at http://
www.pharmgkb.org/pathway/PA166151813.

Pharmacogenet Genomics. Author manuscript; available in PMC 2017 September 01.

 Klein et al. Page 17

Table 1

Genetic variants in genes within the isoniazid pharmacokinetic pathway associated with anti-TB treatment
Author Manuscript

drug-induced liver injury (ATT-DILI).

Gene Genetic Variant Pharmacogenetic Association Referencesa

NAT2 Slow acetylator genotype NAT2 slow acetylator genotype is associated with an [35, 40, 62–81,
increased risk of ATT-DILI. 91].

NAT2 slow acetylator genotype is not associated with [82–86].

an increased risk of ATT-DILI.

GSTM1 Nullb genotype GSTM1 null genotype is associated with an increased [37, 102].
risk of ATT-DILI.

GSTM1 null genotype is not associated with an [35, 63, 65, 74, 92,
increased risk of ATT-DILI. 93, 104–106].

GSTT1 Nullb genotype GSTT1 null genotype is associated with an increased [106].
risk of ATT-DILI.

GSTT1 null genotype is not associated with an [35, 37, 63, 65, 74,
Author Manuscript

increased risk of ATT-DILI. 93, 102, 104, 105].

CYP2E1 *1A, c1, D CYP2E1*1A is associated with increased risk of [85, 91, 92]
c1 is defined as the wildtype allele at ATT-DILI.
rs2031920 (C) and rs3813867 (G), and D is
defined as the presence of the DraI restriction CYP2E1*1A is not associated with increased risk of [35, 62, 63, 65–68,
site denoted by the wildtype allele at ATT-DILI. 71, 74, 75, 77, 78,
rs6413432 (T). 86, 93, 94].

*6, C CYP2E1 *6 is associated with ATT-DILI. [76, 84].

C is defined as the lack of the DraI restriction
site denoted by the variant allele at rs6413432 CYP2E1 *6 is not associated with ATT-DILI. [35, 63, 66, 78,
(A). 93].

rs2070672 Presence of the G allele is not associated with ATT- [75].

NM_000773.3:c.-352A>G DILI.

rs2070673 Presence of the T allele is not associated with ATT- [75].

NM_000773.3:c.-333A>T DILI.

HLA-DQA1 *0102 Lack of this allele is associated with ATT-DILI. [109].

Author Manuscript

HLA-DQB1 *0201 The presence of this allele is not associated with [109] – before the
ATT-DILI. Bonferroni
correction, this
allele was
associated with
ATT-DILI.
SOD2 rs4880 Presence of the C allele is associated with increased [102].
NM_000636.2:c.47T>C risk of DILI when treated with an anti-TB drug
regimen, as well as other drugs.

NOS2A rs11080344 Genotype CC (positive strand) is associated with [108].

NM_000625.4:c.1281+1205A>G increased risk of ATT-DILI.

BACH1 rs2070401 Genotype GG is associated with increased risk of [108].

NM_001186.3:c.*331A>G ATT-DILI.

MAFK rs4720833 Presence of the A allele is associated with increased [108].

NM_002360.3:c.-45+3869A>G risk of ATT-DILI.

a
See www.pharmgkb.org for detailed annotations for individual studies.
Author Manuscript

b
Null genotype refers to the absence of the gene.

Pharmacogenet Genomics. Author manuscript; available in PMC 2017 September 01.