Medical Genetics Summaries

Victoria Pratt • Howard McLeod • Laura Dean • Adriana Malheiro
Wendy Rubinstein
Medical Genetics
Summaries
Last Updated: April 9, 2018
National Center for Biotechnology Information (US)

Bethesda (MD)
National Center for Biotechnology Information (US), Bethesda (MD)
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NLM Citation: Pratt V, McLeod H, Dean L, et al., editors. Medical Genetics Summaries [Internet]. Bethesda
(MD): National Center for Biotechnology Information (US); 2012-.
iii
Medical Genetics Summaries is a growing collection of summaries

which describe the impact that specific sequence variations have on
health. The summaries review genetic variants that underlie inherited
conditions, affect the risk of developing a disease in the future, or
influence how an individual may respond to a specific drug.
iv Medical Genetics Summaries
Editors
Victoria Pratt, Director, Pharmacogenomics and Molecular Genetics Laboratories,
Department of Medical and Molecular Genetics, Indiana University School of Medicine;
Bloomington, IN 47405
Howard McLeod, Medical Director, The DeBartolo Family Personalized Medicine
Institute, Senior Member, Division of Population Sciences, Moffitt Cancer Center; Tampa,
FL 33612
Laura Dean, Senior Medical Writer, Literature Division, National Center for
Biotechnology Information (NCBI), National Library of Medicine, National Institutes of
Health; Bethesda, MD 20894
Adriana Malheiro, Associate Editor, Project Lead, Medical Genetics and Human
Variation, National Center for Biotechnology Information (NCBI), National Library of
Medicine, National Institutes of Health; Bethesda, MD 20894
Wendy Rubinstein, Editor-in-chief, Division Director, Clinical Data Management and
Curation, CancerLinQ LLC; Alexandria, VA
v
Table of Contents
Acknowledgments .................................................................................................................................................... ix
Introduction................................................................................................................................................................ 1
Laura Dean
Genetic variants and drug responses ................................................................................ 5

Abacavir Therapy and HLA-B*57:01 Genotype........................................................................................... 7
Laura Dean
Allopurinol Therapy and HLA-B*58:01 Genotype ....................................................................................... 15

Laura Dean
Amitriptyline Therapy and CYP2D6 and CYP2C19 Genotype.................................................................. 25

Laura Dean
Aripiprazole Therapy and CYP2D6 Genotype ............................................................................................. 47

Laura Dean
Atomoxetine Therapy and CYP2D6 Genotype.............................................................................................. 57

Laura Dean
Azathioprine Therapy and TPMT Genotype .................................................................................................. 67

Laura Dean
Capecitabine Therapy and DPYD Genotype ................................................................................................. 77

Laura Dean
Carbamazepine Therapy and HLA Genotypes ............................................................................................. 87

Laura Dean
Carisoprodol Therapy and CYP2C19 Genotype .......................................................................................... 99

Laura Dean
Celecoxib Therapy and CYP2C9 Genotype................................................................................................... 105

Laura Dean
Clopidogrel Therapy and CYP2C19 Genotype............................................................................................. 111

Laura Dean
Clozapine Therapy and CYP2D6, CYP1A2, and CYP3A4 Genotypes ................................................... 121
Laura Dean
Codeine Therapy and CYP2D6 Genotype ..................................................................................................... 133

Laura Dean
Dabrafenib Therapy and BRAF and G6PD Genotype................................................................................. 147

Laura Dean
Diazepam Therapy and CYP2C19 Genotype ............................................................................................... 157

Laura Dean
Esomeprazole Therapy and CYP2C19 Genotype ........................................................................................ 165

Laura Dean
vi Medical Genetics Summaries
Fluorouracil Therapy and DPYD Genotype .................................................................................................... 175

Laura Dean
Gentamicin Therapy and MT-RNR1 Genotype.............................................................................................. 185

Laura Dean
Imipramine Therapy and CYP2D6 and CYP2C19 Genotype .................................................................... 193

Laura Dean
Irinotecan Therapy and UGT1A1 Genotype.................................................................................................. 213

Laura Dean
Maraviroc Therapy and CCR5 Genotype....................................................................................................... 229

Laura Dean
Mercaptopurine Therapy and TPMT Genotype ............................................................................................. 235

Laura Dean
Metoprolol Therapy and CYP2D6 Genotype................................................................................................. 245

Laura Dean
Omeprazole Therapy and CYP2C19 Genotype ........................................................................................... 255

Laura Dean
Pertuzumab Therapy and ERBB2 (HER2) Genotype..................................................................................... 263

Laura Dean
Phenytoin Therapy and HLA-B*15:02 and CYP2C9 Genotypes............................................................... 273

Laura Dean
Prasugrel Therapy and CYP Genotype............................................................................................................ 287

Laura Dean
Propafenone Therapy and CYP2D6 Genotype ............................................................................................. 295

Laura Dean
Risperidone Therapy and CYP2D6 Genotype ............................................................................................... 305

Laura Dean
Simeprevir Therapy and IFNL3 Genotype...................................................................................................... 317

Laura Dean
Sofosbuvir Therapy and IFNL4 Genotype ...................................................................................................... 325

Laura Dean
Tamoxifen Therapy and CYP2D6 Genotype .................................................................................................. 333

Laura Dean
Thioguanine Therapy and TPMT Genotype.................................................................................................... 345

Laura Dean
Thioridazine Therapy and CYP2D6 Genotypes ............................................................................................ 355

Laura Dean
Tramadol Therapy and CYP2D6 Genotype.................................................................................................... 367

Laura Dean
Contents vii
Trastuzumab (Herceptin) Therapy and ERBB2 (HER2) Genotype.............................................................. 377

Laura Dean
Vemurafenib Therapy and BRAF and NRAS Genotype .............................................................................. 387

Laura Dean
Venlafaxine Therapy and CYP2D6 Genotype ............................................................................................... 395

Laura Dean
Warfarin Therapy and the Genotypes CYP2C9 and VKORC1................................................................. 405

Laura Dean
Genetic variants and disease ......................................................................................................415

ABO Blood Group ............................................................................................................................................... 417
Laura Dean
ACHOO Syndrome ............................................................................................................................................. 421

Laura Dean
McCune-Albright Syndrome .............................................................................................................................. 423

Laura Dean
Methylenetetrahydrofolate Reductase Deficiency.......................................................................................... 427

Laura Dean
Pitt-Hopkins Syndrome........................................................................................................................................ 433

Laura Dean
Schizophrenia ....................................................................................................................................................... 435

Laura Dean
Authoring and Peer Review ...................................................................................................................................441
Medical Genetics Summaries Expert Reviewers................................................................................................445

Laura Dean
viii Medical Genetics Summaries
ix
Acknowledgments
National Institutes of Health (NIH)
National Center for Biotechnology Information, National Library of
Medicine
Marilu Hoeppner, PhD
Staff Scientist, NIH Genetic Testing Registry
Brandi Kattman, MS, CGC
Staff Scientist and Genetic Counselor, NIH Genetic Testing Registry
Donna Maglott, PhD
Senior Staff Scientist, National Center for Biotechnology Information
National Institute of General Medical Sciences

Rochelle M. Long, PhD
Chief, Pharmacological and Physiological Sciences
Pharmacogenomics Knowledge Database (PharmGKB) and

Clinical Pharmacogenetics Implementation Consortium (CPIC) (a
PharmGKB & Pharmacogenomics Research Network
collaboration)
PharmGKB
Russ B. Altman, MD, PhD
Principal Investigator, PharmGKB, Stanford University
Teri E. Klein, PhD
Director, PharmGKB, Stanford University
Co-leader, CPIC
CPIC Consortium Members

Mary V. Relling, PharmD
Chair, Pharmaceutical Sciences, St. Jude Children's Research Hospital
Leader, CPIC
x Medical Genetics Summaries
Julie A. Johnson, PharmD, FCCP, BCPS

Professor, University of Florida
Dan M. Roden, MD
Professor, Vanderbilt University
Alan R. Shuldiner, MD
Professor, University of Maryland
1
Introduction
Laura Dean, MD 1
Created: September 15, 2016.
Medical Genetics Summaries (MGS) is a collection of articles that feature conditions with a
genetic component, for which information useful at the point of care is limited. Topics fall
into two broad categories: diseases and drug responses.
The intended audience of MGS is clinicians who seek practical, evidence-based
information to use in clinical care settings. The summaries are guideline-driven, drawn
from authoritative sources, undergo a formal review process, and are regularly updated.
Genetic variants and disease

Pitt-Hopkins syndrome has a clear genetic component. A variant in the TCF4 gene results
in the syndrome, and genetic testing of the TCF4 gene confirms the diagnosis. However,
for many other diseases, the underlying genetics is complex. For example, although
schizophrenia is highly heritable, many genes have been implicated as contributing to the
disease, and genetic testing is not currently available.
A person's blood group is determined by genetics—the four common blood groups (A, B,
AB, and O) are encoded by ABO alleles. Serological testing is commonly used to
determine an individual's blood type, e.g., before receiving a blood transfusion. However,
in other settings, genetic testing may be used to determine an individual's ABO genotype,
such as in the research setting, e.g., investigating the associations between ABO blood
groups and the risk of diseases such as pancreatic cancer and thromboembolic disease.
Genetic variants and drug responses

There is often a wide variability in how different individuals respond to standard doses of
the same drug. This is because a drug response can be influenced by age, gender, drug-
drug interactions, drug-food interactions, comorbidity, liver and renal function,
pregnancy, and genetic factors. For an increasing number of drugs, genetic testing (also
known as pharmacogenetic testing) can be used to optimize drug therapy.
Currently, about 10% of drug labels approved by the U.S. Food and Drug Administration
(FDA) contain pharmacogenetic information. However, actionable information on
genetic variants can be hard to find, and sources often differ in their recommendations.
MGS draws together information from different authoritative sources to one place, and
includes a summary—thus providing accessible information at the point of care.
1 NCBI; Email: dean@ncbi.nlm.nih.gov.
Corresponding author.
2 Medical Genetics Summaries
To avoid confusion, only generic drug names are used. Nomenclature tables include both
the official and commonly used terms for alleles, and phenotypes are termed “drug
responses”, e.g., omeprazole drug response. Finally, each summary links to the NIH’s
Genetic Testing Registry, which provides information about laboratories that offer genetic
tests and details about the tests, including ordering information.
Genetic testing to ensure the drug has a therapeutic target
A small number of drugs are prescribed after genetic testing has been performed. One
reason for this is that the drug is effective for specific genotypes. These drugs include
trastuzumab—a chemotherapy agent only indicated for specific tumors that overexpress
HER2, and maraviroc—an antiviral agent that is only indicated for a specific strain of the
HIV virus (CCR-5 trophic HIV-1).
Genetic testing can help avoid idiosyncratic drug reactions
Another reason for genetic testing is to avoid severe, and potentially fatal, drug reactions.
A category of drug reactions are idiosyncratic—they are unpredictable, severe, and not
related to the dose and duration of the drug therapy.
The FDA recommends that all individuals be screened for the HLA-B*57:01 allele before
starting treatment with abacavir, a drug used in the treatment of HIV. This is because
around 6% of Caucasians of European origin carry this variant allele, placing them at high
risk of abacavir-induced hypersensitivity reaction. Symptoms include fever, rash, and
acute respiratory symptoms.
An individual’s ancestry may be important
For the epilepsy drug carbamazepine, the FDA states that patients with ancestry in
“genetically at-risk populations” should be screened for the presence of HLA-B*15:02
prior to initiating treatment. Carriers of this variant, which is most commonly found in
individuals of Han Chinese descent, are at a high risk of developing Stevens-Johnson
syndrome (SJS) and toxic epidermal necrolysis (TEN)—both potentially fatal conditions
—during carbamazepine therapy.
Also common in individuals with Han Chinese ancestry is the HLA-B*58:01 allele, which
is strongly associated with severe cutaneous adverse reactions (SCAR) triggered by
allopurinol therapy, which is used to treat gout.
A wide range of gene variants are associated with idiosyncratic drug reactions
Idiosyncratic drug reactions are not just limited to variant HLA-B alleles. For the
antibiotic gentamicin, genetically predisposed individuals who carry a variant in a
mitochondrial gene (MT-RNR1) may suffer from irreversible hearing loss after just a
single dose of gentamicin. And for individuals who require treatment with thiopurines
(e.g., azathioprine), the FDA recommends TPMT genotyping or phenotyping prior to
treatment. This is because patients who carry two non-functional TPMT alleles
universally experience life-threatening myelosuppression when treated with thiopurines.
Introduction 3
Genetic testing can help optimize the drug dose

Drug labels always provide standard dosing information. But a growing number of labels
also include recommendations for adjusting the dose, or selecting an alternative drug,
based on a patient’s genotype (if known). Generally, dose adjustment is recommended for
variants in genes that are known to influence drug metabolism, leading to altered plasma
levels of active drugs and metabolites.
Cytochrome P450 (CYP) genes influence drug levels
The “CYP” gene family encodes enzymes that metabolize over a quarter of commonly
prescribed drugs. One of these genes, CYP2D6, is particularly complex. Over 100 variants
are known, many of which encode enzymes with different levels of activity. Depending on
the level of CYP2D6 activity, individuals may respond poorly to the analgesics codeine
and tramadol. A standard dose of codeine may provide inadequate pain relief in some,
and severe toxicity, such as respiratory depression, in others.
In addition, standard doses of a wide range of drugs (e.g., atomoxetine—used in ADHD,
venlafaxine—an antidepressant, clozapine—an antipsychotic, and tamoxifen—used to
treat breast cancer) will lead to higher than expected active drug plasma levels in
individuals who have low or absent CYP2D6 activity. This can increase the risk of side
effects, and may contribute to non-compliance and treatment failure.
Barriers to genetic testing
Ordering a genetic test to help determine whether a particular drug will be effective or
safe is a relatively new area for doctors and genetic counselors. The field is rapidly
evolving, evidenced by an increasing panorama of genetic tests becoming available. And
there are potential legal concerns, such as a cause for liability in cases where the optimal
dose of a drug was not given. Education and training are needed.
More prospective randomized trials are needed to investigate the clinical outcomes when
drug therapy or a specific dose is selected on the basis of genotype. The effectiveness data
can be used for cost-effectiveness analysis, and be summarized into actionable clinical
guidelines with prescribing recommendations.
Sometimes, genetic testing has not been possible because of the acute nature of the clinical
scenario (e.g., gentamicin and neonatal sepsis). However, as technology improves and
turn-around time is reduced, the use of genetic testing can be expected to increase.
For example, clopidogrel is an antiplatelet agent that is used in patients presenting with
acute coronary syndrome, and patients who may need to undergo percutaneous
intervention. Because clopidogrel is a pro-drug, it must first be metabolized by CYP2C19
before it becomes effective. However, in the 3% of Caucasians and 15 to 20% of Asians
who have low or absent CYP2C19 activity, clopidogrel will have a smaller or no effect on
platelet function. Fortunately, the advent of “bedside testing” and a faster turn-around of
results means that more of these patients can be identified and offered alternative
antiplatelet agents.
The use of genetic testing is often not clear-cut

In the case of warfarin, the FDA-approved drug label provides a dosing table, allowing for
the adjustment of initial doses of warfarin based on CYP2C9 and VKORC1 genotypes.
Warfarin is an anticoagulant, given to prevent the formation of blood clots. If the dose of
warfarin is too low, the risk of thrombosis remains, but if the dose is too high, there is an
increased risk of bleeding. And both outcomes can be a cause of a stroke.
Despite the drug label’s dosing table, it is thought that less than 1% of patients commence
warfarin therapy with their CYP2C9 and VKORC1 genotypes known. Interestingly,
however, the most recent evidence suggests that CYP2C9 and VKORC1 variants may have
less of an effect on warfarin levels than previously thought, with many other clinical
factors having more of an impact.
The future
Genetic testing is important—it can help avoid drug toxicity and help optimize drug
efficacy. As the number of genetic tests grows, Medical Genetics Summaries will expand to
help ensure that healthcare providers have the information they need to provide evidence-
based care.
Helpful Links
NIH Genetic Testing Registry
FDA Table of Pharmacogenomic Biomarkers in Drug Labeling
CPIC Dosing Guidelines
5
Genetic variants and drug

responses
7
Abacavir Therapy and HLA-B*57:01 Genotype

Laura Dean, MD1
Introduction
Abacavir is a nucleoside reverse transcriptase inhibitor used in the treatment of human
immunodeficiency virus (HIV) infection. It is used in combination with other
medications as part of highly active antiretroviral therapy (HAART).
The human leukocyte antigen B (HLA-B) plays an important role in how the immune
system recognizes and responds to pathogens. HLA-B belongs to a class of molecules that
are found on the surface of most cells. These molecules are responsible for presenting
peptides to immune cells. Peptides derived from normal human proteins are recognized
as such, whereas foreign peptides derived from pathogens trigger an immune response.
Abacavir specifically interacts with HLA-B*57:01 and alters the repertoire of self peptides
that are presented to T lymphocytes, which activates an immune reaction known as a
hypersensitivity reaction. Around 6% of Caucasians of European origin have the variant
allele, HLA-B*57:01, and this places them at high risk of having a hypersensitivity reaction
to abacavir (1-5). The association between HLA-B*57:01 and abacavir hypersensitivity has
also been found in Hispanics and individuals with African origins (6).
The FDA recommends screening for the HLA-B*57:01 allele in all patients before starting
abacavir therapy, and before restarting abacavir therapy in a patient who has previously
tolerated the drug if their HLA-B*57:01 status is unknown (7). The Clinical
Pharmacogenetics Implementation Consortium (CPIC) also recommends that HLA-
B*57:01 screening should be performed (see Table 1) (8, 9).

Table 1. HLA-B phenotypes and the therapeutic recommendations for abacavir therapy
Genotype Examples of Phenotype Therapeutic
diplotypes recommendations
Noncarrier of HLA- *X/*Xb Low or reduced risk of Use abacavir per standard
B*57:01 abacavir hypersensitivity. dosing guidelines
Found in ~94% of patients.
Carrier of HLA- *57:01/*Xb *57:01/ Significantly increased risk Abacavir is not
B*57:01 *57:01 of abacavir hypersensitivity. recommended
Found in ~6% of patients
The strength of therapeutic recommendations is “strong”.
HLA-B, human leukocyte antigen B
* X, any HLA-B genotype other than HLA-B*57:01
* Xb, any HLA-B genotype other than HLA-B*57:01
Table is adapted from Martin M.A. et al. Clinical pharmacogenetics implementation consortium guidelines for
HLA-B genotype and abacavir dosing. Clinical pharmacology and therapeutics. 2012;91(4):734–8 (8).
Drug: Abacavir
Abacavir is a nucleoside reverse transcriptase inhibitor (NRTI) that targets HIV. It inhibits
the conversion of the viral genome from RNA to DNA, thus suppressing the ability of the
virus to insert its viral DNA into the host cell’s genome.
Abacavir is a nucleoside analog. It is phosphorylated by intracellular enzymes to form the
active metabolite carbovir triphosphate, which is an analog of deoxyguanosine-5'-
triphosphate (dGTP). Carbovir triphosphate competitively inhibits HIV reverse
transcriptase by competing with its natural substrate (dGTP) to be incorporated into viral
DNA. Once incorporated, the nucleoside analog terminates DNA chain elongation,
preventing further synthesis of viral DNA (10).
During the first 6 weeks of treatment with abacavir, around 5-8% of patients develop a
hypersensitivity reaction. Symptoms include fever, rash, fatigue, gastrointestinal
symptoms (e.g., nausea, vomiting, abdominal pain) and acute respiratory symptoms (e.g.,
cough and dyspnea). If a hypersensitivity reaction is suspected, treatment must be stopped
immediately. Usually symptoms worsen if treatment is not stopped, and improve within
24 hours after treatment is stopped. Re-introduction of abacavir in a patient who had a
prior hypersensitivity reaction is contraindicated due to the risk of severe symptoms, life-
threatening hypotension, and death (11). Data from the PREDICT-1 study suggest that
100% of individuals with immunologically confirmed (abacavir patch test positive)
abacavir hypersensitivity present within 3 weeks of initial dosing (12).
Cytotoxic (CD8+) T cells mediate the hypersensitivity reaction to abacavir. It is thought
that short peptide fragments, derived from either the drug or its metabolites, form a
peptide-HLA complex, specifically with HLA-type HLA-B*57:01. This complex activates
the T cell to release inflammatory cytokines, signaling the start of the hypersensitivity
response. More recently, it has been shown that abacavir might occupy a space below the
region of HLA that presents peptides—this may lead to altered peptide presentation and
Abacavir Therapy and HLA-B*57:01 Genotype 9
trigger an autoimmune reaction. Whatever immune mechanism(s) are involved, the

hypersensitivity reaction to abacavir is thought to be maintained over the lifetime of an
individual (13).
A significant body of work has now accumulated to shed light on the specificity of HLA-
B*57:01 in the immunopathogenesis of abacavir hypersensitivity (14-17). The crystal
structure of abacavir bound to peptide and HLA-B*57:01 has recently been solved by
independent investigators (1, 3). Approximately 45% of those carrying HLA-B*57:01 are
tolerant of abacavir and ongoing research is studying the immunopathogenesis of HLA-
B*57:01 positive abacavir tolerance (12).
Gene: HLA-B*57:01
The HLA-B gene is a member of the major histocompatibility complex (MHC) gene
family, which includes more than 200 genes. The HLA region has been subdivided in to 3
subgroups: Class I, Class II, and Class III.
The class I region contains the “classical” HLA molecules, HLA-A, HLA-B, and HLA-C.
These molecules are expressed on the surfaces of almost all cells and play an important
role in processing and presenting of antigens. The Class I region also contains a variety of
other genes, many of which are not known to be involved in immune function.
An important role of HLA-B is to present peptide fragments to immune cells (CD8+ T
cells). Most of these peptides originate from the normal breakdown of normal cell
proteins (“self ”). However, if foreign peptide fragments are presented, e.g., from a
pathogen, the CD8+T cells will recognize the peptides as “non-self ” and be activated to
release inflammatory cytokines and launch an immune response.
Because the HLA genes need to present such a wide variety of “self ” and “non-self ”
peptides, the HLA genes are both numerous and highly polymorphic—more than 1,500
HLA-B alleles have been identified (8). Variations in the HLA genes play an important
role in determining susceptibility to autoimmune disease and infections; they are also
critical in the field of transplant surgery where the donor and recipient must be HLA-
compatible.
The HLA-B*57:01 allele is associated with an increased risk of hypersensitivity reaction to
abacavir. The allele is co-dominant, so an individual needs to carry only one copy of the
HLA-B*57:01 allele to be at risk. The US FDA recommendations for screening for the
presence of HLA-B*57:01 before initiating abacavir therapy and several studies support
that this has significantly reduced the incidence of abacavir-induced hypersensitivity (18).
To-date, HLA-B*57:01 screening has had a 100% negative predictive value for abacavir
hypersensitivity (confirmed by a positive skin patch test), since hypersensitivity has only
been found in individuals carrying HLA-B*57:01 (12, 19).
HLA-B*57:01 has also been linked to an increased risk of liver damage in individuals
taking flucloxacillin, an antibiotic that is no longer available in the US. Genotype
screening is not routinely done because this adverse reaction is rare (<1 in 5,000) and the
positive predictive value of HLA-B*57:01 carriage for development of flucloxacillin

associated hepatitis is significantly less than 1% (20).
In addition to its role in hypersensitivity reactions, HLA-B*57:01 has an important role in
HIV infection. In Caucasians with HIV, HLA-B*57:01 has been linked with a lower viral
load set point (the amount of viral RNA detected in blood during the asymptomatic phase
of HIV infection) (21). In addition, HLA-B*57:01 has been overrepresented in a small
group of individuals who have HIV which has not progressed to AIDs, despite lack of
treatment with antiretroviral therapy (22).
The frequency of the HLA-B*57:01 allele varies significantly by population (6). It is
relatively common in European populations (6–7%). Approximately 2-3% of African
American and admixed American populations carry HLA-B*57:01; however, it is
uncommon in homogenous South-Asian and African populations, being absent in some
African populations, and in the Japanese. The allele is most common in Northern Thai
and Indian populations (up to 20%) (8).
Genetic Testing
Genetic testing is available for HLA-B*57:01 through commercial laboratories in the US
that typically offer single allele testing with a short turnaround time. The genotype results
are either “positive” (HLA-B*57:01 being present in one or both copies of the HLA-B
gene) or “negative” (no copies of HLA-B*57:01 are present). There are no intermediate
phenotypes because HLA-B is expressed in a codominant manner (8).
Therapeutic Recommendations based on Genotype

This section contains excerpted1 information on gene-based dosing
recommendations. Neither this section nor other parts of this review contain the
complete recommendations from the sources.
Statement from the US Food and Drug Administration (FDA):
Serious and sometimes fatal hypersensitivity reactions have been associated with abacavir.
Hypersensitivity to abacavir is a multi-organ clinical syndrome usually characterized by a
sign or symptom in 2 or more of the following groups:(1) fever, (2) rash, (3)
gastrointestinal (including nausea, vomiting, diarrhea, or abdominal pain), (4)
constitutional (including generalized malaise, fatigue, or achiness), and (5) respiratory
(including dyspnea, cough, or pharyngitis). Discontinue abacavir as soon as a
hypersensitivity reaction is suspected.
1 The FDA labels specific drug formulations. We have substituted the generic names for any
drug labels in this excerpt. The FDA may not have labeled all formulations containing the
generic drug.
Patients who carry the HLA-B*5701 allele are at high risk for experiencing a
hypersensitivity reaction to abacavir. Prior to initiating therapy with abacavir, screening
for the HLA-B*5701 allele is recommended; this approach has been found to decrease the
risk of hypersensitivity reaction. Screening is also recommended prior to reinitiation of
abacavir in patients of unknown HLA-B*5701 status who have previously tolerated
abacavir. HLA- B*5701-negative patients may develop a suspected hypersensitivity
reaction to abacavir; however, this occurs significantly less frequently than in HLA-
B*5701-positive patients.
Regardless of HLA-B*5701 status, permanently discontinue abacavir if hypersensitivity
cannot be ruled out, even when other diagnoses are possible.
Following a hypersensitivity reaction to abacavir, NEVER restart abacavir or any other
abacavir-containing product because more severe symptoms can occur within hours and
may include life-threatening hypotension and death.
Reintroduction of abacavir or any other abacavir-containing product, even in patients
who have no identified history or unrecognized symptoms of hypersensitivity to abacavir
therapy, can result in serious or fatal hypersensitivity reactions. Such reactions can occur
within hours.
Please review the complete therapeutic recommendations that are located here (7).
Statement from the Clinical Pharmacogenetics Implementation Consortium (CPIC):
HLA-B*57:01 screening should be performed in all abacavir-naive individuals before
initiation of abacavir-containing therapy. In abacavir-naive individuals who are HLA-
B*57:01- positive, abacavir is not recommended (see Table 1) and should be considered
only under exceptional circumstances when the potential benefit, based on resistance
patterns and treatment history, outweighs the risk. HLA-B*57:01 genotyping is widely
available in the developed world and is considered the standard of care prior to initiating
abacavir.
Patients testing negative for HLA-B*57:01 also have a 3% risk of developing a clinically
diagnosed hypersensitivity reaction, and standard practice includes patient counseling
and careful monitoring for signs and symptoms of a hypersensitivity reaction. The
development of signs and symptoms of a hypersensitivity reaction warrants that serious
consideration be given to discontinuing abacavir, regardless of the HLA-B genotyping
results.
Summary of recommendations from the Pharmacogenetics Working Group of the
Royal Dutch Association for the Advancement of Pharmacy (KNMP): To date, the
association between HLA-B*5701 genotype and the hypersensitivity reaction to abacavir
remains the only example of a randomized clinical trial of pharmacogenetics. The advice
regarding selection of an alternative drug for treating HLA- B*5701-positive patients is in
agreement with the recommendations of the Food and Drug Administration and the
European Medicines Agency.
Nomenclature
Allele name dbSNP reference identifier for allele location
HLA-B*57:01 rs2395029 is a tag SNP for HLA-B*57:01
* For the MHC region, variations in genes such as HLA-B occur across the whole sequence of the gene, not a
single locus. Therefore, the HLA-B*57:01 allele is defined by its sequence (GenBank: AF196183.1) rather
than single coding or protein variants. If there is strong linkage disequilibrium between one or more SNPs,
the presence of these SNPs (tag SNPs) may be used for HLA typing (24). In the case of HLA-B, the presence
of the rs2395029 allele (a SNP in the HLA complex P5 gene) is 99.9% predictive of the presence of an HLA-
B*57:01 allele (25).
Guidelines on nomenclature of the HLA system are available from HLA Nomenclature:
http://hla.alleles.org/
Acknowledgments
The author would like to thank Elizabeth Phillips, MD, FIDSA, John A. Oates Chair in
Clinical Research, Professor of Medicine and Pharmacology, Director of Personalized
Immunology, Oates Institute for Experimental Therapeutics, Vanderbilt University
Medical Center; and Professor Munir Pirmohamed, David Weatherall Chair of Medicine,
University of Liverpool and Director of the MRC Centre for Drug Safety Sciences, for
reviewing this summary
References
1. Ostrov D.A., Grant B.J., Pompeu Y.A., Sidney J., et al. Drug hypersensitivity caused by
alteration of the MHC-presented self-peptide repertoire. Proc Natl Acad Sci U S A.
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Related Summaries by Gene

Allopurinol Therapy and HLA-B*58:01 Genotype
Carbamazepine Therapy and HLA Genotypes
Phenytoin Therapy and HLA-B*15:02 and CYP2C9 Genotypes
Related Summaries by Drug Class

Maraviroc Therapy and CCR5 Genotype
Tests in GTR by Condition

Abacavir hypersensitivity
Tests in GTR by Gene

HLA-B gene
15
Allopurinol Therapy and HLA-B*58:01

Genotype
Laura Dean, MD1
Created: March 26, 2013; Updated: March 16, 2016.
Introduction
Allopurinol is a xanthine oxidase inhibitor that decreases the production of uric acid. It is
most commonly used in the management of gout and hyperuricemia (high levels of uric
acid).
The human leukocyte antigen B (HLA-B) plays an important role in how the immune
system recognizes and responds to pathogens. The variant HLA-B*58:01 allele is strongly
associated with severe cutaneous adverse reactions (SCAR) during treatment with
allopurinol. This allele is most commonly found in Asian subpopulations, notably in
individuals of Korean, Han Chinese, or Thai descent (1-3).
At this time, the FDA-approved drug label does not discuss HLA-B genotype (4).
However, the Clinical Pharmacogenetics Implementation Consortium (CPIC)
recommends that allopurinol should not be prescribed to patients who have tested
positive for HLA-B*58:01, and that an alternative medication should be considered to
avoid the risk of developing SCAR (see Table 1) (1, 2).
Table 1. HLA-B phenotypes and the therapeutic recommendations for allopurinol therapy, adapted from
CPIC
Noncarrier of HLA- *X/*Xb Low or reduced risk of Use allopurinol per standard
B*58:01 allopurinol-induced dosing guidelines
SCAR
The strength of therapeutic recommendations is “strong” (1).
SCAR, severe cutaneous adverse reaction
*X, any HLA-B genotype other than HLA-B*58:01
*Xb, any HLA-B genotype other than HLA-B*58:01
Table is adapted from Hershfield M.S., Callaghan J.T., Tassaneeyakul W., Mushiroda T., Thorn C.F., Klein
T.E., Lee M.T.Clinical pharmacogenetics implementation consortium guidelines for human leukocyte
antigen-B genotype and allopurinol dosing. Clinical pharmacology and therapeutics. 2013;93(2):153–8 (1,
2).
Table 1. continues on next page...

Table 1. continued from previous page.

Carrier of HLA- *5801/*Xb *5801/ Significantly increased Allopurinol is contraindicated
B*58:01 *5801 risk of allopurinol-
induced SCAR
The strength of therapeutic recommendations is “strong” (1).
SCAR, severe cutaneous adverse reaction
*X, any HLA-B genotype other than HLA-B*58:01
*Xb, any HLA-B genotype other than HLA-B*58:01
Table is adapted from Hershfield M.S., Callaghan J.T., Tassaneeyakul W., Mushiroda T., Thorn C.F., Klein
T.E., Lee M.T.Clinical pharmacogenetics implementation consortium guidelines for human leukocyte
antigen-B genotype and allopurinol dosing. Clinical pharmacology and therapeutics. 2013;93(2):153–8 (1,
2).
Drug: Allopurinol
Allopurinol is a commonly prescribed drug for the management of gout and
hyperuricemia. Uric acid is produced by the breakdown of purine nucleotides, and high
concentrations of uric acid can lead to gout and uric acid kidney stones.
Allopurinol is an analogue of the purine hypoxanthine. Allopurinol decreases the
production of uric acid by inhibiting xanthine oxidase, which catalyzes the conversion of
hypoxanthine and xanthine to uric acid. In addition, allopurinol facilitates the
incorporation of hypoxanthine and xanthine into DNA and RNA, and the resulting
increase in nucleotide concentration leads to a feedback inhibition of de novo purine
synthesis, which in turn leads to a decrease in uric acid levels (5).
Allopurinol is rapidly oxidized in the liver to the active metabolite oxypurinol, which also
inhibits xanthine oxidase. Allopurinol has a short plasma half-life of ~1-2 hours, whereas
oxypurinol has a half-life of ~15 hours. After the rapid oxidation of allopurinol, any
remaining drug is promptly filtered and excreted by the kidneys. However, after
oxypurinol is filtered by the kidneys, it is reabsorbed in a manner similar to how uric acid
is reabsorbed. Therefore, it is thought that the effective inhibition of xanthine oxidase over
a 24-hour period after a single dose of allopurinol is largely brought about by the effects of
oxypurinol (4).
In general, allopurinol is well tolerated; however, allopurinol is one of the most common
causes of severe cutaneous adverse reactions (SCAR), and the HLA-B*58:01 allele is
strongly associated with allopurinol-induced SCAR.
Allopurinol-induced Adverse Drug Reactions

In general, there are two categories of adverse drug reactions. Type A reactions account
for up to 85-90% of all adverse drug reactions. They are predictable based on the known
properties of the drug, and they can affect any individual, if their exposure to the drug is
Allopurinol Therapy and HLA-B*58:01 Genotype 17
high enough. For allopurinol, one of the most common type A adverse effects is an acute
attack of gout after starting allopurinol therapy (4).
Type B reactions account for the remaining 10-15% of adverse drug reactions. These
include hypersensitivity reactions that occur in susceptible individuals. Such idiosyncratic
hypersensitivity reactions can occur at any dose and develop through a mechanism that is
unrelated to the mechanism of action of the drug. For this reason, it is difficult to predict
in whom a drug-induced hypersensitivity reaction is likely to occur.
Severe cutaneous adverse reactions are type B reactions, which include Stevens-Johnson
syndrome (SJS), or the more severe toxic epidermal necrolysis (TEN); as well as drug
reaction with eosinophilia and systemic symptoms (DRESS), and allopurinol
hypersensitivity syndrome (AHS).
Allopurinol is the most common cause of SJS/TEN in Europe (6). SJS /TEN are life-
threatening conditions that are primarily characterized by lesions of the skin (detachment
of the epidermis) and mucus membranes (severe erosions). SJS/TEN is also associated
with fever, raised white cell count, hepatitis, and acute renal failure.
The underlying mechanisms for allopurinol-induced SCARs remain unclear, but cytotoxic
T cells (CD8+ T cells) are involved. In the case of allopurinol, although the presence of
HLA-B*58:01 substantially increases the risk of SCAR, it is not an absolute requirement,
indicating that other variables also contribute to its etiology (1, 7).
One theory, known as the p-I concept, is that there is a direct pharmacological reaction of
the drug (e.g., allopurinol) with the immune receptors (activated drug-specific T cells)
and this provides an initial signal to induce T-cell activation and trigger a T cell–mediated
hypersensitivity reaction. The signal may be strengthened by the additional interaction
with HLA molecules (e.g., HLA-B*58:01) (7-11).
Although allopurinol induced-SCAR is rare (the risk is estimated to be 0.1–0.4%),
allopurinol is one of the most serious causes of SCAR, which carries a mortality rate of up
to 25% (1, 2).
The FDA-approved dose of allopurinol for the management of gout or hyperuricemia is to
start with a daily dose of 100 mg, and titrate the dose upwards to a maximum daily dose
of 800 mg, until the uric acid concentrations are less than 6.0 mg/dl. Allopurinol is often
prescribed in doses that may be too low to achieve a therapeutic goal, an approach taken
in part to reduce the risk of drug hypersensitivity (12). One study has found that a lower
starting dose of allopurinol may reduce the risk of allopurinol hypersensitivity syndrome
(13).
HLA Gene Family

The human leukocyte antigen (HLA) genes are members of the MHC gene family, which
includes more than 200 genes. The MHC family has been subdivided in to 3 subgroups
based on the structure and function of the encoded proteins: Class I, Class II, and Class
III.
The class I region contains the genes encoding the HLA molecules HLA-A, HLA-B, and
HLA-C. These molecules are expressed on the surfaces of almost all immune cells and
play an important role in processing and presenting antigens. The class I gene region also
contains a variety of other genes, many of which are not known to be involved in immune
function.
An important role of HLA class I molecules is to present peptide fragments to immune
cells (CD8+ T cells). Most of these peptides originate from the breakdown of normal
cellular proteins (“self ”). However, if foreign peptide fragments are presented (e.g., from a
pathogen), CD8+T cells will recognize the peptides as “non-self ” and will be activated to
release inflammatory cytokines and launch an immune response to dispose of the
pathogen or foreign body (14).
Because HLA molecules need to present such a wide variety of “self ” and “non-self ”
peptides, the HLA genes are both numerous and highly polymorphic. More than 1,500
HLA-B alleles have been identified. Each HLA allele has a name that is prefixed by HLA,
followed by the gene name, an asterisk and a two digit number that corresponds to
antigen specificity, and the assigned allele number (15). For example, the HLA-
DRB1*13:01 allele is composed of:
• HLA: the HLA prefix (the HLA region on chromosome 6)
• DRB1: the DRB1 gene (a particular HLA gene in this region)
• 13: the allele group (historically determined by serotyping, i.e., a group of alleles
that share the same serotype)
• 01: the specific HLA allele (a specific protein sequence; determined by genetic
analysis).
Additional digits have recently been added to the nomenclature to discriminate alleles
that do not differ in the protein amino acid sequence, but differ in their genetic sequence
(i.e., due to synonymous and noncoding genetic variants).
Variation in the HLA genes plays an important role in the susceptibility to autoimmune
disease and infections and they are also critical in the context of transplant surgery where
better outcomes are observed if the donor and recipient are HLA-compatible (1, 2). More
recently, specific HLA variants have been associated with susceptibility to adverse drug
reactions, including allopurinol-induced hypersensitivity reactions.
Gene: HLA-B
The HLA-B*58:01 allele is associated with an increased risk of severe hypersensitivity
reactions to allopurinol, such as SJS/TEN. The allele is codominant, so an individual needs
to carry only one copy of the HLA-B*58:01 allele to be at increased risk.
The association between HLA-B*58:01 and allopurinol-induced adverse effects was first
discovered in the Han Chinese population, where a study found that all patients who had
allopurinol-induced SJS/TEN (51/51, 100%) carried HLA-B*58:01, compared with only
15% of the allopurinol-tolerant patients (20/135, 15%) (16).
Further studies also found an association with HLA-B*58:01 and severe allopurinol-
induced adverse effects in other populations, including Thai, Korean, European, and
Japanese populations (17-19). The association is stronger in the Han Chinese than in
European and Japanese populations, which is most likely due to differences in HLA-
B*58:01 allele frequencies between racial and ethnic populations (20).
The HLA-B*58:01 allele is most common in individuals of Asian descent, with a frequency
of ~10-15% in the Han Chinese, ~12% in Koreans, and ~6-8% in individuals of Thai
descent (3, 21-25). The risk allele is less common among Europeans and Japanese with a
frequency of only ~1-2% (26, 27).
Although the risk of SCAR due to allopurinol is generally low (0.1–0.4%) and certain
populations have a low frequency of the HLA-B*58:01 risk allele (e.g., Europeans), the risk
of allopurinol-induced SCAR is substantially elevated in HLA-B*58:01 carriers. The odds
ratio for allopurinol-induced SCAR among HLA-B*58:01 carriers in a meta-analysis was
73 using healthy controls and 165 using allopurinol-tolerant controls (5).
Genetic Testing
Genetic testing is available for several HLA-B alleles, including HLA-B*58:01. The
genotype results are either “positive” (HLA-B*58:01 being present in one or both copies of
the HLA-B gene) or “negative” (no copies of HLA-B*58:01 are present). There are no
intermediate phenotypes because HLA-B is expressed in a codominant manner (1, 2).
Several studies have looked in to the cost-effectiveness of HLA-B*58:01 testing to guide
urate-lowering therapy (ULT). A 2012 American College of Rheumatology guideline
recommended that prior to treatment with allopurinol, the HLA-B*58:01 genotype of gout
patients at high risk for SCARs, including Korean patients with chronic renal
insufficiency, should be determined (3). One study reported that in Korean patients with
kidney disease, ULT guided by HLA-B58:01 genotyping was less costly and more effective
than treatment without genotyping, and that HLA-B*58:01 genotyping could considerably
reduce the occurrence of allopurinol-induced SCARs and related deaths (28). Cost-
effectiveness analysis of treating patients with chronic gout (without additional risk
factors) in Singapore and in Portugal found that HLA-B*58:01-guided ULT was not cost-
effective at this time.
A potential alternative to costly HLA genotyping, may be to test for single nucleotide
variants that are tightly associated with HLA-B*58:01. A number of variants have been
found to be in linkage disequilibrium (LD) with HLA-B*58:01, for example, the rs9263726
variant in the PSORS1C1 gene is strongly associated with HLA-B*58:01 in the Japanese
population (20).

2015 Statement from the Clinical Pharmacogenetics Implementation Consortium
(CPIC): Given the high specificity for allopurinol-induced SCAR, allopurinol should not
be prescribed to patients who have tested positive for HLA-B*58:01. Alternative
medication should be considered for these patients to avoid the risk of developing SCAR.
For patients who have tested negative, allopurinol may be prescribed as usual (see Table
1). However, testing negative for HLA-B*58:01 does not totally eliminate the possibility of
developing SCAR, especially in the European population.
Please review the complete therapeutic recommendations that are located here (1, 2).
2012 Statement from the American College of Rheumatology (ACR): Prior to initiation
of allopurinol, rapid polymerase chain reaction-based HLA-B*5801 screening should be
considered as a risk management component in subpopulations where both the HLA-
B*5801 allele frequency is elevated and the HLA-B*5801-positive subjects have a very high
hazard ratio ("high risk") for severe allopurinol hypersensitivity reaction (e.g., Koreans
with stage 3 or worse chronic kidney disease and all those of Han Chinese and Thai
descent).
Nomenclature
Allele name Other name(s) HGVS reference sequence dbSNP reference
identifier for allele
Coding Protein
location
HLA-B*58:01 Not applicable* Not applicable* Not applicable*
single locus. Therefore, the HLA-B*58:01 allele is defined by its sequence (GenBank: EU499350.1) rather
than single coding or protein variants.
Guidelines for the description and nomenclature of gene variations are available from the
Human Genome Variation Society (HGVS): http://www.hgvs.org/content/guidelines
generic drug.
Acknowledgments
The author would like to thank Stuart Scott, Assistant Professor of Genetics and Genomic
Sciences, Icahn School of Medicine at Mount Sinai; and Mia Wadelius, Senior Lecturer,
Uppsala University; for reviewing this summary.
Version history
To view an earlier version (26 March 2013) of this summary, please click here.
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HLA-B gene
25
Amitriptyline Therapy and CYP2D6 and

CYP2C19 Genotype
Laura Dean, MD1
Created: March 23, 2017.
Introduction
Amitriptyline is a tricyclic antidepressant used in the treatment of several psychiatric
disorders, including major depression, obsessive-compulsive disorder, panic attacks,
generalized anxiety disorder, post-traumatic stress disorder, and bulimia. Amitriptyline
also has different off-label uses, including migraine prevention, neuropathic pain
management, fibromyalgia, and enuresis (bedwetting) (1).
Tricyclic antidepressants (TCAs) primarily mediate their therapeutic effect by inhibiting
the reuptake of both serotonin and norepinephrine, leaving more neurotransmitter in the
synaptic cleft stimulating the neuron. Because tricyclics can also block different receptors
(H1 histamine, alpha 1 α1-adrenergic, and muscarinic receptors), side effects are
common. As such, more specific selective serotonin reuptake inhibitors (SSRIs) have
largely replaced the use of them. However, TCAs still have an important use in specific
types of depression and other conditions.
Amitriptyline is metabolized mainly via CYP2C19 and CYP2D6 pathways. Metabolism by
CYP2C19 results in active metabolites, including nortriptyline, which is also a tricyclic
antidepressant. Metabolism catalyzed by CYP2D6 results in the formation of the less
active 10-hydroxy metabolite. Individuals who are “CYP2D6 ultrarapid metabolizers”
carry more than two normal function alleles (i.e., multiple copies) (Table 1, 2), whereas
“CYP2C19 ultrarapid metabolizers” carry two increased function alleles (Table 3, 4).
Individuals who are CYP2D6 or CYP2C19 “poor metabolizers” carry two no function
alleles for CYP2D6 or CYP2C19, respectively.
The FDA-approved drug label for amitriptyline states that CYP2D6 poor metabolizers
have higher than expected plasma concentrations of tricyclic antidepressants when given
usual doses. The FDA recommendations also include monitoring tricyclic antidepressant
plasma levels whenever a tricyclic antidepressant is going to be co-administered with
another drug known to be an inhibitor of CYP2D6 (1).
In 2016, the Clinical Pharmacogenetics Implementation Consortium (CPIC) made dosing
recommendations for tricyclic antidepressants based on CYP2C19 and CYP2D6
genotypes (2). For CYP2D6 ultrarapid metabolizers, CPIC recommends avoiding the use
of a tricyclic due to the potential lack of efficacy, and to consider an alternative drug not

metabolized by CYP2D6. If a TCA is still warranted, CPIC recommends considering

titrating the TCA to a higher target dose (compared to normal metabolizers) and using
therapeutic drug monitoring to guide dose adjustments. For CYP2D6 intermediate
metabolizers, CPIC recommends considering a 25% reduction of the starting dose, and
for CYP2D6 poor metabolizers, to avoid the use of tricyclics because of the potential for
side effects. If a tricyclic is still warranted for CYP2D6 poor metabolizers, CPIC
recommends considering a 50% reduction of the starting dose while monitoring drug
plasma concentrations to avoid side effects.
For CYP2C19 ultrarapid metabolizers, CPIC recommends avoiding the use of tertiary
amines (e.g., amitriptyline) due to the potential for a sub-optimal response, and to
consider an alternative drug not metabolized by CYP2C19, such as the secondary amines
nortriptyline or desipramine. For CYP2C19 poor metabolizers, CPIC recommends
avoiding tertiary amine use due to the potential for sub-optimal response, and to consider
an alternative drug not metabolized by CYP2C19. If a tertiary amine is still warranted for
CYP2C19 poor metabolizers, CPIC recommends considering a 50% reduction of the
starting dose while monitoring drug plasma concentrations while monitoring plasma
concentrations to avoid side effects (2).
Drug Class: Tricyclic Antidepressants

Tricyclic antidepressants (TCAs) are mixed serotonin-norepinephrine reuptake inhibitors.
They increase the amount of neurotransmitter in the synaptic cleft, thought to mediate
their antidepressant effects.
From the 1960s to the 1980s, tricyclics were the first-line treatment for depression, until
the introduction of SSRIs, which have fewer side effects and are safer. The common side
effects of tricyclics include anticholinergic side effects (e.g., blurred vision, dry mouth,
constipation, and sedation), cardiac effects, and orthostatic hypotension.
Today, the main therapeutic use of tricyclics is chronic pain management, such as
neuropathic pain. However, tricyclics are still used in the treatment of depression as well
as other psychiatric disorders, including obsessive–compulsive disorder, panic attacks,
generalized anxiety disorder, post-traumatic stress disorder, bulimia nervosa, smoking
cessation, and enuresis (bedwetting).
Tricyclics are named after their chemical structure of three central rings and a side chain
important for its function and activity. Its structure determines whether a drug is
classified a tertiary amine (amitriptyline, clomipramine, doxepin, imipramine, and
trimipramine) or secondary amine (desipramine and nortriptyline).
Whereas tertiary amines are generally more potent in blocking reuptake of serotonin, the
secondary amines are more potent in blocking the reuptake of norepinephrine. Secondary
amines are better tolerated and are also associated with fewer anticholinergic side effects.
The CYP2C19 enzyme metabolizes tertiary amines to active metabolites, which include
desipramine (the active metabolite of imipramine) and nortriptyline (the active
Amitriptyline Therapy and CYP2D6 and CYP2C19 Genotype 27
metabolite of amitriptyline). Both the tertiary and secondary amines are metabolized by
CYP2D6 to less active metabolites.
The effectiveness and tolerability of tricyclics are affected by CYP2D6 metabolism and
partially by CYP2C19 metabolism. Individuals who carry CYP2D6 or CYP2C19 variants
that influence enzyme activity may be at an increased risk of treatment failure (if plasma
drug levels are decreased) or drug toxicity (if plasma drug levels are increased).
Drug: Amitriptyline
Amitriptyline is used to relieve the symptoms of depression, with endogenous depression
being more likely to respond to treatment than other depressive states (e.g., reactive
depression) (1). Off-label uses of amitriptyline include migraine prevention, and the
treatment of neuropathic pain, fibromyalgia, and enuresis (bedwetting).
Amitriptyline blocks the uptake of both serotonin and norepinephrine, but more potently
blocks the reuptake of serotonin. Amitriptyline also has strong affinities for histamine
(H1), alpha-1 adrenergic, and muscarinic (M1) receptors, which account for its side
effects, including sedation, weight gain, blurred vision, dry mouth, and constipation. The
intensity of these side effects tends to be greater for amitriptyline compared to other
tricyclics (3).
Amitriptyline is metabolized by CYP2C19 to the active metabolite, nortriptyline, which is
also a tricyclic antidepressant thought to be approximately twice as potent as other TCAs.
In contrast to amitriptyline, nortriptyline blocks the reuptake of norepinephrine more
potently than serotonin (3).
Because both the parent drug (amitriptyline) and the CYP2C19 metabolite (nortriptyline)
are pharmacologically active compounds, the plasma levels of both drugs should
monitored (4). The sum of amitriptyline plus nortriptyline plasma levels may correlate
with an individual’s response to amitriptyline therapy (5).
The optimal therapeutic range for amitriptyline has been well-defined (6). Most
individuals display an optimal response to amitriptyline when combined serum levels of
amitriptyline and nortriptyline are between 80 and 200 ng/mL. Higher levels are
associated with an increased risk of adverse events. At levels greater than 300 ng/ml,
cardiac toxicity occurs. This is characterized by ECG changes (widening of QRS), which
may lead to potentially fatal ventricular tachycardia. In some individuals, cardiac toxicity
may occur at lower concentrations or even when they are within the recommended
therapeutic range (7, 8).
Nortriptyline is metabolized by CYP2D6 to hydroxyl metabolites, which have been
associated with cardiac toxicity. Safe levels of hydroxyl metabolites have not yet been
defined (4).
Individuals who are carriers of certain CYP2D6 and/or CYP2C19 variants may have drug
levels that are outside the therapeutic range after treated with standard doses of
amitriptyline. As a result, they may have an increased risk of toxicity (if the level of
amitriptyline and its active metabolites are too high) or treatment failure (if drug levels
are too low).
Gene: CYP2D6
The cytochrome P450 superfamily (CYP) is a large and diverse group of enzymes that
form the major system for metabolizing lipids, hormones, toxins, and drugs. The CYP
genes are very polymorphic and can result in reduced, absent, or increased drug
metabolism.
CYP2D6 is responsible for the metabolism of many commonly prescribed drugs,
including antipsychotics, analgesics, beta-blockers, and TCAs such as amitriptyline.
CYP2D6 is highly polymorphic, with over 100 star (*) alleles described and currently
catalogued at the Human Cytochrome P450 (CYP) Allele Nomenclature Database (9).
CYP2D6 is a particularly complex gene that is difficult to genotype, partly because of the
large number of variants, but also because of the presence of gene deletions, duplications,
and its neighboring pseudogenes. The complexity of genetic variation at this locus
complicates the ability to interrogate CYP2D6.
There is substantial variation in CYP2D6 allele frequencies among different populations
(10). CYP2D6*1 is the wild-type allele and is associated with normal enzyme activity and
the “normal metabolizer” phenotype. The CYP2D6 alleles *2, *33, and *35 are also
considered to have normal activity.
Other alleles include no function variants that produce a non-functioning enzyme (e.g.,
*3, *4, *5,*6, *7, *8, and *12) or an enzyme with decreased activity (e.g., *10, *17, *29, and
*41) (see Table 1) (11) . There are large inter-ethnic differences in the frequency of these
alleles, with *3, *4, *5, *6, and *41 being more common in the Caucasian population, *17
more common in Africans, and *10 more common in Asians (12).
Table 1: 2016 Assignment of CYP2D6 phenotypes by CPIC

Phenotype Activity Score Genotypes Examples of diplotypes
CYP2D6 ultrarapid Greater than 2.0 An individual carrying (*1/*1)xN
metabolizer duplications of functional (*1/*2)xN
(approximately 1–20% of alleles (*2/*2)xNb
patients)a
CYP2D6 normal 1.0 – 2.0c An individual carrying two *1/*1
metabolizer normal function alleles *1/*2
(approximately 72–88% of or two decreased function *2/*2
patients) alleles *1/*9
or one normal and no *1/*41
function allele *41/*41
or one normal function and *1/*5
decreased function allele *1/*4
or combinations of
duplicated alleles that result
in an activity score of 1.0 to
2.0
CYP2D6 intermediate 0.5 An individual carrying one *4/*41
metabolizer decreased function and one *5/*9
(approximately 1–13% of no function allele *4/*10
patients)
CYP2D6 poor metabolizer 0 An individual carrying two *4/*4
(approximately 1–10% of no function alleles *4/*4xN
patients) *3/*4
*5/*5
*5/*6
a For population-specific allele and phenotype frequencies, please see (2).
b Where xN represents the number of CYP2D6 gene copies (N is 2 or more).
c Patients with an activity core of 1.0 may be classified as intermediate metabolizers by some reference
laboratories.
For more information about activity scores, please see the Genetic Testing section.
This table has been adapted from Hicks J.K., Sangkuhl K., Swen J.J., Ellingrod V.L., Müller D.J., Shimoda K.,
Bishop J.R., Kharasch E.D., Skaar T.C., Gaedigk A., Dunnenberger H.M., Klein T.E., Caudle K.E. Clinical
Pharmacogenetics Implementation Consortium Guideline (CPIC®) for CYP2D6 and CYP2C19 Genotypes
and Dosing of Tricyclic Antidepressants: 2016 Update. Clinical pharmacology and therapeutics. 2016 Dec
20 [Epub ahead of print] (2).
Individuals who are intermediate or poor metabolizers carry copies of decreased or no

function CYP2D6 alleles, respectively (Table 1). Approximately 30% of Asians and
individuals of Asian descent are intermediate metabolizers. In these populations, only half
of CYPD6 alleles are fully functional, with the reduced function *10 variant being very
common (~40%, compared to ~2% in Caucasians) (13). As a result, Asians are more likely
to be intermediate metabolizers than Caucasians (14). Similarly, in Africans and African
Americans, only half of CYPD6 alleles are functional. However, a wider range of variants
account for the remaining alleles (14-16).
Approximately 6–10% of European Caucasians and their descendants are poor

metabolizers, mainly due to no function *4 and *5 alleles (14). Notably, less than 40% are
homozygous normal metabolizers (carrying two copies of *1 allele) (17-19).
Individuals who are CYP2D6 poor metabolizers have higher plasma levels of
amitriptyline, compared to normal metabolizers, after standard doses of amitriptyline
(20). Individuals who carry at least one non-functional CYP2D6 variant have been found
to be at medium to high risk of developing side effects (21).
Because standard doses of amitriptyline may lead to an increased risk of adverse events in
individuals who are CYP2D6 poor metabolizers, CPIC recommends avoiding the use of
amitriptyline or other tricyclic antidepressants, and to consider using an alternative drug
that is not metabolized by CYP2D6. If a tricyclic is warranted, CPIC recommends
considering a 50% reduction of the recommended starting dose, and they strongly
recommend therapeutic drug monitoring to guide dose adjustments (4).
Individuals who have more than two copies of normal function CYP2D6 alleles are
CYP2D6 ultrarapid metabolizers. The increased rate of metabolism of amitriptyline leads
to less active drug being available and a poor therapeutic response. Because of the
potential lack of efficacy, CPIC recommends considering an alternative drug to
amitriptyline that is not metabolized by CYP2D6. If a tricyclic is warranted, CPIC
recommends increasing the starting dose and using therapeutic drug monitoring to guide
dose adjustments (4) (Table 2).
Table 2. 2016 CPIC Dosing recommendations for tricyclic antidepressants based on CYP2D6 phenotype
Phenotype Implication Therapeutic recommendation
CYP2D6 ultrarapid Increased metabolism of TCAs to Avoid tricyclic use due to potential lack
metabolizer less active compounds compared to of efficacy. Consider alternative drug
normal metabolizers not metabolized by CYP2D6
Lower plasma concentrations of If a TCA is warranted, consider
active drugs will increase probability titrating to a higher target dose
of pharmacotherapy failure (compared to normal metabolizers)a.
TCAs: Tricyclic Antidepressants
Dosing recommendations only apply to higher initial doses of TCAs for treatment of conditions such as
depression.
The therapeutic recommendations for amitriptyline are classified as “moderate” for intermediate CYP2D6
metabolizers and “strong” for ultrarapid, normal, and poor CYP2D6 metabolizers.
a Titrate dose to observed clinical response with symptom improvement and minimal (if any) side effects.
b Patients may receive an initial low dose of tricyclic, which is then increased over several days to the
recommended steady-state dose. The starting dose in this guideline refers to the recommended steady-state
dose.
Table has been adapted from Hicks J.K., Sangkuhl K., Swen J.J., Ellingrod V.L., Müller D.J., Shimoda K.,

Utilize therapeutic drug monitoring to
guide dose adjustments.
CYP2D6 normal Normal metabolism of TCAs Initiate therapy with recommended
metabolizer starting doseb.
CYP2D6 intermediate Reduced metabolism of TCAs to less Consider a 25% reduction of
metabolizer active compounds compared to recommended starting doseb.
normal metabolizers Utilize therapeutic drug monitoring to
guide dose adjustmentsa.
Higher plasma concentrations of
active drug will increase the
probability of side effects
CYP2D6 poor metabolizer Greatly reduced metabolism of Avoid tricyclic use due to potential for
TCAs to less active compounds side effects. Consider alternative drug
compared to normal metabolizers not metabolized by CYP2D6
Higher plasma concentrations will If a TCA is warranted, consider a 50%
increase the probability of side reduction of recommended starting
effects doseb. Utilize therapeutic drug
monitoring to guide dose
adjustmentsa.
depression.
The therapeutic recommendations for amitriptyline are classified as “moderate” for intermediate CYP2D6
metabolizers and “strong” for ultrarapid, normal, and poor CYP2D6 metabolizers.
dose.
One issue with increasing the dose of amitriptyline dose for CYP2D6 metabolizers is
increasing the level of hydroxyl-metabolites, which have been associated with
cardiotoxicity (22, 23). Currently, the safe range of hydroxy-metabolite plasma
concentrations is not known. In addition, there are few studies on how the combination of
CYP2D6 and CYP2C19 phenotypes influences an individual’s response to amitriptyline
(4).
Gene: CYP2C19
The CYP2C19 enzyme contributes to the metabolism of a range of clinically important
drugs, such as several proton pump inhibitors, clopidogrel, benzodiazepines, and several
tricyclic antidepressants, including amitriptyline.
The CYP2C19 gene is highly polymorphic as 35 variant star (*) alleles are currently
catalogued at the Human Cytochrome P450 (CYP) Allele Nomenclature Database:
(http://www.cypalleles.ki.se/cyp2c19.htm).
The CYP2C19*1 wild-type allele is associated with normal enzyme activity and the
“normal metabolizer” phenotype, whereas the CYP2C19*17 allele is associated with
increased enzyme activity and the “rapid” and “ultrarapid” metabolizer phenotypes (24).
The most common no function variant is CYP2C19*2, which is characterized by c.
681G>A in exon 5 that results in an aberrant splice site and the production of a truncated
and non-functioning protein. The CYP2C19*2 allele frequencies are ~15% in Caucasians
and Africans, and ~29–35% in Asians (24, 25).
Another commonly tested no function variant is CYP2C19*3, which is characterized by c.
636G>A in exon 4 that causes a premature stop codon. The CYP2C19*3 allele frequencies
are ~2–9% in Asian populations, but rare in other racial groups. Other no function
variants occur in less than 1% of the general population, and include CYP2C19*4-*8 (24,
25).
“CYP2C19 intermediate metabolizers” carry one copy of an allele that encodes decreased
or no function (e.g. *1/*2), whereas “poor metabolizers” are homozygous or compound
heterozygous for two no function alleles (e.g., *2/*2, *2/*3) (Table 3).
Table 3: Assignment of CYP2C19 phenotypes by CPIC
Phenotype Genotypes Examples of diplotypes
CYP2C19 ultrarapid metabolizer An individual carrying two *17/*17
(approximately 2–35% of patients)a increased function alleles
CYP2C19 rapid metabolizer An individual carrying one normal *1/*17
(approximately 2–30% of patients) function allele and one increased
function allele
CYP2C19 normal metabolizer An individual carrying two normal *1/*1
(approximately 35–50% of patients) function alleles
CYP2C19 Intermediate metabolizer An individual carrying one normal *1/*2
(approximately 18–45% of patients) function and one no function allele *1/*3
or one no function allele and one *2/*17b
increased function allele
CYP2C19 Poor metabolizer An individual carrying two no *2/*2
(approximately 2–15% of patients) function alleles *2/*3
*3/*3
b The predicted metabolizer phenotype for the *2/*17 genotype is a provisional classification.
Individuals who are CYP2C19 poor metabolizers have a reduced rate of metabolism of
amitriptyline compared to normal metabolizers. As a result, standard doses of
amitriptyline lead to higher plasma levels of amitriptyline, lower levels of nortriptyline,
and may increase the risk of side effects (20, 26-28). Therefore, for CYP2C19 poor
metabolizers, CPIC recommends considering a 50% reduction of the recommended
starting dose, and to use therapeutic drug monitoring to guide dose adjustments (4).
Individuals who are ultrarapid metabolizers may be at an increased risk of treatment
failure and/or metabolites adverse effects. Being a carrier of the increased activity allele
CYP2C19*17 is not associated with an increased level of the sum of amitriptyline plus
nortriptyline levels, but the ratio is altered. A higher level of nortriptyline is seen, which
may be linked to increased side effects. Therefore, for ultrarapid metabolizers, CPIC have
an optional recommendation of considering using an alternative drug to amitriptyline
that is not metabolized by CYP2C19, or if a tricyclic is warranted, to use therapeutic drug
monitoring to guide dose adjustments (4, 26) (Table 4, Table 5).
Table 4. 2016 CPIC Dosing recommendations for amitriptyline based on CYP2C19 phenotype
CYP2C19 ultrarapid Increased metabolism of tertiary Avoid tertiary amine use due to potential
metabolizer and CYP2C19 amines as compared to normal for sub-optimal response. Consider
rapid metabolizer metabolizers alternative drug not metabolized by
Greater conversion of tertiary CYP2C19. TCAs without major CYP2C19
amines to secondary amines metabolism include the secondary amines
may affect response or side nortriptyline and desipramine.
effects
If a tertiary amine is warranted, utilize
therapeutic drug monitoring to guide dose
adjustmentsa.
CYP2C19 normal Normal metabolism of tertiary Initiate therapy with recommended
metabolizer amines starting doseb.
CYP2C19 intermediate Reduced metabolism of tertiary Initiate therapy with recommended
metabolizer amines compared to normal starting doseb.
metabolizers
Dosing recommendations apply only to higher initial doses of amitriptyline for treatment of conditions such
as depression. The therapeutic recommendations for amitriptyline are classified as “strong” for normal and
intermediate CYP2C19 metabolizers, “moderate” for poor metabolizers, and “optional” for ultrarapid
metabolizers.
a Titrate dose to observed clinical response with symptom improvement and minimal (if any) side effects).
dose.

CYP2C19 poor metabolizer Greatly reduced metabolism of Avoid tertiary amine use due to potential
tertiary amines compared to for sub-optimal response.
normal metabolizers Consider alternative drug not metabolized
by CYP2C19. TCAs without major
Decreased conversion of tertiary
CYP2C19 metabolism include the
amines to secondary amines
secondary amines nortriptyline and
may affect response or side
desipramine.
effects
For tertiary amines, consider a 50%
reduction of recommended starting doseb.
guide dose adjustmentsa.
metabolizers.
dose.
Table 5. 2016 CPIC Dosing recommendations for amitriptyline based on both CYP2D6 and CYP2C19
phenotypes a,b
Phenotype CYP2D6 Ultrarapid CYP2D6 Normal CYP2D6 CYP2D6 Poor
metabolizer metabolizer Intermediate metabolizer
metabolizer
CYP2C19 Avoid amitriptyline Consider alternative Consider alternative Avoid amitriptyline
ultrarapid or usec drug not drug not usec
rapid Classification of metabolized by metabolized by Classification of
metabolizer recommendationd: CYP2C19c,e CYP2C19 c,e recommendationd:
Optional Classification of Classification of Optional
recommendationd: recommendationd:
Optional Optional
CYP2C19 Avoid amitriptyline Initiate therapy with Consider a 25% Avoid amitriptyline
normal use. If amitriptyline recommended reduction of use. If amitriptyline
metabolizer is warranted, starting doseh recommended is warranted,
consider titrating to Classification of starting dosef,h consider a 50%
a higher target dose recommendationd: Classification of reduction of
(compared to Strong recommendationd: recommended
normal Moderate starting dosef,h
metabolizers)f,g Classification of
Classification of recommendationd:
recommendationd: Strong
Strong
CYP2C19 Avoid amitriptyline Initiate therapy with Consider a 25% Avoid amitriptyline
intermediate usec recommended reduction of use. If amitriptyline
metabolizer Classification of starting doseh recommended is warranted,
a Dosing recommendations only apply to higher initial doses of TCAs for treatment of conditions such as
depression.
b The dosing recommendations are based on studies focusing on amitriptyline. Because tricyclic
antidepressants have comparable pharmacokinetic properties, it may be reasonable to apply these guidelines
to other tertiary amines including clomipramine, doxepin, imipramine and trimipramine (the classification
of this recommendation is optional).
c If amitriptyline is warranted, utilize therapeutic drug monitoring to guide dose adjustment.
d The rating scheme for the recommendation classification is described in Supplementary Data (2). See
CYP2D6 and CYP2C19 combined dosing recommendations for explanation of classification of
recommendations for this table.
e TCAs without major CYP2C19 metabolism include the secondary amines nortriptyline and desipramine.
f Utilizing therapeutic drug monitoring if a tricyclic is prescribed to a patient with CYP2D6 ultrarapid,
intermediate or poor metabolism in combination with CYP2C19 ultrarapid, intermediate or poor
metabolism is strongly recommended.
g Titrate dose to observed clinical response with symptom improvement and minimal (if any) side effects.
h Patients may receive an initial low dose of TCAs, which is then increased over several days to the
dose.
Phenotype CYP2D6 Ultrarapid CYP2D6 Normal CYP2D6 CYP2D6 Poor

metabolizer metabolizer Intermediate metabolizer
metabolizer
recommendationd: Classification of starting dosef,h consider a 50%
Optional recommendationd: Classification of reduction of
Strong recommendationd: recommended
Optional starting dosef,h
Classification of
recommendationd:
Optional
CYP2C19 Avoid amitriptyline Avoid amitriptyline Avoid amitriptyline Avoid amitriptyline
poor usec use. If amitriptyline usec usec
metabolizer Classification of is warranted, Classification of Classification of
recommendationd: consider a 50% recommendationd: recommendationd:
Optional reduction of Optional Optional
recommended
starting dosef,h
Classification of
recommendationd:
Moderate
a Dosing recommendations only apply to higher initial doses of TCAs for treatment of conditions such as
depression.
b The dosing recommendations are based on studies focusing on amitriptyline. Because tricyclic
antidepressants have comparable pharmacokinetic properties, it may be reasonable to apply these guidelines
to other tertiary amines including clomipramine, doxepin, imipramine and trimipramine (the classification
of this recommendation is optional).
c If amitriptyline is warranted, utilize therapeutic drug monitoring to guide dose adjustment.
d The rating scheme for the recommendation classification is described in Supplementary Data (2). See
CYP2D6 and CYP2C19 combined dosing recommendations for explanation of classification of
recommendations for this table.
e TCAs without major CYP2C19 metabolism include the secondary amines nortriptyline and desipramine.
f Utilizing therapeutic drug monitoring if a tricyclic is prescribed to a patient with CYP2D6 ultrarapid,
intermediate or poor metabolism in combination with CYP2C19 ultrarapid, intermediate or poor
metabolism is strongly recommended.
g Titrate dose to observed clinical response with symptom improvement and minimal (if any) side effects.
h Patients may receive an initial low dose of TCAs, which is then increased over several days to the
dose.
Genetic Testing
Clinical genotyping tests are available for many CYP2D6 and CYP2C19 alleles. The NIH’s
Genetic Testing Registry (GTR) provides a list of test providers for “amitriptyline
response,” and the CYP2D6 and CYP2C19 genes.
Results are typically reported as a diplotype, such as CYP2D6 *1/*1. A result for copy
number, if available, is also important when interpreting CYP2D6 results (29). However, it
is important to note that the number of variants tested can vary among laboratories,
which can result in diplotype result discrepancies between testing platforms and
laboratories (30).
If the test results include an interpretation of the patient’s predicted metabolizer
phenotype, this should be confirmed by checking the diplotype and assigning an activity
score to each allele (e.g., 0 for nonfunctional, 0.5 for reduced function, and 1 for each copy
of a functional allele). The phenotype is defined by the sum of the two scores:
• A normal (previously referred to as “extensive”) metabolizer phenotype has an
activity score of 1 to 2
• An intermediate metabolizer has an activity score of 0.5
• A poor metabolizer has an activity score of 0
• An ultrarapid metabolizer has an activity score greater than 2 (2, 31)

2016 Statement from the US Food and Drug Administration (FDA): The biochemical
activity of the drug metabolizing isozyme cytochrome P450 2D6 (debrisoquin
hydroxylase) is reduced in a subset of the caucasian population (about 7 to 10% of
Caucasians are so called “poor metabolizers”); reliable estimates of the prevalence of
reduced P450 2D6 isozyme activity among Asian, African and other populations are not
yet available. Poor metabolizers have higher than expected plasma concentrations of
tricyclic antidepressants (TCAs) when given usual doses. Depending on the fraction of
drug metabolized by P450 2D6, the increase in plasma concentration may be small, or
quite large (8 fold increase in plasma AUC of the TCA).
In addition, certain drugs inhibit the activity of this isozyme and make normal
metabolizers resemble poor metabolizers. An individual who is stable on a given dose of
TCA may become abruptly toxic when given one of these inhibiting drugs as concomitant
therapy. The drugs that inhibit cytochrome P450 2D6 include some that are not
metabolized by the enzyme (quinidine; cimetidine) and many that are substrates for P450
2D6 (many other antidepressants, phenothiazines, and the Type 1C antiarrhythmics
propafenone and flecainide). While all the selective serotonin reuptake inhibitors (SSRIs),
e.g., fluoxetine, sertraline, and paroxetine, inhibit P450 2D6, they may vary in the extent
generic drug.
of inhibition. The extent to which SSRI-TCA interactions may pose clinical problems will
depend on the degree of inhibition and the pharmacokinetics of the SSRI involved.
Nevertheless, caution is indicated in the coadministration of TCAs with any of the SSRIs
and also in switching from one class to the other. Of particular importance, sufficient time
must elapse before initiating TCA treatment in a patient being withdrawn from
fluoxetine, given the long half-life of the parent and active metabolite (at least 5 weeks
may be necessary).
Concomitant use of tricyclic antidepressants with drugs that can inhibit cytochrome P450
2D6 may require lower doses than usually prescribed for either the tricyclic
antidepressant or the other drug. Furthermore, whenever one of these other drugs is
withdrawn from co-therapy, an increased dose of tricyclic antidepressant may be
required. It is desirable to monitor TCA plasma levels whenever a TCA is going to be
coadministered with another drug known to be an inhibitor of P450 2D6.
Please review the complete therapeutic recommendations that are located here: (1).
(CPIC):
CYP2D6 dosing recommendations.
[…]. The recommended starting dose of amitriptyline or nortriptyline does not need
adjustment for those with genotypes predictive of CYP2D6 normal metabolism. A 25%
reduction of the recommended dose may be considered for CYP2D6 intermediate
metabolizers. The strength of this recommendation is classified as “moderate” because
patients with a CYP2D6 activity score of 1.0 are inconsistently categorized as intermediate
or normal metabolizers in the literature, making these studies difficult to evaluate.
CYP2D6 ultrarapid metabolizers have a higher probability of failing amitriptyline or
nortriptyline pharmacotherapy due to subtherapeutic plasma concentrations, and
alternate agents are preferred. There are documented cases of CYP2D6 ultrarapid
metabolizers receiving large doses of nortriptyline in order to achieve therapeutic
concentrations. However, very high plasma concentrations of the nortriptyline hydroxy-
metabolite were present, which may increase the risk for cardiotoxicity. If a tricyclic is
warranted, there are insufficient data in the literature to calculate a starting dose for a
patient with CYP2D6 ultrarapid metabolizer status, and therapeutic drug monitoring is
strongly recommended. Adverse effects are more likely in CYP2D6 poor metabolizers due
to elevated tricyclic plasma concentrations; therefore, alternate agents are preferred. If a
tricyclic is warranted, consider a 50% reduction of the usual dose, and therapeutic drug
monitoring is strongly recommended.
CYP2C19 dosing recommendations.
[…]. The usual starting dose of amitriptyline may be used in CYP2C19 normal and
intermediate metabolizers. Although CYP2C19 intermediate metabolizers would be
expected to have a modest increase in the ratio of amitriptyline to nortriptyline plasma
concentrations, the evidence does not indicate that CYP2C19 intermediate metabolizers
should receive an alternate dose.
Patients taking amitriptyline who are CYP2C19 rapid or ultrarapid metabolizers may be
at risk for having low plasma concentrations and an imbalance between parent drug and
metabolites causing treatment failure and/or adverse events. Although the CYP2C19*17
allele did not alter the sum of amitriptyline plus nortriptyline plasma concentrations, it
was associated with higher nortriptyline plasma concentrations, possibly increasing the
risk of adverse events. For patients taking amitriptyline, extrapolated pharmacokinetic
data suggest that CYP2C19 rapid or ultrarapid metabolizers may need a dose increase.
Due to the need for further studies investigating the clinical importance of CYP2C19*17
regarding tricyclic metabolism and the possibility of altered concentrations, we
recommend to consider an alternative tricyclic or other drug not affected by CYP2C19.
This recommendation is classified as optional due to limited available data. If
amitriptyline is administered to a CYP2C19 rapid or ultrarapid metabolizer, therapeutic
drug monitoring is recommended.
CYP2C19 poor metabolizers are expected to have a greater ratio of amitriptyline to
nortriptyline plasma concentrations. The elevated amitriptyline plasma concentrations
may increase the chance of a patient experiencing side effects. Use an alternative agent not
metabolized by CYP2C19 (e.g., nortriptyline and desipramine) or consider a 50%
reduction of the usual amitriptyline starting dose along with therapeutic drug monitoring.
2011 Summary of recommendations from the Pharmacogenetics Working Group of
the Royal Dutch Association for the Advancement of Pharmacy (KNMP)
For CYP2D6 ultrarapid metabolizers:
The genetic polymorphism leads to increased metabolic capacity of CYP2D6, which may
cause a decrease in the plasma concentrations of amitriptyline and its active metabolite
nortriptyline and increased plasma concentrations of the active metabolites E-10-OH-
amitriptyline and E-10-OH- nortriptyline.
Recommendation:
1. Choose an alternative if possible. Antidepressants that are not metabolized via
CYP2D6 - or to a lesser extent - include, for example, citalopram and sertraline.
2. If an alternative is not an option: increase the dose to 1.25 times the standard dose,
monitor the plasma concentrations and be alert to potential therapy failure due to
decreased amitriptyline plus nortriptyline plasma concentrations and to increased
plasma concentrations of the potentially cardiotoxic, active hydroxy metabolites.
For CYP2D6 intermediate metabolizers:
The genetic polymorphism leads to decreased metabolic capacity of CYP2D6, which may
cause an increase in the plasma concentrations of amitriptyline and its active metabolite
nortriptyline and decreased plasma concentrations of the active metabolites E-10-OH-

Recommendation:
2. If an alternative is not an option: use 60% of the standard dose and monitor the
plasma concentrations of amitriptyline and nortriptyline
As side effects are related to nortriptyline plasma concentrations and the efficacy to
amitriptyline plus nortriptyline plasma concentrations, which are influenced to a lesser
extent by CYP2D6, it is not known whether it is possible to reduce the dose to such an
extent that the side effects disappear, but the efficacy is maintained.
For CYP2D6 poor metabolizers:
The genetic polymorphism leads to decreased metabolic capacity of CYP2D6, which may
cause an increase in the plasma concentrations of amitriptyline and its active metabolite
nortriptyline and decreased plasma concentrations of the active metabolites E-10-OH-
Recommendation:
2. If an alternative is not an option: use 50% of the standard dose and monitor the
plasma concentrations of amitriptyline and nortriptyline
As side effects are related to nortriptyline plasma concentrations and the efficacy to
amitriptyline plus nortriptyline plasma concentrations, which are influenced to a lesser
extent by CYP2D6, it is not known whether it is possible to reduce the dose to such an
extent that the side effects disappear, but the efficacy is maintained.
Nomenclature
Nomenclature for selected CYP2D6 alleles
Common Alternative HGVS reference sequence dbSNP
allele name names reference
Coding Protein
identifier for
allele location
CYP2D6*4 1846G>A NM_000106.5:c. Not applicable - variant occurs rs3892097
506-1G>A in a non-coding region
CYP2D6*5 Not applicable - variant results in a whole gene deletion
* In the literature, 1023C>T is also referred to as 1111C>T, and 2850C>T is also referred to 2938C>T.
Nomenclature for selected continues on next page...
Nomenclature for selected continued from previous page.

Coding Protein
identifier for
allele location
CYP2D6*6 1707 del T NM_000106.5:c. NP_000097.3:p.Trp152Glyfs rs5030655
Trp152Gly 454delT
CYP2D6*10 100C>T NM_000106.5:c. NP_000097.3:p.Pro34Ser rs1065852
Pro34Ser 100C>T
CYP2D6*17 Includes at least NM_000106.5:c. NP_000097.3:p.Thr107Ile rs28371706
two functional 320C>T NP_000097.3:p.Cys296Arg rs16947
variants*: NM_000106.5:c.
1023C>T 886T>C
(Thr107Ile)
2850C>T
(Cys296Arg)
CYP2D6*41 2988G>A NM_000106.5:c. Not applicable – variant occurs rs28371725
985+39G>A in a non-coding region
Nomenclature for selected CYP2C19 alleles

Common allele Alternative HGVS reference sequence dbSNP
name names reference
Coding Protein
identifier for
allele location
CYP2C19*2 681G>A NM_000769.1:c.681G>A NP_000760.1:p.Pro227= rs4244285
Pro227Pro
CYP2C19*3 636G>A NM_000769.1:c.636G>A NP_000760.1:p.Trp212Ter rs4986893
Trp212Ter
CYP2C19*17 -806C>T NM_000769.2:c.-806C>T Not applicable—variant rs12248560
occurs in a non-coding region
Nomenclature for Cytochrome P450 enzymes is available from the Human Cytochrome
P450 (CYP) Allele Nomenclature Database: http://www.cypalleles.ki.se/
Acknowledgments
The author would like to thank the following individuals for reviewing this summary:
David Kisor, B.S., Pharm.D., Professor and Director of Pharmacogenomics Education,
Pharmacogenomics Program, Manchester University, Indiana; Mohamed Nagy, Clinical
Pharmacist, Head of the Personalised Medication Management Unit, Department of
pharmaceutical Services, Children's Cancer Hospital, Egypt; Yolande Saab, Pharm.D.,
Ph.D., Associate Professor of Pharmacogenomics, School of Pharmacy, Lebanese
American University, Lebanon; Stuart Scott, Assistant Professor of Genetics and Genomic
Sciences, Icahn School of Medicine at Mount Sinai; Chakradhara Rao S Uppugunduri,
Maître-assistant at the CANSEARCH Laboratory, University of Geneva, Switzerland; and
Mandy van Rhenen, secretary of the Dutch Pharmacogenetics Working Group (DPWG),
Centre for Information on Medicines, Royal Dutch Pharmacists Association (KNMP).
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Aripiprazole Therapy and CYP2D6 Genotype
Atomoxetine Therapy and CYP2D6 Genotype
Carisoprodol Therapy and CYP2C19 Genotype
Clopidogrel Therapy and CYP2C19 Genotype
Clozapine Therapy and CYP2D6, CYP1A2, and CYP3A4 Genotypes
Codeine Therapy and CYP2D6 Genotype
Diazepam Therapy and CYP2C19 Genotype
Esomeprazole Therapy and CYP2C19 Genotype
Imipramine Therapy and CYP2D6 and CYP2C19 Genotype
Metoprolol Therapy and CYP2D6 Genotype
Omeprazole Therapy and CYP2C19 Genotype

Prasugrel Therapy and CYP Genotype
Propafenone Therapy and CYP2D6 Genotype
Risperidone Therapy and CYP2D6 Genotype
Tamoxifen Therapy and CYP2D6 Genotype
Thioridazine Therapy and CYP2D6 Genotypes
Tramadol Therapy and CYP2D6 Genotype
Venlafaxine Therapy and CYP2D6 Genotype


Amitriptyline response

CYP2C19 gene
CYP2D6 gene
47

Laura Dean, MD1
Introduction
Aripiprazole is an atypical antipsychotic used in the management of schizophrenia,
bipolar disorder, major depressive disorder, irritability associated with autistic disorder,
and treatment of Tourette’s disorder.
The metabolism and elimination of aripiprazole is mainly mediated through two enzymes,
CYP2D6 and CYP3A4. Approximately 8% of Caucasians, 3–8% of Black/African
Americans and up to 2% of Asians cannot metabolize CYP2D6 substrates and are
classified as “poor metabolizers” (1).
The FDA-approved drug label for aripiprazole states that in CYP2D6 poor metabolizers,
half of the usual dose should be administered. In CYP2D6 poor metabolizers who are
taking concomitant strong CYP3A4 inhibitors (e.g., itraconazole, clarithromycin), a
quarter of the usual dose should be used (Table 1) (2).
Table 1. The FDA-recommended dose adjustments for aripiprazole in patients who are known CYP2D6
poor metabolizers and patients taking concomitant CYP2D6 inhibitors, CYP3A4 inhibitors, and/or
CYP3A4 inducers (2016)
Factors Dosage Adjustments for ABILIFY
Known CYP2D6 Poor Metabolizers Administer half of usual dose
Known CYP2D6 Poor Metabolizers taking concomitant strong Administer a quarter of usual dose
CYP3A4 inhibitors (e.g., itraconazole, clarithromycin)
Strong CYP2D6 (e.g., quinidine, fluoxetine, paroxetine) or CYP3A4 Administer half of usual dose
inhibitors (e.g., itraconazole, clarithromycin)
Strong CYP2D6 and CYP3A4 inhibitors Administer a quarter of usual dose
Strong CYP3A4 inducers (e.g., carbamazepine, rifampin) Double usual dose over 1 to 2 weeks
Table is adapted from a FDA-approved drug label for aripiprazole (2).
Drug: Aripiprazole
Aripiprazole is an atypical antipsychotic primarily used in the treatment of schizophrenia
and bipolar disorder. Aripiprazole may also be used as part of the management of major
depressive disorder, irritability associated with autism, and treatment of Tourette’s
disorder (2).

The first antipsychotics to be discovered in the 1950s were haloperidol and

chlorpromazine. Known as “first-generation” or “typical” antipsychotics, these drugs are
used to treat psychosis (regardless of the cause), chronic psychotic disorders (e.g.,
schizophrenia), and other psychiatric conditions. However, prominent adverse effects
included extrapyramidal side effects such as tardive dyskinesia, muscle rigidity, tremors,
and Parkinsonian-like symptoms.
Newer antipsychotics, known as “second generation” or “atypical” antipsychotics, have a
lower risk of extrapyramidal side effects such as tardive dyskinesia. However, many have
serious metabolic effects. Aripiprazole is an atypical antipsychotic that is noted for having
fewer metabolic side effects than other atypicals, such as clozapine, olanzapine,
risperidone, and quetiapine. Other atypicals currently approved by the FDA include
asenapine, brexpiprazole, cariprazine, lurasidone, paliperidone, and ziprasidone.
The main action of both first-generation and second-generation antipsychotics is thought
to be the post-synaptic blockade of D2 dopamine receptors. All antipsychotics, with the
exception of aripiprazole, are D2 antagonists.
Aripiprazole is a partial D2 agonist. Aripiprazole binds to the D2 receptor with a high
affinity similar to dopamine. However, because it has low intrinsic activity, it causes much
lower activation of the receptor compared to dopamine.
The combination of a high affinity for the D2 receptor and its partial agonist activity may
result in aripiprazole reducing the high-frequency firing of dopamine neurons in the
brain’s mesolimbic system. Overactivity in this region is thought to underlie psychosis and
other positive symptoms of schizophrenia. In addition, the preservation of some D2
receptor activity in other dopamine-rich pathways in the brain (mesocortical and
nigrostriatal areas) may provide more protection against extrapyramidal side effects (3, 4).
Aripiprazole also has a high affinity for the serotonin 5-HT2A receptors, where it acts as
an antagonist and it moderately blocks the alpha 1 adrenergic and histamine H1
receptors, which may account for the lower incidence of orthostatic hypotension and
sedation compared to other antipsychotics (5).
Adverse events to aripiprazole include increased mortality in elderly patients with
psychosis caused by dementia, suicidal thoughts and behavior in children and young
adults, neuroleptic malignant syndrome, and tardive dyskinesia (2).
Aripiprazole is extensively metabolized in the liver by CYP450 enzymes, mainly CYP2D6
and CYP3A4. Aripiprazole activity is thought to be primarily due to the parent drug, and
to a lesser extent its major metabolite, dehydro-aripiprazole. The mean elimination half-
life is about 75 hours for aripiprazole, but in individuals who have no appreciable
CYP2D6 activity (poor metabolizers), the mean elimination half-life for aripiprazole is
about 146 hours.
Genetic variations in the CYP2D6 gene have been found to impact serum levels of
aripiprazole (6, 7). Because standard doses of aripiprazole lead to higher plasma levels of
Aripiprazole Therapy and CYP2D6 Genotype 49
aripiprazole and dehydro-aripiprazole, the dose of aripiprazole should be adjusted in

subjects carrying two nofunction alleles causing poor metabolizer status.
The FDA recommends that patients who are known to be CYP2D6 poor metabolizers
should receive half the standard dose of aripiprazole, or a quarter of the standard dose if
they are also taking medicines that strongly inhibit CYP3A4 (e.g., itraconazole,
clarithromycin) (See Table 1).
A recent study substantiates the FDA recommendations by concluding that poor
metabolizers should receive a reduced dose of aripiprazole (30–50% reduction). This
study also suggested that individuals with increased CYP2D6 activity (ultrarapid
metabolizers) may need to take an alternative antipsychotic not metabolized by CYP2D6
because of reduced drug levels (8).
The cytochrome P450 superfamily

The cytochrome P450 superfamily (CYP450) is a large and diverse group of enzymes that
form the major system for metabolizing lipids, hormones, toxins, and drugs. The CYP450
genes are highly polymorphic and can result in no, decreased, normal or increased
enzyme activity.
Gene: CYP2D6
CYP2D6 is highly polymorphic, with over 100 star (*) alleles described (9). CYP2D6*1 is
the reference (or wild-type) allele encoding enzyme with normal activity. The CYP2D6*2,
*33, and *35 alleles are also considered to confer normal activity (Table 2).
Table 2. Activity status of selected CYP2D6 alleles
Allele type CYP2D6 Alleles
Increased *1xN, *2xN (xN denoting gene duplication or multiplication)
Normal *1, *2, *35
Decreased activity *9, *10, *17, *29, *36, *41
Inactive *3-*8, *11-*16, *18-*21, *38, *40, *42
For a detailed list of CYP2D6 alleles, please see (9).
Individuals who have more than two normal function copies of the CYP2D6 gene are
“ultrarapid metabolizers,” whereas individuals who carry two normal or one normal and
one decreased function allele are classified as “normal metabolizers.” Subjects with one
normal and one no function allele or two decreased function alleles are categorized as
“normal metabolizers” by CPIC guidelines, but have also been categorized as
“intermediate metabolizers” in the literature. Subjects with one decreased and one no
function allele are predicted to be intermediate metabolizers and those with two no
function alleles, as mentioned above, are poor metabolizers.
The most common no function alleles include CYP2D6*3, *4, *5, and *6 (10, 11), and the
most common decreased function alleles include CYP2D6*9, *10, *17, *29 and *41 (Table
2). There are large inter-ethnic differences in the frequency of these alleles. For example,
CYP2D6*4 is the most common no function allele in Caucasians, but less abundant in
subjects with African ancestry, and rare in Asians. In contrast, the decreased function
allele CYP2D6*10 is the most common allele in Asians, and CYP2D6*17 is almost
exclusively found in individuals with African ancestry (1). Consequently, the phenotype
frequencies also vary substantially among the major ethnicities and may vary among
populations. Approximately 6-10% of European Caucasians and their descendants are
poor metabolizers, mainly due to the prevalent no function CYP2D6*4 and *5 alleles (12,
13).
Gene: CYP3A4
In contrast to CYP2D6, genetic variation cannot explain CYP3A4 variability. Although 26
allelic variants are currently described, the majority have not been shown to alter CYP3A4
activity (14, 15). To date, only three no function CYP3A4 alleles, all being rare, have been
identified (CYP3A4*6, CYP3A4*20 and CYP3A4*26) (16, 17). The CYP3A4*20 allele, for
example, has been reported to have a frequency of about 0.2% in European Americans
and 0.05% in African Americans, while it was observed at a frequency of 1.2% in Spain;
notably, it reached up to 3.8% in specific Spanish regions (16). Although a decreased
function allele, CYP3A4*22, has been associated with tacrolimus dose requirements (18),
its clinical utility warrants further investigation.
Genetic Testing
Genetic testing for CYP2D6 and CYP3A4 is available. Test panels may include tests for
additional genes involved in drug metabolism including aripiprazole. For tests available to
predict CYP2D6 activity to optimize aripiprazole therapy (i.e., adjust dosage or opt for an
alternative drug) please see the Genetic Testing Registry.
number, if available, is also important when interpreting CYP2D6 results (19).

generic drug.
2016 Statement from the US Food and Drug Administration (FDA): Dosage
adjustments are recommended in patients who are known CYP2D6 poor metabolizers
and in patients taking concomitant CYP3A4 inhibitors or CYP2D6 inhibitors or strong
CYP3A4 inducers (see Table 1). When the coadministered drug is withdrawn from the
combination therapy, aripiprazole dosage should then be adjusted to its original level.
When the coadministered CYP3A4 inducer is withdrawn, aripiprazole dosage should be
reduced to the original level over 1 to 2 weeks. Patients who may be receiving a
combination of strong, moderate, and weak inhibitors of CYP3A4 and CYP2D6 (e.g., a
strong CYP3A4 inhibitor and a moderate CYP2D6 inhibitor or a moderate CYP3A4
inhibitor with a moderate CYP2D6 inhibitor), the dosing may be reduced to one-quarter
(25%) of the usual dose initially and then adjusted to achieve a favorable clinical response.
the Royal Dutch Association for the Advancement of Pharmacy (KNMP): In CYP2D6
poor metabolizers, reduce the maximum dose of aripiprazole to 10 mg/day (67% of the
maximum recommended daily dose).
Nomenclature
Nomenclature of selected CYP2D6 alleles
Coding Protein
identifier for
allele location
CYP2D6*4 1846G>A NM_000106.5:c. Variant occurs in a non-coding rs3892097
506-1G>A region (splice variant causes a
frameshift)
CYP2D6*5 Variant results in a whole gene deletion
Trp152Gly 454delT
• CYP2D6T
(Pro34Ser) 100C>T
CYP2D6*17 1023C>T[1] NM_000106.5:c. NP_000097.3:p.Thr107Ile rs28371706
(Thr107Ile) 320C>T
2850C>T[1] NM_000106.5:c. NP_000097.3:p.Cys296Arg rs16947
(Cys296Arg) 886T>C
[1] In the literature, 1023C>T is also referred to as 1111C>T, and 2850C>T is also referred to 2938C>T.
[2] In the literature, 2850C>T is also referred to as 2938C>.
Nomenclature of selected continues on next page...
Nomenclature of selected continued from previous page.

Coding Protein
identifier for
allele location
CYP2D6*41 2850C>T[2] NM_000106.5:c. NP_000097.3:p.Cys296Arg rs16947
(Cys296Arg) 886T>C
2988G>A NM_000106.5:c. Variant occurs in a non-coding rs28371725
985+39G> region (impacts slicing).
[2] In the literature, 2850C>T is also referred to as 2938C>.
Nomenclature of selected CYP3A4 alleles

Common Alternative names HGVS reference sequence dbSNP
allele name reference
Coding Protein
identifier for
allele
location
CYP3A4*6 17661_17662insA NM_017460.5:c. NP_059488.2:p.Asp277Glufs rs4646438
277Frameshift 830_831insA
CYP3A4*20 1461_1462insA NM_017460.5:c. NP_001189784.1:p.Pro487Thrfs rs67666821
CYP3A4*26 17633C>T
R268Stop
Guidelines for the description and nomenclature of gene variations are available from the Human Genome
Variation Society (HGVS): http://www.hgvs.org/content/guidelines
Nomenclature for Cytochrome P450 enzymes is available from the Human Cytochrome P450 (CYP) Allele
Nomenclature Database: http://www.cypalleles.ki.se/
Acknowledgments
The author would like to thank Megan J. Ehret, PharmD, MS, BCPP Behavioral Health
Clinical Pharmacy Specialist, Fort Belvoir Community Hospital, Virginia; Andrea
Gaedigk, MS, PhD, Director, Pharmacogenetics Core Laboratory, Division of Clinical
Pharmacology, Toxicology and Therapeutic Innovation, Children's Mercy Hospital,
Kansas City, and Professor, School of Medicine, University of Missouri-Kansas City; and
Steven Leeder, Pharm.D., Ph.D., Marion Merrell Dow/Missouri Endowed Chair in
Pediatric Clinical Pharmacology, and Director, Division of Clinical Pharmacology,
Toxicology and Therapeutic Innovation, Children’s Mercy Hospital, Kansas City; for
reviewing this summary.
References
PMID: 27388693.
2. ABILIFY- aripiprazole tablet [package insert]. Tokyo, Japan: Otsuka America

Pharmaceutical Inc; 2016. Available from: https://dailymed.nlm.nih.gov/dailymed/
drugInfo.cfm?setid=c040bd1d-45b7-49f2-93ea-aed7220b30ac
3. Potkin S.G., Saha A.R., Kujawa M.J., Carson W.H., et al. Aripiprazole, an
antipsychotic with a novel mechanism of action, and risperidone vs placebo in
patients with schizophrenia and schizoaffective disorder. Arch Gen Psychiatry.
2003;60(7):681–90. PubMed PMID: 12860772.
4. Swainston Harrison T., Perry C.M. Aripiprazole: a review of its use in schizophrenia
and schizoaffective disorder. Drugs. 2004;64(15):1715–36. PubMed PMID: 15257633.
5. Muneer A. The Treatment of Adult Bipolar Disorder with Aripiprazole: A Systematic
Review. Cureus. 2016;8(4):e562. PubMed PMID: 27190727.
6. van der Weide K., van der Weide J. The Influence of the CYP3A4*22 Polymorphism
and CYP2D6 Polymorphisms on Serum Concentrations of Aripiprazole, Haloperidol,
Pimozide, and Risperidone in Psychiatric Patients. J Clin Psychopharmacol.
2015;35(3):228–36. PubMed PMID: 25868121.
7. Hendset M., Molden E., Knape M., Hermann M. Serum concentrations of
risperidone and aripiprazole in subgroups encoding CYP2D6 intermediate
metabolizer phenotype. Ther Drug Monit. 2014;36(1):80–5. PubMed PMID:
24232129.
8. Lisbeth P., Vincent H., Kristof M., Bernard S., et al. Genotype and co-medication
dependent CYP2D6 metabolic activity: effects on serum concentrations of
aripiprazole, haloperidol, risperidone, paliperidone and zuclopenthixol. Eur J Clin
Pharmacol. 2016;72(2):175–84. PubMed PMID: 26514968.
CYP2D6 allele nomenclature. [Cited Dember 14, December 2015]. Available from:
10. PharmGKB [Internet]. Palo Alto (CA): Stanford University. Haplotype CYP2D6*3.
PA165816578
PA165948092
11972444.
13. Lerena L.A., Naranjo M.E., Rodrigues-Soares F., Penas L.E.M., et al. Interethnic
variability of CYP2D6 alleles and of predicted and measured metabolic phenotypes
across world populations. Expert Opin Drug Metab Toxicol. 2014;10(11):1569–83.
CYP3A4 allele nomenclature [Cited 30 October 2015]. Available from: http://
www.cypalleles.ki.se/cyp3a4.htm
15. Westlind-Johnsson A., Hermann R., Huennemeyer A., Hauns B., et al. Identification
and characterization of CYP3A4*20, a novel rare CYP3A4 allele without functional
activity. Clin Pharmacol Ther. 2006;79(4):339–49. PubMed PMID: 16580902.
16. Apellaniz-Ruiz M., Inglada-Perez L., Naranjo M.E., Sanchez L., et al. High frequency
and founder effect of the CYP3A4*20 loss-of-function allele in the Spanish
population classifies CYP3A4 as a polymorphic enzyme. Pharmacogenomics J.
2015;15(3):288–92. PubMed PMID: 25348618.
17. Werk A.N., Lefeldt S., Bruckmueller H., Hemmrich-Stanisak G., et al. Identification
and characterization of a defective CYP3A4 genotype in a kidney transplant patient
with severely diminished tacrolimus clearance. Clin Pharmacol Ther. 2014;95(4):416–
22. PubMed PMID: 24126681.
18. Tang J.T., Andrews L.M., van Gelder T., Shi Y.Y., et al. Pharmacogenetic aspects of the
use of tacrolimus in renal transplantation: recent developments and ethnic
considerations. Expert Opin Drug Metab Toxicol. 2016;12(5):555–65. PubMed
PMID: 27010623.
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662–73. PubMed PMID: 21412232.

Amitriptyline Therapy and CYP2D6 and CYP2C19 Genotype


Aripiprazole response

CYP2D6 gene
CYP3A4 gene
57

Laura Dean, MD1
Introduction
Atomoxetine was the first non-stimulant drug to be used in the treatment of attention-
deficit hyperactivity disorder (ADHD). Atomoxetine is a selective noradrenaline reuptake
inhibitor, and is part of a treatment plan for ADHD that may include other measures such
as psychological, educational, and social support.
The CYP2D6 enzyme metabolizes a quarter of all prescribed drugs, including
atomoxetine. Individuals who carry two nonfunctional copies of the CYP2D6 gene are
known as poor metabolizers and have higher plasma concentrations of atomoxetine
compared with individuals who have two copies of normal activity alleles.
The FDA states that the dose of atomoxetine may need to be adjusted in patients known
to be CYP2D6 poor metabolizers (1). A guideline from The Dutch Pharmacogenetics
Working Group includes the recommendation that poor metabolizers can be given the
standard dose of atomoxetine, but physicians should be aware of adverse drug events.
They also state that for individuals who have more than two functional gene copies of
CYP2D6, i.e., individuals with so-called ultrarapid metabolizer status, physicians should
either be alert to reduced efficacy with the standard dose of atomoxetine, or they should
prescribe an alternative drug, such as methylphenidate or clonidine (Table 1) (2).
Table 1. CYP2D6 phenotypes and the therapeutic recommendations for atomoxetine therapy
Phenotype Genotype Recommendations for atomoxetine therapy
Ultrarapid Three or more functional gene Insufficient data to allow calculation of dose
metabolizer copies adjustment. Be alert to reduced efficacy or select
alternative drug (e.g., methylphenidate,
clonidine).
Extensive Two functional gene copies No recommendations.
metabolizer
Intermediate One active allele and one inactive No recommendations.
metabolizer allele, or two decreased activity
alleles, or one decreased activity
allele and one inactive allele
Poor metabolizer Two inactive alleles Standard dose. Dose increase probably not
necessary; be alert to adverse drug events.

The level of evidence for the therapeutic (dose) recommendations is 3/4 (“moderate
quality”) for poor metabolizers, and 4/4 (“good quality”) for intermediate metabolizers.
There are no data for ultrarapid metabolizers. The Table is adapted from Swen J.J.,
Nijenhuis M., de Boer A., Grandia L. et al. Pharmacogenetics: from bench to byte - an
update of guidelines. Clinical pharmacology and therapeutics. 2011;89(5):662–73 (2).
Allele type Alleles
Normal function *1, *2, *33, *35
Decreased function *9, *10, *17, *29, *41
No function *3, *4, *5, *6, *7, *8
For a more detailed list of CYP2D6 alleles, please see (3).
Drug: Atomoxetine
Atomoxetine is used in the treatment of attention-deficit hyperactivity disorder (ADHD),
which is one of the most common childhood disorders. Symptoms include difficulty
focusing and paying attention, difficulty controlling behavior, and hyperactivity.
Symptoms may continue in to adulthood. Atomoxetine may be used alone or in
combination with behavioral treatment, as an adjunct to psychological, educational,
social, and other remedial measures.
Atomoxetine was the first non-stimulant drug to be approved for use in ADHD.
Atomoxetine is a selective norepinephrine reuptake inhibitor and it is thought to exert its
therapeutic effect by increasing the concentration of synaptic norepinephrine. Because it
is a non-stimulant, atomoxetine has the advantages of having less potential for abuse, and
it is not scheduled as a controlled substance (4).
Atomoxetine is primarily metabolized through the CYP2D6 enzymatic pathway. The
main metabolite, 4-hydroxyatomoxetine, is equipotent to atomoxetine as an inhibitor of
the norepinephrine transport, but is found at much lower levels in the plasma (5). In
individuals who lack CYP2D6 activity (poor metabolizers), 4-hydroxyatomoxetine is
formed by other CYP enzymes, but at a much slower rate (1).
CYP2C19, along other CYP enzymes, forms the metabolite N-Desmethylatomoxetine.
Although this metabolite has substantially less pharmacological activity compared to
atomoxetine, and is present at much lower plasma concentrations, one study found that
genetic polymorphisms of the CYP2C19 gene also influenced the pharmacokinetics of
atomoxetine (6).
Atomoxetine has a wide therapeutic window, but the risk of adverse effects may be
increased by the presence of CYP2D6 genetic variants (7-9). Common adverse effects of
atomoxetine therapy include weight loss, headache, and irritability. Psychiatric side effects
Atomoxetine Therapy and CYP2D6 Genotype 59
may also occur; these include anxiety, depression, and the development of suicidal
thoughts.
The FDA-approved drug label for atomoxetine includes a boxed warning and additional
warning statements regarding the increased risk of suicidal thinking in children and
adolescents treated with atomoxetine. The warning includes: “Children and teenagers
sometimes think about suicide, and many report trying to kill themselves. Results from
atomoxetine clinical studies with over 2200 child or teenage ADHD patients suggest that
some children and teenagers may have a higher chance of having suicidal thoughts or
actions. Although no suicides occurred in these studies, 4 out of every 1000 patients
developed suicidal thoughts.”(1)
Gene: CYP2D6
genes are often polymorphic and can result in no decreased or increased activity
impacting drug metabolism.
including antidepressants, antipsychotics, analgesics, and beta-blockers. The CYP2D6
gene is highly polymorphic—more than 100 alleles have been described (10).
CYP2D6*1 is the wild-type allele and is associated with normal enzyme activity and the
normal “extensive metabolizer” phenotype. The CYP2D6 alleles *2, *33, and *35, among
others, are also considered to have normal activity (11, 12).
Individuals who have multiple functional copies of the CYP2D6 gene are known as
“ultrarapid metabolizers” (UM) (Table 1). Because each CYP2D6 allele contributes to the
metabolism and inactivation of atomoxetine, atomoxetine may have decreased efficacy in
UM individuals (2). The UM phenotype is estimated to be present in up to 28% of North
Africans, Ethiopians, and Arabs; up to 10% in Caucasians; 3% in African Americans, and
up to 1% in Hispanics, Chinese, and Japanese (13).
The Dutch Pharmacogenetics Working Group recommendations state that for ultrarapid
metabolizers, there are insufficient data to allow for an adjusted dose to be calculated, and
therefore, the physician should be alert to reduced efficacy of a standard dose of
atomoxetine, or prescribe an alternative drug, such as methylphenidate or clonidine.
The most common non-functional and reduced function CYP2D6 alleles include
CYP2D6*3, *4, *5, and *6 (2, 10, 11, 13-16) and CYP2D6*10, *17 and *41) (4, 12, 17-19)
(Table 2). There are large inter-ethnic differences in the frequency of these alleles, with *3,
*4, *5, *6, and *41 being more common in Caucasians, *17 more common in Africans,
and *10 more common in Asians (20).
Individuals who are intermediate or poor metabolizers carry copies of reduced-activity or
non-functioning CYP2D6 alleles (see Table 1 and 2). In these individuals, the metabolic
capacity of CYP2D6 is decreased which may result in higher levels of atomoxetine. The
FDA-approved drug label for atomoxetine states that poor metabolizers of CYP2D6 have
a higher exposure to atomoxetine (10-fold higher area under the cover and a 5 fold-higher
peak concentration) compared to extensive metabolizers who received the same dose. The
label also states that in individuals who are known to be poor metabolizers, the dose of
atomoxetine should be adjusted—treatment should be initiated at 0.5mg/kg/day and only
increased to the usual target dose of 1.2 mg/kg/day if symptoms fail to improve after 4
weeks and the initial dose is well tolerated (see Therapeutic Recommendations) (1).
However, the Dutch Pharmacogenetics Working Group recommendations state that for
poor metabolizers, “a standard dose of atomoxetine is recommended. An increase in dose
is probably not necessary, but the physician should be alert to adverse drug events. (2)”
One small study of 100 children with ADHD receiving atomoxetine therapy found that
the presence of at least one nonfunctional or reduced function CYP2D6 allele led to an
increase in adverse effects, such as gastrointestinal problems and sleep disorders, and a
late response to treatment (longer than 9 weeks). The study concluded that CYP2D6
genotyping before atomoxetine treatment may be beneficial in preventing overdosing or
early cessation of treatment because of initial adverse effects (21). However, another study
found genotyping to be unnecessary, because during the routine clinical management of
ADHD, investigators were able to adjust the dose of atomoxetine in children and
adolescents who had normal or reduced CYP2D6 activity—so that their treatment was
comparable in safety and efficacy—without knowing what their CYP2D6 genotype was
(22).
Poor metabolizers are commonly found in European Caucasians and their descendants
(6-10%). The most common alleles in this population are the functional CYP2D6*1 and *2
alleles (70%); the remaining alleles include CYP2D6*10 and *41 conveying decreased
function and the nonfunctional CYP2D6*3, *4, *5 and *6 variants that largely account for
the poor metabolizer phenotype in these populations (12). About 2-5% of African
Americans are poor metabolizers, due to the presence of CYP2D6*4 and *5 and a number
of other nonfunctional alleles (1, 11, 15, 18, 20).
Approximately 30% of Asians and individuals of Asian descent are intermediate
metabolizers. In these populations, 40-60% of individuals carry CYP2D6*10, a decreased
function variant (only ~2-3% of Caucasians have this allele) (23, 24). As a result, Asians
are more likely to have decreased CYP2D6 activity compared to Caucasians (12). Neither
the FDA-approved drug label of the Dutch Pharmacogenetic Working Group gives dosing
recommendations for subjects with decreased function alleles, often classified as
intermediate metabolizers.
Genetic Testing
CYP2D6 genetic testing is available. Usually a patient’s result is reported as a diplotype,
such as CYP2D6*1/*1 or *2/*4. A result for copy number is also important when
interpreting results for this gene. However, it needs to be noted that the number of
variants tested varies substantially among laboratories and there is no standardized way to
report results (25).
• An extensive (normal) metabolizer phenotype has an activity score of 1 to 2
• An ultrarapid metabolizer has an activity score greater than 2 (3, 19, 26).

Dosing adjustment for use with a strong CYP2D6 inhibitor or in patients who are known
to be CYP2D6 PMs2 — In children and adolescents up to 70 kg body weight administered
strong CYP2D6 inhibitors, e.g., paroxetine, fluoxetine, and quinidine, or in patients who
are known to be CYP2D6 PMs, atomoxetine should be initiated at 0.5 mg/kg/day and
only increased to the usual target dose of 1.2 mg/kg/day if symptoms fail to improve after
4 weeks and the initial dose is well tolerated.
In children and adolescents over 70 kg body weight and adults administered strong
CYP2D6 inhibitors, e.g., paroxetine, fluoxetine, and quinidine, atomoxetine should be
initiated at 40 mg/day and only increased to the usual target dose of 80 mg/day if
symptoms fail to improve after 4 weeks and the initial dose is well tolerated.
Please review the complete therapeutic recommendations that are located here: (1)
Royal Dutch Association for the Advancement of Pharmacy (KNMP): For individuals
who are poor metabolizers, a standard dose of atomoxetine is recommended. An increase
in dose is probably not necessary, but the physician should be alert to adverse drug events.
For individuals who are ultrarapid metabolizers, there are insufficient data to allow for an
adjusted dose to be calculated. The physician should be alert to reduced efficacy of a
drug labels in this excerpt. The FDA may not have labelled all formulations containing the
generic drug.
2 PMs: Poor metabolizers
standard dose of atomoxetine, or prescribe an alternative drug, such as methylphenidate

or clonidine.
Nomenclature
Coding Protein
identifier
for allele
location
CYP2D6*4 1846G>A NM_000106.4:c.506-1G>A Not applicable—variant rs3892097
occurs in a non-coding
region
CYP2D6*5 CYP2D6,DEL NC_000022.10:g. Not applicable—variant results in a
(42534124_42531353)_(42521970_42519196)del whole gene deletion
CYP2D6*6 1707 del T NM_000106.4:c.454delT NP_000097.2:p.Trp152Glyfs rs5030655
Trp152Gly
CYP2D6*10 100C>T NM_000106.4:c.100C>T NP_000097.2:p.Pro34Ser rs1065852
Pro34Ser
CYP2D6*17 Includes at NM_000106.4:c.320C>T NP_000097.2:p.Thr107Ile rs28371706
least two NM_000106.4:c.886T>C NP_000097.2:p.Cys296Arg rs16947
functional
variants*:
1023C>T
(Thr107Ile)
2850C>T
(Cys296Arg)
CYP2D6*41 2988G>A NM_000106.4:c.985+39G>A Not applicable—variant rs28371725
region
Acknowledgments
The author would like to thank Andrea Gaedigk, MS, PhD, Children's Mercy Kansas City,
Director, Pharmacogenetics Core Laboratory, Division of Clinical Pharmacology,
Toxicology & Therapeutic Innovation, Kansas City, Professor, School of Medicine,
University of Missouri-Kansas City; and Mia Wadelius, Senior Lecturer, Uppsala
University; for reviewing this summary
References
1. STRATTERA (atomoxetine hydrochloride) capsule, STRATTERA (atomoxetine
hydrochloride) kit [package insert]. Indianapolis, IN: Eli Lilly and Company; 2014.
Available from: http://dailymed.nlm.nih.gov/dailymed/drugInfo.cfm?
setid=309de576-c318-404a-bc15-660c2b1876fb
662–73. PubMed PMID: 21412232.
Ther. 2015;98(2):127–34. PubMed PMID: 25974703.
4. Marian S McDonagh, P., Kim Peterson, MS, Sujata Thakurta, MPA:HA, and Allison
Low, BA, Drug Class Review: Pharmacologic Treatments for Attention Deficit
Hyperactivity Disorder. Drug Class Reviews, 2011(Final Update 4 Report).
Atomoxetine. [Cited 15 May 2015]. Available from: http://www.pharmgkb.org/drug/
PA134688071
6. Choi C.I., Bae J.W., Lee Y.J., Lee H.I., et al. Effects of CYP2C19 genetic
polymorphisms on atomoxetine pharmacokinetics. J Clin Psychopharmacol.
2014;34(1):139–42. PubMed PMID: 24346747.
7. Michelson D., Read H.A., Ruff D.D., Witcher J., et al. CYP2D6 and clinical response
to atomoxetine in children and adolescents with ADHD. J Am Acad Child Adolesc
Psychiatry. 2007;46(2):242–51. PubMed PMID: 17242628.
8. Fijal B.A., Guo Y., Li S.G., Ahl J., et al. CYP2D6 predicted metabolizer status and
safety in adult patients with attention-deficit hyperactivity disorder participating in a
large placebo-controlled atomoxetine maintenance of response clinical trial. J Clin
Pharmacol. 2015. PubMed PMID: 25919121.
9. Spina E., de Leon J. Clinical applications of CYP genotyping in psychiatry. J Neural
Transm. 2015;122(1):5–28. PubMed PMID: 25200585.
10. CYP2D6 allele nomenclature. 2014 [Last accessed: 31 October 2014]. Available from:
clinical consequences, evolutionary aspects and functional diversity. The
pharmacogenomics journal. 2005;5(1):6–13. PubMed PMID: 15492763.
11972444.
13. Codeine sulfate tablets for oral use [package insert]. Columbus, OH: Roxane
Laboratories; 2010. Available from: http://dailymed.nlm.nih.gov/dailymed/
lookup.cfm?setid=fa3ed180-298a-4f9d-9d05-15182d7218bf
[Cited 2012 July 24]. Available from: http://www.pharmgkb.org/haplotype/
PA165816581
structure. Pharmacogenetics and genomics. 2007;17(2):93–101. PubMed PMID:
17301689.
PA165948092
PA165816582
pharmacoepigenetic and clinical aspects. Pharmacology & therapeutics. 2007;116(3):
496–526. PubMed PMID: 18001838.
19. Crews K.R., Gaedigk A., Dunnenberger H.M., Klein T.E., et al. Clinical
Pharmacogenetics Implementation Consortium (CPIC) Guidelines for Codeine
Therapy in the Context of Cytochrome P450 2D6 (CYP2D6) Genotype. Clinical
pharmacology and therapeutics. 2012;91(2):321–6. PubMed PMID: 22205192.
21. ter Laak M.A., Temmink A.H., Koeken A., van 't Veer N.E., et al. Recognition of
impaired atomoxetine metabolism because of low CYP2D6 activity. Pediatr Neurol.
2010;43(3):159–62. PubMed PMID: 20691935.
22. Trzepacz P.T., Williams D.W., Feldman P.D., Wrishko R.E., et al. CYP2D6 metabolizer
status and atomoxetine dosing in children and adolescents with ADHD. Eur
Neuropsychopharmacol. 2008;18(2):79–86. PubMed PMID: 17698328.
24. Matsui A., Azuma J., Witcher J.W., Long A.J., et al. Pharmacokinetics, safety, and
tolerability of atomoxetine and effect of CYP2D6*10/*10 genotype in healthy
Japanese men. J Clin Pharmacol. 2012;52(3):388–403. PubMed PMID: 21543662.
2014;15(2):218–32. PubMed PMID: 24524666.
PMID: 23486447.


Atomoxetine response

CYP2D6 gene
67
Azathioprine Therapy and TPMT Genotype

Laura Dean, MD1
Created: September 20, 2012; Updated: May 3, 2016.
Introduction
Azathioprine is an immunosuppressant that belongs to the drug class of thiopurines. It is
used in combination with other drugs to prevent kidney transplant rejection and in the
management of rheumatoid arthritis when other treatments have not been effective (1). In
addition, off-label uses include the treatment of inflammatory bowel disease (2).
Azathioprine is a prodrug that must first be activated to form thioguanine nucleotides
(TGNs), the major active metabolites. Thiopurine S-methyltransferase (TPMT)
inactivates azathioprine, leaving less parent drug available to form TGNs.
An adverse effect of azathioprine therapy is bone marrow suppression, which can occur in
any patient, is dose-dependent, and may be reversed by reducing the dose of azathioprine.
However, patients who carry two nonfunctional TPMT alleles universally experience life-
threatening myelosuppression when treated with azathioprine, due to high levels of
TGNs. Patients who carry one nonfunctional TPMT allele may also be unable to tolerate
conventional doses of azathioprine (3, 4).
The FDA recommends TPMT genotyping or phenotyping before starting treatment with
azathioprine. This allows patients who are at increased risk for toxicity to be identified
and for the starting dose of azathioprine to be reduced, or for an alternative therapy to be
used (1).
The Clinical Pharmacogenetics Implementation Consortium (CPIC) has published
recommendations for TPMT genotype-based azathioprine dosing. These
recommendations include:
Consider an alternate agent or extreme dose reduction of azathioprine for patients with
low or deficient TPMT activity. Start at 30-70% of target dose for patients with
intermediate enzyme activity (see Table 1) (2-4).

Table 1. TPMT phenotypes and the therapeutic recommendations for azathioprine therapy, adapted from
CPIC
Phenotype Phenotype details TPMT Examples of Therapeutic recommendations
Genotype diplotypes for azathioprine
Homozygous High enzyme Two or more *1/*1 Start with normal starting
wild-type activity. functional TPMT dose (e.g., 2–3 mg/kg/d) and
(“normal”) Found in ~86– alleles adjust doses of azathioprine
97% of patients. based on disease-specific
guidelines.
Allow 2 weeks to reach steady
state after each dose
adjustment.
Heterozygous Intermediate One functional *1/*2 If disease treatment normally
enzyme activity. TPMT allele plus *1/*3A starts at the “full dose”,
Found in ~3–14% one nonfunctional *1/*3B consider starting at 30–70% of
of patients. TPMT allele *1/*3C target dose (e.g., 1–1.5
*1/*4 mg/kg/d), and titrate based on
tolerance.
Allow 2–4 weeks to reach
steady state after each dose
adjustment.
Homozygous Low or deficient Two *3A/*3A Consider alternative agents. If
variant enzyme activity. nonfunctional *2/*3A using azathioprine start with
Found in ~1 in TPMT alleles *3C/*3A drastically reduced doses
178 to 1~3736 *3C/*4 (reduce daily dose by 10-fold
patients. *3C/*2 and dose thrice weekly instead
*3A/*4 of daily) and adjust doses of
azathioprine based on degree
of myelosuppression and
disease-specific guidelines.
adjustment.
Azathioprine is the likely
cause of myelosuppression.
The strength of therapeutic recommendations is “strong” for all phenotypes.
Table is adapted from Relling M.V. et al. Clinical Pharmacogenetics Implementation Consortium guidelines
for thiopurine methyltransferase genotype and thiopurine dosing. Clinical pharmacology and therapeutics.
2011;89(3):387–91 (3, 4).
Drug Class: Thiopurines

Thiopurines are used as anticancer agents and as immunosuppressants in inflammatory
bowel disease, rheumatoid arthritis, and other autoimmune conditions. Three thiopurines
are used clinically: thioguanine, mercaptopurine, and azathioprine (a prodrug for
mercaptopurine). All three agents have similar effects but are typically used for different
indications. Thioguanine is most commonly used in the treatment of myeloid leukemias,
Azathioprine Therapy and TPMT Genotype 69
mercaptopurine is used for lymphoid malignancies, and mercaptopurine and azathioprine

are used for immune conditions.
Thiopurines are either activated to form TGNs (the major active metabolite) or
deactivated by TPMT. Individuals who carry two non-functional TPMT alleles (“TPMT
homozygotes”) universally experience life-threatening bone marrow suppression because
of high levels of TGNs when treated with conventional doses. Individuals who carry one
non-functional TPMT allele (“TPMT heterozygotes”) may also be unable to tolerate
conventional doses of thiopurines due to increased levels of TGNs.
Drug: Azathioprine
Azathioprine is an immunosuppressive agent that is used in combination with other
drugs to prevent the rejection of kidney transplants. It is also used in the management of
active rheumatoid arthritis (1).
An off-label use of azathioprine is in the treatment of inflammatory bowel disease (IBD).
Along with the closely related drug mercaptopurine (azathioprine is metabolized to
mercaptopurine), azathioprine is used as an “immunomodulator” and as a “steroid-
sparing agent” in the treatment of Crohn’s disease and ulcerative colitis (2).
Azathioprine is a slow-acting drug and for IBD, it typically takes at least three months of
therapy before a therapeutic effect is observed. Therefore, azathioprine is used for the
induction and maintenance of IBD remission rather than as a monotherapy for acute
relapses (5). Because the discontinuation of azathioprine is associated with a high rate of
relapse of IBD, azathioprine is usually continued long-term if there are no adverse effects
(6, 7).
The use of azathioprine or the related drug mercaptourine has been associated with a 4-
fold increased risk of developing lymphoma, which does not persist after discontinuation
of therapy (8, 9).
The increased risk of malignancy led to the following boxed label on the FDA-approved
drug label for azathioprine:
Malignancy: Patients receiving immunosuppressants, including azathioprine, are at
increased risk of developing lymphoma and other malignancies, particularly of the skin.
Physicians should inform patients of the risk of malignancy with azathioprine. As usual
for patients with increased risk for skin cancer, exposure to sunlight and ultraviolet light
should be limited by wearing protective clothing and using a sunscreen with a high
protection factor (1).
Like all thiopurines, azathioprine is a purine analogue, and acts as an antimetabolite by
interfering with nucleic acid synthesis and inhibiting purine metabolism. Azathioprine is
first metabolized to mercaptopurine, which is then activated via HPRT1 (hypoxanthine
phosphoribosyltransferase). This is followed by a series of reactions to form TGNs. The
cytotoxicity of azathioprine is due, in part, to the incorporation of TGNs into DNA.
Inactivation of azathioprine occurs via two different pathways, via methylation (by
TPMT) or via oxidation (by xanthine oxidase). TPMT activity is highly variable in
patients because of genetic polymorphism in the TPMT gene.
One of the most frequent adverse reactions to azathioprine is myelosuppression, which
can occur in any patient, and can usually be reversed by decreasing the dose of
azathioprine. However, all patients who carry two nonfunctional TPMT alleles
(approximately 0.3%) experience life-threatening myelosuppression after starting
treatment with conventional doses of azathioprine due to high levels of TGNs.
Individuals who are heterozygous for nonfunctional TPMT alleles (approximately 10%)
are at a significantly higher risk for toxicity than individuals with two functional alleles.
However, some of these individuals, approximately 40–70%, can tolerate the full dose of
azathioprine. This may be because heterozygous-deficient individuals have lower
concentrations of less active metabolites, such as MeMPN (methylmercaptopurine
nucleotides), than homozygous-deficient individuals (3, 4).
Approximately 90% of individuals have normal TPMT activity with two functional alleles;
however, all individuals receiving azathioprine require close monitoring (3, 4, 10, 11). One
study reports that in patients with IBD receiving thiopurine therapy, TPMT
polymorphisms are associated with the overall incidence of adverse reactions and with
bone marrow toxicity, but not with other adverse reactions, such as liver damage and
pancreatitis. Therefore, although determining TPMT genotype is helpful before initiating
therapy, regular blood tests to monitor for side effects are needed during therapy (12, 13).
The other azathioprine inactivation pathway is via oxidation, which is catalyzed by
xanthine oxidase. If this pathway is inhibited, for example, in patients taking allopurinol
(an inhibitor of xanthine oxidase), the decreased break down of azathioprine can lead to
azathioprine toxicity (13). However, some studies have found that the co-administration
of allopurinol, with a reduced dose of azathioprine (or mercaptopurine), can help
optimize the treatment response in patients with IBD (14, 15).
Gene: TPMT
The TPMT gene encodes one of the important enzymes of phase II metabolism,
thiopurine S-methyltransferase. TPMT is one of the main enzymes involved in the
metabolism of thiopurines, such as azathioprine. TPMT activity is inherited as a co-
dominant trait, as the TPMT gene is highly polymorphic with over 40 reported variant
alleles (16-19).
The wild-type TPMT*1 allele is associated with normal enzyme activity. Individuals who
are homozygous for TPMT*1 (TPMT normal metabolizers) are more likely to have a
typical response to azathioprine and a lower risk of myelosuppression. This accounts for
the majority of patients (~86–97%) (3, 4).
Individuals who are TPMT poor (approximately 0.3%) or intermediate (approximately 3–
14%) metabolizers carry variant TPMT alleles that encode reduced or absent enzyme
activity. Three variant TPMT alleles account for over 90% of the reduced or absent activity
TPMT alleles (16, 17):
• TPMT*2 (c.238G>C)
• TPMT*3A (c.460G>A and c.719A>G)
• TPMT*3B (c.460G>A)
• TPMT*3C (c.719A>G)
The frequency of TPMT alleles varies among different populations. In the United States,
the most common low-activity allele in the Caucasian population is TPMT*3A (~5%).
This allele is also found in individuals who originate from India and Pakistan, but less
frequently (18, 19).
In East Asian, African-American, and some African populations, the most common
variant is TPMT*3C (~2%), although TPMT*8 may be more common in African
populations than previously thought (~2%). In general, TPMT*2 occurs much less
commonly, and TPMT*3B occurs rarely (18, 20).
Genetic Testing
Genetic testing is available for several TPMT variant alleles, which most commonly
includes TPMT*2, *3A, and *3C as they account for >90% of inactivating alleles. Of note,
rare and/or previously undiscovered variants will not be detected by variant-specific
genotyping methods (3, 4, 21-24).
TPMT phenotype enzyme activity testing is also available by measuring TPMT activity in
red blood cells directly. However, the results will not be accurate in patients who have
received recent blood transfusions (13) and TPMT activity will also be falsely low in
patients with leukemia, because of atypical hematopoiesis (25).
One study reported that TPMT genotyping was more reliable than phenotyping in
identifying patients at risk of adverse reactions from thiopurine treatment (26). In
addition, several studies report that the TPMT genotype is a better indicator than TPMT
activity for predicting TGN accumulation or treatment outcome (11, 27-29).

generic drug.
2015 Statement from the US Food and Drug Administration (FDA): TPMT TESTING
CANNOT SUBSTITUTE FOR COMPLETE BLOOD COUNT (CBC) MONITORING IN
PATIENTS RECEIVING AZATHIOPRINE. TPMT genotyping or phenotyping can be
used to identify patients with absent or reduced TPMT activity. Patients with low or
absent TPMT activity are at an increased risk of developing severe, life threatening
myelotoxicity from azathioprine if conventional doses are given. Physicians may consider
alternative therapies for patients who have low or absent TPMT activity (homozygous for
non-functional alleles). Azathioprine should be administered with caution to patients
having one non-functional allele (heterozygous) who are at risk for reduced TPMT
activity that may lead to toxicity if conventional doses are given. Dosage reduction is
recommended in patients with reduced TPMT activity. Early drug discontinuation may
be considered in patients with abnormal CBC results that do not respond to dose
reduction.
(CPIC): Testing for TPMT status is recommended prior to starting azathioprine therapy
so that the starting dosages can be adjusted accordingly—see Table 1 for dosing
recommendations. In homozygous variant individuals, either an alternative agent should
be used, or the doses of azathioprine should be drastically reduced. In heterozygous
individuals, depending on the disease being treated, starting doses should be reduced. In
both patient groups, a longer period of time should be left after each dose adjustment to
allow for a steady state to be reached.
Please review the complete therapeutic recommendations that are located here: (3, 4).
Nomenclature
Common Alternative HGVS reference sequence dbSNP reference
allele name names identifier for allele
Coding Protein
location
TPMT*2 238G>C NM_000367.2:c. NP_000358.1:p.Ala80Pro rs1800462
Ala80Pro 238G>C
TPMT*3A This allele contains two variants in cis: c.460G>A and c.719A>G
TPMT*3B 460G>A NM_000367.2:c. NP_000358.1:p.Ala154Thr rs1800460
Ala154Thr 460G>A
TPMT*3C 719A>G NM_000367.2:c. NP_000358.1:p.Tyr240Cys rs1142345
Tyr240Cys 719A>G
The TPMT Nomenclature Committee defines the nomenclature and numbering of novel
TPMT variants: http://www.imh.liu.se/tpmtalleles
Acknowledgments
The author would like to thank Stuart A. Scott, Assistant Professor of Genetics and
Genomic Sciences, Icahn School of Medicine at Mount Sinai; for reviewing this summary.
First edition:
The author would like to thank:
The Pharmacogenomics Knowledgebase: http://www.pharmgkb.org
The Clinical Pharmacogenetics Implementation Consortium: http://www.pharmgkb.org/
page/cpic
Version History
To view an earlier version of this summary (Update: March 18, 2013), please click here.
References
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Pharmaceuticals Inc.; 2015. Available from: http://dailymed.nlm.nih.gov/dailymed/
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chemical/PA448515
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Pharmacogenetics Implementation Consortium guidelines for thiopurine
methyltransferase genotype and thiopurine dosing. Clinical pharmacology and
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10. DiPiero J., Teng K., Hicks J.K. Should thiopurine methyltransferase (TPMT) activity
be determined before prescribing azathioprine, mercaptopurine, or thioguanine?
Cleve Clin J Med. 2015;82(7):409–13. PubMed PMID: 26185939.
11. Lennard L., Cartwright C.S., Wade R., Vora A. Thiopurine dose intensity and
treatment outcome in childhood lymphoblastic leukaemia: the influence of
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methyltransferase polymorphisms and thiopurine-induced adverse drug reactions in
patients with inflammatory bowel disease: a meta-analysis. PLoS One.
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dailymed/drugInfo.cfm?setid=40b09616-5bb1-4ef8-98cd-d87537254296
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www.pharmgkb.org/gene/PA356
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PA165819270
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28. Lennard L., Cartwright C.S., Wade R., Richards S.M., et al. Thiopurine
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Mercaptopurine Therapy and TPMT Genotype
Thioguanine Therapy and TPMT Genotype


Azathioprine response

TPMT gene
77
Capecitabine Therapy and DPYD Genotype

Laura Dean, MD1
Introduction
Capecitabine is a chemotherapy agent that belongs to the drug class of fluoropyrimidines.
It is widely used in the treatment of colon cancer, metastatic colorectal cancer, and
metastatic breast cancer. Capecitabine is a prodrug that is enzymatically converted to its
active form, fluorouracil, which acts as an antimetabolite to slow tumor growth.
The DPYD gene encodes dihydropyrimidine dehydrogenase (DPD), an enzyme that
catalyzes the rate-limiting step in fluorouracil metabolism. Individuals who are carriers of
non-functional DPYD variants, such as DPYD*2A, may not be able to metabolize
capecitabine at normal rates, and are at risk of potentially life-threatening capecitabine
toxicity, such as bone marrow suppression and neurotoxicity. The prevalence of DPD
deficiency in Caucasians is approximately 3%-5%.
The FDA-approved drug label for capecitabine states that no capecitabine dose has been
proven safe in patients with absent DPD activity, and that there is insufficient data to
recommend a specific dose in patients with partial DPD activity as measured by any
specific test (1).
The Clinical Pharmacogenetics Implementation Consortium (CPIC) has published dosing
recommendations for fluoropyrimidines (capecitabine, fluorouracil, and tegafur) based on
DPYD genotype (2) (Table 1). CPIC recommends using an alternative drug for patients
who are “poor metabolizers”. These individuals carry two copies of non-functional DPYD
variants and typically have complete DPD deficiency. CPIC also recommends considering
a 50% reduction in starting dose for “intermediate metabolizers”. These individuals carry a
combination of a normal-function and a non-functional variant and typically have
reduced DPD activity (approximately 50% reduced) (2, 3).
Drug Class: Fluoropyrimidines

Fluoropyrimidines are a class of antimetabolite drugs that are widely used in the
treatment of cancer. Currently, there are three types of fluoropyrimidines in clinical use:
capecitabine, fluorouracil, and tegafur. Capecitabine and tegafur are both prodrugs of
fluorouracil.
Fluoropyrimidines are thought to exert their chemotherapeutic effects in a number of
ways, through several active metabolites. The main mechanism of action is thought to be

the inhibition of thymidylate synthase, which plays an important part in the folate-
homocysteine cycle, and purine and pyrimidine synthesis pathways. Also, active
metabolites can be incorporated into RNA and DNA, ultimately leading to cell death (4).
Approximately 10-40% of patients develop severe and potentially life-threatening toxicity
early during treatment with fluoropyrimidines (5). This typically leads to an interruption
or discontinuation of potentially effective anticancer therapy, and often requires
hospitalization (6).
The inter-individual variation in the occurrence and severity of adverse events in patients
receiving fluoropyrimidines can be partly explained by clinical factors, such as age and
sex. However, much of the variability in adverse events remains unexplained (7).
Of the genetic factors thought to contribute to fluoropyrimidine intolerance, the DPYD
gene has been the most studied. This gene encodes the primary enzyme involved in
breaking down fluoropyrimidines to inactive metabolites. Individuals who have a
deficiency of the DPD enzyme have a significantly increased risk of suffering from severe
fluoropyrimidine toxicity, and the stratification of patients on the basis of the DPYD
genotype may help to prevent such adverse events (8-13)
genetics-based dosing recommendations for fluoropyrimidines based on DPYD genotype
(Table 1).
Table 1. 2013 Recommended dosing of Fluoropyrimidines by DPD phenotype, from Clinical
Pharmacogenetics Implementation Consortium (CPIC)
Phenotype Implications for Dosing recommendations Classification of
phenotypic measures recommendationsa
Normal metabolizer Normal DPD activity and Use label-recommended Moderate
“normal” risk for dosage and administration
fluoropyrimidine toxicity
Intermediate Decreased DPD activity Start with at least a 50% Moderate
metabolizer (leukocyte DPD activity at reduction in starting dose,
30–70% that of the normal followed by titration of
population) and increased dose based on toxicityb or
risk for severe or even fatal
Fluoropyrimidines: 5-fluorouracil, capecitabine, and tegafur.
DPD, dihydropyrimidine dehydrogenase.
a Rating scheme is described here (2)
b Increase the dose in patients experiencing no or clinically tolerable toxicity to maintain efficacy; decrease
the dose in patients who do not tolerate the starting dose to minimize toxicities.
Table is adapted from Caudle KE, Thorn CF, Klein TE, Swen JJ, McLeod HL, Diasio RB, Schwab M. Clinical
Pharmacogenetics Implementation Consortium guidelines for dihydropyrimidine dehydrogenase genotype
and fluoropyrimidine dosing. Clinical pharmacology and therapeutics.2013:94(6):640-5 (2)
Note: The nomenclature used in this table reflects the standardized nomenclature for pharmacogenetic
terms proposed by CPIC in a 2016 paper, “Standardizing terms for clinical pharmacogenetic test results:
consensus terms from the Clinical Pharmacogenetics Implementation Consortium (CPIC)” (14).
Capecitabine Therapy and DPYD Genotype 79

drug toxicity when treated pharmacokinetic test (if
with fluoropyrimidine available)
drugs
Poor metabolizer Complete DPD deficiency Select alternative drug Strong
and increased risk for
severe or even fatal drug
toxicity when treated with
fluoropyrimidine drugs
Drug: Capecitabine
Capecitabine is a form of chemotherapy used as an adjunct treatment for colon cancer,
and as either monotherapy or part of combination therapy for metastatic colorectal cancer
and metastatic breast cancer (1).
Capecitabine is an orally administered prodrug—it is converted to its active form,
fluorouracil, by thymidine phosphorylase—an enzyme that tends to be found in higher
concentrations in tumors compared to normal tissue and plasma. Fluorouracil is
structurally similar to pyrimidines, and the enzyme that catalyzes the rate-limiting step in
the breakdown of pyrimidines (DPD, dihydropyrimidine dehydrogenase) also catalyzes
the rate-limiting step in 5-fluorouracil catabolism. DPD catalyzes the conversion of
fluorouracil to the non-cytotoxic dihydrofluorouracil (DHFU) (15).
Symptomatic DPD deficiency is a rare autosomal recessive disorder with a wide range of
symptoms, ranging from no symptoms or signs, to severe neurological problems. In
affected individuals, the absent or greatly reduced DPD activity results in uracil and
thymine accumulating in the blood, urine, and cerebrospinal fluid. Neurological
symptoms typically manifest in early childhood and include seizures, small head size, and
delayed cognitive and motor development (16).
Symptomatic DPD deficiency is typically caused by homozygous inactivation of DPYD;
whereas individuals who are heterozygotes tend to be asymptomatic. However, all patients
with less than 70% DPD activity are considered at risk for the development of severe drug
toxicity when treated with fluoropyrimidines (17). Signs of capecitabine toxicity include
severe diarrhea, severe mucositis, neutropenia, hand-foot syndrome, and neurotoxicity
(1).
Approximately 3-5% of Caucasians have partial DPD deficiency and 0.2% have complete
DPD deficiency (18). Currently, most patients are not screened for DPD deficiency before
starting capecitabine therapy (19).
Gene: DPYD
The DPYD gene encodes the enzyme dihydropyrimidine dehydrogenase (DPD), which
catalyzes the first and the rate-limiting step in the breakdown of the pyrimidine
nucleotides thymine and uracil. DPD also catalyzes the rate-limiting step in the
breakdown of fluoropyrimidines.
Many DPYD variants have been described, although only a few have been demonstrated
to influence DPD enzyme activity. DPYD*1 is the wild-type allele and is associated with
normal enzyme activity. Individuals who carry two copies of DPYD alleles with normal
activity are known as “normal metabolizers” and have fully functional DPD enzyme
activity (Table 2 and Table 3). Next to DPYD*1, the DPYD alleles *4, *5, *6, and *9A are
also considered to have normal activity (20).
Table 2. Activity status of selected DPYD Alleles
Allele type Alleles
Functional *1, *4, *5, *6, *9A
Nonfunctional *2A, *13, rs67376798
Table is adapted from (12, 15) For the nomenclature of human DPYD alleles, please see (21)
The nonfunctional DPYD variants which have been associated with low DPD activity and
an increased risk of toxicity with fluoropyrimidines include *2A, *13, and rs67376798
(15). The most well studied variant is DPYD*2A, in which a single nucleotide substitution
at the invariant splice donor site of intron 14 leads to translation skipping exon 14,
resulting in the production of a truncated protein with virtually no enzyme activity.
Individuals who carry combinations of normal function, decreased function, and/or no
function DPYD alleles are known as “intermediate metabolizers”. They have partial DPD
deficiency and are at increased risk of capecitabine toxicity. And individuals who carry a
combination of nonfunctional DPYD alleles and/or decreased function DPYD alleles are
known as “poor metabolizers”. They have complete DPD deficiency and are at an even
higher risk of capecitabine toxicity. Overall, the prevalence of individuals who are
heterozygous for nonfunctional variant DPYD alleles (partially DPD deficient) that place
them at risk of severe drug reactions is estimated to be as high as 3-5%, but this varies in
different populations (5, 17, 22-25). For example, in the Dutch population, the DPYD*2A
had an allele frequency of 0.91% in Caucasians (17).
Table 3 Assignment of likely phenotype based on DPYD genotypes

Likely phenotype Functional definition Genetic definition Example diplotypes
Normal metabolizer Fully functional DPD Combinations of normal DPYD*1/*1
enzyme activity function and decreased
function alleles
Intermediate Decreased DPD enzyme Combinations of normal *1/*2A; *1/*13; or *1/
metabolizer activity (activity between function, decreased rs67376798
(~3–5% of patients) normal and poor function, and/or no
metabolizer) function alleles
Poor metabolizer Little to no DPD enzyme Combination of no *2A/*2A; 13/*13; *2/
(~0.2% of patients) activity function alleles and/ or *13; or rs67376798/
decreased function alleles rs67376798
terms proposed by CPIC in the 2016 paper, “Standardizing terms for clinical pharmacogenetic test results:
A recent study proposed distinguishing between the various DPYD alleles and their
functionality by assigning gene activity scores. The use of such scores could result in
differentiated individualized dosing advice for fluororpyrimidines, which is essential for
reducing toxic side effects while maintaining efficacy (12).
Genetic Testing
The NIH Genetic Testing Registry, GTR, displays genetic tests that are currently available
for the DPYD gene and the capecitabine drug response. The DPYD*2A variant is the most
commonly tested.
Biochemical genetic tests may also be used, which assess the level of activity of the DPD
enzyme. These tests include biochemical assays such as analyte testing (e.g., measuring the
amount of thymine and uracil in the urine or blood) or an enzyme assay (e.g., directly
measuring the activity of DPD using RNA extracted from blood cells and measuring the
DPD mRNA copy number) (2, 26, 27).
GTR provides a list of biochemical tests that assess the levels of thymine and uracil
analytes, and the activity of the enzyme dihydropyrimidine dehydrogenase.

2016 Statement from the US Food and Drug Administration (FDA): Based on
postmarketing reports, patients with certain homozygous or certain compound
heterozygous mutations in the DPD2 gene that result in complete or near complete
absence of DPD activity are at increased risk for acute early-onset of toxicity and severe,
life-threatening, or fatal adverse reactions caused by capecitabine (e.g., mucositis,
diarrhea, neutropenia, and neurotoxicity). Patients with partial DPD activity may also
have increased risk of severe, life-threatening, or fatal adverse reactions caused by
capecitabine.
Withhold or permanently discontinue capecitabine based on clinical assessment of the
onset, duration and severity of the observed toxicities in patients with evidence of acute
early-onset or unusually severe toxicity, which may indicate near complete or total
absence of DPD activity. No capecitabine dose has been proven safe for patients with
complete absence of DPD activity. There is insufficient data to recommend a specific dose
in patients with partial DPD activity as measured by any specific test.
(CPIC): [...] Furthermore, patients who are heterozygous for the nonfunctional DPYD
variants mostly demonstrate partial DPD deficiency (leukocyte DPD activity at 30–70%
that of the normal population).Thus, our recommendation is to start with at least a 50%
reduction of the starting dose; followed by an increase in dose in patients experiencing no
or clinically tolerable toxicity, to maintain efficacy; and a decrease in dose in patients who
do not tolerate the starting dose, to minimize toxicities. An alternative is
pharmacokinetic-guided dose adjustment (if available). Patients who are homozygous for
DPYD*2A, *13, or rs67376798 may demonstrate complete DPD deficiency, and the use of
5-fluouracil or capecitabine is not recommended in these patients. Because capecitabine
and tegafur are converted to 5-fluorouracil and then metabolized by DPD, the clearance
of and exposure to 5-fluorouracil, in addition to its toxic effects, are similar in patients
with these variants.
generic drug.
2 Note: the official gene symbol is DYPD. DPD is an alternate gene symbol.
Nomenclature
Coding Protein
identifier for
allele location
DPYD*2A IVS14+1G>A NM_000110.3:c. Not applicable—deletion of rs3918290
c.1905+1G>A 1905+1G>A exon 14 leads to the
production of a truncated
protein
DPYD*13 1679T>G NM_000110.3:c. NP_000101.2:p.Ile560Ser rs55886062
Ile560Ser 1679T>G
rs67376798 2846A>T NM_000110.3:c. NP_000101.2:p.Asp949Val rs67376798
Asp949Val 2846A>T
Acknowledgments
The author would like to thank Linda Henricks, PharmD, and Professor Jan HM
Schellens, MD PhD, The Netherlands Cancer Institute, Amsterdam, NL; Mohamed Nagy,
Clinical Pharmacist, Head of the Personalised Medication Management Unit, Department
of Pharmaceutical Services, Children's Cancer Hospital, Egypt; and Emily K. Pauli,
Director of Research, Clearview Cancer Institute, Alabama; for reviewing this summary.
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Fluorouracil Therapy and DPYD Genotype


Capecitabine response

DPYD gene
87

Laura Dean, MD1
Created: October 14, 2015.
Introduction
Carbamazepine is an antiseizure drug used in the treatment of epilepsy. It is also used to
relieve pain in trigeminal neuralgia and is used to treat bipolar disorder (1, 2).
The human leukocyte antigens A and B (HLA-A and HLA-B) play an important role in
how the immune system recognizes and responds to pathogens. HLA-A and -B belong to
a class of molecules that are found on the surface of most cells. These molecules are
responsible for presenting peptides to immune cells. Peptides derived from normal
human proteins are recognized as such, whereas foreign peptides derived from pathogens
trigger an immune response whose goal is to dispose of the pathogen or foreign body.
The genes encoding HLA-A and -B are among the most polymorphic genes in the human
genome, and certain variant alleles can influence an individual’s response to medication.
HLA-B*15:02 is a variant allele that occurs most commonly in individuals of Southeast
Asian descent. Carriers of HLA-B*15:02 are at a high risk of developing Stevens-Johnson
syndrome (SJS) and toxic epidermal necrolysis (TEN), a severe, and sometimes fatal,
cutaneous hypersensitivity reaction, while taking carbamazepine (Table 1).
Individuals most likely to carry HLA-B*15:02 are those of Han Chinese descent, followed
by those in Vietnam, Cambodia, the Reunion Islands, Thailand, India (specifically
Hindus), Malaysia, and Hong Kong (3). Another HLA variant, HLA-A*31:01, which is
present more globally, may also be a risk factor for other carbamazepine-induced
hypersensitivity reactions, such as drug-induced hypersensitivity syndrome (HSS) or
maculopapular exanthema (MPE) (2).
The FDA recommends that patients with ancestry in genetically at-risk populations
should be screened for the presence of HLA-B*15:02 prior to initiating treatment with
carbamazepine. Patients testing positive for the allele should not be treated with
carbamazepine unless the benefit clearly outweighs the risk (1). The Clinical
Pharmacogenetics Implementation Consortium (CPIC) cautions that many people may
be unaware of, or fail to disclose, more distant Asian ancestry in their families, a fact that
the healthcare professional needs to be aware of. CPIC also points out that both children
and adults are at risk (3).

Table 1. HLA-B genotype and the therapeutic recommendations for carbamazepine therapy
Genotype Phenotypic implications Therapeutic Classification of
recommendations recommendations
Noncarrier of HLA- Normal or reduced risk Use carbamazepine per Strong
B*15:02 of carbamazepine- standard dosing guidelines
induced SJS/TEN
Carrier of HLA- Increased risk of If patient is carbamazepine- Strong
B*15:02 carbamazepine-induced naive, do not use
SJS/TEN carbamazepine*
If patient has previously Optional
used carbamazepine for
longer than 3 months
without incidence of
cutaneous adverse reactions,
cautiously consider use of
carbamazepine
Noncarrier of HLA-B*15:02: No *1502 alleles reported, often reported as “negative” on a genotyping test.
Carrier of HLA-B*15:02: One or two *1502 alleles, often reported as “positive” on a genotyping test.
SJS/TEN: Stevens–Johnson syndrome/toxic epidermal necrolysis.
* Alternative medications such as phenytoin, fosphenytoin, oxcarbazepine, eslicarbazepine acetate, and
lamotrigine have some evidence linking SJS/TEN with the HLA-B*15:02 allele, and thus caution should be
used in choosing alternatives to carbamazepine.
Table is adapted from Leckband SG, Kelsoe JR, Dunnenberger HM, George AL Jr, Tran E, Berger R, Müller
DJ, Whirl-Carrillo M, Caudle KE, Pirmohamed M. Clinical pharmacogenetics implementation consortium
guidelines for HLA-B genotype and carbamazepine dosing. Clinical pharmacology and therapeutics.
2013:94(3):324-8 (3).
Drug: Carbamazepine
Carbamazepine is an antiseizure drug used in the treatment of epilepsy. Carbamazepine is
also used as analgesic in trigeminal neuralgia, and may be used in the treatment of bipolar
disorder (2, 4).
Epilepsy is characterized by spontaneous recurrent epileptic seizures, which may be
classified as focal or generalized. The symptoms of focal seizures depend upon where the
focus of the seizure originates in the brain e.g., jerking of a limb indicates a focus in the
contralateral motor cortex. In contrast, generalized seizures appear to originate in all
regions of the cortex simultaneously and include absence seizures (sudden impaired
consciousness and staring) and general tonic-clonic seizures (loss of consciousness,
stiffening of limbs in the tonic phase, and twitching or jerking muscles in the clonic
phase).
Recent guidelines for the treatment of epilepsy recommend carbamazepine as one of the
first-line treatments for focal seizures in adults, adolescents, and children; and also as
drug for consideration in the treatment of general tonic-clonic seizures (2, 5).
Carbamazepine Therapy and HLA Genotypes 89
Carbamazepine is a tricyclic compound that belongs to the class of antiseizure drugs that
act by blocking voltage-dependent sodium channels present on neuronal cell membranes.
Carbamazepine stabilizes the sodium channel in the inactivated state, leaving fewer of the
channels available to open. This prolonged inactivated phase of the channel inhibits the
rapid and repetitive generation of action potentials in the epileptic focus (3, 6).
Carbamazepine is metabolized in the liver by the cytochrome P-450 (CYP) system. The
major metabolite is carbamazepine-epoxide, which has an anticonvulsant activity of
uncertain significance. CYP3A4 is the main enzyme involved in the metabolism of
carbamazepine; a lesser role is played by CYP2C8 and possibly CYP3A5. Minor metabolic
pathways include multiple CYP enzymes, such as CYP2B6.
Carbamazepine stimulates transcriptional upregulation of CYP3A4 and other genes
involved in its own metabolism. In addition, there are many drug-drug interactions with
carbamazepine, because numerous drugs have been shown to induce or inhibit CYP3A4,
or are metabolized by CYP3A4. Therefore, when carbamazepine is given with drugs that
can decrease or increase carbamazepine levels, close monitoring of carbamazepine levels
is indicated and dosage adjustment may be required (7, 8).
Carbamazepine-induced Adverse Drug Reactions

In general, there are two categories of adverse drug reactions. Type A reactions account
for up to 85-90% of all adverse drug reactions. They are predictable based on the known
properties of the drug, and they can affect any individual, if their exposure to the drug is
high enough. For carbamazepine, type A adverse effects include sedation, CNS
depression, and vestibular symptoms such as nystagmus and ataxia.
Type B reactions account for the remaining 10-15% of adverse drug reactions. These
include hypersensitivity reactions that occur in susceptible individuals. Such idiosyncratic
hypersensitivity reactions can occur at any dose and develop through a mechanism that is
unrelated to the mechanism of action of the drug. For this reason, it is difficult to predict
in whom a drug-induced hypersensitivity reaction is likely to occur. For carbamazepine,
however, carriers of specific HLA variants are known to be susceptible to carbamazepine-
induced hypersensitivity reactions, and HLA testing of patients can identify those at-risk
individuals so that an alternative drug can be used.
Carbamazepine-induced hypersensitivity reactions frequently involve the skin. Cutaneous
adverse drug reactions (cADR) are experienced by approximately 5-10% of patients
taking carbamazepine. Most of these carbamazepine-induced cutaneous reactions are
considered to be mild, such as maculopapular exanthema (MPE) and erythema
multiforme. Nevertheless, these cutaneous reactions can cause considerable discomfort to
the patient and often lead to the discontinuation of carbamazepine therapy (2, 9, 10). Due
to their structural similarity, up to 80% of patients who have an unexpected adverse
reaction to carbamazepine will also have an adverse reaction to other anticonvulsants,
thereby restricting treatment options (11).
More rarely, the use of carbamazepine can trigger serious hypersensitivity reactions, such
as Stevens-Johnson syndrome (SJS) and the more severe form, toxic epidermal necrolysis
(TEN) (12). SJS /TEN are life-threatening conditions that are primarily characterized by
lesions of the skin (detachment of the epidermis) and mucus membranes (severe erosions)
(12). SJS/TEN occurs in approximately 1-10 per 10,000 patients taking carbamazepine.
Onset is delayed and may occur several weeks after the initiation of carbamazepine
therapy. The mortality rate is high—up to 10% for SJS, and 50% for TEN (12-14).
Other severe and potentially life-threatening carbamazepine-induced hypersensitivity
reactions include drug-induced hypersensitivity syndrome (HSS), also known as drug
reaction with eosinophilia and systemic symptoms (DRESS); and acute generalized
exanthematous pustulosis (AGEP).
The mechanisms underlying these hypersensitivity reactions are largely unknown, but
they are thought to involve the drug, or a molecule derived from the drug, interacting
with the major histocompatibility complex (MHC) expressed on the surface of cells,
resulting in a stimulation of the immune system, particularly T cells and eosinophils (2,
14).
HLA gene family

The human leukocyte antigen (HLA) genes are members of the MHC gene family, which
includes more than 200 genes. The MHC family has been subdivided in to 3 subgroups
based on the structure and function of the encoded proteins: Class I, Class II, and Class
III.
The class I region contains the genes encoding the HLA molecules HLA-A, HLA-B, and
HLA-C. These molecules are expressed on the surfaces of almost all cells and play an
important role in processing and presenting of antigens. The class I gene region also
contains a variety of other genes, many of which are not known to be involved in immune
function.
cellular proteins (“self ”). However, if foreign peptide fragments are presented, e.g., from a
pathogen, CD8+T cells will recognize the peptides as “non-self ” and will be activated to
pathogen (or foreign body).
HLA-B alleles have been identified (15). Each HLA allele has a name that is prefixed by
HLA, followed by the gene name, an asterisk and a two digit number that corresponds to
antigen specificity, and the assigned allele number (16). For example, for the allele HLA-
DRB1*13:01 is composed of:
• DRB1: the DRB1 gene (a particular HLA gene in this region)

analysis).
Variation in the HLA genes plays an important role in the susceptibility to autoimmune
better outcomes are observed if the donor and recipient are HLA-compatible. More
recently, HLA variants have been associated with the susceptibility to Type B adverse drug
reactions, including carbamazepine hypersensitivity reactions. Specifically, two HLA
variants have been found to be associated with carbamazepine-induced hypersensitivity
reactions: HLA-B*15:02 and HLA-A*31:01.
HLA-B*15:02
The association between the HLA-B*15:02 allele and carbamazepine-induced SJS/TEN
was first reported in the Han Chinese. In the initial study, every patient who had
carbamazepine-induced SJS/TEN was found to be a carrier of the HLA-B*15:02 allele
(44/44, 100%), whereas the allele was much less common in carbamazepine-tolerant
patients (3/101, 3%)(17). In subsequent studies, this strong association was replicated,
with a HLA-B*15:02 carrier frequency of between 70100% among cases of
carbamazepine-induced SJS/TEN (2).
The HLA-B*15:02 allele frequency is highest in Southeast Asia, and the prevalence of
carbamazepine-induced SJS/TEN is higher in populations where HLA-B*15:02 is
common. The HLA*15:02 allele is strongly associated with carbamazepine-induced
SJS/TEN in Taiwanese, Chinese, Indians, Malay, and Chinese-Americans, but not in
Caucasians or Japanese individuals (17-24).
In Hong Kong, Thailand, Malaysia, Vietnam, and parts of the Philippines, the allele
frequency is over 15%; it is slightly lower (around 10-13%) in Taiwan and Singapore, and
around 4% in North China. South Asians, including Indians, appear to have intermediate
prevalence of HLA-B*15:02, averaging 2 to 4%, with higher frequencies in some
subpopulations (1-3, 25-28).
The HLA-B*15:02 allele is rare (carrier frequency of less than 1%) in East Asia (Japan and
Korea) and in individuals who are not of Asian descent. For example, the variant is very
rare in Europeans, Hispanics, Africans, African Americans, and Native Americans (2, 25).
The absence of this variant in these population explains the lack of association of this
variant with carbamazepine-induced SJS/TEN in Caucasians and Japanese individuals.
Current data suggest that HLA-B*15:02 is a risk factor specific to SJS/TEN since it does
not appear to increase the risk of other carbamazepine-induced cutaneous reactions, such
as maculopapular exanthema or the carbamazepine-induced hypersensitivity syndrome
(2).
HLA-A*31:01
The HLA-A*31:01 allele has been consistently associated with carbamazepine-induced
hypersensitivity syndrome and maculopapular exanthema (MPE) in Europeans, Han
Chinese, Japanese, and North Americans of mixed ancestries (13, 18, 29-31). This variant
may also be associated with SJS/TEN but so far the association has been inconsistent (2).
Whereas the HLA-B*15:02 allele is mainly found in individuals of Asian descent, the
HLA-A*31:01 variant is common globally with carrier frequencies of at least 3% in many
populations (2-5% in Northern Europeans, 2% in Han Chinese, 9% in Japanese
populations) (2, 13, 30).
Genetic Testing
Genetic testing is available for HLA-B*15:02 and HLA-A*31:01. The genotype results for
an HLA allele such as HLA-B*15:02 can either be “positive” (the HLA allele being present
in one or both copies of the gene) or “negative” (no copies of HLA allele are present).
There are no intermediate phenotypes because the HLA genes are expressed in a
codominant manner (15).

Statement from the US Food and Drug Administration (FDA): Serious and sometimes
fatal dermatologic reactions, including toxic epidermal necrolysis (TEN) and Stevens-
Johnson syndrome (SJS), have been reported during treatment with carbamazepine. These
reactions are estimated to occur in 1 to 6 per 10,000 new users in countries with mainly
Caucasian populations, but the risk in some Asian countries is estimated to be about 10
times higher. Studies in patients of Chinese ancestry have found a strong association
between the risk of developing SJS/TEN and the presence of HLA-B*1502, an inherited
allelic variant of the HLA-B gene. HLA-B*1502 is found almost exclusively in patients
with ancestry across broad areas of Asia. Patients with ancestry in genetically at-risk
populations should be screened for the presence of HLA-B *1502 prior to initiating
generic drug.
treatment with carbamazepine. Patients testing positive for the allele should not be treated
with carbamazepine unless the benefit clearly outweighs the risk.
Please review the complete therapeutic recommendations from the FDA that are
located here: (1).
Currently, the Food and Drug Administration recommends that “patients with ancestry in
at-risk populations should be screened for the presence of HLA-B*1502 allele prior to
starting carbamazepine”. Individuals at highest risk are those of Han Chinese descent,
followed by those in Vietnam, Cambodia, the Reunion Islands, Thailand, India
(specifically Hindus), Malaysia, and Hong Kong. The frequency of HLA-B*15:02 is very
low in other populations. However, it is important that the prescribing physician bear in
mind that many people may be unaware of or fail to disclose more distant Asian ancestry
in their families. In addition, much of the evidence linking HLA-B*15:02 to SJS/TEN was
generated in both children and adults. Therefore, regardless of ancestry or age of the
individual, if the genetic testing results are “positive” for the presence of at least one copy
of the HLA-B*15:02 allele, it is recommended that a different agent be used depending on
the underlying disease, unless the benefits clearly outweigh the risk (Table 1).
Carbamazepine-induced SJS/TEN usually develops within the first 3 months of therapy;
therefore, patients who have been taking carbamazepine for longer than 3 months without
developing cutaneous reactions are at low risk (but not zero) of carbamazepine-induced
adverse events in the future, regardless of HLA-B*15:02 status.
Recommendations from the Canadian Pharmacogenomics Network for Drug Safety
(CPNDS):
Recommendation 1.1: Genetic testing for HLA- B*15:02 is recommended for all CBZ-
naive patients before initiation of CBZ therapy (Level A – strong in patients originating
from populations where HLA- B*15:02 is common, its frequency unknown or whose
origin is unknown; Level C – optional in patients originating from populations where
HLA-B*15:02 is rare). Genetic testing for HLA-A*31:01 is recommended for all CBZ-naive
patients before initiation of CBZ therapy (Level B – moderate in all patients; Table 2).
Recommendation 1.2: In patients who have previously taken CBZ for > 3 months without
any adverse effects, and in whom reinitiation of CBZ is considered, genetic testing is NOT
recommended (B). In patients who have previously taken CBZ for a shorter period,
genetic testing should be considered (B).
Recommendation 1.3: In patients who have previously experienced a HSR potentially
related to CBZ, genetic testing is recommended as part of the differential diagnosis and
for the direction of future therapy (B).
Recommendation 1.4: In patients for whom no alternative treatment options are available,
genetic testing is recommended to ensure increased alertness to hypersensitivity
symptoms in positive patients (B).
Recommendation 2.1: Genetic testing for HLA- B*15:02 is most beneficial in patients
originating from a population where HLA-B*15:02 is common (e.g., Chinese, Thai,
Indian, Malay, Filipino, Indonesian; A). Nevertheless, genotyping for HLA-B*15:02 should
be considered in ALL patients, irrespective of their ancestry, as the safest option (C).
Recommendation 2.2: HLA-A*31:01 is common in most populations studied so far.
Therefore, genetic testing for this variant is recommended in patients of all ancestries (B).
Recommendation 3.1: In patients who are positive for HLA-B*15:02 or HLA-A*31:01,
alternative medications should be used as first-line therapy (A). Consideration in the
choice of alternative medications should be given to the possibility of cross-reactivity with
structurally similar AEDs (oxcarbazepine, lamotrigine, phenytoin, phenobarbital,
primidone).
Recommendation 3.2: In patients who are negative for HLA-B*15:02 and HLA-A*31:01,
CBZ can be used as first-line therapy (A). However, the occurrence of a HSR cannot be
excluded based on a negative genetic test result.
Table 2. Grading scheme used for clinical practice recommendations
Level Strength Evidence basis
A Strong Based on strong scientific evidence; benefits
clearly outweigh risks
B Moderate Based on reduced confidence scientific evidence
and expert opinion;
benefits likely to outweigh risks
C Optional Based mainly on expert opinion,
for use with evidence development in a research
context
Table adapted from: Amstutz, U., N.H. Shear, M.J. Rieder, S. Hwang, et al., Recommendations for HLA-
B*15:02 and HLA-A*31:01 genetic testing to reduce the risk of carbamazepine-induced hypersensitivity
reactions. Epilepsia, 2014. 55(4): p. 496-506 (2).
Nomenclature
HLA-B*15:02 rs2844682 and rs3909184**
HLA-A*31:01 rs1061235 and rs16333021**
single locus. Therefore, the HLA-B*15:02 allele is defined by its sequence rather than single coding or
protein variations. If there is strong linkage disequilibrium between one or more SNPs and a specific HLA
allele, the presence of these SNPs (tag SNPs) may be used for HLA typing (32).
** Because of the extreme diversity at the HLA locus, different tag SNPs may be associated with different
HLA variants in different populations. For HLA-B*15:02, rs2844682 and rs3909184 are the tag SNPs (33).
For HLA-A*31:01, rs1061235 is a tag SNP in Europeans (13) and rs16333021 is a tag SNP in Japanese (29).
A study involving North American children of various ancestries showed that rs1061235 is not a suitable tag
SNP in non-Caucasian individuals (30).
Acknowledgments
The author would like to thank Michael A. Rogawski, Professor of Neurology, University
of California, Davis; and Ursula Amstutz, Research Group Leader at the Institute of
Clinical Chemistry, Inselspital University Hospital, University of Bern; and an investigator
of the Canadian Institutes of Health Research Drug Safety and Effectiveness Network and
the Canadian Pharmacogenomics Network for Drug Safety, for reviewing this summary.
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Carbamazepine response
Carbamazepine hypersensitivity

HLA-B gene
HLA-A gene
99

Laura Dean, MD1
Created: April 4, 2017.
Introduction
Carisoprodol is a centrally acting muscle relaxant used to relieve acute back pain. Due to
the risk of dependence and abuse, carisoprodol should only be used for treatment periods
of up to two or three weeks. Carisoprodolol is a Schedule IV controlled substance and
carisoprodol overdose can lead to CNS respiratory depression, seizures, and death.
Carisoprodol is metabolized by CYP2C19 to meprobamate, a sedative used to treat
anxiety disorders. In individuals who have little or no CYP2C19 activity (“CYP2C19 poor
metabolizers”), standard doses of carisoprodol can lead to a 4-fold increase in exposure to
carisoprodol and a concomitant 50% reduced exposure to meprobamate compared to
normal metabolizers. Approximately 3‑5% of Caucasians and Africans, and 15‑20% of
Asians, are CYP2C19 poor metabolizers (1).
The FDA-approved drug label for carisoprodol states that caution should be used when
administering carisoprodol to patients with reduced CYP2C19 activity and when co-
administering drugs that inhibit or induce CYP2C19 (1). There are no data on the use of
carisoprodol in pregnancy, and the efficacy, safety, and pharmacokinetics of carisoprodol
have not been established in pediatric patients (less than 16 years of age).
Drug: Carisoprodol
Carisoprodol is a centrally acting muscle relaxant used to treat acute musculoskeletal
pain. It is often used to treat acute low back pain, providing pain relief and helping
patients mobilize. However, its clinical use is limited by the risk of abuse (it is a Schedule
IV controlled substance) and its toxic effects in overdose, which may be fatal.
The mechanism of action of carisoprodol is not well understood, but it is an indirect
agonist of the GABAA receptor associated with altered neuronal communication at the
reticular formation in the brainstem and at the spinal cord. In addition to its skeletal
muscle relaxing effects, carisoprodol also has weak anticholinergic, antipyretic, and
analgesic properties. Adverse effects include sedation, tachycardia, shortness of breath,
and dizziness (2, 3).
Carisoprodol is metabolized by CYP2C19 into meprobamate—an active metabolite that
has similar potency to carisoprodol. Meprobamate is used to treat anxiety. Again, its

mechanism of action is not well understood, but it has barbiturate-like properties and is
toxic in overdose (4).
Individuals who have reduced or absent activity of CYP2C19 have higher plasma levels of
carisoprodol, and a higher ratio of carisoprodol:meprobamate, compared to individuals
who have normal levels of CYP2C19 activity. Carisoprodol’s narrow therapeutic index
implies there may be increased risk of toxicity in CYP2C19 poor metabolizers. However,
data are limited. Small studies have found no evidence to support an association between
CYP2C19 genotype status and the mortality risk of carisoprodol or adverse effects after a
single dose of carisoprodol (4-6).
The FDA-approved drug label for carisoprodol states that caution should be used when
administering carisoprodol to patients with reduced CYP2C19 activity. The label also
states that the co-administration of CYP2C19 inhibitors, such as omeprazole or
fluvoxamine, could result in increased exposure of carisoprodol and decreased exposure
of meprobamate, and the co-administration of CYP2C19 inducers, such as rifampin or St.
John’s Wort, could result in decreased exposure of carisoprodol and increased exposure of
meprobamate. Low dose aspirin also showed induction effect on CYP2C19. The label
states that the full pharmacological impact of these potential alterations of exposures in
terms of either efficacy or safety of carisoprodol is unknown (1).
Gene: CYP2C19
tricyclic antidepressants, including imipramine.
The CYP2C19 gene is highly polymorphic—35 variant star (*) alleles are catalogued at the
Human Cytochrome P450 (CYP) Allele Nomenclature Database: http://
www.cypalleles.ki.se/cyp2c19.htm.
The most common loss-of-function variant is CYP2C19*2, which contains a c.681G>A
variant in exon 5 that results in an aberrant splice site. This leads to the production of a
truncated and non-functioning protein. The CYP2C19*2 allele frequencies are ~15% in
Caucasians and Africans, and ~29–35% in Asians (7, 8).
Another commonly tested loss-of-function variant is CYP2C19*3, which contains a c.
636G>A variant in exon 4 that causes a premature stop codon. The CYP2C19*3 allele
frequencies are ~2–9% in Asian populations, but rare in other racial groups. Other loss-
of-function variants occur in less than 1% of the general population and include
CYP2C19*4-*8 (7, 8).
Carisoprodol Therapy and CYP2C19 Genotype 101
CYP2C19 intermediate metabolizers carry one copy of an allele that encodes reduced or
absent function (e.g. *1/*2), whereas “poor metabolizers” are homozygous or compound
heterozygous for two loss-of-function alleles (e.g., *2/*2, *2/*3) (table 1).
Table 1. CYP2C19 functional status and phenotypes
Phenotype Genotype Examples of diplotypes
CYP2C19 Ultrarapid metabolizer An individual carrying two *17/*17
(~2˗5% of patients)a increased function alleles.
CYP2C19 Rapid metabolizer An individual carrying one normal *1/*17
(~2‑30% of patients) function allele and one increased
function allele.
CYP2C19 Normal metabolizer An individual carrying two normal *1/*1
(~35‑50% of patients) function alleles.
CYP2C19 Intermediate An individual carrying one normal *1/*2
metabolizer function allele and one no function *1/*3
(~18‑45% of patients) allele or one no function allele and *2/*17b
one increased function allele.
CYP2C19 Poor metabolizer An individual carrying two no *2/*2
(~2‑15% of patients) function alleles. *2/*3
*3/*3
a CYP2C19 metabolizer status frequencies are based on average multi-ethnic frequencies. See the CYP2C19
Frequency Tables for population-specific allele and phenotype frequencies (9).
b The predicted metabolizer phenotype for the*2/*17 genotype is a provisional classification. The currently
available evidence indicates that the CYP2C19*17 increased function allele is unable to completely
compensate for the CYP2C19*2 no function allele.
Table is adapted from Hicks J.K., Sangkuhl K., Swen J.J., Ellingrod V.L., Müller D.J., Shimoda K., Bishop J.R.,
Kharasch E.D., Skaar T.C., Gaedigk A., Dunnenberger H.M., Klein T.E., Caudle K.E., and Stingl J.C. Clinical
and Dosing of Tricyclic Antidepressants: 2016 Update. 2016 Dec 20; doi: 10.1002/cpt.597. [Epub ahead of
print] (9)
Genetic Testing
Clinical genotyping tests are available for several CYP2C19 alleles. The NIH’s Genetic
Testing Registry (GTR) provides examples of the genetic tests that are currently available
for carisoprodol response, CYP2C19-related poor drug metabolism, and the CYP2C19
gene.

2016 Statement from the US Food and Drug Administration (FDA):

Carisoprodol Tablets are metabolized in the liver by CYP2C19 to form meprobamate. Co-
administration of CYP2C19 inhibitors, such as omeprazole or fluvoxamine, with
Carisoprodol Tablets could result in increased exposure of carisoprodol and decreased
exposure of meprobamate. Co-administration of CYP2C19 inducers, such as rifampin or
St. John’s Wort, with Carisoprodol Tablets could result in decreased exposure of
carisoprodol and increased exposure of meprobamate. Low dose aspirin also showed
induction effect on CYP2C19.
The full pharmacological impact of these potential alterations of exposures in terms of
either efficacy or safety of Carisoprodol Tablets is unknown.
[...]
Patients with Reduced CYP2C19 Activity: Carisoprodol Tablets should be used with
caution in patients with reduced CYP2C19 activity. Published studies indicate that
patients who are poor CYP2C19 metabolizers have a 4-fold increase in exposure to
carisoprodol, and concomitant 50% reduced exposure to meprobamate compared to
normal CYP2C19 metabolizers. The prevalence of poor metabolizers in Caucasians and
African Americans is approximately 3-5% and in Asians is approximately 15-20%.

Coding Protein
identifier for
allele location
Pro227Pro
Trp212Ter
generic drug.
Carisoprodol Therapy and CYP2C19 Genotype 103
Acknowledgments
The author would like to thank JT Callaghan, M.D., Ph.D., Associate Dean of Veterans
Affairs Research, Associate Professor of Medicine, and Pharmacology and Toxicology,
Department of Veterans Affairs and Indiana University School of Medicine; Ben Kong,
PharmD, BCPS, Clinical Pharmacist, Oregon Health & Science University, Oregon; Gouri
Mukerjee, Scientific Officer at Geneyouin Inc., Toronto, Canada; and Mohamed Nagy,
Clinical Pharmacist, Head of the Personalised Medication Management Unit, Department
of Pharmaceutical Services, Children's Cancer Hospital, Egypt; for reviewing this
summary.
References
1. CARISOPRODOL- carisoprodol tablet [Package insert]. Eatontown, NJ: Corp, W.-
W.P.; 2016. Available from: https://dailymed.nlm.nih.gov/dailymed/drugInfo.cfm?
setid=88cd0b26-6575-4132-9749-0f038d8663c7 - _12_3_Pharmacokinetics
2. Horsfall J.T., Sprague J.E. The Pharmacology and Toxicology of the 'Holy Trinity'.
Basic Clin Pharmacol Toxicol. 2016. PubMed PMID: 27550152.
3. Witenko C., Moorman-Li R., Motycka C., Duane K., et al. Considerations for the
appropriate use of skeletal muscle relaxants for the management of acute low back
pain. P T. 2014;39(6):427–35. PubMed PMID: 25050056.
4. Hoiseth G., Majid U., Morland J., Bramness J.G., et al. CYP2C19 genetics in fatal
carisoprodol intoxications. Eur J Clin Pharmacol. 2012;68(11):1561–5. PubMed
PMID: 22527345.
5. Bramness J.G., Skurtveit S., Gulliksen M., Breilid H., et al. The CYP2C19 genotype
and the use of oral contraceptives influence the pharmacokinetics of carisoprodol in
healthy human subjects. Eur J Clin Pharmacol. 2005;61(7):499–506. PubMed PMID:
16021435.
6. Bramness J.G., Skurtveit S., Fauske L., Grung M., et al. Association between blood
carisoprodol:meprobamate concentration ratios and CYP2C19 genotype in
carisoprodol-drugged drivers: decreased metabolic capacity in heterozygous
CYP2C19*1/CYP2C19*2 subjects? Pharmacogenetics. 2003;13(7):383–8. PubMed
PMID: 12835613.
PMID: 22027650.
2011;90(2):328–32. PubMed PMID: 21716271.

Ther. 2016.
PMID: 27441996.


Carisoprodol response

CYP2C19 gene
105
Celecoxib Therapy and CYP2C9 Genotype

Laura Dean, MD1
Created: August 18, 2016.
Introduction
Celecoxib is a nonsteroidal anti-inflammatory drug (NSAID) that is used in the
management of osteoarthritis, rheumatoid arthritis, menstrual symptoms, and acute pain.
Most NSAIDs inhibit both types of cyclooxygenase, COX-1 and COX-2. These enzymes
catalyze pathways that play a key role in the generation of the inflammatory response;
however, celecoxib, selectively inhibits COX-2.
The CYP2C9 gene encodes an enzyme involved in the metabolism of many drugs, and is
one of the main enzymes that metabolizes and inactivates celecoxib. Two common
variants, CYP2C9*2 and CYP2C9*3, are associated with significantly reduced CYP2C9
enzyme activity. Individuals who carry two copies of these variants (or other loss-of-
function variant CYP2C9 alleles) are considered CYP2C9 “poor metabolizers” and may be
exposed to high drug levels after standard celecoxib doses.
The FDA-approved drug label for celecoxib states: “patients who are known or suspected
to be poor CYP2C9 metabolizers based on genotype or previous history/experience with
other CYP2C9 substrates (such as warfarin, phenytoin) should be administered celecoxib
with caution. Consider starting treatment at half the lowest recommended dose in poor
metabolizers (i.e., CYP2C9*3/*3). Consider using alternative management in juvenile
rheumatoid arthritis (JRA) patients who are poor metabolizers” (1).
Drug: Celecoxib
Celecoxib is a NSAID that is used to treat osteoarthritis, rheumatoid arthritis, ankylosing
spondylitis, painful menstruation, and acute pain (1). It is also used to reduce the number
of colon and rectum polyps in patients with familial adenomatous polyposis.
Worldwide, it is estimated that more than 30 million people receive NSAIDs daily (2).
They are one of the most commonly used classes of medicine. Several NSAIDs (aspirin,
ibuprofen, and naproxen) are available over-the-counter, but stronger doses and other
types of NSAIDs, such as celecoxib, are only available via prescription. It is thought that
approximately 25% of the population has experienced NSAID-related side effects that
require medical care (3).
Most NSAIDs are non-selective COX inhibitors that reduce the production of pro-
inflammatory prostaglandins by inhibiting both COX-1 and COX-2. COX is the central

enzyme in the synthesis of prostaglandins and thromboxane A2 from arachidonic acid.

Prostaglandins can be protective (e.g., protect the gastric mucosal lining and aids platelet
aggregation) or inflammatory (e.g., recruiting inflammatory white blood cells).
Celecoxib is a selective COX-2 inhibitor, which promotes the production of the gastric
mucosal lining. Although celecoxib may be more gastroprotective than non-selective
NSAIDs (4-7), the use of celecoxib still increases the risks of gastrointestinal adverse
events. The FDA-approved label for celecoxib includes the warning that:
NSAIDs, including CELECOXIB, cause an increased risk of serious gastrointestinal
adverse events including bleeding, ulceration, and perforation of the stomach or
intestines, which can be fatal. These events can occur at any time during use and without
warning symptoms (1).
In the US, acute gastrointestinal bleeding associated with the use of NSAIDs may cause
more than 30,000 hospitalizations per year (8). Several risk factors for NSAID-related
bleeding have been identified, including old age, a history of peptic ulcer disease, high
dosages of NSAIDs, concomitant use of different NSAIDs (9), and CYP2C9 genotype.
Gene: CYP2C9
form the major system for metabolizing lipids, hormones, toxins, and drugs in the liver.
The CYP450 genes are very polymorphic and can result in reduced, absent, or increased
enzyme activity. CYP2C9 metabolizes approximately 15% of clinically used drugs, and
atypical metabolic activity caused by genetic variants in the CYP2C9 gene can play a
major role in adverse drug reactions (10, 11).
At least 16 different NSAIDS are metabolized, in part, by CYP2C9 (12). Celecoxib is
extensively metabolized by CYP2C9, with minor contributions from CYP3A4, CYP2C8
and CYP2C19 (3).
CYP2C9*1 is the wild-type allele and is associated with normal enzyme activity and the
normal metabolizer phenotype. Two common variants, CYP2C9*2 (p.Arg144Cys) and
CYP2C9*3 (p.Ile359Leu), are associated with significantly reduced enzyme activity.
Carriers of these variants have altered pharmacokinetics of several NSAIDs: celecoxib,
flurbiprofen, ibuprofen, and tenoxicam (12, 13). This could potentially lead to dose
recommendations based upon CYP2C9 genotype, and be used to identify individuals who
are at increased risk of adverse events. However, pharmacogenetic testing has been limited
to retrospective studies to identify the causes of an atypical response to NSAID (11).
Studies have found that CYP2C9*3 is associated with an increased risk of bleeding
associated with NSAID use (9, 14). In contrast, CYP2C9*3 was found to be beneficial in a
trial where celecoxib was given to prevent colorectal adenomas. High dose celecoxib had
greater efficacy in preventing new adenomas than low-dose celecoxib, but only among
individuals who were carriers of CYP2C9*3 (15, 16).
Celecoxib Therapy and CYP2C9 Genotype 107
The frequencies of variant CYP2C9 alleles vary between different ethnic groups (17-19).
The *2 allele is more common in Caucasian and Middle Eastern populations (10-20%),
than in Asian or African populations (0-6%) (19-21). The *3 allele is less common (<10%
in most populations) and extremely rare in African populations (19, 22).
The influence of other variant alleles, such as CYP2C9*8 and CYP2C9*11, on celecoxib
levels in the plasma has not yet been evaluated.
Genetic Testing
Clinical genotyping tests are available for several CYP2C9 alleles, and a list of tests is
available at the Genetic Testing Registry (GTR) of the National Institutes of Health: http://
www.ncbi.nlm.nih.gov/gtr/tests/?term=1559[geneid].
The variants that are most commonly tested for are CYP2C9*2 and CYP2C9*3. Test results
are typically reported as a diplotype (e.g., CYP2C9 *3/*3), and may also include an
interpretation of the patient’s predicted metabolizer phenotype: ultrarapid, normal
(extensive), intermediate, or poor.

2015 Statement from the US Food and Drug Administration (FDA): Poor Metabolizers
of CYP2C9 Substrates: Patients who are known or suspected to be poor CYP2C9
metabolizers based on genotype or previous history/experience with other CYP2C9
substrates (such as warfarin, phenytoin) should be administered celecoxib with caution.
Consider starting treatment at half the lowest recommended dose in poor metabolizers
(i.e., CYP2C9*3/*3). Consider using alternative management in junior rheumatoid
arthritis (JRA) patients who are poor metabolizers.
generic drug.
Nomenclature
Coding Protein
identifier for
allele location
CYP2C9*2 430C>T NM_000771.3:c. NP_000762.2:p.Arg144Cys rs1799853
Arg144Cys 430C>T
CYP2C9*3 1075A>C NM_000771.3:c. NP_000762.2:p.Ile359Leu rs1057910
Ile359Leu 1075A>C
Acknowledgments
The author would like to thank Anita Gupta D.O., Pharm.D., Vice Chair, Associate
Professor, Division of Pain Medicine and Regional Anesthesiology, Department of
Anesthesiology and Perioperative Medicine, Drexel University College of Medicine; Stuart
Scott, Assistant Professor of Genetics and Genomic Sciences, Icahn School of Medicine at
Mount Sinai; and Chakradhara Rao S. Uppugunduri, Maître-assistant at the
CANSEARCH Laboratory, University of Geneva, Switzerland; for reviewing this
summary.
References
1. CELEBREX- celecoxib capsule [package insert]. New York, NY: Pfizer Inc; 2015.
Available from: https://dailymed.nlm.nih.gov/dailymed/drugInfo.cfm?
setid=8d52185d-421f-4e34-8db7-f7676db2a226
2. Singh G., Triadafilopoulos G. Epidemiology of NSAID induced gastrointestinal
complications. J Rheumatol Suppl. 1999;56:18–24. PubMed PMID: 10225536.
3. Agundez J.A., Garcia-Martin E., Martinez C. Genetically based impairment in
CYP2C8- and CYP2C9-dependent NSAID metabolism as a risk factor for
gastrointestinal bleeding: is a combination of pharmacogenomics and metabolomics
required to improve personalized medicine? Expert Opin Drug Metab Toxicol.
2009;5(6):607–20. PubMed PMID: 19422321.
4. Lanza F.L., Chan F.K., Quigley E.M. Prevention of NSAID-Related Ulcer
Complications. Am J Gastroenterol. 2009;104(3):728–38. PubMed PMID: 19240698.
5. Peterson, K., M. McDonagh, S. Thakurta, T. Dana, et al., in Drug Class Review:
Nonsteroidal Antiinflammatory Drugs (NSAIDs): Final Update 4 Report. 2010:
Portland (OR). Available from: http://www.ncbi.nlm.nih.gov/pubmed/21542548
Celecoxib Therapy and CYP2C9 Genotype 109
6. L., D., Comparing NSAIDs, in Pubmed Clinical Q&A [Internet]. 2011, National Center
for Biotechnology Information (US): Bethesda (MD). Available from: http://
www.ncbi.nlm.nih.gov/books/NBK45590/
7. Rostom, A., K. Muir, C. Dube, E. Jolicoeur, et al., Gastrointestinal safety of
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inflammatory drugs and gastrointestinal bleeding: relative and absolute risk estimates
from recent epidemiologic studies. Am J Ther. 2004;11(1):17–25. PubMed PMID:
14704592.
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nonsteroidal anti-inflammatory drug-related gastroduodenal bleeding: role of
cytochrome P450 2C9 polymorphisms. Gastroenterology. 2007;133(2):465–71.
10. Van Booven D., Marsh S., McLeod H., Carrillo M.W., et al. Cytochrome P450 2C9-
CYP2C9. Pharmacogenet Genomics. 2010;20(4):277–81. PubMed PMID: 20150829.
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Testing in the Identification of CYP2C9 Polymorphisms Related to NSAID-Induced
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anti-inflammatory agents: clinical implications. Eur J Clin Pharmacol. 2013;69(7):
1369–73. PubMed PMID: 23435614.
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relationship between polymorphisms in CYP2C8 and CYP2C9 and the
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PMID: 23996211.
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of NSAIDs Other Than Aspirin. Clin Pharmacol Ther. 2010;87(6):693–8. PubMed
PMID: 20445534.
15. Arber N., Eagle C.J., Spicak J., Racz I., et al. Celecoxib for the prevention of colorectal
adenomatous polyps. N Engl J Med. 2006;355(9):885–95. PubMed PMID: 16943401.
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17. Sistonen J., Fuselli S., Palo J.U., Chauhan N., et al. Pharmacogenetic variation at
CYP2C9, CYP2C19, and CYP2D6 at global and microgeographic scales.
Pharmacogenetics and genomics. 2009;19(2):170–9. PubMed PMID: 19151603.
18. Solus J.F., Arietta B.J., Harris J.R., Sexton D.P., et al. Genetic variation in eleven phase
I drug metabolism genes in an ethnically diverse population. Pharmacogenomics.
2004;5(7):895–931. PubMed PMID: 15469410.
19. Lee C.R., Goldstein J.A., Pieper J.A. Cytochrome P450 2C9 polymorphisms: a
comprehensive review of the in-vitro and human data. Pharmacogenetics.
2002;12(3):251–63. PubMed PMID: 11927841.
20. Zand N., Tajik N., Moghaddam A.S., Milanian I. Genetic polymorphisms of
cytochrome P450 enzymes 2C9 and 2C19 in a healthy Iranian population. Clin Exp
Pharmacol Physiol. 2007;34(1-2):102–5. PubMed PMID: 17201743.
21. Hamdy S.I., Hiratsuka M., Narahara K., El-Enany M., et al. Allele and genotype
frequencies of polymorphic cytochromes P450 (CYP2C9, CYP2C19, CYP2E1) and
dihydropyrimidine dehydrogenase (DPYD) in the Egyptian population. Br J Clin
Pharmacogenet Genomics. 2009;19(2):170–9. PubMed PMID: 19151603.

Warfarin Therapy and the Genotypes CYP2C9 and VKORC1

Celecoxib response

CYP2C9 gene
111

Laura Dean, MD1
Created: March 8, 2012; Updated: November 19, 2015.
Introduction
Clopidogrel is an antiplatelet agent used to reduce the risk of myocardial infarction (MI)
and stroke among high-risk patients. It is also approved for secondary prevention of
atherosclerotic events for patients who have recently had an MI or a stroke and those with
established peripheral arterial disease, and administered with aspirin as dual antiplatelet
therapy (DAPT) for patients with acute coronary syndrome (ACS) caused by an MI or
unstable angina.
CYP2C19 is one of the principal enzymes involved in the hepatic bioactivation of
clopidogrel. Of note, the recommended doses of clopidogrel are less effective in patients
with loss-of-function variant alleles in the CYP2C19 gene. Approximately 2% of
Caucasians, 4% of African Americans, and 14% of Chinese carry two loss-of-function
variant alleles and are classified as “poor metabolizers” due to having little or no CYP2C19
enzyme activity (1).
The FDA-approved drug label for clopidogrel contains a boxed warning, stating that
clopidogrel has diminished effectiveness among CYP2C19 poor metabolizers. It advises
that tests are available to identify a patient’s CYP2C19 genotype, they can be used as an
aid in determining therapeutic strategy, and that alternative treatment strategies should be
considered in patients identified as CYP2C19 poor metabolizers.
The Clinical Pharmacogenetics Implementation Consortium (CPIC) has made antiplatelet
therapy recommendations based on CYP2C19 genotype for patients with ACS who are
undergoing percutaneous coronary interventions (PCI), such as the placement of a stent.
Given the reduced efficacy reported for both CYP2C19 intermediate and poor
metabolizers, CPIC recommends using an alternative antiplatelet agent (e.g., prasugrel or
ticagrelor) when not contraindicated (Table 1) (2).

Table 1. Antiplatelet therapy recommendations based on CYP2C19 status when considering clopidogrel for
ACS/PCI patients
Phenotype Phenotype details Examples of Therapeutic recommendations
diplotypes for clopidogrel in ACS/PCI
Ultrarapid Normal or increased *1/*17 Dose recommended by drugs
metabolizer enzyme activity. *17/*17 label
Found in ~5–30% of
patients.
Extensive metabolizer Normal enzyme activity *1/*1 Dose recommended by drugs
(homozygous wild-type). label
Found in ~35-50% of
patients.
Intermediate Intermediate enzyme *1/*2 Alternative antiplatelet therapy
metabolizer activity. *1/*3 recommended if no
Found in ~18-45% of *2/*17 contraindication, e.g.,
patients. prasugrel, ticagrelor
Poor metabolizer Low or absent enzyme *2/*2 Alternative antiplatelet therapy
activity. *2/*3 recommended if no
Found in ~2-15% of *3/*3 contraindication, e.g.,
patients. prasugrel, ticagrelor
The strength of therapeutic recommendations is “moderate” for intermediate metabolizers and “strong” for
all other metabolizers.
ACS, acute coronary syndrome
PCI, percutaneous coronary intervention
Table is adapted from Scott S.A., Sangkuhl K., Stein C.M., Hulot J.S., et al. Clinical Pharmacogenetics
Implementation Consortium guidelines for CYP2C19 genotype and clopidogrel therapy: 2013 update. Clinical
pharmacology and therapeutics. 2013;94(3):317–23 (2)
Drug: Clopidogrel
Clopidogrel is a second-generation thienopyridine antiplatelet agent, which binds
irreversibly to the P2RY12 receptor and inhibits ADP-mediated platelet activation and
aggregation. Other currently approved antiplatelet agents include prasugrel and ticagrelor.
As an antiplatelet agent, clopidogrel is used to inhibit the formation of blood clots in the
coronary, peripheral, and cerebrovascular arteries. It is typically given in addition to daily
aspirin and other standard treatments, and is used in patients with ACS, and in patients
who have either had a recent MI or stroke, or have established peripheral arterial disease
(1).
ACS reflects a decreased blood flow in the coronary arteries, and comprises the entities’
unstable angina, “STEMI” and “NSTEMI”. Unstable angina, in contrast to stable angina,
occurs suddenly, often at rest or with minimal exertion. It may be new in onset, or it may
occur with less exertion than previously. An MI may be classified in two types, depending
on what is shown on the EKG. If the EKG findings include an elevation of the ST-segment,
this is known as an “ST segment elevation MI” (STEMI), and if there is no elevation but
Clopidogrel Therapy and CYP2C19 Genotype 113
an increase in myocardial biomarkers such as troponin I or T, this is known as a “non-ST

segment elevation MI” (NSTEMI).
In patients who have ACS caused by STEMI, clopidogrel has been found to reduce the
rate of death from any cause (3). In patients who have ACS caused by NSTEMI or
unstable angina, clopidogrel has been found to decrease the rate of a combined endpoint
of cardiovascular death, MI, stroke, or refractory ischemia (4).
In patients with atherosclerotic vascular disease, as indicated by a recent MI, a recent
ischemic stroke, or symptomatic peripheral arterial disease, the long-term administration
of clopidogrel reduces the combined risk of a new ischemic stroke or MI, and other
vascular death (5).
Clopidogrel is a potent antithrombotic drug that inhibits ADP-induced platelet
aggregation by selectively binding to the platelet purinergic receptor, P2RY12 (6). Because
clopidogrel is a pro-drug, it first requires conversion into an active metabolite before it can
act as an antiplatelet agent.
Clopidogrel activation takes place via two sequential oxidation reactions that are
catalyzed by the cytochrome P450 (CYP450) system: the first involving CYP1A2,
CYP2B6, and CYP2C19, and the second involving CYP2B6, CYP2C9, CYP2C19,
CYP3A4, and CYP3A5. Less than 15% of the clopidogrel pro-drug is activated, the
remaining 85% is hydrolyzed by esterases to inactive forms and excreted (6-9). Of note,
one small study suggested that a non P450 (CYP) enzyme, paraoxonase 1 (PON1), may
also be involved in clopidogrel activation (10); however, this finding has not been
replicated in dedicated studies (11-13) or in meta-analysis (14)
The active clopidogrel metabolite contains a reactive thiol group, which forms a disulfide
bridge with a free cysteine residue on the P2RY12 receptor. Once bound, the receptor is
unable to bind ADP, and platelet activation via this pathway is prevented for the rest of its
lifespan (~10 days) (6).
Despite the general efficacy of clopidogrel to inhibit platelet aggregation, a substantial
variability in response to clopidogrel is frequently observed—resistance and treatment
failure can occur in some patients. It has been estimated that between 16-50% of patients
treated with clopidogrel have “high on-treatment platelet reactivity” (HTPR), which
indicates that a major portion of P2RY12 receptors are not blocked, despite treatment
with clopidogrel (15).
An individual’s response to clopidogrel can be influenced by many factors, such as age,
comorbidities, and drug-drug interactions. In addition, genetic susceptibility to
clopidogrel response has been reported, including variant alleles in the ABCB1 gene,
which influence the absorption of clopidogrel from the gut (16, 17), and variant alleles in
the CYP2C19 gene, which influence the generation of the active clopidogrel metabolite
(18, 19).
CYP2C19 is the principal hepatic enzyme involved in converting clopidogrel to its active
metabolite, and CYP2C19 loss-of-function alleles result in reduced active clopidogrel
metabolites and HTPR, as well as an increased risk for both major adverse cardiovascular
events (MACE) and stent thrombosis compared to CYP2C19 wild-type patients with
ACS/PCI (20-22).
Gene: CYP2C19
metabolism.
drugs, such as antidepressants, benzodiazepines, some proton pump inhibitors, and the
antiplatelet agent clopidogrel.
The variability of clopidogrel metabolism and treatment outcomes between individuals is
partly determined by variant alleles of the CYP2C19 gene. CYP2C19 is highly
polymorphic, as more than 25 variant star (*) alleles are currently catalogued at the
Human Cytochrome P450 (CYP) Allele Nomenclature Database (http://
www.cypalleles.ki.se/cyp2c19.htm). The CYP2C19*1 wild-type allele and is associated
with normal enzyme activity and the “extensive metabolizer” phenotype.
The CYP2C19*17 allele is associated with increased enzyme activity due to increased gene
transcription and has allele frequencies range from 3 to 21% across different populations
(2). Individuals with one or two copies of the *17 allele are typically classified as
“ultrarapid metabolizers”.
Individuals who carry one and two reduced-activity or non-functioning CYP2C19 alleles
are “intermediate” and “poor metabolizers”, respectively. Given that the efficacy of
clopidogrel is, in part, dependent upon it being metabolized by CYP2C19 to an active
metabolite, intermediate and poor metabolizers can have reduced antiplatelet responses
when treated with clopidogrel. However, only 6 to 12% of the observed variability in
antiplatelet effect of clopidogrel is thought to be attributed to carriage of CYP2C19*2
allele(s) (23). Approximately 2% of Caucasians, 4% of African Americans, and 14% of
Chinese are CYP2C19 poor metabolizers (1).
Caucasians and Africans, and ~29–35% in Asians (2).
frequencies are ~2-9% in Asian populations, but rare in other racial groups. Other loss-of-
function variants occur in less than 1% of the general population, and include
CYP2C19*4-*8 (2).
As noted above, ACS/PCI patients that are CYP2C19 intermediate or poor metabolizers
and who are treated with clopidogrel have increased risks for major cardiovascular events
including stent thrombosis (1) (17, 21).
Genetic Testing
Clinical genotyping tests are available for several CYP2C19 alleles, and a list of test
providers is available at the Genetic Testing Registry (GTR) of the National Institutes of
Health: http://www.ncbi.nlm.nih.gov/gtr/tests/?term=1557[geneid].
Usually a patient’s result is reported as a diplotype, such as CYP2C19 *1/*1, and may also
include an interpretation of the patient’s predicted metabolizer phenotype (ultrarapid,
extensive, intermediate, or poor). Table 1 summarizes common CYP2C19 phenotypes
with antiplatelet therapy recommendations developed by CPIC.
The association between CYP2C19*2 and *3 and clopidogrel response has been
extensively studied; however, the less common loss-of-function alleles (e.g., CYP2C19*4-
*8) also likely influence clopidogrel response similar to *2 and *3. Therefore, when other
loss-of-function alleles are identified in patients with ACS/PCI, these alleles should be
considered to reduce the effectiveness of clopidogrel therapy in a similar manner to the
more common CYP2C19*2 allele (2, 24).

Statement from the US Food and Drug Administration (FDA): WARNING:
DIMINISHED EFFECTIVENESS IN POOR METABOLIZERS. The effectiveness of
clopidogrel is dependent on its activation to an active metabolite by the cytochrome P450
(CYP) system, principally CYP2C19. Clopidogrel at recommended doses forms less of
that metabolite and has a smaller effect on platelet function in patients who are CYP2C19
poor metabolizers. Poor metabolizers with acute coronary syndrome or undergoing
percutaneous coronary intervention treated with clopidogrel at recommended doses
exhibit higher cardiovascular event rates than do patients with normal CYP2C19
function. Tests are available to identify a patient's CYP2C19 genotype; these tests can be
used as an aid in determining therapeutic strategy. Consider alternative treatment or
generic drug.
treatment strategies in patients identified as CYP2C19 poor metabolizers.

Standard dosing of clopidogrel, as recommended in the product insert, is warranted
among ACS/PCI patients with a predicted CYP2C19 extensive metabolizer or ultrarapid
metabolizer phenotype (i.e., *1/*1, *1/*17, and *17/*17). If genotyping from a Clinical
Laboratory Improvement Amendments–certified laboratory identifies a patient as a
CYP2C19 PM (i.e., *2/*2), current literature supports the use of an alternative antiplatelet
agent (e.g., prasugrel or ticagrelor) when not contraindicated clinically.
The most challenging patient population to address is the CYP2C19 IM phenotype (e.g.,
*1/*2, *1/*3, and *2/*17). IMs have higher on-treatment residual platelet activity on
average as compared with extensive metabolizers, and ACS/PCI CYP2C19*2
heterozygotes treated with clopidogrel have increased risks for serious adverse CV
outcomes, including stent thrombosis. Consequently, these data support switching to an
alternative antiplatelet agent for IMs when not contraindicated. However, given the wide
interindividual variability in residual platelet activity observed among clopidogrel-treated
IMs, clinical judgment also taking into account other factors that may place an IM at
increased risk of a CV event (or adverse bleeding event) must be considered to most
effectively individualize therapy.
Royal Dutch Association for the Advancement of Pharmacy (KNMP): There is an
increased risk for a reduced response to clopidogrel in CYP2C19 intermediate and poor
metabolizers. Consider using an alternative drug. Prasugrel is not or to a much smaller
extent metabolized by CYP2C19 but is associated with an increased bleeding risk
compared to clopidogrel (Table 2).
Table 2. CYP2C19 phenotypes and the therapeutic recommendations for clopidogrel therapy
Phenotype Genotype Therapeutic (dose) recommendation for
clopidogrel
Ultrarapid metabolizer More than two copies of No
functional alleles
Intermediate metabolizer One active allele and one Increased risk for reduced response to
inactive allele, or two clopidogrel. Consider alternative drug.
decreased activity alleles, or Prasugrel is not or to a much smaller extent
metabolized by CYP2C19 but is associated
with an increased bleeding risk compared to
clopidogrel
The strength of the clopidogrel therapeutic recommendations scored a maximum of 4/4 (the highest quality
of evidence) for poor and intermediate metabolizers, and a score of 3/4 for ultrarapid metabolizers. Table is
adapted from Swen J.J., Nijenhuis M., de Boer A., Grandia L. et al. Pharmacogenetics: from bench to byte - an
Phenotype Genotype Therapeutic (dose) recommendation for

clopidogrel
one decreased activity allele
and one inactive allele
Poor metabolizer Two inactive alleles Increased risk for reduced response to
clopidogrel. Consider alternative drug.
Prasugrel is not or to a much smaller extent
metabolized by CYP2C19 but is associated
with an increased bleeding risk compared to
clopidogrel
The strength of the clopidogrel therapeutic recommendations scored a maximum of 4/4 (the highest quality
of evidence) for poor and intermediate metabolizers, and a score of 3/4 for ultrarapid metabolizers. Table is
adapted from Swen J.J., Nijenhuis M., de Boer A., Grandia L. et al. Pharmacogenetics: from bench to byte - an
Nomenclature
Coding Protein
identifier for
allele location
Pro227Pro
Trp212Ter
CYP2C19*17 -806C>T NM_000769.1:c.-806C>T Not applicable - variant rs12248560
region
Acknowledgments
Sciences, Icahn School of Medicine at Mount Sinai; and Dietmar Trenk, Head of Clinical
Pharmacology at the University Heart Center, Bad Krozingen and Professor at the Albert
Ludwig University of Freiburg, Germany; for reviewing this summary.
References
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Clopidogrel response

CYP2C19 gene
121
Clozapine Therapy and CYP2D6, CYP1A2, and

CYP3A4 Genotypes
Laura Dean, MD1
Created: June 8, 2016.
Introduction
Clozapine is one of the most effective antipsychotics available in the treatment of
schizophrenia and the only antipsychotic found to be effective in treatment-resistant
schizophrenia. Clozapine is also used to reduce the risk of recurrent suicidal behavior in
patients with schizophrenia or schizoaffective disorder (1, 2).
Compared to typical antipsychotics, clozapine is far less likely to cause movement
disorders, known as extrapyramidal side effects, which include dystonia, akathisia,
parkinsonism, and tardive dyskinesia. However, there are significant risks associated with
clozapine therapy that limits its use to only the most severely ill patients who have not
responded adequately to standard drug therapy. Most notably, because of the risk of
clozapine-induced agranulocytosis, clozapine treatment requires monitoring of white
blood counts and absolute neutrophil counts, and in the US, the FDA requires that
patients receiving clozapine be enrolled in a computer-based registry (3).
Clozapine is metabolized in the liver by the cytochrome P450 (CYP) system of enzymes.
CYP1A2 is the main CYP isoform in clozapine metabolism and CYP1A2 activity is an
important determinant of clozapine dose (4). Other CYP enzymes involved in clozapine
metabolism include CYP2D6 and CYP3A4.
Approximately 6-10% of Caucasians have reduced activity of CYP2D6 (“poor
metabolizers”). These individuals may develop higher than expected plasma
concentrations of clozapine with usual doses. The FDA-approved drug label for clozapine
states that a dose reduction may be necessary in patients who are CYP2D6 poor
metabolizers (1).
Drug: Clozapine
Clozapine is an antipsychotic used in the treatment of schizophrenia. Schizophrenia is a
severe neurodevelopmental disorder with a worldwide prevalence of around 1%. The
etiology of schizophrenia is unknown, but it is thought to result from a combination of
complex genetic and environmental factors. Before the discovery of the first
antipsychotics in the 1950s, the management of schizophrenia relied heavily upon
sedation, electroconvulsive therapy, and institutionalization.

The symptoms of schizophrenia fall in to three main categories: positive, negative, and
cognitive. Positive symptoms are generally not found in healthy individuals, but may
come and go or persist in individuals with schizophrenia. Positive symptoms include
reality distortion (e.g., delusions, hallucinations), and thought disorders. These symptoms
often respond well to treatment.
Negative symptoms are deficits in normal emotions and behavior, and may be mistaken
for depression. Symptoms divide into reduced expression of emotion (e.g., speaking
without moving or with a monotonous voice), and avolition (a lack of motivation to start
or continue with a task). No treatment has established efficacy for these pathologies.
Cognitive symptoms may also be difficult to recognize. They include poor executive
functioning (understanding information and using it to make decisions) and trouble
focusing or paying attention. And again, no treatment has established efficacy.
Clozapine is unique among the antipsychotics because it effectively treats positive
symptoms, and appears to be more effective in treating negative symptoms, and some
cognitive symptoms when compared with other antipsychotics that cause negative
symptoms or impair cognition (5-7).
Clozapine has also been shown to reduce aggression and reduce the risk of suicide, and is
the only antipsychotic found to be effective in treatment-resistant schizophrenia (2, 8-10).
More than one third of patients are thought to have schizophrenia that only partially
responds or is resistant to standard drugs; these patients may then be treated with
clozapine (2, 10, 11).
chlorpromazine. Known as “first generation” or “typical” antipsychotics, these drugs are
used to treat psychosis (regardless of the cause), chronic psychotic disorders (e.g.,
schizophrenia), and other psychiatric conditions. However, prominent adverse effects
included extrapyramidal side effects such as tardive dyskinesia, muscle rigidity, tremors,
and Parkinsonian-like symptoms.
lower risk of extrapyramidal side effects such as tardive dyskinesia. However, many have
serious metabolic effects. These antipsychotics include aripiprazole, clozapine,
iloperidone, olanzapine, and risperidone.
Clozapine was introduced in 1971 as the first atypical antipsychotic, but the manufacturer
(Novartis, formerly Sandoz) voluntarily withdrew the drug in 1975 because of safety
concerns (7). One of the most dangerous risks reported was that of clozapine-induced
neutropenia—a severely low level of neutrophils (a type of white blood cell), which places
patients at high risk of infection. However, because it was later shown that clozapine was
the most effective antipsychotic in the management of treatment-resistant schizophrenia,
in 1989 the FDA reapproved clozapine for that use (5, 7, 9).
Clozapine Therapy and CYP2D6, CYP1A2, and CYP3A4 Genotypes 123
The main action of both first-generation and second-generation antipsychotics appears to

be the post-synaptic blockade of D2 dopamine receptors in the brain. (An exception is
aripiprazole, which is a D2 partial agonist.) Blockade of the D2 receptor in the brain’s
limbic system are thought to improve the “positive” symptoms of schizophrenia (12).
However, because the first-generation antipsychotics also block dopamine receptors in the
nigrostriatal pathway, they cause movement disorders known as extrapyramidal side
effects. These disorders include akathisia (motor restlessness), dystonia (abnormal muscle
tone), and tardive dyskinesia (involuntary and repetitive movements).
Clozapine only transiently occupies D2 receptors and then rapidly dissociates to allow
normal dopamine neurotransmission. It is thought that because clozapine has a relatively
low affinity for the D2 receptor and binds “loosely,” extrapyramidal side effects are less
likely (11, 13).
In addition to binding the D2 receptor, clozapine has a high affinity for the serotonin 5-
HT2A receptors. Blockade of 5-HT2A in the mesocortical tract may also provide some
protection against extrapyramidal side effects by increasing amounts of dopamine.
Clozapine and its major metabolite (N-desmethylclozapine) have been shown to
indirectly activate NMDA receptors, and may also modulate GABA and cholinergic
pathways. However, despite these findings, it remains unclear what gives clozapine its
superior efficacy to other antipsychotics (7).
One of the most prominent side effects of clozapine therapy is weight gain. The most
severe side effects are included in five boxed warnings on the drug label: 1) severe
neutropenia, 2) seizures (more likely at higher doses), 3) myocarditis (inflammation of the
heart muscle induced by clozapine, that can be fatal), 4) increased mortality in elderly
patients with dementia-related psychosis, and 5) an increased risk of orthostatic
hypotension, bradycardia, and syncope (1).
Because of the risk of neutropenia, clozapine can only be prescribed according to a
schedule that monitors the patient’s white blood cell count (WBC) and absolute
neutrophil count (ANC). Neutropenia, defined as an ANC of less than 500/mm3, is
estimated to occur in around 1% of patients, and could prove fatal if not detected early by
regular monitoring (14).
Genetic risk factors for clozapine-induced neutropenia have been identified, consisting of
two independent amino acid changes in HLA-DQB1 (126Q) and HLA-B (158T). HLA-
DQB1 is associated with autoimmune disease and HLA-B is an important component of
severe drug reactions, including carbamazepine-induced Stevens-Johnson syndrome and
abacavir hypersensitivity. Despite this genetic insight, a genetic test based solely on HLA-
DQB1 and HLA-B would not be able to adequately identify if all the patients are truly at
low risk of clozapine-induced neutropenia (15).
The Cytochrome P450 Superfamily

genes are very polymorphic and can result in reduced, absent, or increased enzyme
activity.
Clozapine is extensively metabolized in the liver by CYP450 enzymes, especially by
CYP1A2, CYP3A4, and CYP2D6. Most of the metabolites are inactive, but N-
desmethylclozapine has been found to have limited activity (7, 16).
The dose of clozapine may need to be adjusted when clozapine is given with medications
that inhibit or induce the enzymes responsible for metabolizing clozapine. Inhibitors of
CYP enzymes include the antibiotic ciprofloxacin (CYP1A2 inhibitor) and the
antidepressant fluvoxamine (CYP3A4 and CYP2D6 inhibitor). Inducers include the
antiseizure drug carbamazepine (strong CYP3A4 inducer). In addition, other agents can
influence CYP enzymes—caffeine and oral contraceptives are weak or moderate CYP1A2
inhibitors, and tobacco smoke is a moderate inducer of CYP1A2 (and smoking is
common among patients with schizophrenia).
Gene: CYP2D6
CYP2D6 is highly polymorphic, with more than 100 star (*) alleles described (17).
“extensive metabolizer” phenotype. The CYP2D6 alleles *2, *33, and *35 are also
considered to have near-normal activity (Table 1).
Table 1. Activity status of CYP2D6 alleles
Active *1, *2, *33, *35
Inactive *3-*8, *11-*16, *19-*21, *38, *40, *42
Individuals who have multiple functional copies of the CYP2D6 gene are known as
“ultrarapid metabolizers,” whereas individuals who carry one or two copies of reduced-
activity or non-functioning CYP2D6 alleles are known as “intermediate” or “poor
metabolizers.”
The most common non-functional alleles include *3, *4, *5, and *6 (19-22), and the most
common reduced activity alleles include *10, *17, and *41 (23-25). There are large inter-
ethnic differences in the frequency of these alleles, with *3, *4, *5, *6, and *41 being more
common in Caucasians, *17 more common in Africans, and *10 more common in Asians
(26-29).
Approximately 6-10% of European Caucasians and their descendants are poor

metabolizers, mainly due to the more prevalent nonfunctional *4 and *5 alleles (26, 30).
These individuals may develop higher than expected plasma concentrations of clozapine
when given in usual doses. Therefore, the FDA-approved drug label for clozapine states
that in poor metabolizers, a lower dose of clozapine may be necessary (1).
However, although in theory poor metabolizers may require lower doses of clozapine to
achieve the desired therapeutic effects, evidence for this is lacking. Several studies
investigating the association between CYP2D6 genotypes and response to antipsychotic
therapy did not report significant findings (31, 32).
Gene: CYP1A2
CYP1A2 alleles influence the treatment response of several antipsychotics (4). However,
understanding the pharmacogenomic effects of CYP1A2 variation is still at an early stage
compared with that of other CYP2D6 and other CYP enzymes (33).
CYP1A2 comprises around 13% of all CYP protein in the liver, whereas CYP2D6
comprises around 2%. Approximately 25 variant alleles of CYP1A2 have been reported,
some of which have been shown to alter the activity of CYP1A2. For example, the *1C
allele is associated with decreased enzyme activity (by altering the binding site of an
unknown transcription factor in the gene promoter), and the *1F allele is associated with
increased enzyme activity (by increasing the induction of expression) (33, 34).
CYP1A2 is the main CYP isoform in clozapine metabolism (35). Case studies have found
that patients with one or more copies of CYP1A2*1F (ultrarapid metabolizers) respond
poorly to clozapine therapy. However, the treatment response is improved by increasing
the dose of clozapine, and also co-administering fluvoxamine, a CYP1A2 inhibitor (36,
37).
The frequency of CYP1A2*1F (defined by a C > A polymorphism in intron 1) exists at
similar frequencies in all populations (starting at around 0.29) with the highest frequency
among Africans (up to 0.51) (38). Environmental factors also strongly influence CYP1A2
activity, such as oral contraceptive use (inhibition) and smoking (induction). Indeed, the
sudden cessation of smoking during clozapine therapy may trigger side effects, because of
sudden increase in drug levels (39).
Gene: CYP3A4
In contrast to CYP2D6, CYP1A2, and other genes that encode drug-metabolizing
enzymes, CYP3A4 shows little genetic variation. Although around 40 variant alleles of
CYP3A4 have been reported, most have not been shown to alter the activity of CYP3A4
(40, 41). To date, only three loss-of-function CYP3A4 alleles have been identified
(CYP3A4*6, CYP3A4*20 and CYP3A4*26) (42, 43).
The CYP3A4*20 allele contains a premature stop codon which results in a loss-of-function
of CYP3A. It appears to be the most common CYP3A4-defective allele but is still relatively
rare, with about 0.2% of European Americans and 0.05% African Americans being
carriers. However in Spain, the CYP3A4*20 allele is present in 1.2% of the population, and
up to 3.8% in specific Spanish regions (42).
Genetic Testing
Genetic testing is available for common CYP2D6, CYP3A4, and CYP1A2 alleles. Often a
panel of tests is performed. These panels test for variants in multiple genes, which are
involved in the metabolism of many drugs, including clozapine. For examples of the tests
available for the clozapine drug response, please see the Genetic Testing Registry.
• An ultrarapid metabolizer has an activity score greater than 2

2014 Statement from the US Food and Drug Administration (FDA): Dose reduction
may be necessary in patients who are CYP2D6 poor metabolizers. Clozapine
concentrations may be increased in these patients, because clozapine is almost completely
metabolized and then excreted.
generic drug.
Nomenclature
CYP2D6 Nomenclature
Coding Protein
identifier for
allele location
Trp152Gly 454delT
Pro34Ser 100C>T
1023C>T 886T>C
(Thr107Ile)
2850C>T
(Cys296Arg)
CYP1A2 Nomenclature
Common allele Alternative HGVS reference sequence dbSNP reference
name names identifier for
Coding Protein
allele location
CYP1A2*1C -3860G>A Unknown Not applicable— rs2069514
-2964G>A variant occurs in a
non-coding region
CYP1A2*1F -
NM_000761.4:c.-9-154C>A Not applicable— rs762551
variant occurs in a
non-coding region
CYP3A4 Nomenclature
Coding Protein
identifier for
allele location
CYP3A4*6 17661_17662insA NM_017460.5:c. NP_059488.2:p.Asp277Glufs rs4646438
CYP3A4 Nomenclature continues on next page...
CYP3A4 Nomenclature continued from previous page.

Coding Protein
identifier for
allele location
CYP3A4*20 1461_1462insA NM_017460.5:c. NP_001189784.1:p.Pro487Thrfs rs67666821
CYP3A4*26 17633C>T
R268Stop
Acknowledgments
The author would like to thank Anil K. Malhotra, MD, Director, Division of Psychiatry
Research, The Zucker Hillside Hospital and Vice Chair of Research, Department of
Psychiatry, Hofstra Northwell School of Medicine; William T. Carpenter Jr., MD,
Professor of Psychiatry and Pharmacology, Maryland Psychiatric Research Center,
University of Maryland School of Medicine; and Daniel J. Müller, Head,
Pharmacogenetics Research Clinic, Centre for Addiction and Mental Health, and
Associate Professor, Department of Psychiatry, University of Toronto, for reviewing this
summary.
References
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activity is an important determinant of clozapine dosage in schizophrenic patients.
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2002;47(1):27–38. PubMed PMID: 11873706.
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15. Goldstein J.I., Jarskog L.F., Hilliard C., Alfirevic A., et al. Clozapine-induced
agranulocytosis is associated with rare HLA-DQB1 and HLA-B alleles. Nat Commun.
2014;5:4757. PubMed PMID: 25187353.
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does not determine response to clozapine. Br J Clin Pharmacol. 1995;39(4):417–20.
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7. PubMed PMID: 21989077.
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schizophrenia. Mol Psychiatry. 2000;5(4):410–7. PubMed PMID: 10889552.
36. Ozdemir V., Kalow W., Okey A.B., Lam M.S., et al. Treatment-resistance to clozapine
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and ultrarapid CYP1A2 activity: clinical data and analysis of CYP1A2 gene. J Clin
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patients administered clozapine medication? A case report. Ther Drug Monit.
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41. Westlind-Johnsson A., Hermann R., Huennemeyer A., Hauns B., et al. Identification
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42. Apellaniz-Ruiz M., Inglada-Perez L., Naranjo M.E., Sanchez L., et al. High frequency
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22. PubMed PMID: 24126681.




Clozapine response

CYP2D6 gene
CYP1A2 gene
CYP3A4 gene
133

Laura Dean, MD1
Created: September 20, 2012; Updated: March 16, 2017.
Introduction
Codeine is used to relieve mild to moderately severe pain, and it belongs to the drug class
of opioid analgesics.
The hepatic CYP2D6 enzyme metabolizes a quarter of all prescribed drugs, including
codeine. CYP2D6 converts codeine in to its active metabolite, morphine, which provides
its analgesic effect. However, pain relief may be inadequate in individuals who carry two
inactive copies of CYP2D6 (“poor metabolizers”), because of reduced morphine levels.
In contrast, individuals who carry more than two normal function copies of the CYP2D6
gene (“ultrarapid metabolizers”) are able to metabolize codeine to morphine more rapidly
and more completely. As a result, even with normal doses of codeine, these individuals
may experience the symptoms of morphine overdose, which include extreme sleepiness,
confusion, and shallow breathing. Nursing mothers may also produce breast milk
containing higher than expected levels of morphine that can lead to severe adverse events
in their infants (1).
The FDA drug label for codeine states that even at labeled dosage regimens, individuals
who are ultra-rapid metabolizers may have life-threatening or fatal respiratory depression
or experience signs of overdose. The label also contains a boxed warning, which states that
respiratory depression and death have occurred in children who received codeine
following tonsillectomy and/or adenoidectomy and had evidence of being ultra-rapid
metabolizers of codeine due to a CYP2D6 polymorphism (1).
The Clinical Pharmacogenetics Implementation Consortium (CPIC) recommends that for
a patient identified as a CYP2D6 ultrarapid metabolizer, another analgesic should be used
to avoid the risk of severe toxicity with a “normal” dose of codeine. CPIC also
recommends avoiding codeine in patients identified as CYP2D6 poor metabolizers due to
the possibility of lack of effect (see Table 1) (2).

Table 1. 2014 Codeine therapy recommendations based on cytochrome P4502D6 (CYP2D6) phenotype,
adapted from CPIC
Phenotype Activity Phenotype Genotype Examples Recommendations Considerations
score details of for codeine for alternative
diplotypes therapy1 opioids
Ultrarapid Greater Increased More than *1/*1xN Avoid codeine use Alternatives
metabolizer than enzyme two copies of *1/*2xN due to potential that are not
(approximately 2.0 activity. normal for toxicity. affected by this
1–2% of Increased function CYP2D6
patients) formation of alleles phenotype
morphine include
following morphine and
codeine non-opioid
administration, analgesics.
leading to Tramadol and,
higher risk of to a lesser
toxicity. extent,
hydrocodone
and oxycodone
are not good
alternatives
because their
metabolism is
affected by
CYP2D6
activity.
Normal 1.0-2.0* Normal Two normal *1/*1 Use label-
metabolizer enzyme function *1/*2 recommended
(approximately activity. alleles, or *2/*2 age- or weight-
77–92% of Normal two *1/*41 specific dosing.
patients) morphine decreased *1/*4
formation. function *2/*5
alleles, or *1/*10
one normal
function
allele and one
decreased or
no function
allele, or
* Activity scores are based on the formation of morphine from codeine. Other investigators may define
normal metabolizers with a score of 1.5-2.0, and intermediate metabolizers with a score of 0.5-1.0.
1 The strength of therapeutic recommendations is “moderate” for intermediate metabolizers, and “strong”
for all other metabolizers.
Table is adapted from Crews K.R. et al. Clinical Pharmacogenetics Implementation Consortium guidelines
for cytochrome P450 2D6 genotype and codeine therapy: 2014 update. Clinical pharmacology and
therapeutics. 2014;95(4):376-82 (2). Please note, the nomenclature used in this table reflects the
standardized nomenclature for pharmacogenetic terms proposed by CPIC in a 2016 paper, “Standardizing
terms for clinical pharmacogenetic test results: consensus terms from the Clinical Pharmacogenetics
Implementation Consortium (CPIC)” (3).
Codeine Therapy and CYP2D6 Genotype 135

combinations
of duplicated
alleles that
result in an
activity score
of 1.0 to 2.0
Intermediate 0.5* Intermediate One *4/*10 Use label- Monitor
metabolizer enzyme decreased *5/*41 recommended tramadol use
(approximately activity. function age- or weight- for response.
2–11% of Reduced allele and one specific dosing.
patients) morphine no function If no response,
formation. allele consider
alternative
analgesics such as
morphine or a
nonopioid.
Poor 0 Low or absent Two no *4/*4 Avoid codeine use Alternatives
metabolizer enzyme function *4/*5 due to lack of that are not
(approximately activity. alleles *5/*5 efficacy. affected by this
5–10% of Greatly *4/*6 CYP2D6
patients) reduced phenotype
morphine include
formation morphine and
following non-opioid
codeine analgesics.
administration, Tramadol and,
leading to to a lesser
insufficient extent,
pain relief. hydrocodone
and oxycodone
are not good
alternatives
because their
metabolism is
affected by

CYP2D6
activity; these
agents should
be avoided.
Drug: Codeine
Codeine is an opioid analgesic. It exerts its effects via the opioid receptors found
throughout the body including the central nervous system and the gastrointestinal system.
Codeine is a prodrug that only weakly binds the mu opioid receptor. Its analgesic
properties depend upon its conversion to morphine that binds to the mu opioid receptor
with 200-fold greater affinity than codeine.
Codeine is indicated for the relief of mild to moderately severe pain, where the use of an
opioid analgesic is appropriate. Codeine is a Schedule II controlled substance, and there is
a risk of misuse and abuse. As with any opioid drug, the dosing regimen should be
adjusted for each individual patient. When the patient no longer requires codeine, the
doses should be tapered gradually to prevent withdrawal symptoms in patients who have
become physically dependent (1).
For codeine to exert its opioid activity, it must first undergo o-demethylation by CYP2D6
to morphine. Only about 5-10% of codeine is metabolized in this pathway, with about
80% of an administered dose of codeine being converted to inactive metabolites and
excreted. However, the percentage of codeine converted to morphine can be much higher
in individuals who have 3 or more active copies of CYP2D6 (“ultrarapid metabolizers”)
(2). In contrast, individuals who lack active copies of CYP2D6 (“poor metabolizers”) have
lower levels of morphine.
Morphine is further metabolized to morphine-6-glucuronide, which also has analgesic
properties. Other metabolites are thought to be mostly inactive; they include codeine-6-
glucuronide (~60%) and norcodeine (~5–10%), both of which share with codeine a
similarly weak affinity for the mu opioid receptor (4).
To avoid treatment complications in patients who are either ultrarapid or poor

metabolizers, opioids that are not metabolized by CYP2D6 may be used (e.g., morphine,
oxymorphone, buprenorphine, fentanyl, methadone, hydromorphone), alongside non-
opioids, depending upon the type of pain being treated (2, 5-7).
The most common adverse reactions to codeine include drowsiness, lightheadedness,
dizziness, sedation, shortness of breath, nausea, vomiting, and sweating. One of the main
serious adverse reactions associated with codeine is respiratory depression. The FDA-drug
label for codeine now includes a boxed warning that states “Warning: Death related to
ultra-rapid metabolism of codeine to morphine. Respiratory depression and death have
occurred in children who received codeine following tonsillectomy and/or adenoidectomy
and had evidence of being ultra-rapid metabolizers of codeine due to a CYP2D6
polymorphism” (1, 8, 9).
Gene: CYP2D6
The CYP450 genes are very polymorphic and can result in decreased, absent, or increased
enzyme activity.
gene is highly polymorphic, with more than 100 star (*) alleles described (10).
“normal metabolizer” phenotype. The CYP2D6 alleles *2, *33, and *35 are also considered
to have near-normal activity.
About 77–92% of individuals have at least one copy of a normal function allele (*1 or *2),
or two partially functioning alleles. These individuals are also “normal metabolizers” and
are most likely to have a phenotypically normal response to codeine. However, there is a
large amount of variability in codeine response within patients genotyped as normal
metabolizers, and the causes of this variation, among individuals with the same diplotype,
are unknown (2).
Other CYP2D6 alleles include variants that produce a non-functioning enzyme (e.g., *3,
*4, *5, and *6) (4, 11-13) or an enzyme with decreased activity (e.g., *10, *17, and *41)
(14-16) (see Table 2). There are large inter-ethnic differences in the frequency of these
alleles, with *3, *4, *5, *6, and *41 being more common in Caucasians, *17 more common
in Africans, and *10 more common in Asians (17).
About 2–11% of patients are intermediate metabolizers—they carry either two decreased
function alleles or one decreased function and one no function allele (18). These
individuals may not respond as well to codeine because the metabolism of codeine to
morphine is reduced.
In Asians and in individuals of Asian descent, only about 50% of CYPD6 alleles are
normal function, and the frequency of CYP2D6 allele duplications is as high as 45% (19).
Common no function variants are CYP2D6*36 (the most commonly duplicated CYP2D6
allele in the Asian population) and CYP2D6*10. Both these variants contain the SNP
“100C>T” (see Nomenclature table) (17, 19-21). In Africans and African Americans,
again, only about 50% of CYPD6 alleles are normal function (11, 16, 17, 22).
About 5–10% of patients are poor metabolizers—they carry two no function alleles (18).
In these individuals, codeine will provide little or no pain relief. Poor metabolizers are
more commonly found in European Caucasians and their descendants. The majority allele
in this population is the normal function CYP2D6*1 (70%), but the remaining alleles
include the no function CYP2D6*4 and CYP2D6*5 variants that largely account for the
poor metabolizer phenotype in these populations (12, 15, 23).
Patients who are ultrarapid metabolizers carry at least 3 copies of the CYP2D6 gene. The
ultrarapid metabolizer phenotype has been estimated to be present in 1–2% of patients,
but the prevalence varies widely in different populations. It is estimated to be present in
up to 28% of North Africans, Ethiopians, and Arabs; up to 10% in Caucasians; 3% in
African Americans, and up to 1% in Hispanics, Chinese, and Japanese (1, 18).
Each normal function CYP2D6 allele increases the rate of codeine metabolism, increasing
the risk of an initial morphine "overdose", with more side effects and a shorter duration of
pain control (24). Even low codeine doses can result in toxic levels of morphine in
patients with more than 2 normal function alleles (2). Several case reports have recorded
the severe or life-threatening adverse effects that have occurred in patients who were
ultrarapid metabolizers and were treated with standard doses of codeine (25, 26).
Genetic Testing
Genetic testing is available for many (~30) of the variant CYP2D6 alleles. Usually a
patient’s result is reported as a diplotype, which includes one maternal and one paternal
allele, e.g., CYP2D6 *1/*2. When patients have more than two copies of the CYP2D6, the
copies of the allele are denoted by an “xN”, e.g., CYP2D6*2x2.
phenotype, this should be confirmed by checking the diplotype and calculating the
CYP2D6 activity score. Each allele is assigned an activity value: 0 for no function, 0.5 for
decreased function, and 1 for each copy of a normal function allele. The total CYP2D6
activity score is the sum of the values assigned to each allele—patients with a score of 1.0,
1.5, or 2.0 represent a range of normal metabolizers with normal enzyme activity. Poor
metabolizers have an activity score of 0, patients with a score of 0.5 are intermediate
metabolizers, and patients with a score of greater than 2.0 are ultrarapid metabolizers (see
Table 1) (2).
Variants in other genes, such as COMT, ABCB1, UGT2B7 and OPRM1, may also influence
an individual’s response to codeine. However, evidence is lacking on whether genetic
testing for these variants will aid optimum codeine dosing (7, 27-29).

This section contains excerpted1,2 information on gene-based dosing
2015 Statement from the US Food and Drug Administration (FDA): Respiratory
depression and death have occurred in children who received codeine in the post-
operative period following tonsillectomy and/or adenoidectomy and had evidence of
being ultra-rapid metabolizers of codeine (i.e., multiple copies of the gene for cytochrome
P450 isoenzyme 2D6 [CYP2D6] or high morphine concentrations). Deaths have also
occurred in nursing infants who were exposed to high levels of morphine in breast milk
because their mothers were ultra-rapid metabolizers of codeine.
Some individuals may be ultra-rapid metabolizers because of a specific CYP2D6 genotype
(gene duplications denoted as *1/*1xN or *1/*2xN). The prevalence of this CYP2D6
phenotype varies widely and has been estimated at 0.5 to 1% in Chinese and Japanese, 0.5
to 1% in Hispanics, 1 to 10% in Caucasians, 3% in African Americans, and 16 to 28% in
North Africans, Ethiopians, and Arabs. Data are not available for other ethnic groups.
These individuals convert codeine into its active metabolite, morphine, more rapidly and
completely than other people. This rapid conversion results in higher than expected
serum morphine levels. Even at labeled dosage regimens, individuals who are ultra-rapid
metabolizers may have life-threatening or fatal respiratory depression or experience signs
of overdose (such as extreme sleepiness, confusion, or shallow breathing).
(CPIC): A standard starting dose of codeine, as recommended in the product label, is
warranted in patients with an extensive metabolizer phenotype (i.e., a CYP2D6 activity
score of 1.0–2.0). Likewise, a standard starting dose of codeine is warranted in patients
generic drug.
2 Please note, the term “extensive metabolizer” has been replaced by the term “normal
metabolizer” in the standardized nomenclature for pharmacogenetic terms proposed by CPIC in
a 2016 paper, “Standardizing terms for clinical pharmacogenetic test results: consensus terms
from the Clinical Pharmacogenetics Implementation Consortium (CPIC)” 3. Caudle, K.E., H.M.
Dunnenberger, R.R. Freimuth, J.F. Peterson, et al., Standardizing terms for clinical
pharmacogenetic test results: consensus terms from the Clinical Pharmacogenetics
Implementation Consortium (CPIC). Genet Med, 2017. 19(2): p. 215-223..
with an intermediate metabolizer phenotype (i.e., activity score of 0.5); these patients
should be monitored closely for less-than-optimal response and should be offered an
alternative analgesic if warranted. If the CYP2D6 substrate tramadol is selected as
alternative therapy in intermediate metabolizers, therapy should be monitored closely due
to the possibility of poor response.
If clinical genotyping identifies a patient as a CYP2D6 poor metabolizer (i.e., activity
score of 0), current evidence supports the avoidance of codeine and the use of an
alternative analgesic due to the possibility of lack of effect. Use of an analgesic other than
the CYP2D6 substrates tramadol, hydrocodone, or oxycodone in poor metabolizers may
be preferable. There is insufficient evidence in the literature to recommend a higher dose
of codeine in poor metabolizers, especially considering the evidence that select adverse
effects do not differ between poor and extensive metabolizers. In a patient identified as a
CYP2D6 ultrarapid metabolizer (i.e., activity score of >2.0), the choice of another
analgesic should be made to avoid the risk of severe toxicity with a “normal” dose of
codeine.
2013 Clinical practice Guideline from the “Canadian Pharmacogenomics Network for
Drug Safety (CPNDS) Clinical Recommendations Group: CYP2D6 genotyping for safe
and efficacious codeine therapy”:
1. Who should be tested and when?
⚬ Young children about to receive codeine for pain management and women
about to receive codeine for postpartum pain while breastfeeding should be
tested for CYP2D6 (Grade A – strong recommendation).
⚬ Children and adults who continue to have pain despite high doses of codeine
should be tested for CYP2D6 (Grade B – moderate recommendation).
⚬ Genetic testing for CYP2D6 should be considered before administering
codeine for the first time in all children and adults in order to rule out non-
responders and to identify individuals who may be susceptible to adverse
effects from codeine (Grade C – optional recommendation).
2. What gene variants should be tested?
Given the numerous polymorphisms in CYP2D6 and the diversity of the Canadian
population, a full-scale analysis of both common and rare CYP2D6 variants is advised
(Grade B- moderate recommendation)
• CYP2D6 alleles with decreased or no function: CYP2D6 *3- 12, 14-15, 17, 19-20, 29,
40-42, 44, 49, 50, 54- 56, 59; *4XN, *10XN
• CYP2D6 alleles with normal or increased function: CYP2D6 *2 (normal), *1XN
(increased), *2XN (increased), *17XN, *35XN (increased), *41XN, in addition to
CYP2D6 copy number determination.
Recommendations: Genotype-Specific Treatment Options
• Poor metabolizers of CYP2D6 should not receive codeine for pain relief (Grade A-
strong recommendation).
• Ultrarapid metabolizers of CYP2D6 should avoid codeine for pain relief and receive
alternative analgesics that do not have potent CYP2D6 metabolites (Grade B-
moderate recommendation).
• Certain populations, especially opioid naïve breastfed neonates of mothers with
functional CYP2D6 gene duplications taking codeine and young children may be
particularly susceptible to codeine-induced central nervous system depression.
Breastfeeding mothers and young children who are ultrarapid metabolizers of
CYP2D6 should avoid codeine (Grade A – strong recommendation).
• In individuals with IM or EM CYP2D6 genotypes, codeine can be used as per
standard of care. Existing evidence suggests that caution is still warranted in
CYP2D6 EMs receiving codeine if they are receiving maximal therapeutic doses of
codeine and have additional risk factors for toxicity.
Nomenclature
Coding Protein
identifier for
allele location
frameshift)
Trp152Gly 454delT
CYP2D6T
(Pro34Ser) 100C>T
(Thr107Ile) 320C>T
(Cys296Arg) 886T>C
(Cys296Arg) 886T>C
985+39G>A region (impacts slicing).
[1] In the literature, 1023C>T is also referred to as 1111C>T
[2] In the literature, 2850C>T is also referred to as 2938C>T
Acknowledgments
The author would like to thank Todd Skaar, Associate Professor of Medicine, Indiana
University; and Kristine R. Crews, Director, Translational Research Laboratory, and
Director, PGY2 Pharmacogenetics Residency Program, St. Jude Children’s Research
Hospital, Memphis, TN, for reviewing this summary.
First edition:
page/cpic
Version History
To view an earlier version of this summary, please see:
Update 08 March 2016
Update 18 March 2013
References
2. Crews K.R., Gaedigk A., Dunnenberger H.M., Leeder J.S., et al. Clinical
Pharmacogenetics Implementation Consortium guidelines for cytochrome P450 2D6
genotype and codeine therapy: 2014 update. Clin Pharmacol Ther. 2014;95(4):376–
82. PubMed PMID: 24458010.
Pharmacogenetics Implementation Consortium (CPIC). Genet Med. 2017;19(2):215–
223. PubMed PMID: 27441996.
4. PharmGKB [Internet]. Palo Alto (CA): Stanford University. Codeine and Morphine
Pathway, Pharmacokinetics [Cited 2012 July 24]. Available from: http://
5. Nicholson W.T., Formea C.M. Clinical perspective on the Clinical Pharmacogenetics
Implementation Consortium Updated 2014 guidelines for CYP2D6 and codeine. Clin
Chem. 2015;61(2):319–21. PubMed PMID: 25301855.
6. Crews K.R., Caudle K.E., Dunnenberger H.M., Sadhasivam S., et al. Considerations
for the Utility of the CPIC Guideline for CYP2D6 Genotype and Codeine Therapy.
Clin Chem. 2015;61(5):775–6. PubMed PMID: 25770140.
7. Bell G.C., Donovan K.A., McLeod H.L. Clinical Implications of Opioid
Pharmacogenomics in Patients With Cancer. Cancer Control. 2015;22(4):426–32.
8. Boyle K.L., Rosenbaum C.D. Oxycodone overdose in the pediatric population: case
files of the University of Massachusetts Medical Toxicology Fellowship. J Med
Toxicol. 2014;10(3):280–5. PubMed PMID: 24610706.
9. Racoosin J.A., Roberson D.W., Pacanowski M.A., Nielsen D.R. New evidence about
an old drug--risk with codeine after adenotonsillectomy. N Engl J Med. 2013;368(23):
2155–7. PubMed PMID: 23614474.
10. Reny J.L., Fontana P. Antiplatelet drugs and platelet reactivity: is it time to halt
clinical research on tailored strategies? Expert Opin Pharmacother. 2015;16(4):449–
52. PubMed PMID: 25495963.
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PA165816576
PA165816579
PA165816581
PA165816582
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19. Ramamoorthy A., Flockhart D.A., Hosono N., Kubo M., et al. Differential
quantification of CYP2D6 gene copy number by four different quantitative real-time
PCR assays. Pharmacogenet Genomics. 2010;20(7):451–4. PubMed PMID: 20421845.
20. Wu X., Yuan L., Zuo J., Lv J., et al. The impact of CYP2D6 polymorphisms on the
pharmacokinetics of codeine and its metabolites in Mongolian Chinese subjects. Eur
J Clin Pharmacol. 2014;70(1):57–63. PubMed PMID: 24077935.
21. Hosono N., Kato M., Kiyotani K., Mushiroda T., et al. CYP2D6 genotyping for
functional-gene dosage analysis by allele copy number detection. Clin Chem.
2009;55(8):1546–54. PubMed PMID: 19541866.
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496–526. PubMed PMID: 18001838.
24. Weinshilboum R. Inheritance and drug response. The New England journal of
medicine. 2003;348(6):529–37. PubMed PMID: 12571261.
25. Gasche Y., Daali Y., Fathi M., Chiappe A., et al. Codeine intoxication associated with
ultrarapid CYP2D6 metabolism. N Engl J Med. 2004;351(27):2827–31. PubMed
PMID: 15625333.
26. Ciszkowski C., Madadi P., Phillips M.S., Lauwers A.E., et al. Codeine, ultrarapid-
metabolism genotype, and postoperative death. N Engl J Med. 2009;361(8):827–8.
27. Somogyi A.A., Coller J.K., Barratt D.T. Pharmacogenetics of opioid response. Clin
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Codeine response

CYP2D6 gene gene
147
Dabrafenib Therapy and BRAF and G6PD

Genotype
Laura Dean, MD1
Introduction
Dabrafenib is a kinase inhibitor used in the treatment of patients with unresectable or
metastatic melanoma with specific BRAF variants. Dabrafenib can be used as a single
agent to treat melanoma with the BRAF V600E variant, or in combination with the MEK
inhibitor trametinib to treat melanoma with BRAF V600E or V600K variants.
BRAF is an intracellular kinase in the mitogen-activated protein kinases (MAPK)
pathway. BRAF is involved in regulating important cell functions such as cell growth,
division, differentiation, and apoptosis. BRAF is also a proto-oncogene—when mutated it
has the ability to transform normal cells into cancerous cells.
Variation in the kinase domain of BRAF have been associated with various cancers. The
most common BRAF variant, V600E, constitutively activates the kinase, and causes cell
proliferation in the absence of growth factors that would normally be required. The
V600E variant is detected in approximately 50% of melanomas (1, 2).
The FDA-approved label for dabrafenib states that the presence of BRAF mutation in
tumor specimens (V600E for dabrafenib monotherapy; V600E or V600K for dabrafenib
plus trametinib) should be confirmed, using an FDA-approved test, before starting
treatment with dabrafenib. Dabrafenib is not indicated for treatment of patients with
wild-type BRAF melanoma.
The label also states that patients who have glucose-6-phosphate dehydrogenase (G6PD)
deficiency should be monitored for signs of hemolytic anemia while taking dabrafenib (3).
Drug: Dabrafenib
Dabrafenib is a BRAF kinase inhibitor indicated for the treatment of patients with
unresectable or metastatic melanoma. It acts by decreasing signaling through the MAPK
pathway, leading to the reduced transcription of genes involved in various cellular
responses.
Dabrafenib can be used as a single agent to treat melanoma with BRAF V600E variant, or
in combination with trametinib to treat melanoma with BRAF V600E or V600K variants
(3). Dabrafenib and other BRAF inhibitors have also demonstrated responses in patients

with rare BRAF V600 variants (V600R, V600D) (4). These agents appear to be less active
in pre-clinical studies of melanomas with atypical (non-V600) variants (e.g. L597, K601)
(5).
Skin cancer is the most common of all cancers. Although melanoma is the least common
type of skin cancer, accounting for approximately 1% of cases, it is responsible for the
majority of deaths from skin cancer. In the US, the lifetime risk of melanoma is
approximately 2.5% for whites, 0.5% for Hispanics, and 0.1% for blacks (6).
Most cases of malignant melanoma are diagnosed at an early stage, when the tumor is
localized and surgical excision can be curative. However, the 5-year survival rate drops
from 98% for localized disease, to only 16% for patients with metastatic disease.
For patients with advanced metastatic or unresectable malignant melanoma, treatment
options typically include immunotherapy and targeted therapy. Although chemotherapy
was once widely used, it does not increase survival and therefore its use is now limited to
patients who are not candidates for further treatment with either immunotherapy or
targeted therapy, and for whom there is no appropriate clinical trial.
High-dose interleukin 2 (IL2) therapy may be successful in a minority of cases, but can
only be used in select patients with good organ function because of the risk of severe
toxicity. Immunotherapy drugs include antibodies that target programmed cell death
protein 1 (PD-1), e.g., nivolumab and pembrolizumab (7); and ipilimumab, a monoclonal
antibody that targets cytotoxic T-lymphocyte-associated protein 4 (CTLA4). Oncolytic
virus therapy with T-VEC (talimogene laherparepvec) is one of the newer
immunotherapy drugs approved for melanoma.
Targeted therapies are designed to inhibit components of the MAPK signaling pathway,
primarily when it is constitutively activated in melanomas with the activating BRAF
variant, V600E. Drugs in this category include vemurafenib and dabrafenib, which inhibit
BRAF, and trametinib and cobimetinib, which target downstream kinases MEK1 and
MEK2, respectively.
Dabrafenib is a potent inhibitor of the kinase domain of the variant BRAF V600E. It acts
by decreasing signaling through the MAPK pathway, leading to the reduced transcription
of genes involved in various cellular responses. Combining dabrafenib with MEK
inhibitors has been shown to extend survival (8, 9), and dabrafenib is often used in
combination with a MEK inhibitor, e.g., trametinib.
Dabrafenib increased progression-free survival, compared to cytoxic chemotherapy (e.g.,
dacarbazine), in patients with advanced melanoma with the BRAF V600E variant (10, 11).
However, at this time there are no randomized trials that compare targeted therapies such
as dabrafenib, with immunotherapy, and there are no data regarding the appropriate
combinations and sequencing of these therapies for patients with a V600E variant.
A recent phase 3 trial for patients with melanoma with a V600E variant was stopped early
because of positive results. The study found that the combination of dabrafenib plus
Dabrafenib Therapy and BRAF and G6PD Genotype 149
trametinib led to a higher 3-year overall survival rate, compared to vemurafenib

monotherapy (25% versus 11%). In addition, the incidence of cutaneous squamous cell
carcinoma was decreased in patients taking the combination of dabrafenib plus
trametinib (12).
The drug label advises that a dermatological evaluation should be carried out prior to
initiating dabrafenib therapy, and every 2 months during therapy. The most common
adverse events associated with dabrafenib are skin lesions (benign and malignant). Other
side effects include fever, arthralgia, fatigue, alopecia, and palmar-plantar
erythrodysesthesia syndrome (“hand-foot syndrome”).
In vitro experiments with BRAF inhibitors, such as dabrafenib, have been found to cause a
paradoxical activation of signaling pathways and proliferation in BRAF wild-type cells.
Therefore, dabrafenib should only be used after the presence of BRAF V600E variant in
tumor specimens has been confirmed using an FDA-approved test (3). The FDA also
recommends to permanently discontinue dabrafenib use in patients who develop RAS
mutation-positive non-cutaneous malignancies.
Gene: BRAF
RAF is a family of intracellular kinases within the MAPK signaling pathway. The RAF
family has three members, ARAF, BRAF, and CRAF (13). RAF, along with RAS (see
below), are proto-oncogenes.
Proto-oncogenes are genes that, when mutated or expressed at abnormally high levels, can
transform normal cells into cancerous cells. Proto-oncogenes typically encode proteins
that stimulate cell division, inhibit cell differentiation, and halt cell death. The increased
production of oncogenic proteins can lead to the proliferation of poorly differentiated
cancer cells (14).
Germline mutations in BRAF, as well as other components of the MAPK signaling
pathway, are associated with birth defects, such as cardiofaciocutaneous syndrome,
characterized by heart defects, mental retardation, and a distinctive facial dysmorphology.
Somatic BRAF mutations are also associated with several malignancies, including lung
adenocarcinoma, mucinous adenoma, ductal carcinoma of the pancreas, colorectal
carcinoma, and malignant melanoma.
Variations in BRAF are detectable in approximately 50% of malignant melanomas, and
drive progression of the disease (1, 2). The BRAF variant V600E accounts for
approximately 90% of variants. This variant is a substitution of adenine for thymine at
position 1799 and results in the substitution of valine for glutamate at codon 600. The
variant BRAF protein kinase is constitutively active and a highly potent oncogene, with an
increase in kinase activity by as much as 500-fold compared to the wild-type (15). The
second most common BRAF variant is V600K. Substitutions at other sites are rarer (16,
17).
Several drugs are being developed to target BRAF variants, and so far, two drugs have
been FDA- approved: vemurafenib and dabrafenib. Unfortunately, less progress has been
made in developing targeted therapies for melanoma with wild-type BRAF. There are
fewer treatment options available, but these include immunotherapy and MEK inhibitors
(7, 18).
Gene: G6PD
Glucose-6-phosphate dehydrogenase (G6PD) deficiency is an inherited X-linked recessive
disorder that results from genetic variation in the G6PD gene. The G6PD gene is located
on the X chromosome and G6PD deficiency occurs almost exclusively in males, who have
only one X chromosome. G6PD deficiency mainly affects red blood cells, which carry
oxygen from the lungs to tissues throughout the body.
G6PD deficiency affects 400 million people worldwide (19), and is common among
African Americans, affecting approximately 12% (20). G6PD deficiency appears to be
protective against malaria infection (21).
G6PD catalyzes the initial step in the hexose monophosphate (HMP) pathway. In mature
red blood cells, the HMP pathway is the only source of NADPH, a coenzyme essential for
protection against oxidative stress and repair of oxidative damage.
Red blood cells that are G6PD deficient are more susceptible to oxidative stress caused by
exposure to drugs (e.g. sulfamethoxazole, primaquine, and dabrafenib), infections,
diabetic ketoacidosis, or following ingestion of fresh fava beans (favism). Because of the
oxidative stress, the red blood cells become rigid, become trapped, and are subsequently
destroyed by macrophages in the spleen, bone marrow, and liver. Premature and/or fast
destruction of red blood cells is called hemolysis and can result in hemolytic anemia.
Most affected individuals are asymptomatic; however, those with symptoms may suffer
from episodes of acute hemolytic anemia or chronic hemolytic anemia. The management
of hemolytic episodes depends on the severity of hemolysis. More severe cases may
require a transfusion of packed red blood cells. Folic acid may be given to prevent the
worsening of anemia in individuals with folate deficiency.
The normal (wild-type) copy of the G6PD gene is known as G6PD A+ (p.Asn126Asp),
and is found in up to 30% of blacks from Africa (22). More than 400 genetic variants of
the G6PD gene have been identified so far, and most are missense point mutations (23).
Common variants include:
• G6PD A- (p.Asn126Asp and p.Val68Met) which is associated with mild to
moderate hemolysis, and is found in up to 15% of African-Americans (24)
• G6PD Mediterranean (p.Ser218Phe) which can cause severe hemolysis, and is the
most common variant in Caucasians (25)
• G6PD Canton (p.Arg489Leu) which can cause severe hemolysis, and is found in
Asians (26)
All individuals with G6PD deficiency should avoid oxidizing agents when possible,
including specific drugs and chemicals. Dabrafenib can cause hemolytic anemia. The
FDA-approved drug label for dabrafenib warns that “dabrafenib, which contains a
sulfonamide moiety, confers a potential risk of hemolytic anemia in patients with
glucose-6-phosphate dehydrogenase (G6PD) deficiency. Monitor patients with G6PD
deficiency for signs of hemolytic anemia while taking dabrafenib” (3).
No cases of hemolytic anemia associated with dabrafenib have been published, although it
is unclear whether individuals with G6PD deficiency have received dabrafenib.
Genetic Testing
for the genes BRAF and G6PD.
The FDA-approved label for dabrafenib states that the presence of BRAF mutation in
tumor specimens (V600E for dabrafenib monotherapy; V600E or V600K for dabrafenib
plus trametinib) should be confirmed, using an FDA-approved test, before starting
treatment with dabrafenib. The label also states that dabrafenib is not indicated for
treatment of patients with wild-type BRAF melanoma.
G6PD deficiency is typically diagnosed by screening tests that measure the activity of
G6PD in red blood cells. A false positive may result immediately after an episode of
hemolysis, so the test should be repeated at a later date. Molecular genetic testing can be
used to confirm the diagnosis of G6PD, and may also be used to screen females with a
family history of G6PD to see if they are carriers (27).
Screening for G6PD deficiency is recommended so that affected individuals can avoid
agents that can cause oxidative stress and trigger hemolysis. G6PD deficiency is inherited
in an X-linked recessive pattern. A heterozygous mother has a 50% chance of passing
G6PD deficiency to a son and a 50% chance of passing the carrier trait to a daughter.
Affected fathers pass the variant G6PD to their daughters, but not to their sons.

BRAF V600E Mutation-Positive Unresectable or Metastatic Melanoma: Dabrafenib is
indicated as a single agent for the treatment of patients with unresectable or metastatic
melanoma with BRAF V600E mutation as detected by an FDA-approved test.
BRAF V600E or V600K Mutation-Positive Unresectable or Metastatic Melanoma:
Dabrafenib is indicated, in combination with trametinib, for the treatment of patients
with unresectable or metastatic melanoma with BRAF V600E or V600K mutations, as

detected by an FDA-approved test.
Limitation of Use: Dabrafenib is not indicated for treatment of patients with wild-type
BRAF melanoma.
Patient Selection: Confirm the presence of BRAF V600E mutation in tumor specimens
prior to initiation of treatment with dabrafenib as a single agent. Confirm the presence of
BRAF V600E or V600K mutation in tumor specimens prior to initiation of treatment
with dabrafenib and trametinib. Information on FDA-approved tests for the detection of
BRAF V600 mutations in melanoma is available at: http://www.fda.gov/
CompanionDiagnostics.
[…]
Dabrafenib, which contains a sulfonamide moiety, confers a potential risk of hemolytic
anemia in patients with glucose-6-phosphate dehydrogenase (G6PD) deficiency. Monitor
patients with G6PD deficiency for signs of hemolytic anemia while taking dabrafenib.
Nomenclature
Selected BRAF variants
allele name names identifier for
Coding Protein
allele location
V600E p.Val600Glu NM_004333.4:c.1799T>A NP_004324.2:p.Val600Glu rs113488022
V600K p.Val600Lys NM_004333.4:c. NP_004324.2:p.Val600Lys rs121913227
1798_1799delGTinsAA
V600R p.Val600Arg NM_004333.4:c. NP_004324.2:p.Val600Arg rs121913227
1798_1799delGTinsAG
V600D p.Val600Asp NM_004333.4:c. NP_004324.2:p.Val600Asp rs121913377
1799_1800delTGinsAT
Selected G6PD variants

name / names / reference
Coding Protein
condition condition identifier for
allele
location
G6PD A- p.Asn126Asp NM_000402.4:c.466A>G NP_001035810.1:p.Asn126Asp rs1050828
and NM_000402.4:c.292G>A NP_001035810.1:p.Val68Met
p.Val68Met
Table continues on next page...
Table continued from previous page.

name / names / reference
Coding Protein
condition condition identifier for
allele
location
G6PD p.Ser218Phe NM_000402.4(G6PD):c. NP_000393.4:p.Ser218Phe rs5030868
Mediterranean 653C>T
GP6D Canton p.Arg489Leu NM_000402.4(G6PD):c. NP_000393.4:p.Arg489Leu rs72554665
1466G>T
Acknowledgments
The author would like to thank Matthew Hardison, PhD, FACMG, Director of BioPharma
Laboratory, Aegis Sciences Corporation, Nashville, TN; Douglas B. Johnson, MD,
Assistant Professor of Medicine, Clinical Director of Melanoma Research Program, and
Medical Oncologist at Vanderbilt University Medical Center, Nashville, Tennessee,
Avadhut Joshi, PhD, Clinical Pharmacogenomics Lead, Translational Software, Bellevue,
Washington; and Pamala A. Pawloski, PharmD, Research Investigator, HealthPartners
Institute, Bloomington, MN; for reviewing this summary.
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1962;48:1868–76. PubMed PMID: 14014720.
23. Miwa S., Fujii H. Molecular basis of erythroenzymopathies associated with
hereditary hemolytic anemia: tabulation of mutant enzymes. American journal of
hematology. 1996;51(2):122–32. PubMed PMID: 8579052.
24. Reys L., Manso C., Stamatoyannopoulos G. Genetic studies on southeastern Bantu of
Mozambique. I. Variants of glucose-6-phosphate dehydrogenase. American journal
of human genetics. 1970;22(2):203–15. PubMed PMID: 5435642.
25. Oppenheim A., et al. G6PD Mediterranean accounts for the high prevalence of G6PD
deficiency in Kurdish Jews. Human genetics. 1993;91(3):293–4. PubMed PMID:
8478015.
26. McCurdy P.R., et al. A Chinese variant of glucose-6-phosphate dehydrogenase. The
Journal of laboratory and clinical medicine. 1966;67(3):374–85. PubMed PMID:
4379606.
27. Lab Tests Online: G6PD. December 2016]; Available from: https://labtestsonline.org/
understanding/analytes/g6pd/tab/test.

Vemurafenib Therapy and BRAF and NRAS Genotype

Vemurafenib Therapy and BRAF and NRAS Genotype

BRAF gene
G6PD gene
157

Laura Dean, MD1
Introduction
Diazepam is a benzodiazepine with several clinical uses, including the management of
anxiety, insomnia, muscle spasms, seizures, and alcohol withdrawal. The clinical response
to benzodiazepines, such as diazepam, varies widely between individuals (1, 2).
Diazepam is primarily metabolized by CY2C19 and CYP3A4 to the major active
metabolite, desmethyldiazepam. Approximately 3% of Caucasians and 15 to 20% of
Asians have reduced or absent CYP2C19 enzyme activity (“poor metabolizers”). In these
individuals, standard doses of diazepam may lead to a higher exposure to diazepam.
The FDA-approved drug label for diazepam states that “The marked inter-individual
variability in the clearance of diazepam reported in the literature is probably attributable
to variability of CYP2C19 (which is known to exhibit genetic polymorphism; about 3-5%
of Caucasians have little or no activity and are “poor metabolizers”) and CYP3A4” (1).
Drug: Diazepam
Diazepam is used in the management of anxiety disorders or for the short-term relief of
the symptoms of anxiety. In acute alcohol withdrawal, diazepam may provide
symptomatic relief from agitation, tremor, delirium tremens, and hallucinations.
Diazepam is also useful as an adjunct treatment for the relief of acute skeletal muscle
spasms, as well as spasticity caused by upper motor neuron disorders (3).
There are currently 16 benzodiazepines licensed by the FDA. Diazepam was the second
benzodiazepine to be used clinically (after chlordiazepoxide), after being approved for use
in 1963. It remains a commonly used drug today, and is included in the World Health
Organization’s core list of essential medicines needed for a basic healthcare system (4).
The use of benzodiazepines has replaced the use of barbiturates. Although these drug
classes share similar therapeutic effects, barbiturates have a narrower therapeutic index,
they are more sedative at therapeutic doses, and a barbiturate overdose is more likely to be
fatal (5).
Like all benzodiazepines, diazepam is a controlled substance. Chronic use, either at
standard therapeutic doses or through recreational abuse, can lead to tolerance and
physical dependence. If diazepam treatment is abruptly discontinued, withdrawal

symptoms can arise which can be severe and include seizures. Therefore, a gradual
tapering of dose is recommended after chronic therapy.
Diazepam has several therapeutic effects—it is a sedative, anxiolytic, anticonvulsant
muscle relaxant, and has amnesic effects. Diazepam is thought to exert these effects
through an interaction with GABA A-type receptors (GABAA). GABA is the major
inhibitory neurotransmitter in the central nervous system. When GABA binds to the
GABAA receptor, the receptor opens, allowing the influx of chloride ions into neurons.
This reduces the ability of neurons to depolarize and produce action potentials (excessive
action potentials are implicated in seizures). It is thought that diazepam enhances the
effects of GABA by increasing the affinity between GABA and its receptor, causing GABA
to bind more tightly to the GABAA receptor (1).
Diazepam is primarily metabolized via CYP2C19 and CYP3A4 to the major active
metabolite (desmethyldiazepam), which is found in the plasma at concentrations
equivalent to diazepam. Two minor active metabolites include temazepam and
oxazaepam, which are usually not detectable. Other CYP enzymes involved in diazepam
metabolism include CYP2C9, CYP2B, and CYP3A5 (2).
It is well documented that wide inter-individual variation in the metabolism of
benzodiazepines occurs, which includes diazepam metabolism. This can result in marked
differences in drug levels when standard dosing is used, and may potentially influence
both therapeutic and adverse effects. It is thought that the variability in clearance of many
benzodiazepines, including diazepam, is due to the variability in CYP2C19 and CYP3A4
genotypes (2, 3, 6, 7).
Gene: CYP2C19
metabolism.
drugs, such as antidepressants, several proton pump inhibitors, clopidogrel, and
benzodiazepines, including diazepam.
The CYP2C19 gene is highly polymorphic, as 35 variant star (*) alleles are currently
catalogued at the Human Cytochrome P450 (CYP) Allele Nomenclature Database (http://
www.cypalleles.ki.se/cyp2c19.htm). The CYP2C19*1 wild-type allele is associated with
normal enzyme activity and the “normal metabolizer” phenotype, whereas the
CYP2C19*17 allele is associated with increased enzyme activity and the “ultrarapid
metabolizer” phenotype (8).
Diazepam Therapy and CYP2C19 Genotype 159
Caucasians and Africans, and ~29–35% in Asians (8, 9).
of-function variants occur in less than 1% of the general population, and include
CYP2C19*4-*8 (8, 9).
“Intermediate CYP2C19 metabolizers” carry one copy of an allele that encodes reduced or
absent function (e.g., *1/*2), whereas “poor metabolizers” are homozygous or compound
heterozygous for two loss-of-function alleles (e.g., *2/*2, *2/*3) (table 1).
Table 1: CYP2C19 phenotypes
Phenotype Phenotype Definition Genetic Definition Diplotype Examples
CYP2C19 Ultrarapid Increased enzyme activity Two increased function *17/*17
metabolizer compared to rapid alleles
metabolizers
CYP2C19 Rapid Increased enzyme activity Combinations of normal *1/*17
metabolizer compared to normal function and increased
metabolizers, but less than function alleles
ultrarapid metabolizers
CYP2C19 Normal Fully functional enzyme Two normal function alleles *1/*1
metabolizer activity
CYP2C19 Decreased enzyme activity Combinations of normal *1/*2
Intermediate (activity between normal function, decreased *1/*3
metabolizer and poor metabolizer) function, and/or no function *2/*17
alleles *3/*17
CYP2C19 Poor Little or no enzyme activity Combination of no function *2/*2
metabolizer alleles, and/or decreased *2/*3
function alleles *3/*3
Studies have found that individuals who are poor metabolizers have a lower plasma
clearance of diazepam compared to normal metabolizers, and that diazepam had a longer
plasma half-life (7, 11-13). However, currently, the FDA does not recommend a reduced
dose of diazepam in CYP2C19 poor metabolizers.
One common use of diazepam is to relieve preoperative anxiety in patients. One study
found that CYP2C19 poor metabolizers took a longer period of time to emerge from
general anesthesia than normal metabolizers. This study also found that the “slow
emergers” had lower levels of CYP3A4 mRNA (14).
Although CYP3A4 is also involved in diazepam metabolism, there have been conflicting
results from studies of the impact of CYP3A4 and CYP3A5 variants on benzodiazepine
metabolism (15-18).
Genetic Testing
Clinical genotyping tests are available for several CYP2C19 alleles, and a list of test
Health.
include an interpretation of the patient’s predicted metabolizer phenotype: ultrarapid,
rapid, normal, intermediate, or poor (see table 1).

Statement from the US Food and Drug Administration (FDA): It has been reported in
the literature that diazepam is extensively metabolized to one major active metabolite
(desmethyldiazepam) and two minor active metabolites, 3- hydroxydiazepam
(temazepam) and 3-hydroxy-N-diazepam (oxazepam) in plasma. At therapeutic doses,
desmethyldiazepam is found in plasma at concentrations equivalent to those of diazepam
while oxazepam and temazepam are not usually detectable. The metabolism of diazepam
is primarily hepatic and involves demethylation (involving primarily CYP2C19 and
CYP3A4) and 3-hydroxylation (involving primarily CYP3A4), followed by
glucuronidation. The marked inter-individual variability in the clearance of diazepam
reported in the literature is probably attributable to variability of CYP2C19 (which is
known to exhibit genetic polymorphism; about 3-5% of Caucasians have little or no
activity and are “poor metabolizers”) and CYP3A4. No inhibition was demonstrated in
the presence of inhibitors selective for CYP2A6, CYP2C9, CYP2D6, CYP2E1, or CYP1A2,
indicating that these enzymes are not significantly involved in metabolism of diazepam.
generic drug.
Nomenclature
Coding Protein
identifier for
allele location
Pro227Pro
Trp212Ter
region
Acknowledgments
Sciences, Icahn School of Medicine at Mount Sinai; Jitesh Kawedia, Pharmaceutical/
Pharmacy Research Specialist at the University of Texas MD Anderson Cancer Center;
Chakradhara Rao S. Uppugunduri, Maître-assistant at the CANSEARCH Laboratory,
University of Geneva, Switzerland; and Megan J. Ehret, PharmD, MS, BCPP Behavioral
Health Clinical Pharmacy Specialist, Fort Belvoir Community Hospital, Virginia, for
References
1. DIAZEPAM- diazepam gel [package insert]. North Wales, PA: Teva Pharmaceuticals
USA Inc; 2015. Available from: https://dailymed.nlm.nih.gov/dailymed/
drugInfo.cfm?setid=7733052d-177b-49da-949e-4d950bd2afeb
2. Fukasawa T., Suzuki A., Otani K. Effects of genetic polymorphism of cytochrome
P450 enzymes on the pharmacokinetics of benzodiazepines. J Clin Pharm Ther.
2007;32(4):333–41. PubMed PMID: 17635335.
3. DIAZEPAM- diazepam tablet [package insert]. Parsippany, NJ: Actavis Pharma Inc;
2015. Available from: https://dailymed.nlm.nih.gov/dailymed/drugInfo.cfm?
setid=ab4e5d9c-64fa-4bab-9e7f-ed02109568af
4. WHO Model Lists of Essential Medicines. April 2015 [Last accessed: 20 May 2016].
Available from: http://www.who.int/medicines/publications/essentialmedicines/en/
5. Mandrioli R., Mercolini L., Raggi M.A. Benzodiazepine metabolism: an analytical
perspective. Curr Drug Metab. 2008;9(8):827–44. PubMed PMID: 18855614.
6. Qin X.P., Xie H.G., Wang W., He N., et al. Effect of the gene dosage of CgammaP2C19
on diazepam metabolism in Chinese subjects. Clin Pharmacol Ther. 1999;66(6):642–
7. Bertilsson L., Henthorn T.K., Sanz E., Tybring G., et al. Importance of genetic factors
in the regulation of diazepam metabolism: relationship to S-mephenytoin, but not
debrisoquin, hydroxylation phenotype. Clin Pharmacol Ther. 1989;45(4):348–55.
PMID: 22027650.
2011;90(2):328–32. PubMed PMID: 21716271.
PMID: 27441996.
11. Sohn D.R., Kusaka M., Ishizaki T., Shin S.G., et al. Incidence of S-mephenytoin
hydroxylation deficiency in a Korean population and the interphenotypic differences
in diazepam pharmacokinetics. Clin Pharmacol Ther. 1992;52(2):160–9. PubMed
PMID: 1505151.
12. Zhang Y.A., Reviriego J., Lou Y.Q., Sjoqvist F., et al. Diazepam metabolism in native
Chinese poor and extensive hydroxylators of S-mephenytoin: interethnic differences
in comparison with white subjects. Clin Pharmacol Ther. 1990;48(5):496–502.
13. Wan J., Xia H., He N., Lu Y.Q., et al. The elimination of diazepam in Chinese subjects
is dependent on the mephenytoin oxidation phenotype. Br J Clin Pharmacol.
1996;42(4):471–4. PubMed PMID: 8904619.
14. Inomata S., Nagashima A., Itagaki F., Homma M., et al. CYP2C19 genotype affects
diazepam pharmacokinetics and emergence from general anesthesia. Clin Pharmacol
Ther. 2005;78(6):647–55. PubMed PMID: 16338280.
15. He P., Court M.H., Greenblatt D.J., Von Moltke L.L. Genotype-phenotype
associations of cytochrome P450 3A4 and 3A5 polymorphism with midazolam
clearance in vivo. Clin Pharmacol Ther. 2005;77(5):373–87. PubMed PMID:
15900284.
16. He P., Court M.H., Greenblatt D.J., von Moltke L.L. Factors influencing midazolam
hydroxylation activity in human liver microsomes. Drug Metab Dispos. 2006;34(7):
1198–207. PubMed PMID: 16638818.
17. Maekawa K., Yoshimura T., Saito Y., Fujimura Y., et al. Functional characterization of
CYP3A4.16: catalytic activities toward midazolam and carbamazepine. Xenobiotica.
2009;39(2):140–7. PubMed PMID: 19255940.
18. Park J.Y., Kim K.A., Park P.W., Lee O.J., et al. Effect of CYP3A5*3 genotype on the
pharmacokinetics and pharmacodynamics of alprazolam in healthy subjects. Clin


Diazepam response

CYP2C19 gene
165

Laura Dean, MD1
Created: October 1, 2012; Updated: March 8, 2016.
Introduction
Esomeprazole blocks the secretion of gastric acid and belongs to the drug class of proton
pump inhibitors. It is used to treat gastroesophageal reflux disease (GERD) and to reduce
the risk of gastric ulcers associated with the use of non-steroidal anti-inflammatory
drugs (NSAIDs). Esomeprazole is also used in the treatment of hypersecretory conditions,
such as Zollinger-Ellison syndrome, and is used in combination with antibiotics to
eradicate Helicobacter pylori (H. pylori) infection (1).
Esomeprazole is metabolized primarily by the CYP2C19 enzyme. Approximately 3% of
Caucasians and 15 to 20% of Asians have reduced or absent CYP2C19 enzyme activity
(“poor metabolizers”). In these individuals, standard doses of esomeprazole leads to
higher exposure of the drug (2). In contrast, individuals with increased CYP2C19 activity
(“ultrarapid metabolizers”) may be exposed to lower levels of esomeprazole and have an
insufficient response to treatment.
The FDA-approved drug label for esomeprazole states that poor metabolizers are exposed
to approximately twice the level of drug compared to the rest of the population (“extensive
metabolizers”), but the label does not require dose changes for poor metabolizers (1).
However, the Pharmacogenetics Working Group of the Royal Dutch Association for the
Advancement of Pharmacy (KNMP) has published dose alterations based on CYP2C19
genotype. For CYP2C19 poor metabolizers, they do not recommend altering the dose;
however for ultrarapid metabolizers, they recommend being extra alert to an insufficient
response to treatment. For the eradication of H. pylori in ultrarapid metabolizers, KNMP
recommends increasing the dose of omeprazole by 50–100%, and to consider the same
dose increase for other conditions (see Table 1) (3, 4).

Table 1. CYP2C19 phenotypes and the therapeutic recommendations for esomeprazole therapy, adapted
from the Pharmacogenetics Working Group of the Royal Dutch Association for the Advancement of
Pharmacy (KNMP).
Phenotype Phenotype details Examples of Therapeutic recommendations
diplotypes for esomeprazole
Ultrarapid metabolizer Normal or increased *17/*17 Be extra alert to insufficient
CYP2C19 activity response. For the eradication of
H. pylori, increase dose by 50–
100%.
For other conditions, consider
dose increase by 50–100%.
Extensive metabolizer Normal CYP2C19 *1/*1 No recommendations
activity
Intermediate Decreased CYP2C19 *1/*2 No recommendations
metabolizer activity *1/*3
*2/*17
*3/*17
Poor metabolizer Markedly reduced or *2/*2 No recommendations
absent CYP2C19 *2/*3
activity *3/*3
Good quality evidence supports the dose recommendations for poor and intermediate metabolizers; data
are lacking for ultrarapid metabolizers.
Table is adapted from Swen J.J., Nijenhuis M., de Boer A., Grandia L. et al. Pharmacogenetics: from bench to
byte - an update of guidelines. Clinical pharmacology and therapeutics. 2011;89(5):662–73 (4).
Drug class: Proton Pump Inhibitors

Proton pump inhibitors (PPIs) are inhibitors of gastric acid secretion that are used in the
treatment of stomach-acid related disorders. PPIs are also used to prevent and treat ulcers
associated with nonsteroidal anti-inflammatory drugs (NSAIDs), and can be used in
combination with antibiotics to eradicate H. pylori infection.
Six PPIs are currently FDA-approved for clinical use: esomeprazole, dexlansoprazole,
lansoprazole, omeprazole, pantoprazole, and rabeprazole. All PPIs are similarly potent at
inhibiting gastric acid secretion and are thought to be similarly efficacious (5, 6).
PPIs are metabolized and inactivated by a number of CYP enzymes, including CYP2C19,
which has a principal role in the metabolism of omeprazole. The increased function
CYP2C19*17 variant allele may enhance PPI clearance (7) resulting in less active PPI
available to inhibit gastric acid secretion. In contrast, the CYP2C19*2 loss-of-function
allele is associated with decreased PPI clearance, resulting in more active PPI available
and enhanced treatment. For several PPIs, including omeprazole and lansoprazole, higher
drug levels in patients with low or absent CYP2C19 activity have been associated with
increased drug efficacy and improved treatment outcomes (2, 8).
Esomeprazole Therapy and CYP2C19 Genotype 167
Drug: Esomeprazole
Esomeprazole is used in the treatment of GERD in both adults and children. In adults,
esomeprazole is also used to reduce the risk of developing a gastric ulcer associated with
NSAID use, and in the treatment of pathological hypersecretory conditions such as
Zollinger-Ellison syndrome (1).
The human stomach contains approximately one billion parietal cells that secrete
hydrochloric acid (HCl) into the gastric lumen. Gastric acid aids digestion by hydrolyzing
dietary protein and facilitating the absorption of calcium, iron, and vitamin B. Gastric
acid also helps maintain a sterile environment by suppressing the growth of bacteria (9).
Hydrogen ions (H+) are actively secreted in to the gastric lumen in exchange for
potassium ions (K+) via an H+/K+-ATPase, which is also known as a “proton pump”.
Located on the surface of gastric parietal cells, the proton pump controls the last step in
acid secretion, and by targeting this step, esomeprazole and the other PPIs are able to
potently inhibit gastric acid secretion.
Esomeprazole is metabolized in the liver by the cytochrome P450 system to inactive
metabolites. CYP2C19 metabolizes esomeprazole to hydroxy and desmethyl metabolites,
and the remaining drug is metabolized by CYP3A4 to sulphone metabolites (1).
Individuals with reduced CYP2C19 enzyme activity may experience twice the exposure to
esomeprazole compared to individuals with normal enzyme function. For other PPIs,
such as omeprazole and lansoprazole, increased drug levels are associated with improved
clinical outcomes (10, 11). For example, one study reported that when using omeprazole
as part of the treatment to eradicate H. pylori, success was achieved in all patients who
had little or no CYP2C19 activity, but in only 29% of patients who had “normal”
CYP2C19 activity. Similar results were found in another study that evaluated lansoprazole
in the treatment of GERD: the cure rate was 85% for patients with little or no CYP2C19
activity, compared to 16% for patients with normal CYP219 activity (12-14).
However, the efficacy of esomeprazole appears to be less influenced by CYP2C19
genotype, at least for the treatment of GERD (15-17). This may be because of the shift
towards CYP3A4-mediated metabolism and elimination of the drug (9).
The FDA-approved drug label for esomeprazole does not comment on dose adjustments
based on CYP2C19 status. However, guidelines from KNMP recommend that patients
with increased CYP2C19 activity (“ultrarapid metabolizers”) should receive an increased
dose of esomeprazole for the eradication of H. pylori, and that an increased dose should
be considered for other indications (Table 1).
The long-term use of PPIs has been associated with several adverse effects. Daily
treatment with any PPI for longer than three years may lead to malabsorption of vitamin
B12, caused by hypochlorhydria. Because prolonged hypochlorhydria also increases the
risk of Clostridium difficile infection, and may increase the risk for osteoporosis-related
fractures, the FDA recommends that patients should use the lowest dose and shortest
duration of PPI therapy appropriate to the condition being treated (1).
Gene: CYP2C19
metabolism.
drugs, such as antidepressants, benzodiazepines, and some of the PPIs, including
esomeprazole.
CYP2C19 is highly polymorphic, as 35 variant star (*) alleles are currently catalogued at
the Human Cytochrome P450 (CYP) Allele Nomenclature Database (http://
normal enzyme activity and the “extensive metabolizer” phenotype (18).
Caucasians and Africans, and ~29–35% in Asians (19). “Intermediate metabolizers” carry
one copy of an allele that encodes reduced or absent function (e.g. *1/*2), whereas “poor
metabolizers” are homozygous or compound heterozygous for two loss-of-function alleles
(e.g., *2/*2, *2/*3).
CYP2C19*4-*8 (19, 20).
In contrast to non-functional alleles, the CYP2C19*17 allele (c.-806C>T) is associated
with increased enzyme activity. Allele frequencies range from 3 to 21% across different
populations (21). Individuals who are homozygous for the *17 allele are known as
“ultrarapid metabolizers”, and it is this patient group who may benefit from an increased
dose of omeprazole. However, not all studies have identified a significant effect
of CYP2C19*17 on the metabolism of PPIs and treatment outcomes (14, 22, 23).
Genetic Testing
Currently, the FDA does not provide recommendations about the use of CYP2C19 genetic
testing for esomeprazole treatment (1).
Clinical genotyping tests are available for several CYP2C19 alleles, and a list of some test
extensive, intermediate, or poor).
Table 1 summarizes common CYP2C19 phenotypes with recommendations developed by
the Pharmacogenetics Working Group of the Royal Dutch Association for the
Advancement of Pharmacy (KNMP).

2015 Statement from the US Food and Drug Administration (FDA): Esomeprazole is
extensively metabolized in the liver by the cytochrome P450 (CYP) enzyme system. The
metabolites of esomeprazole lack antisecretory activity. The major part of esomeprazole’s
metabolism is dependent upon the CYP2C19 isoenzyme, which forms the hydroxy and
desmethyl metabolites. The remaining amount is dependent on CYP3A4 which forms the
sulphone metabolite. CYP2C19 isoenzyme exhibits polymorphism in the metabolism of
esomeprazole, since some 3% of Caucasians and 15 to 20% of Asians lack CYP 2C19 and
are termed Poor Metabolizers. At steady state, the ratio of AUC in Poor Metabolizers to
AUC in the rest of the population (Extensive Metabolizers) is approximately 2.
the Royal Dutch Association for the Advancement of Pharmacy (KNMP): For
individuals who are ultrarapid metabolizers, physicians should be vigilant to an
insufficient response to esomeprazole therapy. For the eradication of H. pylori, the dose of
esomeprazole should be increased by 50–100%.
generic drug.
Nomenclature
Coding Protein
identifier for
allele location
Pro227Pro
Trp212Ter
region
Acknowledgments
Genomic Sciences, Icahn School of Medicine at Mount Sinai; and Mia Wadelius, Senior
Lecturer, Uppsala University; for reviewing this summary.
Version History
To view an earlier version of this summary (update: 18 March 2013), please click here.
References
1. ESOMEPRAZOLE MAGNESIUM- esomeprazole magnesium capsule, delayed
release [package insert]. India: Inc, D.R.s.L.; 2015. Available from: http://
dailymed.nlm.nih.gov/dailymed/drugInfo.cfm?
setid=15023261-51c8-2388-3439-48dace49ec02
2. Tang H.L., Li Y., Hu Y.F., Xie H.G., et al. Effects of CYP2C19 loss-of-function variants
on the eradication of H. pylori infection in patients treated with proton pump
inhibitor-based triple therapy regimens: a meta-analysis of randomized clinical trials.
esomeprazole. [Cited 2012 March 12]. Available from: http://www.pharmgkb.org/
drug/PA10075
662–73. PubMed PMID: 21412232.
5. Vakil N., Fennerty M.B. Direct comparative trials of the efficacy of proton pump
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6. Stanley IP, M.C., Moorthy D, Yu WW, Lee J, Chan JA, BS, Bonis PA, MD, and Lau J.
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accessed: 21 Jan 2016]. Available from: http://www.ncbi.nlm.nih.gov/books/
NBK65406/
7. Roman M., Ochoa D., Sanchez-Rojas S.D., Talegon M., et al. Evaluation of the
relationship between polymorphisms in CYP2C19 and the pharmacokinetics of
omeprazole, pantoprazole and rabeprazole. Pharmacogenomics. 2014;15(15):1893–
901. PubMed PMID: 25495411.
8. Sugimoto M., Shirai N., Nishino M., Kodaira C., et al. Comparison of acid inhibition
with standard dosages of proton pump inhibitors in relation to CYP2C19 genotype in
Japanese. Eur J Clin Pharmacol. 2014;70(9):1073–8. PubMed PMID: 24996380.
9. Schwab M., Klotz U., Hofmann U., Schaeffeler E., et al. Esomeprazole-induced
healing of gastroesophageal reflux disease is unrelated to the genotype of CYP2C19:
evidence from clinical and pharmacokinetic data. Clinical pharmacology and
10. Shi S., Klotz U. Proton pump inhibitors: an update of their clinical use and
pharmacokinetics. European journal of clinical pharmacology. 2008;64(10):935–51.
11. Desta Z., Zhao X., Shin J.G., Flockhart D.A. Clinical significance of the cytochrome
P450 2C19 genetic polymorphism. Clinical pharmacokinetics. 2002;41(12):913–58.
12. Furuta T., Shirai N., Watanabe F., Honda S., et al. Effect of cytochrome P4502C19
genotypic differences on cure rates for gastroesophageal reflux disease by
lansoprazole. Clin Pharmacol Ther. 2002;72(4):453–60. PubMed PMID: 12386647.
13. Furuta T., Ohashi K., Kamata T., Takashima M., et al. Effect of genetic differences in
omeprazole metabolism on cure rates for Helicobacter pylori infection and peptic
ulcer. Ann Intern Med. 1998;129(12):1027–30. PubMed PMID: 9867757.
14. Furuta T., Shirai N., Takashima M., Xiao F., et al. Effect of genotypic differences in
CYP2C19 on cure rates for Helicobacter pylori infection by triple therapy with a
proton pump inhibitor, amoxicillin, and clarithromycin. Clinical pharmacology and
15. Hunfeld N.G., Touw D.J., Mathot R.A., van Schaik R.H., et al. A comparison of the
acid-inhibitory effects of esomeprazole and rabeprazole in relation to
pharmacokinetics and CYP2C19 polymorphism. Aliment Pharmacol Ther.
2012;35(7):810–8. PubMed PMID: 22324425.
16. Kuo C.H., Lu C.Y., Shih H.Y., Liu C.J., et al. CYP2C19 polymorphism influences
Helicobacter pylori eradication. World J Gastroenterol. 2014;20(43):16029–36.
17. Sahara S., Sugimoto M., Uotani T., Ichikawa H., et al. Twice-daily dosing of
esomeprazole effectively inhibits acid secretion in CYP2C19 rapid metabolisers
compared with twice-daily omeprazole, rabeprazole or lansoprazole. Aliment

PMID: 22027650.
23698643.
20. Lee S.J., Kim W.Y., Kim H., Shon J.H., et al. Identification of new CYP2C19 variants
exhibiting decreased enzyme activity in the metabolism of S-mephenytoin and
omeprazole. Drug Metab Dispos. 2009;37(11):2262–9. PubMed PMID: 19661214.
2011;90(2):328–32. PubMed PMID: 21716271.
22. PharmGKB [Internet]. Palo Alto (CA): Stanford University. Haplotype CYP2C19 *17.
[Cited 2016 March 02]. Available from: http://www.pharmgkb.org/haplotype/
PA165816533
23. Baldwin R.M., Ohlsson S., Pedersen R.S., Mwinyi J., et al. Increased omeprazole
metabolism in carriers of the CYP2C19*17 allele; a pharmacokinetic study in healthy
volunteers. British journal of clinical pharmacology. 2008;65(5):767–74. PubMed
PMID: 18294333.



Esomeprazole response

CYP2C19 gene
175

Laura Dean, MD1
Created: November 3, 2016.
Introduction
Fluorouracil is a chemotherapy agent that belongs to the drug class of fluoropyrimidines.
When given as an IV solution, fluorouracil is used in the palliative management of
carcinoma of the colon, rectum, breast, stomach, and pancreas (1). When prescribed as a
cream for topical use, fluorouracil is used to treat multiple actinic or solar keratoses of the
face and scalp (2).
The DPYD gene encodes dihydropyrimidine dehydrogenase (DPD), an enzyme that
catalyzes the rate-limiting step in fluorouracil metabolism. Individuals who carry at least
one copy of no function DPYD variants, such as DPYD*2A, may not be able to metabolize
fluorouracil at normal rates, and are at risk of potentially life-threatening fluorouracil
toxicity, such as bone marrow suppression and neurotoxicity. The prevalence of DPD
deficiency in Caucasians is approximately 3%-5%.
The FDA-approved drug label for fluorouracil states that “rarely, unexpected, severe
toxicity (e.g., stomatitis, diarrhea, neutropenia and neurotoxicity) associated with 5-
fluorouracil has been attributed to deficiency of dipyrimidine dehydrogenase activity” (1).
recommendations for fluoropyrimidines (capecitabine, fluorouracil, and tegafur) based on
DPYD genotype (3) (Table 1). CPIC recommends using an alternative drug for patients
who are “poor metabolizers.” These individuals carry two copies of no function DPYD
variants and typically have complete DPD deficiency. CPIC also recommends considering
a 50% reduction in starting dose for “intermediate metabolizers.” These individuals carry
a combination of a normal function and a no function variant and typically have reduced
DPD activity (approximately 50% reduced) (3, 4).
Drug Class: Fluoropyrimidines

Fluoropyrimidines are a class of antimetabolite drugs that are widely used in the
treatment of cancer. Currently, there are three types of fluoropyrimidines in clinical use:
capecitabine, fluorouracil, and tegafur. Capecitabine and tegafur are both active
precursors of fluorouracil.
Fluoropyrimidines are thought to exert their chemotherapeutic effects in a number of
ways, through several active metabolites. The main mechanism of action is thought to be

the inhibition of thymidylate synthase, which plays an important part in the folate-
homocysteine cycle, and purine and pyrimidine synthesis pathways. Also, active
metabolites can be incorporated into RNA and DNA, ultimately leading to cell death (5).
Approximately 10-40% of patients develop severe and potentially life-threatening toxicity
early during treatment with fluoropyrimidines (6). This toxicity typically leads to an
interruption or discontinuation of potentially effective anticancer therapy, and often
requires hospitalization (7).
The inter-individual variation in the occurrence and severity of adverse events in patients
receiving fluoropyrimidines can be partly explained by clinical factors, such as age and
sex. However, much of the variability in adverse events remains unexplained (8).
Of the genetic factors thought to contribute to fluoropyrimidine intolerance, the DPYD
gene has been the most studied. This gene encodes the primary enzyme involved in
breaking down fluoropyrimidines to inactive metabolites. Individuals who have a
deficiency of the DPD enzyme have a significantly increased risk of suffering from severe
fluoropyrimidine toxicity, and the stratification of patients on the basis of the DPYD
genotype may help to prevent such adverse events (9-14).
genetics-based dosing recommendations for fluoropyrimidines based on DPYD genotype
(Table 1).
Table 1. 2013 Recommended dosing of Fluoropyrimidines by DPD phenotype, from Clinical
Pharmacogenetics Implementation Consortium (CPIC)
Normal metabolizer Normal DPD activity and Use label-recommended Moderate
“normal” risk for dosage and administration
fluoropyrimidine toxicity
Intermediate Decreased DPD activity Start with at least a 50% Moderate
metabolizer (leukocyte DPD activity at reduction in starting dose,
30–70% that of the normal followed by titration of
population) and increased dose based on toxicityb or
risk for severe or even fatal
Fluorouracil Therapy and DPYD Genotype 177

drug toxicity when treated pharmacokinetic test (if
with fluoropyrimidine available)
drugs
Poor metabolizer Complete DPD deficiency Select alternative drug Strong
and increased risk for
severe or even fatal drug
toxicity when treated with
fluoropyrimidine drugs
Drug: Fluorouracil
Fluorouracil is a form of chemotherapy that when given as an IV solution, is used in the
palliative management of carcinoma of the colon, rectum, breast, stomach, and pancreas.
Fluorouracil may also be used topically as a cream, for the treatment of multiple actinic or
solar keratoses of the face and anterior scalp.
Fluorouracil is structurally similar to pyrimidines, and the enzyme that catalyzes the rate-
limiting step in the breakdown of pyrimidines (DPD, dihydropyrimidine dehydrogenase)
also catalyzes the rate-limiting step in 5-fluorouracil catabolism. DPD catalyzes the
conversion of fluorouracil to the non-cytotoxic dihydrofluorouracil (DHFU) (16).
Fluorouracil is a highly toxic drug with a narrow margin of safety. The FDA-approved
label contains the following boxed warning: “It is recommended that Fluorouracil
Injection, USP be given only by or under the supervision of a qualified physician who is
experienced in cancer chemotherapy and who is well versed in the use of potent
antimetabolites. Because of the possibility of severe toxic reactions, it is recommended
that patients be hospitalized at least during the initial course of therapy. These
instructions should be thoroughly reviewed before administration of Fluorouracil
Injection, USP.”
The FDA also states that fluorouracil therapy should be discontinued promptly whenever
one of the following signs of toxicity appears:
• Stomatitis or esophageal pharyngitis, at the first visible sign
• Leukopenia (WBC under 3500) or a rapidly falling white blood count

• Vomiting, intractable
• Diarrhea, frequent bowel movements, or watery stools
• Gastrointestinal ulceration and bleeding
• Thrombocytopenia (platelets under 100,000)
• Hemorrhage from any site
Symptomatic DPD deficiency is a rare autosomal recessive disorder with a wide range of
symptoms, ranging from no symptoms or signs, to severe neurological problems. In
affected individuals, the absent or greatly reduced DPD activity results in uracil and
thymine accumulating in the blood, urine, and cerebrospinal fluid. Neurological
symptoms typically manifest in early childhood and include seizures, small head size, and
delayed cognitive and motor development (17).
Symptomatic DPD deficiency is typically caused by homozygous inactivation of DPYD;
whereas individuals who are heterozygotes tend to be asymptomatic. However, all patients
with less than 70% DPD activity are considered at risk for the development of severe drug
toxicity when treated with fluoropyrimidines (18). Signs of fluorouracil toxicity include
severe diarrhea, severe mucositis, neutropenia, neurotoxicity, and hand-foot syndrome
(redness, swelling, and blisters on the palms of the hands an soles of the feet) (1).
Approximately 3-5% of Caucasians have partial DPD deficiency and 0.2% have complete
DPD deficiency (19). Currently, most patients are not screened for DPD deficiency before
starting capecitabine therapy (20).
Gene: DPYD
The DPYD gene encodes the enzyme dihydropyrimidine dehydrogenase (DPD), which
catalyzes the first and the rate-limiting step in the breakdown of the pyrimidine
nucleotides thymine and uracil. DPD also catalyzes the rate-limiting step in the
breakdown of fluoropyrimidines.
Many DPYD variants have been described, although only a few have been demonstrated
to influence DPD enzyme activity. DPYD*1 is the wild-type allele and is associated with
normal enzyme activity. Individuals who carry two copies of DPYD alleles with normal
activity are known as “normal metabolizers” and have fully functional DPD enzyme
activity (Table 2 and Table 3). Next to DPYD*1, the DPYD alleles *4, *5, *6, and *9A are
also considered to have normal activity (21).
Table 2. Activity Status of Selected DPYD Alleles
Allele type Alleles
Functional *1, *4, *5, *6, *9A
No function *2A, *13, rs67376798
Table is adapted from (13, 16) For the nomenclature of human DPYD alleles, please see (22)
The no function DPYD variants which have been associated with low DPD activity and an
increased risk of toxicity with fluoropyrimidines include *2A, *13, and rs67376798 (16).
The most well studied variant is DPYD*2A, in which a single nucleotide substitution at the
invariant splice donor site of intron 14 leads to translation skipping exon 14, resulting in
the production of a truncated protein with virtually no enzyme activity.
Individuals who carry combinations of normal function, decreased function, and/or no
function DPYD alleles are known as “intermediate metabolizers.” They have partial DPD
deficiency and are at increased risk of capecitabine toxicity. And individuals who carry a
combination of no function DPYD alleles and/or decreased function DPYD alleles are
known as “poor metabolizers.” They have complete DPD deficiency and are at an even
higher risk of capecitabine toxicity. Overall, the prevalence of individuals who are
heterozygous for no function variant DPYD alleles (partially DPD deficient) that place
them at risk of severe drug reactions is estimated to be as high as 3-5%, but this varies in
different populations (6, 23-27). For example, in the Dutch population, the DPYD*2A had
an allele frequency of 0.91% in Caucasians (18).
Table 3 Assignment of likely phenotype based on DPYD genotypes
Likely phenotype Functional definition Genetic definition Example diplotypes
Normal metabolizer Fully functional DPD Combinations of normal DPYD*1/*1
enzyme activity function and decreased
function alleles
Intermediate Decreased DPD enzyme Combinations of normal *1/*2A; *1/*13; or *1/
metabolizer activity (activity between function, decreased rs67376798
(~3–5% of patients) normal and poor function, and/or no
metabolizer) function alleles
Poor metabolizer Little to no DPD enzyme Combination of no *2A/*2A; 13/*13; *2/
(~0.2% of patients) activity function alleles and/ or *13; or rs67376798/
decreased function alleles rs67376798
terms proposed by CPIC in the 2016 paper, “Standardizing terms for clinical pharmacogenetic test results:
A recent study proposed distinguishing between the various DPYD alleles and their
functionality by assigning gene activity scores. The use of such scores could result in
differentiated individualized dosing advice for fluororpyrimidines, which is essential for
reducing toxic side effects while maintaining efficacy (13).
Genetic Testing
for the DPYD gene and the fluorouracil drug response. The DPYD*2A variant is the most
commonly tested.
Biochemical genetic tests may also be used, which assess the level of activity of the DPD
enzyme. These tests include biochemical assays such as analyte testing (e.g., measuring the
amount of thymine and uracil in the urine or blood) or an enzyme assay (e.g., directly
measuring the activity of DPD using RNA extracted from blood cells and measuring the
DPD mRNA copy number) (3, 28, 29).
GTR provides a list of biochemical tests that assess the levels of thymine and uracil
analytes, and the activity of the enzyme dihydropyrimidine dehydrogenase.

2016 Statement from the US Food and Drug Administration (FDA): Rarely,
unexpected, severe toxicity (e.g., stomatitis, diarrhea, neutropenia and neurotoxicity)
associated with 5-fluorouracil has been attributed to deficiency of dipyrimidine
dehydrogenase activity. A few patients have been rechallenged with 5-fluorouracil and
despite 5-fluorouracil dose lowering, toxicity recurred and progressed with worse
morbidity. Absence of this catabolic enzyme appears to result in prolonged clearance of 5-
fluorouracil.
(CPIC): [...] Furthermore, patients who are heterozygous for the nonfunctional DPYD
variants mostly demonstrate partial DPD deficiency (leukocyte DPD activity at 30–70%
that of the normal population). Thus, our recommendation is to start with at least a 50%
reduction of the starting dose; followed by an increase in dose in patients experiencing no
or clinically tolerable toxicity, to maintain efficacy; and a decrease in dose in patients who
do not tolerate the starting dose, to minimize toxicities. An alternative is
pharmacokinetic-guided dose adjustment (if available). Patients who are homozygous for
DPYD*2A, *13, or rs67376798 may demonstrate complete DPD deficiency, and the use of
5-fluouracil or capecitabine is not recommended in these patients. Because capecitabine
and tegafur are converted to 5-fluorouracil and then metabolized by DPD, the clearance
of and exposure to 5-fluorouracil, in addition to its toxic effects, are similar in patients
with these variants.
generic drug.
Nomenclature
Coding Protein
identifier for
allele location
DPYD*2A IVS14+1G>A NM_000110.3:c. Not applicable—deletion of rs3918290
c.1905+1G>A 1905+1G>A exon 14 leads to the
production of a truncated
protein
DPYD*13 1679T>G NM_000110.3:c. NP_000101.2:p.Ile560Ser rs55886062
Ile560Ser 1679T>G
rs67376798 2846A>T NM_000110.3:c. NP_000101.2:p.Asp949Val rs67376798
Asp949Val 2846A>T
Acknowledgments
The author would like to thank George P. Patrinos, Associate Professor of
Pharmacogenomics and Pharmaceutical Biotechnology, University of Patras, Department
of Pharmacy, Greece; Mohamed Nagy, Clinical Pharmacist, Head of the Personalised
Medication Management Unit, Department of pharmaceutical Services, Children's
Cancer Hospital, Egypt; and Victoria M. Pratt, Ph.D., FACMG, Director,
Pharmacogenomics Laboratory, Department of Medical and Molecular Genetics, Indiana
University School of Medicine, for reviewing this summary.
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Fluorouracil response

DPYD gene
185
Gentamicin Therapy and MT-RNR1 Genotype

Laura Dean, MD1
Introduction
Gentamicin is an aminoglycoside antibiotic that is active against gram-negative bacteria.
It is administered by injection to treat serious infections caused by susceptible strains of
the following microorganisms: Pseudomonas aeruginosa, Proteus species, Escherichia coli,
Klebsiella-Enterobacter-Serratia species, Citrobacter species and Staphylococcus species (1).
Gentamicin may also be used topically to treat ophthalmic and dermatological infections.
There are reports that a single injection of gentamicin may cause hearing loss in
individuals who have a variant in the mitochondrial gene MT-RNR1, known as m.
1555A>G. Hearing loss is bilateral, usually moderate to profound, and irreversible.
Importantly, this occurs in genetically susceptible individuals even in cases where drug
levels remain within the therapeutic range. Note that this effect is distinct from “dose-
dependent ototoxicity” (damage to the inner ear), which can affect any individual,
typically occurring after 5-7 days of aminoglycoside therapy (2).
Currently, the FDA-approved drug label for gentamicin does not include a statement
about m.1555A>G. However, an American College of Medical Genetics and Genomics
(ACMG) guideline includes the following recommendation: “Single-gene testing may be
warranted in cases in which the medical or family history, or presentation of the hearing
loss, suggests a specific etiology. For example, testing for mitochondrial DNA mutations
associated with aminoglycoside ototoxicity may be considered for individuals with a
history of use of aminoglycoside antibiotics” (3, 4).
Drug: Gentamicin
Aminoglycosides such as gentamicin are among the earliest formulations of antibiotics
(5). They act by inhibiting protein synthesis in susceptible microorganisms through
ribosome binding and are effective against most Gram-positive and -negative aerobic
bacteria but are inactive against anaerobes. They may be used in combination with
another antibiotic, such as a beta-lactam antibiotic or a cephalosporin, to increase
coverage (1).
Six aminoglycoside drugs currently are approved for use by the FDA: amikacin,
gentamicin, neomycin, paromomycin, streptomycin, and tobramycin. The ending of these
drug names, -mycin or -micin, reflects from which genus of bacteria the aminoglycoside
was derived, respectively Streptomyces or Micromonospora (6).

Aminoglycosides exert antibacterial effects by binding to bacterial ribosomes and

inhibiting bacterial protein synthesis. They bind to the 30s ribosomal subunit, which
interferes with the decoding site—this is where the ribosome has to accurately select
tRNA in accordance with the appropriate mRNA codon. Errors here lead to inappropriate
translation of the mRNA codons so that incorrect amino acids are inserted into the
polypeptide chain, which can disrupt elongation of the peptide chain (7, 8).
Like all aminoglycosides, gentamicin is poorly absorbed from the gut so is not
administered orally. It is either given by injection, with regular blood tests to monitor
drug levels, or given topically in the form of drops, cream, or ointment, to treat infections
of the eye or skin.
The toxicity of aminoglycosides, along with the discovery of equally potent but less toxic
antibiotics, has meant that the use of aminoglycoside injections is reserved for serious
infections that are proven, or strongly suspected, to be caused by susceptible
microorganisms. They are most commonly used in the treatment of neonatal septicemia,
especially in premature babies. They are used as surgical prophylaxis in patients who are
allergic to penicillin and for febrile neutropenia, septic shock, and drug-resistant
tuberculosis (5).
The main toxicities of aminoglycoside injections are kidney damage (nephrotoxicity) and
damage to the inner ear (ototoxicity) (9). Nephrotoxicity primarily involves the proximal
tubules and is generally reversible (10). In contrast, aminoglycoside-induced otoxocity is
usually irreversible. Damage may occur to the cochlea, resulting in sensorineural hearing
loss, and/or to the vestibular system, causing problems with balance, vertigo, ataxia,
nausea, and vomiting. Gentamicin is considered to be more toxic to the vestibular system,
and for this reason is used for vestibular ablation to treat Ménière’s disease. Amikacin and
neomycin are examples of aminoglycosides that are more toxic to the cochlea (9, 11).
Rarely, neuromuscular blockade can occur after aminoglycoside therapy. The boxed
warning on the FDA-approved drug label recommends that aminoglycosides “be used
with caution in patients with neuromuscular disorders, such as myasthenia gravis or
parkinsonism, because they may aggravate muscle weakness (1)”; whereas the British
National Formulary states that aminoglycosides should not be given to patients with
myasthenia gravis (12).
Gene: MT-RNR1
Mitochondria are the principal source of energy in most cells—they use oxygen and
sugars and fats to create energy in the form of ATP, in a process known as oxidative
phosphorylation. Mitochondria have their own genome, which is small and circular,
resembling the bacterial prokaryotes from which they evolved. The genome is passed
down from mother to child (maternal inheritance) and contains 37 genes, one of which is
the MT-RNR1 gene (mitochondrially encoded 12S RNA).
Gentamicin Therapy and MT-RNR1 Genotype 187
The MT-RNR1 gene may have variants associated with both aminoglycoside-induced and
nonsyndromic hearing loss (see Nomenclature). The rRNA encoded by MT-RNR1 is
found only within mitochondria, and it is essential in the synthesis of proteins that carry
out oxidative phosphorylation.
Consistent with their bacterial origin, mitochondrial rRNA resembles bacterial rRNA
more closely than human rRNA found in the cell cytoplasm. However, at the highly
conserved decoding region in the 12S RNA gene, the sequence in humans is different to
the corresponding site in bacterial ribosomes. Thus, aminoglycosides that bind to
bacterial ribosomes do not normally bind to human ribosomes (7).
However, sequence variants in the ribosomal decoding region make mitochondrial RNA
more similar to bacterial rRNA, thereby facilitating the binding of aminoglycosides.
Although the mechanism is unclear, aminoglycosides damage the sensory hair cells in the
cochlea that mediate hearing, which may be mediated by the generation of free radicals
(13-15).
The most common MT-RNR1 variant is a single nucleotide substitution of a guanine at
position 1555 for an adenine (m.1555A>G). Individuals with this variant are exquisitely
sensitive to aminoglycoside-induced hearing loss, which is moderate to profound,
bilateral, irreversible, and may have a rapid onset. This presentation occurs in the setting
of receiving standard doses of aminoglycosides with monitoring to ensure the drug levels
are within therapeutic range. Even a single dose can be sufficient to cause ototoxicity (2,
16).
The m.1555A>G variant is nearly always homoplasmic (present in all mitochondria), and
the penetrance of hearing loss after exposure to aminoglycosides is high (16). Susceptible
individuals who are not exposed to aminoglycosides may nonetheless develop hearing
loss, referred to as “non-syndromic mitochondrial hearing loss.” The course of hearing
loss may be affected by the presence of additional genetic factors as well as environmental
factors, such as exposure to loud noise. However, normal hearing is usually preserved
until at least 44 years of age (2). In cases with m.1555A>G heteroplasmy (variant is
present in some but not all mitochondria), the proportion of variant mitochondria
generally correlates with the degree of hearing loss (17).
The prevalence of the m.1555A>G variant varies among different populations but
frequency data are limited. In the US, the population prevalence is estimated to be 0.09%,
and in the UK, 0.20% (4, 18, 19). In hearing impaired populations, the prevalence is much
greater, but the estimates vary widely based on study differences such as the age of onset
of hearing loss and whether there has been exposure to aminoglycosides. Estimates
include a prevalence of 3.5% among the hearing impaired population in Japan (20), 5%
among deaf individuals in Indonesia (21), and 6% of individuals with post-lingual hearing
loss from the UK and Southern Italy (22). Additionally, a prevalence of 15% has been
reported in “ethnically diverse patients in the United States with hearing loss after
aminoglycoside exposure” (23), and in 15-20% of individuals from Spain with hearing loss
(24).
Interestingly, although m.1555A>G is present in mitochondria in all tissues of affected

individuals, it appears that only the cochlea of the inner ear—but not the vestibular
system—is extremely susceptible to aminoglycosides. In contrast, “dose-dependent
ototoxicity” can occur after aminoglycoside therapy in any individual, including those
with wild-type MT-RNR1, and the toxicity involves both the cochlea and vestibular
system (see above) (9).
Several studies have highlighted the complex issues regarding genetic testing for m.
1555A>G, with the aim of preventing avoidable hearing loss in carriers by administering
an alternative antibiotic whenever possible. These issues include the costs and benefits of
universal screening, for example, as part of the newborn screening program, given that
the prevalence of m.1555A>G is thought to be 1 in 385 Caucasians (2, 25, 26), versus
limiting genetic testing to a case-by-case basis (e.g., patients with tuberculosis, children
with leukemia, individuals with cystic fibrosis, and surgical patients allergic to beta-
lactam antibiotics)(4).
Genetic screening may provide more benefit in countries where aminoglycosides are more
commonly used, or when their use becomes more widespread because of growing
resistance to other antibiotics (27). In the US, aminoglycoside use is most common in the
neonatal intensive care unit where acute, life-threatening situations may dictate that
aminoglycosides are given before the results of genetic testing are available (28). One
potential alternative would be to screen all pregnant women, because mitochondrial
variants are maternally inherited and m.1555A>G is almost always homoplasmic (4).
A report from the World Health Organization’s Essential Medicines and Pharmaceutical
Policies comments that “pre-treatment screening is an important consideration to prevent
aminoglycoside related hearing loss but given cost and access issues, asking about a
maternal family history of deafness may be more practical” (29). In countries where the
use of aminoglycosides is more common, a quarter of people with aminoglycoside-
induced hearing loss have maternal relatives who also have drug-related hearing loss (30,
31).
Genetic Testing
As with all mitochondrial variants, variants of the MT-RNR1 gene are either maternally
inherited, or occur sporadically.
Genetic testing is available for the MT-RNR1 gene. Targeted mutation panels vary among
testing laboratories but laboratories typically include m.1555A>G at a minimum.
MT-RNR1 variants are associated with both extreme idiosyncratic aminoglycoside
hypersensitivity, resulting in post-exposure deafness, and nonsyndromic mitochondrial
hearing loss, which tends to develop gradually over time. While the presence of an MT-
RNR1 variant indicates a predisposition to aminoglycoside hypersensitivity, the test
results do not predict the age of onset or severity of nonsyndromic mitochondrial hearing
loss (16).

Excerpt from the American College of Medical Genetics and Genomics (ACMG)
Guideline for the Clinical Evaluation and Etiologic Diagnosis of Hearing Loss:
For individuals lacking physical findings suggestive of a known syndrome and having
medical and birth histories that do not suggest an environmental cause of hearing loss, a
tiered diagnostic approach should be implemented.
Pretest genetic counseling should be provided, and, with patient’s informed consent,
genetic testing should be ordered.
Single-gene testing may be warranted in cases in which the medical or family history, or
presentation of the hearing loss, suggests a specific etiology. For example, testing for
mitochondrial DNA mutations associated with aminoglycoside ototoxicity may be
considered for individuals with a history of use of aminoglycoside antibiotics.
Nomenclature
Common allele name Alternative names HGVS reference sequence dbSNP reference identifier
for allele location
Coding Protein
m.1555A>G A1555G NA NA (encodes ribosomal rs267606617
MTRNR1 RNA)
1555A-G
Acknowledgments
Sciences, Icahn School of Medicine at Mount Sinai; Shamima Rahman, FRCP, PhD,
Professor of Paediatric Metabolic Medicine at University College London and Honorary
Consultant in Paediatric Metabolic Medicine at Great Ormond Street Hospital; and Maria
Bitner-Glindzicz, FRCP, PhD, Professor of Clinical Molecular Genetics at University
College London and Honorary Consultant in Clinical Genetics at Great Ormond Street
Hospital.
References
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d992152363b1
2. Rahman S., Ecob R., Costello H., Sweeney M.G., et al. Hearing in 44-45 year olds
with m.1555A>G, a genetic mutation predisposing to aminoglycoside-induced
deafness: a population based cohort study. BMJ open. 2012;2:e000411. PubMed

PMID: 22223843.
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and Genomics guideline for the clinical evaluation and etiologic diagnosis of hearing
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mitochondrial 1555A-->G mutation in European children. The New England journal
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opinion on pharmacotherapy. 2013;14(12):1585–97. PubMed PMID: 23746121.
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on the dynamics of translation elongation. Cell reports. 2013;3(2):497–508. PubMed
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9. Forge A., Schacht J. Aminoglycoside antibiotics. Audiology & neuro-otology.
2000;5(1):3–22. PubMed PMID: 10686428.
10. Xie J., Talaska A.E., Schacht J. New developments in aminoglycoside therapy and
ototoxicity. Hearing research. 2011;281(1-2):28–37. PubMed PMID: 21640178.
11. Ahmed R.M., Hannigan I.P., MacDougall H.G., Chan R.C., et al. Gentamicin
ototoxicity: a 23-year selected case series of 103 patients. The Medical journal of
Australia. 2012;196(11):701–4. PubMed PMID: 22554194.
12. British National Formulary. June 2014, BMJ Group and Pharmaceutical Press:
London.
13. Guan M.X. Mitochondrial 12S rRNA mutations associated with aminoglycoside
ototoxicity. Mitochondrion. 2011;11(2):237–45. PubMed PMID: 21047563.
14. Selimoglu E. Aminoglycoside-induced ototoxicity. Current pharmaceutical design.
2007;13(1):119–26. PubMed PMID: 17266591.
15. Bates D.E. Aminoglycoside ototoxicity. Drugs of today. 2003;39(4):277–85. PubMed
PMID: 12743643.
16. Pandya, A., Nonsyndromic Hearing Loss and Deafness, Mitochondria, A.M. Pagon RA,
Ardinger HH, et al., editors., Editor., University of Washington: Seattle (WA).
17. del Castillo F.J., Rodriguez-Ballesteros M., Martin Y., Arellano B., et al. Heteroplasmy
for the 1555A>G mutation in the mitochondrial 12S rRNA gene in six Spanish
families with non-syndromic hearing loss. Journal of medical genetics. 2003;40(8):
632–6. PubMed PMID: 12920080.
18. Vandebona H., Mitchell P., Manwaring N., Griffiths K., et al. Prevalence of
mitochondrial 1555A-->G mutation in adults of European descent. The New England
journal of medicine. 2009;360(6):642–4. PubMed PMID: 19196685.
19. Tang, H.Y., E. Hutcheson, S. Neill, M. Drummond-Borg, et al., Genetic susceptibility

to aminoglycoside ototoxicity: how many are at risk? Genetics in medicine : official
journal of the American College of Medical Genetics, 2002. 4(5): p. 336-45.
20. Usami S., Abe S., Akita J., Namba A., et al. Prevalence of mitochondrial gene
mutations among hearing impaired patients. Journal of medical genetics. 2000;37(1):
38–40. PubMed PMID: 10633132.
21. Malik S.G., Pieter N., Sudoyo H., Kadir A., et al. Prevalence of the mitochondrial
DNA A1555G mutation in sensorineural deafness patients in island Southeast Asia.
Journal of human genetics. 2003;48(9):480–3. PubMed PMID: 12955586.
22. Jacobs H.T., Hutchin T.P., Kappi T., Gillies G., et al. Mitochondrial DNA mutations in
patients with postlingual, nonsyndromic hearing impairment. European journal of
human genetics. EJHG. 2005;13(1):26–33. PubMed PMID: 15292920.
23. Fischel-Ghodsian N., Prezant T.R., Chaltraw W.E., Wendt K.A., et al. Mitochondrial
gene mutation is a significant predisposing factor in aminoglycoside ototoxicity.
American journal of otolaryngology. 1997;18(3):173–8. PubMed PMID: 9164619.
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gene. Biochemical and biophysical research communications. 2006;344(2):511–6.
25. Linden Phillips L., Bitner-Glindzicz M., Lench N., Steel K.P., et al. The future role of
genetic screening to detect newborns at risk of childhood-onset hearing loss.
International journal of audiology. 2013;52(2):124–33. PubMed PMID: 23131088.
26. McLeod H.L., Isaacs K.L. Preemptive pharmacogenetic testing: insufficient data equal
unsatisfactory guidance. Annals of internal medicine. 2011;154(12):842–4. PubMed
PMID: 21690601.
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century? Current opinion in infectious diseases. 2013;26(6):516–25. PubMed PMID:
24141453.
28. Boles R.G., Friedlich P. Should patients be screened for 12S rRNA mutations before
treatment with aminoglycosides? Mitochondrion. 2010;10(4):391–2. PubMed PMID:
20302974.
29. Matthai, D.E. Gentamicin - Ototoxicity in children in Second Meeting of the
Subcommittee of the Expert Committee on the Selection and Use of Essential Medicine.
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2007;335(7624):784–5. PubMed PMID: 17947747.

MT-RNR1 gene
193
Imipramine Therapy and CYP2D6 and CYP2C19

Genotype
Laura Dean, MD1
Introduction
Imipramine is a tricyclic antidepressant used in the treatment of several psychiatric
disorders including major depression, obsessive-compulsive disorder, generalized anxiety
disorder, post-traumatic stress disorder, and bulimia. Imipramine may also be useful as an
adjunctive treatment in the management of panic attacks, neuropathic pain, attention-
deficit disorder, and childhood enuresis (bedwetting) (1).
Tricyclic antidepressants (TCAs) primarily mediate their therapeutic effect by inhibiting
the reuptake of both serotonin and norepinephrine, leaving more neurotransmitter in the
synaptic cleft stimulating the neuron. Because tricyclics can also block different receptors
(histamine H1, α1-adrenergic, and muscarinic receptors), side effects are common. As
such, more specific selective serotonin reuptake inhibitors (SSRIs) have largely replaced
the use of them. However, TCAs still have an important use in specific types of depression
and other conditions.
Imipramine is primarily metabolized via CYP2C19 to active metabolites, including
desipramine, also a tricyclic antidepressant. Further metabolism is catalyzed by CYP2D6.
Individuals who are “CYP2D6 ultrarapid metabolizers” carry more than two normal
function alleles (i.e., multiple copies) (Table 1, 2), whereas individuals who are “CYP2C19
ultrarapid metabolizers” carry two increased function alleles (Table 3, 4). Individuals who
are CYP2D6 or CYP2C19 “poor metabolizers” carry two no function alleles for CYP2D6
or CYP2C19, respectively.
The FDA-approved drug label for imipramine states that CYP2D6 poor metabolizers have
higher than expected plasma concentrations of tricyclic antidepressants when given usual
doses. Their recommendations include monitoring tricyclic antidepressant plasma levels
whenever a tricyclic antidepressant is going to be co-administered with another drug
known to be an inhibitor of CYP2D6 (1).
In 2016, the Clinical Pharmacogenetics Implementation Consortium (CPIC) made dosing
recommendations for tricyclic antidepressants based on CYP2C19 and CYP2D6
genotypes. Amitriptyline and nortriptyline were used as model drugs for this guideline
because the majority of pharmacogenomic studies have focused on these two drugs.
According to the CPIC guideline, because TCAs have comparable pharmacokinetic

properties, it may be reasonable to apply the recommendations to other tricyclics,

including imipramine (2).
For CYP2D6 ultrarapid metabolizers, CPIC recommends avoiding the use of a tricyclic
due to the potential lack of efficacy, and to consider an alternative drug not metabolized
by CYP2D6. If a TCA is still warranted, CPIC recommends considering titrating the TCA
to a higher target dose (compared to normal metabolizers) and using therapeutic drug
monitoring to guide dose adjustments. For CYP2D6 intermediate metabolizers, CPIC
recommends considering a 25% reduction of the starting dose, and for CYP2D6 poor
metabolizers, to avoid the use of tricyclics because of the potential for side effects. If a
tricyclic is still warranted for CYP2D6 poor metabolizers, CPIC recommends considering
a 50% reduction of the starting dose while monitoring drug plasma concentrations to
avoid side effects.
For CYP2C19 ultrarapid metabolizers, CPIC recommends avoiding the use of tertiary
amines (e.g., imipramine) due to the potential for a sub-optimal response, and to consider
an alternative drug not metabolized by CYP2C19, such as the secondary amines
nortriptyline or desipramine. For CYP2C19 poor metabolizers, CPIC recommends
avoiding tertiary amine use due to the potential for sub-optimal response, and to consider
an alternative drug not metabolized by CYP2C19. If a tertiary amine is still warranted for
CYP2C19 poor metabolizers, CPIC recommends considering a 50% reduction of the
starting dose while monitoring drug plasma concentrations to avoid side effects (2).
Drug Class: Tricyclic Antidepressants

Tricyclic antidepressants (TCAs) are mixed serotonin-norepinephrine reuptake inhibitors.
They increase the amount of neurotransmitter in the synaptic cleft, thought to mediate
their antidepressant effects.
From the 1960s to the 1980s, tricyclics were the first-line treatment for depression, until
the introduction of SSRIs, which have fewer side effects and are safer. The common side
effects of tricyclics include anticholinergic side effects (e.g., blurred vision, dry mouth,
constipation, and sedation), cardiac effects, and orthostatic hypotension.
Today, the main therapeutic use of tricyclics is chronic pain management, such as
neuropathic pain. However, tricyclics are still used in the treatment of depression as well
as other psychiatric disorders including obsessive-compulsive disorder, panic attacks,
generalized anxiety disorder, post-traumatic stress disorder, bulimia nervosa, smoking
cessation, and enuresis (bedwetting).
Tricyclics are named after their chemical structure of three central rings and a side chain
important for their function and activity. Its structure determines whether a drug is
classified a tertiary amine (amitriptyline, clomipramine, doxepin, imipramine, and
trimipramine) or secondary amine (desipramine and nortriptyline).
Imipramine Therapy and CYP2D6 and CYP2C19 Genotype 195
Whereas tertiary amines are generally more potent in blocking reuptake of serotonin, the
secondary amines are more potent in blocking the reuptake of norepinephrine. Secondary
amines are better tolerated and are also associated with fewer anticholinergic side effects.
The CYP2C19 enzyme metabolizes tertiary amines to active metabolites, which include
desipramine (the active metabolite of imipramine) and nortriptyline (the active
metabolite of amitriptyline). Both the tertiary and secondary amines are metabolized by
CYP2D6 to less active metabolites.
The effectiveness and tolerability of tricyclics are affected by CYP2D6 metabolism and
partially by CYP2C19 metabolism. Individuals who carry CYP2D6 or CYP2C19 variants
that influence enzyme activity may be at an increased risk of treatment failure (if plasma
drug levels are decreased) or drug toxicity (if plasma drug levels are increased).
Drug: Imipramine
Imipramine was the first tricyclic used in the treatment of depression in the late 1950s.
Imipramine is still used to relieve the symptoms of major depressive disorder, and it may
be useful too as temporary adjunctive therapy in reducing enuresis (bedwetting) in
children aged 6 years and older. Off-label uses of imipramine also include the treatment of
neuropathic pain and attention deficit disorder.
Imipramine is a tertiary amine and is similar in structure to amitriptyline, another
tertiary amine. Both drugs potently block the reuptake of serotonin and to a lesser degree
norepinephrine. Imipramine has also strong affinities for alpha-1 adrenergic, histamine
H1, and muscarinic M1 receptors, which account for its side effects of orthostatic
hypotension, sedation, weight gain, and anticholinergic effects. However, the intensity of
these side effects is generally less than it is for amitriptyline (3).
Imipramine is metabolized by CYP2C19 to desipramine, which is also a tricyclic
antidepressant with distinct clinical features that differ from the imipramine. Desipramine
is then metabolized by CYP2D6 to the less active hydroxy-imipramine. For therapeutic
drug monitoring, the levels of imipramine and hydroxy-imipramine should be monitored
(4).
The optimal therapeutic range for imipramine is well-defined (5). Most individuals
display an optimal response to imipramine when combined serum levels of imipramine
and desipramine are between 175 and 300 ng/mL (6). However, individuals who are
carriers of certain CYP2D6 and/or CYP2C19 variants may have drug levels that are
outside this range even after being treated with standard doses of imipramine. As a result,
they may have an increased risk of side effects (if the level of imipramine and its active
metabolites are too high) or treatment failure (if drug levels are too low).
Gene: CYP2D6
metabolism.
including antipsychotics, analgesics, beta-blockers, and TCAs such as imipramine.
CYP2D6 is highly polymorphic, with over 100 star (*) alleles described and currently
CYP2D6 is a particularly complex gene that is difficult to genotype, partly because of the
large number of variants, but also because of the presence of gene deletions, duplications,
and its neighboring pseudogenes. The complexity of genetic variation at this locus
complicates the ability to interrogate CYP2D6.
There is substantial variation in CYP2D6 allele frequencies among different populations
(8). CYP2D6*1 is the wild-type allele and is associated with normal enzyme activity and
the “normal metabolizer” phenotype. The CYP2D6 alleles *2, *33, and *35 are also
considered to have normal activity.
Other alleles include no function variants that produce a non-functioning enzyme (e.g.,
*3, *4, *5, *6, *7, *8, and *12) or an enzyme with decreased activity (e.g., *10, *17, *29, and
*41) (see Table 1) (9). There are large inter-ethnic differences in the frequency of these
alleles, with *3, *4, *5, *6, and *41 being more common in the Caucasian population, *17
more common in Africans, and *10 more common in Asians (10).
patients)a
laboratories.
Bishop J.R.,
Kharasch E.D., Skaar T.C., Gaedigk A., Dunnenberger H.M., Klein T.E., Caudle K.E. Clinical
Table 1 continues on next page...
Table 1 continued from previous page.

or combinations of
2.0
patients)
patients) *3/*4
*5/*5
*5/*6
laboratories.
Bishop J.R.,
Kharasch E.D., Skaar T.C., Gaedigk A., Dunnenberger H.M., Klein T.E., Caudle K.E. Clinical

no function CYP2D6 alleles, respectively (Table 1). Approximately 30% of Asians and
individuals of Asian descent are intermediate metabolizers. In these populations, only half
of CYP2D6 alleles are fully functional, with the reduced function *10 variant being very
common (~40%, compared to ~2% in Caucasians) (11). As a result, Asians are more likely
to be intermediate metabolizers than Caucasians (12). Similarly, in Africans and African
Americans, only half of CYPD6 alleles are functional; however, a wider range of variants
account for the remaining alleles (12-14).
metabolizers, mainly due to no function *4 and *5 alleles (12). Notably, less than 40% are
homozygous normal metabolizers (carrying two copies of *1 allele) (15-17).
Individuals who are CYP2D6 poor metabolizers require a lower dose of imipramine to be
in therapeutic range than CYP2D6 normal metabolizers (18). When treated with standard
doses of imipramine, individuals who are CYP2D6 poor metabolizers will also have
higher plasma concentrations of imipramine and desipramine compared to CYP2D6
normal metabolizers (19).
Because adverse effects are more likely due to elevated tricyclic plasma concentrations,
CPIC recommends alternative agents for individuals who are CYP2D6 poor metabolizers.
If a tricyclic is warranted, CPIC recommends considering a 50% reduction of the usual
starting dose, and they strongly recommend therapeutic drug monitoring (4).
Individuals who have more than two copies of normal function CYP2D6 alleles are
CYP2D6 ultrarapid metabolizers. These individuals require higher doses of imipramine to
be within therapeutic range compared to normal metabolizers (18). However, increasing
the dose of imipramine can lead to high plasma concentrations of desipramine, which
may increase the risk for cardiotoxicity. Therefore, CPIC recommends that an alternative
agent be used for CYP2D6 ultrarapid metabolizers. However, if a tricyclic is warranted,
there is insufficient evidence to calculate a starting dose, and so therapeutic drug
monitoring is strongly recommended (4) (Table 2).
Table 2. 2016 CPIC Dosing recommendations for tricyclic antidepressants based on CYP2D6 phenotype
CYP2D6 ultrarapid Increased metabolism of TCAs to Avoid tricyclic use due to potential
metabolizer less active compounds compared to lack of efficacy. Consider alternative
normal metabolizers drug not metabolized by CYP2D6
Lower plasma concentrations of If a TCA is warranted, consider
active drugs will increase probability titrating to a higher target dose
of pharmacotherapy failure (compared to normal metabolizers)a.
guide dose adjustments.
depression.
The therapeutic recommendations for amitriptyline and nortriptyline are classified as “moderate” for
intermediate CYP2D6 metabolizers, and “strong” for ultrarapid, normal, and poor CYP2D6 metabolizers.
CPIC state that it may be reasonable to apply these recommendations to other TCAs also metabolized by
CYP2D6, including clomipramine, desipramine, doxepin, imipramine, and trimipramine.
dose.

CYP2D6 normal Normal metabolism of TCAs Initiate therapy with recommended
metabolizer starting doseb.
CYP2D6 intermediate Reduced metabolism of TCAs to Consider a 25% reduction of
metabolizer less active compounds compared to recommended starting doseb. Utilize
normal metabolizers therapeutic drug monitoring to guide
dose adjustmentsa.
Higher plasma concentrations of
active drug will increase the
probability of side effects
CYP2D6 poor metabolizer Greatly reduced metabolism of Avoid tricyclic use due to potential for
TCAs to less active compounds side effects. Consider alternative drug
compared to normal metabolizers not metabolized by CYP2D6
Higher plasma concentrations will If a TCA is warranted, consider a 50%
increase the probability of side reduction of recommended starting
effects doseb. Utilize therapeutic drug
monitoring to guide dose
adjustmentsa.
depression.
The therapeutic recommendations for amitriptyline and nortriptyline are classified as “moderate” for
intermediate CYP2D6 metabolizers, and “strong” for ultrarapid, normal, and poor CYP2D6 metabolizers.
CPIC state that it may be reasonable to apply these recommendations to other TCAs also metabolized by
CYP2D6, including clomipramine, desipramine, doxepin, imipramine, and trimipramine.
dose.
Gene: CYP2C19
tricyclic antidepressants, including imipramine.
The CYP2C19 gene is highly polymorphic as 35 variant star (*) alleles are currently
catalogued at the Human Cytochrome P450 (CYP) Allele Nomenclature Database:
(http://www.cypalleles.ki.se/cyp2c19.htm).
The most common no function variant is CYP2C19*2, which is characterized by c.
681G>A in exon 5 that results in an aberrant splice site and the production of a truncated
and non-functioning protein. The CYP2C19*2 allele frequencies are ~15% in Caucasians
and Africans, and ~29–35% in Asians (20, 21).
Another commonly tested no function variant is CYP2C19*3, which is characterized by c.
636G>A in exon 4 that causes a premature stop codon. The CYP2C19*3 allele frequencies
are ~2–9% in Asian populations, but rare in other racial groups. Other no function
variants occur in less than 1% of the general population, and include CYP2C19*4-*8 (20,
21).
“CYP2C19 intermediate metabolizers” carry one copy of a no function allele (e.g. *1/*2),
whereas “poor metabolizers” are homozygous or compound heterozygous for two no
function alleles (e.g., *2/*2, *2/*3) (Table 3).
Table 3: 2016 Assignment of CYP2C19 phenotypes by CPIC
Phenotype Genotypes Examples of diplotypes
CYP2C19 ultrarapid metabolizer An individual carrying two *17/*17
(approximately 2–35% of patients)a increased function alleles
CYP2C19 rapid metabolizer An individual carrying one normal *1/*17
(approximately 2–30% of patients) function allele and one increased
function allele
CYP2C19 normal metabolizer An individual carrying two normal *1/*1
(approximately 35–50% of patients) function alleles
CYP2C19 intermediate metabolizer An individual carrying one normal *1/*2
(approximately 18–45% of patients) function and one no function allele *1/*3
or one no function allele and one *2/*17b
increased function allele
CYP2C19 poor metabolizer An individual carrying two no *2/*2
(approximately 2–15% of patients) function alleles *2/*3
*3/*3
b The predicted metabolizer phenotype for the *2/*17 genotype is a provisional classification.
Studies have found that individuals who are CYP2C19 poor metabolizers have a lower
plasma clearance of imipramine compared to normal metabolizers. When given standard
doses of imipramine, CYP2C19 poor metabolizers have greater concentrations of
imipramine and its active metabolite desipramine (22-24). Increased drug levels could
potentially lead to an increased risk of adverse events. CPIC recommends considering a

50% reduction in the starting dose of tricyclics for CYP2C19 poor metabolizers (4)
Individuals who are CYP2C19 ultrarapid metabolizers may require an increased dose of
tricyclics (25).
One study found that the imipramine plasma concentration was significantly lower in
ultrarapid metabolizers (i.e., CYP2C19*17/*17) when compared to normal metabolizers
(i.e., CYP2C19*1/*1) patients. However, the imipramine + desipramine plasma
concentrations were not significantly different between CYP2C19 genotypes (26). Because
of the possibility of altered tricyclic plasma concentrations, CPIC recommends an
alternative tricyclic or other drug for ultrarapid metabolizers (4) (Table 4).
Table 4. 2016 CPIC Dosing recommendations for tertiary amines based on CYP2C19 phenotype
CYP2C19 ultrarapid Increased metabolism of tertiary Avoid tertiary amine use due to potential
metabolizer and CYP2C19 amines as compared to normal for sub-optimal response. Consider
rapid metabolizer metabolizers alternative drug not metabolized by
Greater conversion of tertiary CYP2C19. TCAs without major CYP2C19
amines to secondary amines metabolism include the secondary amines
may affect response or side nortriptyline and desipramine.
effects
If a tertiary amine is warranted, utilize
therapeutic drug monitoring to guide
dose adjustmentsa.
CYP2C19 normal Normal metabolism of tertiary Initiate therapy with recommended
metabolizer amines starting doseb.
CYP2C19 intermediate Reduced metabolism of tertiary Initiate therapy with recommended
metabolizer amines compared to normal starting doseb.
metabolizers
CYP2C19 poor metabolizer Greatly reduced metabolism of Avoid tertiary amine use due to potential
tertiary amines compared to for sub-optimal response.
normal metabolizers Consider alternative drug not
metabolized by CYP2C19. TCAs without
metabolizers. CPIC state that it may be reasonable to apply these recommendations to other TCAs also
metabolized by CYP2C19, including clomipramine, doxepin, imipramine, and trimipramine.
dose.

Decreased conversion of tertiary major CYP2C19 metabolism include the
amines to secondary amines secondary amines nortriptyline and
may affect response or side desipramine.
effects For tertiary amines, consider a 50%
reduction of recommended starting
doseb. Utilize therapeutic drug
monitoring to guide dose adjustmentsa.
metabolizers. CPIC state that it may be reasonable to apply these recommendations to other TCAs also
metabolized by CYP2C19, including clomipramine, doxepin, imipramine, and trimipramine.
dose.
Genetic Testing
Clinical genotyping tests are available for many CYP2D6 and CYP2C19 alleles. The NIH’s
Genetic Testing Registry (GTR) provides a list of test providers for “imipramine response,”
and the CYP2D6 and CYP2C19 genes.
is important to note that the number of variants tested can vary among laboratories,
which can result in diplotype result discrepancies between testing platforms and
laboratories (28).

2016 Statement from the US Food and Drug Administration (FDA): The biochemical
activity of the drug metabolizing isozyme cytochrome P450 2D6 (debrisoquin
hydroxylase) is reduced in a subset of the Caucasian population (about 7% to 10% of
Caucasians are so-called “poor metabolizers”); reliable estimates of the prevalence of
reduced P450 2D6 isozyme activity among Asian, African, and other populations are not
yet available. Poor metabolizers have higher than expected plasma concentrations of
tricyclic antidepressants (TCAs) when given usual doses. Depending on the fraction of
drug metabolized by P450 2D6, the increase in plasma concentration may be small, or
quite large (8-fold increase in plasma AUC of the TCA).
In addition, certain drugs inhibit the activity of this isozyme and make normal
metabolizers resemble poor metabolizers. An individual who is stable on a given dose of
TCA may become abruptly toxic when given one of these inhibiting drugs as concomitant
therapy. The drugs that inhibit cytochrome P450 2D6 include some that are not
metabolized by the enzyme (quinidine; cimetidine) and many that are substrates for P450
2D6 (many other antidepressants, phenothiazines, and the Type 1C antiarrhythmics
propafenone and flecainide). While all the selective serotonin reuptake inhibitors (SSRIs),
e.g., fluoxetine, sertraline, and paroxetine, inhibit P450 2D6, they may vary in the extent
of inhibition. The extent to which SSRI-TCA interaction may pose clinical problems will
depend on the degree of inhibition and the pharmacokinetics of the SSRI involved.
Nevertheless, caution is indicated in the co-administration of TCAs with any of the SSRIs
and also in switching from one class to the other. Of particular importance, sufficient time
must elapse before initiating TCA treatment in a patient being withdrawn from
fluoxetine, given the long half-life of the parent and active metabolite (at least 5 weeks
may be necessary).
Concomitant use of tricyclic antidepressants with drugs that can inhibit cytochrome P450
2D6 may require lower doses than usually prescribed for either the tricyclic
antidepressant or the other drug. Furthermore, whenever one of these other drugs is
withdrawn from co-therapy, an increased dose of tricyclic antidepressant may be
required. It is desirable to monitor TCA plasma levels whenever a TCA is going to be co-
administered with another drug known to be an inhibitor of P450 2D6.
generic drug.

(CPIC):
Because the TCAs have comparable pharmacokinetic properties, it may be reasonable to
extrapolate this guideline to other TCAs including clomipramine, desipramine, doxepin,
imipramine, and trimipramine, with the acknowledgement that there are fewer data
supporting dose adjustments for these drugs than for amitriptyline or nortriptyline. […]
CYP2D6 dosing recommendations.
[…]. The recommended starting dose of amitriptyline or nortriptyline does not need
adjustment for those with genotypes predictive of CYP2D6 normal metabolism. A 25%
reduction of the recommended dose may be considered for CYP2D6 intermediate
metabolizers. The strength of this recommendation is classified as “moderate” because
patients with a CYP2D6 activity score of 1.0 are inconsistently categorized as intermediate
or normal metabolizers in the literature, making these studies difficult to evaluate.
CYP2D6 ultrarapid metabolizers have a higher probability of failing amitriptyline or
nortriptyline pharmacotherapy due to subtherapeutic plasma concentrations, and
alternate agents are preferred. There are documented cases of CYP2D6 ultrarapid
metabolizers receiving large doses of nortriptyline in order to achieve therapeutic
concentrations. However, very high plasma concentrations of the nortriptyline hydroxy-
metabolite were present, which may increase the risk for cardiotoxicity. If a tricyclic is
warranted, there are insufficient data in the literature to calculate a starting dose for a
patient with CYP2D6 ultrarapid metabolizer status, and therapeutic drug monitoring is
strongly recommended. Adverse effects are more likely in CYP2D6 poor metabolizers due
to elevated tricyclic plasma concentrations; therefore, alternate agents are preferred. If a
tricyclic is warranted, consider a 50% reduction of the usual dose, and therapeutic drug
monitoring is strongly recommended.
CYP2C19 dosing recommendations.
[…]. The usual starting dose of amitriptyline may be used in CYP2C19 normal and
intermediate metabolizers. Although CYP2C19 intermediate metabolizers would be
expected to have a modest increase in the ratio of amitriptyline to nortriptyline plasma
concentrations, the evidence does not indicate that CYP2C19 intermediate metabolizers
should receive an alternate dose.
Patients taking amitriptyline who are CYP2C19 rapid or ultrarapid metabolizers may be
at risk for having low plasma concentrations and an imbalance between parent drug and
metabolites causing treatment failure and/or adverse events. Although the CYP2C19*17
allele did not alter the sum of amitriptyline plus nortriptyline plasma concentrations, it
was associated with higher nortriptyline plasma concentrations, possibly increasing the
risk of adverse events. For patients taking amitriptyline, extrapolated pharmacokinetic
data suggest that CYP2C19 rapid or ultrarapid metabolizers may need a dose increase.
Due to the need for further studies investigating the clinical importance of CYP2C19*17
regarding tricyclic metabolism and the possibility of altered concentrations, we
recommend to consider an alternative tricyclic or other drug not affected by CYP2C19.

This recommendation is classified as optional due to limited available data. If
amitriptyline is administered to a CYP2C19 rapid or ultrarapid metabolizer, therapeutic
drug monitoring is recommended.
CYP2C19 poor metabolizers are expected to have a greater ratio of amitriptyline to
nortriptyline plasma concentrations. The elevated amitriptyline plasma concentrations
may increase the chance of a patient experiencing side effects. Use an alternative agent not
metabolized by CYP2C19 (e.g., nortriptyline and desipramine) or consider a 50%
reduction of the usual amitriptyline starting dose along with therapeutic drug monitoring.
the Royal Dutch Association for the Advancement of Pharmacy (KNMP):
For CYP2D6 poor metabolizers, defined as patients carrying two inactive alleles, reduce
the dose of imipramine by 70% and monitor imipramine and desipramine plasma
concentrations.
For CYP2D6 intermediate metabolizers, defined as patients carrying two decreased-
activity alleles or one active/ decreased-activity allele and one inactive allele, reduce the
dose of imipramine by 30% and monitor imipramine and desipramine plasma
concentrations.
For CYP2D6 ultrarapid metabolizers, defined as patients carrying a gene duplication in
the absence of inactive or decreased-activity alleles, select an alternative drug (e.g.,
citalopram, sertraline) or increase dose by 70% and monitor imipramine and desipramine
plasma concentration (Table 5).
For CYP2C19 poor metabolizers, reduce the dose of imipramine by 30% and monitor
plasma concentration of imipramine and desipramine or select an alternative drug (e.g.,
fluvoxamine, mirtazapine).
For CYP2C19 intermediate metabolizers, there is insufficient data to allow calculation of
dose adjustment for imipramine, select an alternative drug (e.g., fluvoxamine,
mirtazapine)
There are no data for dose recommendations for CYP2C19 ultrarapid metabolizers (Table
6).
Table 5. CYP2D6 phenotypes and the therapeutic recommendations for imipramine therapy, from The
Dutch Pharmacogenetics Working Group (2011)
Phenotype Recommendations for imipramine therapy
Ultrarapid metabolizer Select alternative drug (e.g., citalopram, sertraline) or increase
dose by 70% and monitor imipramine and desipramine plasma
concentration
Intermediate metabolizer Reduce dose by 30% and monitor imipramine and desipramine
plasma concentrations
Poor metabolizer Reduce dose by 70% and monitor imipramine and desipramine
plasma concentrations
The level of evidence for the therapeutic (dose) recommendations is 4/4 (“good quality”) for all metabolizer
types. There are no data for ultrarapid metabolizers. The Table is adapted from Swen J.J., Nijenhuis M., de
Boer A., Grandia L. et al. Pharmacogenetics: from bench to byte - an update of guidelines. Clinical
pharmacology and therapeutics. 2011;89(5):662–73 (30).
Table 6. CYP2C19 phenotypes and the therapeutic recommendations for imipramine therapy, from The
Phenotype Recommendations for imipramine therapy
Ultrarapid metabolizer No dose recommendations
Intermediate metabolizer No dose recommendations
Poor metabolizer Reduce dose by 70% and monitor plasma concentration of imipramine and
desipramine or select alternative drug (e.g., fluvoxamine, mirtazapine)
The level of evidence for the therapeutic (dose) recommendations is 4/4 (“good quality”) for all metabolizer
types. The table is adapted from (31)
Please review the complete therapeutic recommendations that are located here: (30,
31).
Nomenclature
Coding Protein
identifier for
allele location
Trp152Gly 454delT
Pro34Ser 100C>T
Nomenclature for selected continues on next page...
Nomenclature for selected continued from previous page.

Coding Protein
identifier for
allele location
1023C>T 886T>C
(Thr107Ile)
2850C>T
(Cys296Arg)

Coding Protein
identifier for
allele location
Pro227Pro
Trp212Ter
Acknowledgments
David Kisor, B.S., Pharm.D., Professor and Director of Pharmacogenomics Education,
Pharmacogenomics Program, Manchester University, Indiana; Mohamed Nagy, Clinical
pharmaceutical Services, Children's Cancer Hospital, Egypt; Yolande Saab, Pharm.D.,
Ph.D., Associate Professor of Pharmacogenomics, School of Pharmacy, Lebanese
American University, Lebanon; Stuart Scott, Assistant Professor of Genetics and Genomic
Sciences, Icahn School of Medicine at Mount Sinai; Ranjit K Thirumaran, M.Pharm,
Ph.D., Director, Clinical Pharmacogenomics & Clinical Research Trials, YouScript® /
Genelex Labs;
Chakradhara Rao S Uppugunduri, Maître-assistant at the CANSEARCH Laboratory,

University of Geneva, Switzerland; and Mandy van Rhenen, secretary of the Dutch
Pharmacogenetics Working Group (DPWG), Centre for Information on Medicines, Royal
Dutch Pharmacists Association (KNMP).
References
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Ther. 2016.
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for therapeutic drug monitoring in psychiatry: update 2011. Pharmacopsychiatry.
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Desipramine, Serum [Cited 23 Jan 2017]. Available from: http://
www.mayomedicallaboratories.com/test-catalog/Clinical+and+Interpretive/63508
7. Nunez S.B., Calis K., Cutler G.B. Jr, Jones J., et al. Lack of efficacy of fadrozole in
treating precocious puberty in girls with the McCune-Albright syndrome. The
Journal of clinical endocrinology and metabolism. 2003;88(12):5730–3. PubMed
PMID: 14671160.
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18. Schenk P.W., van Fessem M.A., Verploegh-Van Rij S., Mathot R.A., et al. Association
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605. PubMed PMID: 17667959.
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imipramine in oriental subjects: relation to metoprolol alpha-hydroxylation and S-
mephenytoin 4'-hydroxylation phenotypes. J Pharmacol Exp Ther. 1994;271(2):860–
23. Koyama E., Tanaka T., Chiba K., Kawakatsu S., et al. Steady-state plasma
concentrations of imipramine and desipramine in relation to S-mephenytoin 4'-
hydroxylation status in Japanese depressive patients. J Clin Psychopharmacol.

1996;16(4):286–93. PubMed PMID: 8835703.
24. Skjelbo E., Brosen K., Hallas J., Gram L.F. The mephenytoin oxidation polymorphism
is partially responsible for the N-demethylation of imipramine. Clin Pharmacol Ther.
1991;49(1):18–23. PubMed PMID: 1988236.
26. Schenk P.W., van Vliet M., Mathot R.A., van Gelder T., et al. The CYP2C19*17
genotype is associated with lower imipramine plasma concentrations in a large group
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Imipramine response

CYP2C19 gene
CYP2D6 gene
213
Irinotecan Therapy and UGT1A1 Genotype

Laura Dean, MD1
Created: May 27, 2015; Updated: April 4, 2018.
Introduction
Irinotecan (brand name Camptosar) is a topoisomerase I inhibitor widely used in the
treatment of cancer. It is most frequently used in combination with other drugs to treat
advanced or metastatic colorectal cancer. However, irinotecan therapy is associated with a
high incidence of toxicity, including severe neutropenia and diarrhea (1).
Irinotecan is converted in the body to an active metabolite known as SN-38, which is then
inactivated and detoxified by a UDP-glucuronosyltransferase (UGT) enzyme encoded by
the UGT1A1 gene. The UGT enzymes are responsible for glucuronidation, a process that
transforms lipophilic metabolites into water-soluble metabolites that can be excreted from
the body.
The risk of irinotecan toxicity increases with genetic variants associated with reduced
UGT enzyme activity, such as UGT1A1*28. The presence of this variant results in reduced
excretion of irinotecan metabolites, which leads to increased active irinotecan metabolites
in the blood. Approximately 10% of North Americans carry 2 copies of the UGT1A1*28
allele (homozygous, UGT1A1 *28/*28), and are more likely to develop neutropenia
following irinotecan therapy (1-3).
The FDA-approved drug label for irinotecan states that “when administered as a single-
agent, a reduction in the starting dose by at least one level of irinotecan hydrochloride
injection should be considered for patients known to be homozygous for the UGT1A1*28
allele. However, the precise dose reduction in this patient population is not known and
subsequent dose modifications should be considered based on individual patient
tolerance to treatment” (Table 1) (1).
The Dutch Pharmacogenetics Working Group (DPWG) of the Royal Dutch Association
for the Advancement of Pharmacy (KNMP) recommends starting with 70% of the
standard dose for homozygous carriers of the UGT1A1*28 allele. If the patient tolerates
this initial dose, the dose can be increased guided by the neutrophil count. They state that
no action is needed for heterozygous carriers of the UGT1A1*28 allele (e.g., UGT1A1 *1/
*28) (Table 2) (4). In addition, the French National Network of Pharmacogenetics
(RNPGx) has proposed a decision tree for guiding irinotecan prescribing based on the
UGT1A1 genotype and irinotecan dose (Table 3) (5).

Table 1. FDA (2017) Drug Label for Irinotecan. Therapeutic Recommendations based on UGT1A1
Genotype. Dosage and Administration.
Genotype Recommendations
UGT1A1 *28/*28 When administered as a single-agent, a reduction in the starting dose by at least one
level of irinotecan hydrochloride injection, USP1 should be considered for patients
known to be homozygous for the UGT1A1*28 allele. However, the precise dose
reduction in this patient population is not known and subsequent dose modifications
should be considered based on individual patient tolerance to treatment.
Please see Therapeutic Recommendations based on Genotype for more information from the FDA. Table
adapted from (1).
Table 2. DPWG (2014) Recommendations for Irinotecan and UGT1A1 Genotype.
Phenotype / genotype Recommendations
UGT1A1 intermediate metabolizer NO action is needed for this gene-drug interaction.
(IM)
UGT1A1 poor metabolizer (PM) Start with 70% of the standard dose
If the patient tolerates this initial dose, the dose can be increased,
guided by the neutrophil count.
UGT1A1 *1/*28 NO action is needed for this gene-drug interaction.
UGT1A1 *28/*28 Start with 70% of the standard dose
If the patient tolerates this initial dose, the dose can be increased,
guided by the neutrophil count.
Please see Therapeutic Recommendations based on Genotype for more information from the DPWG. Table
is adapted from (4).
Table 3. RNPGx (2017) Recommendations for Irinotecan and UGT1A1 Genotype.
Dose of irinotecan Recommendation
low doses Presence of the UGT1A1*28 allele is not a major risk factor (little difference
(<180 mg/m2/week) in risk of hematological or digestive toxicity irrespective of the genotype)
180—230 mg/m2 spaced by Patients who are homozygous for the UGT1A1*28 allele have a higher risk of
2—3-week intervals hematological and/or digestive toxicity than patients who are heterozygous
or non-carriers.
For these *28/*28 patients, a 25-30% dose reduction is recommended,
especially if the patient presents other risk factors for toxicity.
Dose can be adjusted for subsequent cycles depending on the tolerance.
Please see Therapeutic Recommendations based on Genotype for more information from the RNPGx. Table
1 USP stands for the United States Pharmacopeia. The USP establishes standards that promote
safe medication use (e.g., procurement, prescribing, transcribing, order entry, preparation,
dispensing, administration, and monitoring of medications).
Irinotecan Therapy and UGT1A1 Genotype 215
Dose of irinotecan Recommendation

240 mg/m2 or higher Homozygous UGT1A1*28 patients have a greatly increased risk of
spaced by 2—3-week hematological toxicity (neutropenia) compared with other genotypes,
intervals contraindicating administration at this higher dose and leading to
discussion of a standard dose depending on the associated risk factors.
Administration of an intensive dose (240 mg/m2) is recommended only for
*1/*1 patients, or for *1/*28 patients who have no other risk factors and who
benefit from intensive surveillance.
Please see Therapeutic Recommendations based on Genotype for more information from the RNPGx. Table
Drug: Irinotecan
Irinotecan is used to treat colorectal cancer, which is the third most common cancer
worldwide (6). It is often used in combination with other drugs to treat patients with
advanced or metastatic colorectal cancer, when the cancer has recurred, or has progressed
following initial treatment. A common irinotecan-based combination therapy is referred
to as FOLFIRI (FOLinic acid [also known as leucovorin], Fluorouracil, IRInotecan).
Irinotecan is a semisynthetic derivative of the antineoplastic agent camptothecin, which
derives its name from the Camptotheca tree where it was first isolated. Like camptothecin,
irinotecan is an inhibitor of the nuclear enzyme, topoisomerase I. This enzyme catalyzes a
number of nuclear processes; regulation of DNA supercoiling, replication, recombination,
and repair.
Topoisomerase I decreases the torsional strain in the helical strands of DNA by making
single strand breaks in the DNA. Single strands of DNA pass through the breaks and bind
to the topoisomerase to form a cleavable complex. Once the DNA is sufficiently relaxed
and the passage of strands has been completed, topoisomerase re-ligates the broken DNA
strands and allows for transcription to proceed (7, 8).
Irinotecan is a pro-drug, and is converted by carboxylesterase enzymes to the active
metabolite SN-38, which is 100–1000 times more potent that its parent drug, after
administration by intravenous injection (9). The SN-38 metabolite exerts its cytotoxic
effects by binding to the cleavable complex to form a ternary drug-topoisomerase-DNA
complex. This complex is thought to prevent the re-ligation of the single strand breaks,
which interrupts the moving DNA replication fork. The arrest of replication and the
interaction between replication enzymes and the ternary complex introduces lethal
double-stranded breaks in DNA causing irreparable DNA damage and subsequent cell
apoptosis. (10, 11).
SN-38 is lipophilic, and it needs to be inactivated by undergoing phase II metabolism
(glucuronidation). The resulting conjugated SN-38 glucuronide is water-soluble, and is
mainly excreted through the bile, with about 30% excreted by the kidneys (12).
Irinotecan-based combination therapy has been found to be superior in overall response

and survival when compared with the use of 5-fluorouracil/leucovorin therapy alone for
patients with metastatic colorectal cancer (3). However, the use of irinotecan is limited by
a high incidence of unpredictable and severe dose-limiting toxicity, including severe
neutropenia, fever, and diarrhea (13). The rate of grade 3 or 4 adverse events is around
20-25% (14). Approximately 7% of patients who present with severe neutropenia and
fever following treatment with irinotecan will die from these complications (3, 15-18).
Gene: UGT1A1
The UGT enzymes (uridine diphosphate-glucuronosyltransferase, or UDP-
glucuronosyltransferase) are a superfamily of enzymes that metabolize a wide range of
lipophilic molecules such as bilirubin, steroids, toxins, and drugs—including irinotecan’s
active metabolite, SN-38. These enzymes mediate the process of glucuronidation, which is
a phase II metabolic pathway during which glucuronic acid is conjugated to specific
targets to convert them to water-soluble metabolites that can then be eliminated from the
body.
The UGT genes are polymorphic, and genomic processes, such as copy-number
variations, variant splicing, and epigenetic factors, likely contribute to their diversity. As a
result, the substrates that the UGT enzymes catalyze are particularly variable (19).
The UGT superfamily contains at least 117 enzymes divided into 4 families, of which
UGT1A is a member (20). The UGT1A gene locus, located on chromosome 2q37, is
complex—it encodes multiple genes and pseudogenes, and alternatively spliced isoforms
also exist (21).
The UGT1A locus contains multiple alternative first coding exons, each of which has its
own promoter site, enabling the transcription of 9 unique UGT1A enzymes (22). One of
these transcripts is UGT1A1, which encodes UGT1A1, the bilirubin-UGT enzyme.
Whereas many UGT enzymes overlap in the substrates they glucuronidate, UGT1A1 is
the only enzyme that glucuronidates bilirubin (23).
Bilirubin is a yellow waste product produced during the catabolism of heme, a constituent
of hemoglobin. When old or damaged red blood cells are broken down in the spleen, their
hemoglobin is broken down to heme, which is then converted into bilirubin. The
UGT1A1 enzyme converts this toxic, insoluble form of bilirubin (unconjugated bilirubin)
to its nontoxic form (conjugated bilirubin). Because conjugated bilirubin is water-soluble,
it can be dissolved in bile and eliminated with solid waste. If bilirubin is not eliminated
and instead accumulates to high levels (hyperbilirubinemia), it can cause a yellowish
discoloration of the skin and eyes, a condition known as jaundice.
Variants of the UGT1A1 gene that decrease UGT1A1 enzyme activity can lead to
jaundice. The data suggests that one copy of *28 allele results in about a 35% decrease in
transcriptional activity, and 2 copies (*28/*28, homozygous) results in about a 70%
decrease (24, 25).
The jaundice may be mild, as seen in Gilbert syndrome, or severe, as seen in Crigler-
Najjar syndrome. Crigler-Najjar syndrome presents in 2 forms called type 1 and type 2.
Type 1 is the extremely severe form where affected individuals can die in childhood due to
kernicterus (bilirubin-induced brain injury), although they may survive for longer with
treatment. Type 2 is less severe; the affected individuals are less likely to develop
kernicterus and most survive into adulthood.
Currently, over 135 genetic variants of UGT1A1 have been reported (23, 26). UGT1A1*1
is the wild-type allele associated with normal enzyme activity. The most common variant
allele is UGT1A1*28, which is commonly found in African-Americans (0.42–0.45 allele
frequency) and Caucasians (0.26–0.31), and is less common in Asian populations (0.09–
0.16) (27, 28). Within Caucasian and African American populations, the UGT1A1*28
variant is a common cause of Gilbert syndrome and is also a cause of Crigler-Najjar
syndrome types 1 and 2 (19, 27).
The UGT1A1*28 [(TA)7TAA] variant contains an extra thymine-adenine (TA) repeat
within the TATA box promoter region (7 TA repeats compared with 6 in the wild-type
allele) (29). This extra (TA) repeat decreases the rate of transcription initiation of the
UGT1A1 gene, leading to decreased enzyme activity and decreased glucuronidation of
bilirubin to about 30% of wild-type levels (30).
Another variant allele, UGT1A1*37 [(TA)8TAA], has 8 TA repeats at this site, and results
in reduced promoter activity of the gene to levels lower than the UGT1A1*28 allele. In
contrast, the UGT1A1*36 [(TA)5TAA] allele only has 5 repeats and is associated with
increased promoter activity and a reduced risk of neonatal hyperbilirubinemia (a
common, and typically benign condition). Both UGT1A1*36 and UGT1A1*37 occur
almost exclusively in populations of African origin, with estimated allele frequencies of
0.03–0.10 and 0.02–0.07, respectively.
The UGT1A1*28 variant is also associated with drug toxicity. Approximately 10% of the
North American population is homozygous for the *28 allele (*28/*28 genotype, also
known as UGT1A1 7/7 genotype) and are at an increased risk of neutropenia following
intravenous irinotecan therapy (28). The rate of severe neutropenia in *28/*28
homozygous patients is as high as 36%, and is strongly associated with a higher
hospitalization rate (7, 31, 32).
There is less evidence to support a link between UGT1A1 genotype and irinotecan
treatment-related diarrhea, and there is conflicting data on whether an individual’s
UGT1A1 genotype influences their response to irinotecan therapy (8, 33).
Another variant allele, UGT1A1*6, is more prevalent in Asian populations, with an allele
frequency of around 15–30% in Chinese, Korean, and Japanese populations (24, 34, 35).
In this variant, there is a switch of amino acids, from a glycine to an arginine at position
71 within a coding region (p.Arg71Gly). Individuals who are homozygous for this allele
have reduced UGT1A1 enzyme activity, which can cause Gilbert syndrome and prolonged
neonatal jaundice (36-39). This variant also appears to be an important predictor of severe
toxicity to irinotecan therapy in Asian populations (35, 40-47).
In addition to genetic variations in the UGT1A1 gene, several other genetic markers may
influence the risk of irinotecan toxicity. These include genetic variation in the adenosine
triphosphate (ATP)-binding cassette (ABC) transporter genes, ABCC1 and ABCB2 (43,
48, 49), the solute carrier (SLC) transporter genes (48, 50, 51), the transforming growth
factor (TGFB) gene (52), and the xenobiotic-sensing receptor, NR1I2 (53).
The emerging data suggests that other variant alleles may have a protective effect. The
newly discovered marker rs11563250 (NM_001287395.1:c.-1068A>G), located in the 3′-
flanking region of UGT1A1, has a major A allele (rs11563250A) and a relatively common
variant G allele (rs11563250G, found in 12% of the population). Carriers of the G allele
have a lower risk of irinotecan-induced neutropenia. They also tend to have lower total
plasma bilirubin levels, suggesting that this variant is associated with an enhanced
capacity for glucuronidation. Evidence suggests that carriers of rs11563250G could
tolerate a higher dose of irinotecan, especially if they also have the UGT1A1*1/*1
genotype (54).
Genetic Testing
The NIH’s Genetic Testing Registry provides examples of the genetic tests currently
available for irinotecan response and for the UGT1A1 gene.
Genetic testing can be used to optimize irinotecan dosing. For example, the use of
genotyping in selective cases may make the following patient choices possible:
• If the patient prefers aggressive treatment: genotyping might allow higher dosing
for *1/*1 and *1/*28 genotypes (55-59).
• If the patient prefers maximizing quality of life: genotyping might allow lower
dosing for *28/*28 genotype (7, 31, 32).
Genotyping may also enable irinotecan to be added to the treatment of other
gastrointestinal tumors without the risk of hematologic toxicity (60). Genotyping may also
be used as part of the management of Gilbert syndrome (15).
In the USA, the common *1 and *28 UGT1A1 alleles comprise 98–99% of genotypes (61).
Routine genotyping typically tests for UGT1A1 *1/*1, *1/*28, and *28/*28 genotypes (also
known as 6/6, 6/7, and 7/7, respectively).
Routine screening does not rule out other UGT1A1 polymorphisms that are more
common in specific populations (7). For example, the UGT1A1*6 allele is common in
Asian populations, and in Japan, a reduced dose of irinotecan is recommended for
individuals with UGT1A1 *6/*6, *6/*28, and *28/*28 genotypes (62). In addition, routine
screening does not identify patients who are being under-dosed and could potentially
tolerate a much higher dose of irinotecan.
The adoption of preemptive UGT1A1*28 genotyping to increase irinotecan safety and

efficacy in clinical practice is still limited and often not covered by health insurance,
despite the significant costs of treating irinotecan-related toxicities (63, 64).
Part of the reason that healthcare providers forgo testing may be because the standard
dose of irinotecan used in FOLFIRI is low (180 mg/m2). A phase II trial is currently
determining whether dosing irinotecan based on genotype, as part of a FOLFIRI
treatment regime, is effective and safe. The standard irinotecan dose of 180 mg/m2 is
being used for patients with the 28/*28 genotype, a dose of 260 mg/m2 is being used for
patients with the *1/*28 genotype, and a dose of 310 mg/m2 is being used for patients with
the *1/*1 genotype (65).

2017 Statement from the US Food and Drug Administration (FDA)

Individuals who are homozygous for the UGT1A1*28 allele (UGT1A1 7/7 genotype) are at
increased risk for neutropenia following initiation of Irinotecan Hydrochloride Injection,
USP treatment.
In a study of 66 patients who received single-agent Irinotecan Hydrochloride Injection,
USP (350 mg/m2 once-every-3-weeks), the incidence of grade 4 neutropenia in patients
homozygous for the UGT1A1*28 allele was 50%, and in patients heterozygous for this
allele (UGT1A1 6/7 genotype) the incidence was 12.5%. No grade 4 neutropenia was
observed in patients homozygous for the wild-type allele (UGT1A1 6/6 genotype).
When administered as a single-agent, a reduction in the starting dose by at least one level
of Irinotecan Hydrochloride Injection, USP should be considered for patients known to
be homozygous for the UGT1A1*28 allele. However, the precise dose reduction in this
patient population is not known and subsequent dose modifications should be considered
based on individual patient tolerance to treatment.
UGT1A1 Testing
A laboratory test is available to determine the UGT1A1 status of patients. Testing can
detect the UGT1A1 6/6, 6/7 and 7/7 genotypes.
generic drug.
2017 Recommendations from the French National Network of

Pharmacogenetics (RNPGx)
Interpreting Results
The RNPGx has proposed a decision tree for guiding irinotecan prescription based on the
UGT1A1 genotype and the protocol’s theoretical dose:
• for low doses (< 180 mg/m2 /week), presence of the UGT1A1*28 allele is not a
major risk factor (little difference in risk of hematological or digestive toxicity
irrespective of the genotype);
• for doses in the 180—230mg/m2 spaced by 2—3-week intervals, patients who are
homozygous for the UGT1A1*28 allele have a higher risk of hematological and/or
digestive toxicity than patients who are heterozygous or non-carriers. For these
*28/*28 patients, a 25% to 30% dose reduction is recommended, especially if the
patient presents other risk factors for toxicity. Dose can be adjusted for subsequent
cycles depending on the tolerance;
• for doses of 240mg/m2 or higher spaced by 2—3 weeks intervals, homozygous
UGT1A1*28 patients have a greatly increased risk of hematological toxicity
(neutropenia) compared with other genotypes, contraindicating administration at
this higher dose and leading to discussion of a standard dose depending on the
associated risk factors. Administration of an intensive dose (240 mg/m2) is
recommended only for *1/*1 patients, or for *1/*28 patients who have no other risk
factors and who benefit from intensive surveillance.
[...]
The first-intention of this strategy for analysis of UGT1A1 status is to detect the *28
variant, the most common deficiency variant observed in the Caucasian population, to be
performed before initiating treatment. Referring to the level of evidence classification for
RNPGx recommendations detailed in the article by Picard et al. in this issue, UGT1A1
genotyping is advisable for a standard dose (180—230mg/m2) and essential for intensified
dose (> 240 mg/m2).
Thus, individualized treatment can be proposed based on the UGT1A1 genotype, with
either a dose reduction for *28/*28 homozygous patients, or possibly dose intensification
for non-carriers of the *28 allele.
For the other UGT1A1 alleles, genotyping is performed by a limited number of
laboratories and is considered a second- intention test.
Moreover, the RNPGx suggests that this analysis could be performed concomitantly with
other genetic explorations for colorectal cancer patients (search for KRAS, BRAF
mutations. . .) and constitutional (search for DYPD variants) in order to guarantee optimal
irinotecan therapy within adequate delay for optimal hospital practices.
2014 Recommendations from the Dutch Pharmacogenetics Working

Group (DPWG) of the Royal Dutch Association for the Advancement of
Pharmacy (KNMP)
UGT1A1 Intermediate Metabolizers (IM)
NO action is needed for this gene-drug interaction.
This genetic variation (IM) is more common in Western populations than the wild-type
(*1/*1). This means that treatment is largely geared to patients with this genetic variation.
Adjustment of the treatment is therefore not useful.
UGT1A1 Poor Metabolizers (PM)
Genetic variation reduces conversion of irinotecan to inactive metabolites. This increases
the risk of serious, life-threatening adverse events.
Recommendation:
1. Start with 70% of the standard dose
If the patient tolerates this initial dose, the dose can be increased, guided by the
neutrophil count.
UGT1A1 *1/*28
NO action is needed for this gene-drug interaction.
This genetic variation (*1/*28) is more common in Western populations than the wild-
type (*1/*1). This means that treatment is largely geared to patients with this genetic
variation. Adjustment of the treatment is therefore not useful.
UGT1A1 *28/*28
Genetic variation reduces conversion of irinotecan to inactive metabolites. This increases
the risk of serious, life-threatening adverse events.
Recommendation:
1. Start with 70% of the standard dose
If the patient tolerates this initial dose, the dose can be increased, guided by the
neutrophil count.
Nomenclature of selected UGT1A1 variants

Coding Protein
identifier
for allele
location
UGT1A1*1 (TA)6TAA NM_000463.2:c.-53_-52TA[7] Not applicable—variant rs8175347
(TATA box promoter)
region
UGT1A1*6 211G>A NM_000463.2:c.211G>A NP_000454.1:p.Gly71Arg rs4148323
Gly71Arg
(TATA box promoter)
region
UGT1A1*28 (TA)7TAA NM_000463.2:c.-53_-52[8] Not applicable—variant rs8175347
(TATA box promoter)
region
(TATA box promoter)
region
UGT1A1*1 is the wild-type allele and is associated with normal enzyme activity.
Note: The UGT1A1*28 variant has 8 TA repeats, as shown by the “[8]” in the official HGVS term,
“NM_000463.2:c.-53_-52[8]”. In the medical literature, the term “(TA)7TAA” is commonly used. Here, 7 of
the TA repeats are shown in parentheses “(TA)7”, followed by the 8th repeat “(TAA)”.
For an overview of the haplotypes for UGT1A1, please see the PharmGKB’s Haplotype Translation Table.
Variation Society (HGVS).
Acknowledgments
The author would like to thank Ben Kong, PharmD, BCPS, Clinical Pharmacist, Oregon
Health & Science University, Oregon, USA; Otito F. Iwuchukwu, RPh, PhD, Assistant
Professor of Pharmaceutical Sciences, Fairleigh Dickinson University School of Pharmacy,
New Jersey, USA; Man Yee Merl, PharmD, BCOP, Senior Clinical Pharmacy Specialist,
Smilow Cancer Hospital at Yale-New Haven Hospital, New Haven, Connecticut, USA;
Jai N. Patel, PharmD, BCOP, Chief, Pharmacology Research, and Associate Professor,
Division of Hematology/Oncology, Department of Cancer Pharmacology, Levine Cancer
Institute, Charlotte, North Carolina, USA; Ryouichi Tsunedomi, PhD, Assistant Professor,
Department of Gastroenterological, Breast and Endocrine Surgery, Yamaguchi University
Graduate School of Medicine, Japan; and Ji-Ye Yin, Department of Clinical Pharmacology,
Xiangya Hospital, Central South University, China; for reviewing this summary.
First Edition (2015)

The author would like to thank Victoria M. Pratt, PhD, FACMG, Director,
Pharmacogenomics Diagnostic Laboratory, Indiana University School of Medicine,
Indiana, USA; Mia Wadelius, Senior Lecturer, Uppsala University, Uppsala, Sweden; and
Wafaa M. Rashed, Head of Clinical Trials Unit, GCT Research Specialist, and IRB
Coordinator, at the Children’s Cancer Hospital, Cairo, Egypt, for reviewing this summary.
Version History
To view earlier versions of this summary, please see:
Update: June 3, 2015
Created: May 27, 2015
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Irinotecan response

UGT1A1 gene
229
Maraviroc Therapy and CCR5 Genotype

Laura Dean, MD1
Created: March 18, 2015; Updated: April 10, 2017.
Introduction
Maraviroc is a chemokine receptor antagonist that is used in combination with other
antiretroviral agents to treat human immunodeficiency virus type 1 (HIV-1) infection.
Maraviroc exerts its therapeutic activity by blocking entry of the HIV-1 virus into
immune cells—specifically the CD4-expressing T-helper cells, which play a major role in
protecting the body from infection—precursor cells, and dendritic cells.
HIV-1 infection is classified in two major forms according to the co-receptor it employs to
gain entry in to the cell, namely the chemokine receptor 5 (CCR5) or the CXC chemokine
receptor 4 (CXCR4). These co-receptors are expressed on different types of cells, and HIV
tropism refers to the types of cells and tissues in which the virus infects and replicates. A
tropism assay is conducted to determine which co-receptor the HIV-1 virus uses, i.e.,
whether the virus is CCR5-tropic, CXCR4-tropic, dual tropic (i.e., HIV-1 virus that is able
to use both receptors), or mixed tropic (i.e., a mixture of HIV-1 viruses, some of which
use CCR5 and others that use CXCR4).
Maraviroc is only indicated for treatment of adults with CCR5 tropic HIV-1 and is not
recommended when the CXCR4-tropic virus has been detected. The FDA-approved drug
label for maraviroc states that “prior to initiation of maraviroc, test all patients for CCR5
tropism using a highly sensitive tropism assay” (1).
Drug: Maraviroc
Maraviroc is the first FDA-approved drug in a class of HIV drugs called entry and fusion
inhibitors. Maraviroc blocks the interaction between HIV-1 and CCR5 in healthy immune
cells, preventing certain strains (CCR5-tropic) of HIV from entering and infecting the
cell. Maraviroc must be taken twice daily and must always be used with other HIV drugs.
Taken in combination with these drugs, maraviroc may lower the HIV virus load in the
blood.
Currently, maraviroc is the only CCR5 co-receptor inhibitor that has been approved for
clinical use (2). It is used to treat HIV-1-infected patients who have a virus that uses
CCR5 for entry, and either never received antiretroviral treatment before, or have
experienced therapeutic failure following traditional antiretroviral therapies (3). Among
other CCR5 antagonists currently under investigation is cenicriviroc, which is in Phase II
trials and appears to block the CCR2 receptor (4, 5).

Maraviroc treatment regimens may be used less often than other regimens. Possible
reasons include the requirement to test for tropism, which is time-consuming and
expensive (see Genetic Testing). Furthermore, there is a large selection of potent and
tolerable treatment regimens currently available that do not require genotyping prior to
use. These treatment regimens may be based on nucleoside reverse transcriptase
inhibitors (NRTI), non-nucleoside reverse-transcriptase inhibitors (NNRTI), boosted
protease inhibitors (PI), and integrase inhibitors (2, 6).
The entry of HIV-1 into a host cell is a complex process, which begins when the viral
envelope glycoprotein, gp120, binds to the cellular protein, CD4. Binding induces
conformational changes in gp120 resulting in the exposure of gp4, another viral envelope
protein that helps mediate the interaction between the virus and cellular co-receptors, and
the fusion of viral and cellular membranes.
The CD4 count is often used to determine the stages of HIV disease. CD4 is a
glycoprotein found on the surface of T helper immune cells. HIV-1 infection leads to a
progressive reduction in the number of T cells that express CD4, and a CD4 count of less
than 200 cells/mm3 is one of the qualifications for a diagnosis of AIDS (7, 8).
Measurement of the CD4 count is useful before HIV treatment is started because the CD4
count provides information on the overall immune function of the patient. In the United
States, antiretroviral therapy (ART) is now recommended for all HIV-infected patients,
regardless of their CD4 count or viral load (9), to keep viral loads at undetectable levels
for as long as possible. In adults receiving optimized background treatment for infection
with CCR5-tropic HIV-1, the addition of maraviroc leads to a greater increase in CD4
counts compared to the addition of placebo (1).
HIV-1 most commonly uses either the CCR5 or CXCR4 co-receptors to enter its target
cells (10). Maraviroc is an effective antiretroviral agent in individuals who only harbor the
CCR5-tropic HIV-1 virus. It is incapable of inhibiting infection against viruses that do not
use CCR5 (i.e., CXCR-using virus or dual/mixed virus) (1).
Maraviroc is metabolized by the cytochrome P450 system, mainly CYP3A, in the liver to
inactive metabolites (11, 12). As noted above, maraviroc must be used in combination
with other antiretroviral medications; the recommended dosage of maraviroc depends on
whether the co-medications are inhibitors or inducers of CYP3A (1).
Gene: CCR5
The chemokine (CC motif) receptor 5 (CCR5) is primarily expressed on the surface of
white blood cells. Chemokines are a type of cytokine—they are small, secreted proteins
that have a crucial role in the inflammatory response by helping immune cells migrate to
areas of tissue damage. Other functions of chemokines include influencing the maturation
of various immune cells and promoting the growth of new blood vessels.
Most chemokines have four characteristic cysteine residues in a conserved location, and
they are classified into four families by the location of the first two cysteine residues: CXC,
Maraviroc Therapy and CCR5 Genotype 231
CC, C, and CX3C. For example, members of the “CC” cytokine family have two adjacent
cysteine residues near their amino terminus.
The receptors for chemokines are G-protein coupled, seven-transmembrane domain
receptors. Two of these receptors, CCR5 (binds CC chemokines) and CXCR4 (binds CXC
chemokines), are also co-receptors used by HIV to enter human white blood cells. CCR5
is expressed on fewer cells (e.g., specific T cells, precursor cells (or macrophages) and
dendritic cells) than CXCR4 (e.g., most immune cells, vascular endothelial cells, and
neurons).
HIV-1 virus that uses the CCR5 co-receptor (CCR5-tropic) is more commonly found in
the early stages of infection. It is also more common among individuals who have yet to
receive treatment, and at least half of all infected individuals harbor only CCR5-tropic
viruses throughout the course of infection. The CXCR4-tropic virus is more commonly
found during later stages of disease and among individuals who have received HIV
treatment. The presence of CXCR4-tropic virus is a predictor of lower CD4 count, a
higher viral load, and a more rapid progression to AIDS (7).
A variant of CCR5, CCR5-Δ32 (NM_000579.3:c.554_585del32), contains a 32 bp deletion
and codes a nonfunctional receptor that hinders the entry of CCR5-tropic virus in to cells.
Individuals who have two copies of this allele are highly resistant to HIV infection, and
although individuals who have one copy of the allele remain susceptible to HIV infection,
the progression of HIV infection to AIDS is delayed (13).
The CCR5-Δ32 allele occurs at high frequency in European Caucasians (5%–14%) but is
rare among African, Native American, and East Asian populations, suggesting that the
allele may have conferred an evolutionary survival advantage (14). Possible causes of a
positive selection pressure include protection against the bubonic plague (Yersinia pestis)
or smallpox (Variola virus) during the Middle Ages. However, other studies have found
that the CCR5-Δ32 allele arose long before this time and underwent neutral evolution
(15).
Genetic Testing
Testing of the HIV-1 virus (i.e., the virus, not the patient) should be carried out prior to
initiation of treatment with maraviroc. A tropism assay is needed to identify individuals
with CCR5-tropic HIV-1. The assay must be highly sensitive to detect low levels of
CXCR4-tropic viruses. Maraviroc should not be prescribed if non-CCR5 variants
(CXCR4-tropic or dual/mixed-tropic) are detected (1, 11). HIV tropism can be
determined by phenotype or genotype testing. Phenotypic assays can be performed using
plasma RNA (if viral load is greater than 1000 copies/ml) or cell-associated DNA (if viral
load is less than 1000 copies/ml). Phenotypic assays use replication-defective laboratory
viruses that carry the complete cloned viral envelope proteins gp120 and gp41 derived
from the patient. Phenotypic assays measure the ability of these pseudoviruses to infect
CD4+ target cells that express either CCR5 or CXCR4 (9).
Genotyping methods are used to predict which co-receptors on the cell are used by the
virus rather than directly assessing tropism. Genotyping methods involve sequencing the
third variable region (V3) of gp120 and using algorithms to predict co-receptor usage.
While phenotypic assays are still considered to be the gold standard, the use of genotyping
to determine patient eligibility for maraviroc is increasing due to low cost, greater
accessibility, and faster turnaround time for the results as compared to the other methods
(16, 17). Although there can be discrepancies between the results from phenotypic and
genotypic assays, the correlation between genotypic assays and the clinical efficacy of
maraviroc is improving (18).
The NIH’s Genetic Testing Registry (GTR) displays genetic testing information for human
genes and conditions, including tests for maraviroc response. These tests investigate the
human genes that contribute to the pharmacokinetics of maraviroc, as opposed to the
FDA-recommended genetic tests, which are tests for viral genes.

2016 Statement from the US Food and Drug Administration (FDA): Prior to initiation
of maraviroc, test all patients for CCR5 tropism using a highly sensitive tropism assay.
Maraviroc is recommended for patients with only CCR5-tropic HIV-1 infection.
Outgrowth of pre-existing low-level CXCR4- or dual/mixed-tropic HIV-1 not detected by
tropism testing at screening has been associated with virologic failure while on maraviroc.
Nomenclature
Allele name Other HGVS reference sequence dbSNP reference
name(s) identifier for allele
Coding Protein
location
CCR5delta32 NM_000579.3:c. NP_000570.1:p.Ser185Ilefs rs333
554_585del32 NP_001093638.1:p.Ser185Ilefs
NM_001100168.1:c.
554_585del32
generic drug.
Maraviroc Therapy and CCR5 Genotype 233
Acknowledgments
The author would like to thank Aniwaa Owusu Obeng, PharmD, Assistant Professor, The
Charles Bronfman Institute for Personalized Medicine, Icahn School of Medicine at
Mount Sinai; and Victoria M. Pratt, Ph.D., FACMG, Director, Pharmacogenomics
Laboratory, Department of Medical and Molecular Genetics, Indiana University School of
Medicine; for reviewing this summary.
First edition:
The author would like to thank Mark Wainberg, Professor of Molecular Biology/Virology
at McGill University; and Timothy Henrich, Assistant Professor of Medicine, Brigham
and Women’s Hospital.
Version History
To view an earlier version of this summary (18 March 2015), please click here.
References
1. SELZENTRY- maraviroc tablet, film coated SELZENTRY- maraviroc solution
[package insert]. Freiberg, Germany: Pfizer Laboratories; 2016. Available from:
https://dailymed.nlm.nih.gov/dailymed/drugInfo.cfm?setid=46f30ac5-
c96b-429e-976d-8c5ee1c0761b
2. Sax P.E. Maraviroc for treatment-naive patients with HIV-1 infection: is the glass half
empty or half full? J Infect Dis. 2010;201(6):797–9. PubMed PMID: 20151843.
3. Parra J., Portilla J., Pulido F., Sanchez-de la Rosa R., et al. Clinical utility of maraviroc.
Clin Drug Investig. 2011;31(8):527–42. PubMed PMID: 21595497.
4. Maraviroc. AIDSinfo Drug Database, Department of Health and Human Services.
November 7, 2016; Available from: http://aidsinfo.nih.gov/drugs/408/maraviroc/0/
patient.
5. Cenicriviroc. AIDSinfo Drug Database, Department of Health and Human Services.;
Available from: http://aidsinfo.nih.gov/drugs/512/cenicriviroc/0/patient.
6. Wyatt H., Herman O., Macartney M., Conibear T., et al. The utility of genotypic
tropism testing in clinical practice. Int J STD AIDS. 2014. [Epub ahead of print].
7. Goetz M.B., Leduc R., Kostman J.R., Labriola A.M., et al. Relationship between HIV
coreceptor tropism and disease progression in persons with untreated chronic HIV
infection. Journal of acquired immune deficiency syndromes. 2009;50(3):259–66.
8. Shepherd J.C., Jacobson L.P., Qiao W., Jamieson B.D., et al. Emergence and
persistence of CXCR4-tropic HIV-1 in a population of men from the multicenter
AIDS cohort study. The Journal of infectious diseases. 2008;198(8):1104–12. PubMed
PMID: 18783316.
10. Michaud V., Bar-Magen T., Turgeon J., Flockhart D., et al. The dual role of
pharmacogenetics in HIV treatment: mutations and polymorphisms regulating
antiretroviral drug resistance and disposition. Pharmacological reviews. 2012;64(3):
803–33. PubMed PMID: 22759796.
PMID: 27388693.
12. Woollard S.M., Kanmogne G.D. Maraviroc: a review of its use in HIV infection and
beyond. Drug Des Devel Ther. 2015;9:5447–68. PubMed PMID: 26491256.
13. Ioannidis J.P., Rosenberg P.S., Goedert J.J., Ashton L.J., et al. Effects of CCR5-Delta32,
CCR2-64I, and SDF-1 3'A alleles on HIV-1 disease progression: An international
meta-analysis of individual-patient data. Annals of internal medicine. 2001;135(9):
782–95. PubMed PMID: 11694103.
14. Stephens J.C., Reich D.E., Goldstein D.B., Shin H.D., et al. Dating the origin of the
CCR5-Delta32 AIDS-resistance allele by the coalescence of haplotypes. American
15. Sabeti P.C., Walsh E., Schaffner S.F., Varilly P., et al. The case for selection at CCR5-
Delta32. PLoS biology. 2005;3(11):e378. PubMed PMID: 16248677.
16. Kagan R.M., Johnson E.P., Siaw M., Biswas P., et al. A Genotypic Test for HIV-1
Tropism Combining Sanger Sequencing with Ultradeep Sequencing Predicts
Virologic Response in Treatment-Experienced Patients. PloS one. 2012;7(9):e46334.
17. Vandekerckhove L.P., Wensing A.M., Kaiser R., Brun-Vezinet F., et al. European
guidelines on the clinical management of HIV-1 tropism testing. The Lancet
infectious diseases. 2011;11(5):394–407. PubMed PMID: 21429803.
18. Perez-Olmeda M., Alcami J. Determination of HIV tropism and its use in the clinical
practice. Expert Rev Anti Infect Ther. 2013;11(12):1291–302. PubMed PMID:
24191978.


CCR5 gene
235

Laura Dean, MD1
Created: September 20, 2012; Updated: May 3, 2016.
Introduction
Mercaptopurine is an immunosuppressant and antineoplastic agent that belongs to the
drug class of thiopurines. It is used in combination with other drugs to treat acute
lymphoblastic leukemia, which is the most common form of cancer in children (1). In
addition, off-label uses include the treatment of inflammatory bowel disease (IBD).
Mercaptopurine is a prodrug that must first be activated to form thioguanine nucleotides
inactivates mercaptopurine, leaving less parent drug available to form TGNs.
An adverse effect of mercaptopurine therapy is bone marrow suppression, which can
occur in any patient, is dose-dependent, and may be reversed by reducing the dose of
mercaptopurine. However, patients who carry two nonfunctional TPMT alleles
universally experience life-threatening myelosuppression when treated with
mercaptopurine, due to high levels of TGNs. Patients who carry one nonfunctional TPMT
allele may also be unable to tolerate conventional doses of mercaptopurine (2, 3).
The FDA-approved drug label for mercaptopurine states that heterozygous patients with
low or intermediate TPMT activity accumulate higher concentrations of active TGNs than
people with normal TPMT activity and are more likely to experience mercaptopurine
toxicity; and that TPMT genotyping or phenotyping (red blood cell TPMT activity) can
identify patients who are homozygous deficient or have low or intermediate TPMT
activity (1).
recommendations for TPMT genotype-based mercaptopurine dosing. These
Start with reduced doses of mercaptopurine for patients with one nonfunctional TPMT
allele, or drastically reduced doses for patients with malignancy and two nonfunctional
alleles; adjust dose based on degree of myelosuppression and disease-specific guidelines.
Consider alternative nonthiopurine immunosuppressant therapy for patients with
nonmalignant conditions and two nonfunctional alleles (see Table 1) (2-4).

Table 1. TPMT phenotypes and the therapeutic recommendations for mercaptopurine therapy, adapted
from CPIC
Phenotype Phenotype TPMT Examples of Therapeutic recommendations for
details Genotype diplotypes mercaptopurine (MP)
Homozygous High enzyme Two or more *1/*1 Start with normal starting dose
wild-type activity. functional TPMT (e.g., 75 mg/m2/d or 1.5 mg/kg/d)
(“normal”) Found in ~86-– alleles and adjust doses of MP (and of any
97% of patients. other myelosuppressive therapy)
without any special emphasis on
MP compared to other agents.
Allow 2 weeks to reach steady state
after each dose adjustment.
Heterozygous Intermediate One functional *1/*2 Start with reduced doses (start at
enzyme activity. TPMT allele plus *1/*3A 30–70% of full dose: e.g., at 50
Found in ~3-– one *1/*3B mg/m2/d or 0.75 mg/kg/d) and
14% of patients. nonfunctional *1/*3C adjust doses of MP based on
TPMT allele *1/*4 degree of myelosuppression and
disease-specific guidelines.
Allow 2–4 weeks to reach steady
state after each dose adjustment.
In those who require a dosage
reduction based on
myelosuppression, the median
dose may be ~40% lower (44
mg/m2) than that tolerated in
wild-type patients (75 mg/ m2).
In setting of myelosuppression,
and depending on other therapy,
emphasis should be on reducing
MP over other agents.
Homozygous Low or deficient Two *3A/*3A For malignancy, start with
variant enzyme activity. nonfunctional *2/*3A drastically reduced doses (reduce
Found in ~1 in TPMT alleles *3C/*3A daily dose by 10-fold and reduce
178 to 1~3736 *3C/*4 frequency to thrice weekly instead
patients. *3C/*2 of daily, e.g., 10 mg/m2/d given
*3A/*4 just 3 days/week) and adjust doses
of MP based on degree of
myelosuppression and disease-
specific guidelines.
Allow 4–6 weeks to reach steady
state after each dose adjustment.
emphasis should be on reducing
MP over other agents. For
MP: Mercaptopurine
2011;89(3):387–91 (2, 3).
Mercaptopurine Therapy and TPMT Genotype 237
Phenotype Phenotype TPMT Examples of Therapeutic recommendations for

details Genotype diplotypes mercaptopurine (MP)
nonmalignant conditions, consider
alternative nonthiopurine
immunosuppressant therapy.
MP: Mercaptopurine
2011;89(3):387–91 (2, 3).

Drug: Mercaptopurine
Mercaptopurine is a neoplastic agent and an immunosuppressive agent that is used in the
treatment of acute lymphoblastic leukemia (ALL) as part of a combination regimen. ALL
is the most common form of cancer in children, accounting for approximately 30% of
childhood malignancies with a peak incidence occurring at 3 to 5 years of age (5).
An off-label use of mercaptopurine is in the treatment of inflammatory bowel disease
(IBD). Along with the closely related azathioprine (which is metabolized to
mercaptopurine), mercaptopurine is used as an “immunomodulator” and as a “steroid-
sparing agent” in the treatment of Crohn’s disease and ulcerative colitis.
Mercaptopurine is a slow-acting drug and for IBD, it typically takes at least three months
of therapy before a therapeutic effect is observed. Therefore, mercaptopurine is used for
the induction and maintenance of IBD remission rather than as a monotherapy for acute
relapses (6). Because the discontinuation of mercaptopurine is associated with a high rate
of relapse of IBD, mercaptopurine is usually continued long-term if there are no adverse

effects (7, 8).
The use of mercaptopurine or the related drug azathioprine, has been associated with a 4-
fold increased risk of developing lymphoma, which does not persist after discontinuation
of therapy (9, 10).
Like all thiopurines, mercaptopurine is a purine analogue, and acts as an antimetabolite
by interfering with nucleic acid synthesis and inhibiting purine metabolism. Activation of
mercaptopurine occurs via HPRT1 (hypoxanthine phosphoribosyltransferase) followed by
a series of reactions to form TGNs. The cytotoxicity of mercaptopurine is due, in part, to
the incorporation of TGNs into DNA.
Inactivation of mercaptopurine occurs via two different pathways, via methylation (by
TPMT) or via oxidation (by xanthine oxidase). TPMT activity is highly variable in
patients because of genetic polymorphism in the TPMT gene.
One of the most frequent adverse reactions to mercaptopurine is myelosuppression, which
can occur in any patient, and can usually be reversed by decreasing the dose of
mercaptopurine. However, all patients who carry two nonfunctional TPMT alleles
(approximately 0.3%) experience life-threatening myelosuppression after starting
treatment with conventional doses of mercaptopurine, due to high levels of TGNs.
Individuals who are heterozygous for nonfunctional TPMT alleles (approximately 10%)
are at a significantly higher risk for toxicity than individuals with two functional alleles.
However, some of these individuals, approximately 40–70%, can tolerate the full dose of
mercaptopurine. This may be because heterozygous-deficient individuals have lower
concentrations of less active metabolites, such as MeMPN (methylmercaptopurine
nucleotides), than homozygous-deficient individuals (2, 3).
Approximately 90% of individuals have normal TPMT activity with two functional alleles;
however, all individuals receiving mercaptopurine require close monitoring (2, 3, 11, 12).
One study reports that in patients with IBD receiving thiopurine therapy, TPMT
polymorphisms are associated with the overall incidence of adverse reactions and with
bone marrow toxicity, but not with other adverse reactions, such as liver damage and
pancreatitis. Therefore, although determining TPMT genotype is helpful before initiating
therapy, regular blood tests to monitor for side effects are needed during therapy (1, 13).
The other mercaptopurine inactivation pathway is via oxidation, which is catalyzed by
xanthine oxidase. If this pathway is inhibited, for example, in patients taking allopurinol
(an inhibitor of xanthine oxidase), the decreased break down of mercaptopurine can lead
to mercaptopurine toxicity (1). However, some studies have found that the co-
administration of allopurinol, with a reduced dose of mercaptopurine (or azathioprine),
can help optimize the treatment response in patients with IBD (14, 15).
Gene: TPMT
metabolism of thiopurines, such as mercaptopurine. TPMT activity is inherited as a co-
alleles (16-19).
typical response to mercaptopurine and a lower risk of myelosuppression. This accounts
for the majority of patients (~86–97%) (2, 3).
• TPMT*2 (c.238G>C)
frequently (16, 20).
Genetic Testing
red blood cells directly (11). In adult patients taking mercaptopurine as an
immunosuppressive agent, there is strong evidence of a near 100% concordance between
phenotype and genotype testing. Inflammatory disease processes do not interfere with the
accuracy of TPMT activity measurements if the blood sample is taken under standard
conditions (e.g., not within two months of a blood transfusion).
However, in patients with leukemia, the concordance between TPMT phenotype and
genotype is poor (27). By the time of diagnosis, red cell TPMT activity is typically greatly
reduced because of atypical hematopoiesis. Therefore, phenotype testing may wrongly
identify an individual as having a TPMT deficiency, e.g., a patient who has two functional
copies of the TPMT gene (homozygous wild-type) may be determined as having only one
functional copy and one nonfunctional variant (TPMT heterozygous); and a patient who
is TPMT heterozygous may be wrongly determined to be TPMT homozygous (two copies
of nonfunctional TPMT variants). In addition, during the course of chemotherapy, TPMT
phenotype testing may reveal excessively high TPMT activity. This is thought to be due to
an excess of young red blood cells with their associated higher level of TPMT enzyme
activity. Therefore, to avoid an incorrect TPMT status, genotype testing is recommended
for patients with leukemia (27).
Finally, one study reported that TPMT genotyping was more reliable than phenotyping in
identifying patients at risk of adverse reactions from thiopurine treatment (28), and
several studies reported that the TPMT genotype is a better indicator than TPMT activity
for predicting TGN accumulation or treatment outcome (12, 29-31).

2015 Statement from the US Food and Drug Administration (FDA): Individuals who
are homozygous for an inherited defect in the TPMT (thiopurine-S-methyltransferase)
gene are unusually sensitive to the myelosuppressive effects of mercaptopurine and prone
to developing rapid bone marrow suppression following the initiation of treatment.
Laboratory tests are available, both genotypic and phenotypic, to determine the TPMT
status. Substantial dose reductions are generally required for homozygous-TPMT
deficient patients (two non-functional alleles) to avoid the development of life threatening
bone marrow suppression. Although heterozygous patients with intermediate TPMT
activity may have increased mercaptopurine toxicity, this is variable, and the majority of
patients tolerate normal doses of mercaptopurine. If a patient has clinical or laboratory
evidence of severe toxicity, particularly myelosuppression, TPMT testing should be
considered. In patients who exhibit excessive myelosuppression due to 6-mercaptopurine,
it may be possible to adjust the mercaptopurine dose and administer the usual dosage of
other myelosuppressive chemotherapy as required for treatment.
generic drug.

(CPIC): Testing for TPMT status is recommended prior to starting mercaptopurine
therapy so that the starting dosages can be adjusted accordingly—see Table 1 for dosing
recommendations. In homozygous variant individuals, consider an alternative agent for
nonmalignant conditions and drastically reduce doses in malignant conditions. In
heterozygous individuals, depending on the disease being treated, starting doses should
be reduced. In both patient groups, a longer period of time should be left after each dose
adjustment to allow for a steady state to be reached.
Nomenclature
Coding Protein
location
Ala80Pro 238G>C
Ala154Thr 460G>A
Tyr240Cys 719A>G
Acknowledgments
First edition:
page/cpic
Version History
References
1. MERCAPTOPURINE- mercaptopurine tablet [package insert]. Spring Valley, NY:
Par Phamaceutical Companies; 2015. Available from: http://dailymed.nlm.nih.gov/
dailymed/drugInfo.cfm?setid=40b09616-5bb1-4ef8-98cd-d87537254296
Ther. 2013;93(4):324–5. PubMed PMID: 23422873.
mercaptopurine. [Cited 2012 July 23]. Available from: http://www.pharmgkb.org/
drug/PA450379
5. Hunger S.P., Mullighan C.G. Acute Lymphoblastic Leukemia in Children. N Engl J
Med. 2015;373(16):1541–52. PubMed PMID: 26465987.
6. Prefontaine E., Macdonald J.K., Sutherland L.R. Azathioprine or 6-mercaptopurine
for induction of remission in Crohn's disease. Cochrane Database Syst Rev. 2009;
(4):CD000545. PubMed PMID: 19821270.
7. Vilien M., Dahlerup J.F., Munck L.K., Norregaard P., et al. Randomized controlled
azathioprine withdrawal after more than two years treatment in Crohn's disease:
increased relapse rate the following year. Aliment Pharmacol Ther. 2004;19(11):1147–
52. PubMed PMID: 15153167.
8. Treton X., Bouhnik Y., Mary J.Y., Colombel J.F., et al. Azathioprine withdrawal in
patients with Crohn's disease maintained on prolonged remission: a high risk of
relapse. Clin Gastroenterol Hepatol. 2009;7(1):80–5. PubMed PMID: 18849016.
9. Kotlyar, D.S., J.D. Lewis, L. Beaugerie, A. Tierney, et al., Risk of lymphoma in patients
with inflammatory bowel disease treated with azathioprine and 6-mercaptopurine: a
meta-analysis. Clin Gastroenterol Hepatol, 2015. 13(5): p. 847-58 e4; quiz e48-50.
10. Khan, N., A.M. Abbas, G.R. Lichtenstein, E.V. Loftus, Jr., et al., Risk of lymphoma in
patients with ulcerative colitis treated with thiopurines: a nationwide retrospective
cohort study. Gastroenterology, 2013. 145(5): p. 1007-1015 e3.
13. Liu Y.P., Wu H.Y., Yang X., Xu H.Q., et al. Association between thiopurine S-
methyltransferase polymorphisms and thiopurine-induced adverse drug reactions in
patients with inflammatory bowel disease: a meta-analysis. PLoS One.

2015;10(3):e0121745. PubMed PMID: 25799415.
14. Smith M.A., Blaker P., Marinaki A.M., Anderson S.H., et al. Optimising outcome on
thiopurines in inflammatory bowel disease by co-prescription of allopurinol. J
Crohns Colitis. 2012;6(9):905–12. PubMed PMID: 22386736.
15. Goel R.M., Blaker P., Mentzer A., Fong S.C., et al. Optimizing the use of thiopurines
in inflammatory bowel disease. Ther Adv Chronic Dis. 2015;6(3):138–46. PubMed
PMID: 25954498.
17. Katara P., Kuntal H. TPMT Polymorphism: When Shield Becomes Weakness.
Interdiscip Sci. 2015. PubMed PMID: 26297310.
18. Schaeffeler E., Fischer C., Brockmeier D., Wernet D., et al. Comprehensive analysis of
thiopurine S-methyltransferase phenotype-genotype correlation in a large population
of German-Caucasians and identification of novel TPMT variants.
Pharmacogenetics. 2004;14(7):407–17. PubMed PMID: 15226673.
19. TPMT Nomenclature Committee [Internet]. Sweden: Linköping University. Table of
TPMT alleles. [Cited 2016 February 02]. Available from: http://www.imh.liu.se/
tpmtalleles/tabell-over-tpmt-alleler?l=en
PMID: 11966406.
21. PharmGKB [Internet]. Palo Alto (CA): Stanford University. Gene: Thiopurine S-
methyltransferase (TPMT). [Cited 2012 July 23]. Available from: http://
2014;24(6):320–3. PubMed PMID: 24710034.
2011;17(6):1441–2. PubMed PMID: 20945351.
PMID: 11736862.
2012;6(6):655–9. PubMed PMID: 22398041.
2013;76(1):125–36. PubMed PMID: 23252716.



Mercaptopurine response

TPMT gene
245

Laura Dean, MD1
Introduction
Metoprolol is a beta blocker used in the treatment of hypertension, angina, and heart
failure. Metoprolol selectively blocks beta1 adrenoreceptors mainly expressed in cardiac
tissue. Blockade of these receptors reduces the heart rate and decreases the force of heart
contractions.
Metoprolol is primarily metabolized by the CYP2D6 enzyme. Approximately 8% of
Caucasians and 2% of most other populations have absent CYP2D6 activity and are
known as “CYP2D6 poor metabolizers.” In addition, a number of drugs inhibit CYP2D6
activity, such as quinidine, fluoxetine, paroxetine, and propafenone.
The FDA-approved drug label for metoprolol states that CYP2D6 poor metabolizers, and
normal metabolizers who concomitantly take drugs that inhibit CYP2D6, will have
increased (several-fold) metoprolol blood levels, decreasing metoprolol’s cardioselectivity
(1).
The Dutch Pharmacogenetics Working Group (DPWG) of the Royal Dutch Association
for the Advancement of Pharmacy (KNMP) has published metoprolol dosing
recommendations based on CYP2D6 genotype. For individuals who have a CYP2D6 gene
variation that reduces the conversion of metoprolol to inactive metabolites, DPWG states
that the clinical consequences are limited mainly to the occurrence of asymptomatic
bradycardia. For CYP2D6 poor metabolizers, if a gradual reduction in heart rate is
desired, or in the event of symptomatic bradycardia, DPWG recommends increasing the
dose of metoprolol in smaller steps and/or prescribing no more than 25% of the standard
dose. For other cases, no action is required (2).
Please note: Beta blockers such as metoprolol have been demonstrated in several large
trials to be safe and effective for treatment of patients with cardiovascular disease. As a
mainstay of therapy associated with improvements in quality of life, hospitalization rates,
and survival (3, 4), clinical care pathways that might lead to underutilization of beta
blockers require scrutiny. FDA points out that CYP2D6 poor metabolizers will have
decreased cardioselectivity for metoprolol due to increased metoprolol blood levels. Yet, it
is common clinical practice to adjust the dose of metoprolol according to the patient’s
heart rate. FDA does not specifically comment on the role of genetic testing for initiating
therapy.

Drug: Metoprolol
Metoprolol is a commonly prescribed drug that belongs to the drug class of beta-
adrenoreceptor antagonists, also known as “beta blockers.” Metoprolol is indicated to treat
hypertension, angina, and heart failure (stable, symptomatic (NYHA Class II or III) heart
failure). Metoprolol selectively blocks the beta1 adrenoreceptor (1).
There are two main types of adrenoreceptors, alpha and beta, each of which have
numbered subtypes. The beta adrenoreceptors have three subtypes, beta1, beta2, and
beta3. All three subtypes are coupled to the Gs protein, which in turn activates adenylate
cyclase enzyme, which catalyzes the production of cyclic AMP (cAMP).
The binding of an agonist, such as the catecholamines adrenaline and noradrenaline, to
beta receptors leads to a rise in the intracellular concentration of cAMP, which triggers
signaling pathways. Stimulation of the beta1 receptor, which is predominantly expressed
in cardiac tissue, leads to an increase in heart rate and an increase in the contractility of
the atria and ventricles. It also leads to the increased secretion of hormones from other
tissues—renin (from the kidneys), ghrelin (from the stomach), and amylase (from the
salivary glands).
In the treatment of heart failure, beta blockers such as extended-release metoprolol are
thought to protect the heart from increased catecholamine stimulation. In the short term,
adrenergic activation can help the heart maintain cardiac performance, but over time,
continued activation can be detrimental. Harmful effects include a persistently increased
heart rate, down-regulation and impaired functioning of the beta receptors, and myocyte
hypertrophy and death—which leads to adverse remodeling of heart tissue (5, 6).
Metoprolol exerts its therapeutic effects by reducing the impact of catecholamine
stimulation. Metoprolol reduces the heart rate, improves contractile function by
stimulating the upregulation of beta-1 receptors, reduces vasoconstriction, and possibly
also reduces the risk of arrhythmias (3, 5, 7, 8).
Metoprolol is a racemic mixture of R- and S-enantiomers (an equal amount of left- and
right-handed enantiomers, which are molecules that are mirror images of each other, but
are not superimposable on one another).
Metoprolol is primarily metabolized by CYP2D6, an enzyme which is absent in about 8%
of Caucasians (poor metabolizers) and about 2% of most other populations. Individuals
who lack CYP2D6 activity will have higher plasma concentrations of metoprolol, almost
5-fold higher, and may be at an increased risk of side effects (9-12).
In addition, at higher plasma concentrations, metoprolol is less cardio-selective.
Metoprolol can inhibit beta2 receptors, which are mainly located in the bronchial and
vascular musculature.
Genetic variants of the CYP2D6 gene have been found to influence the ratio of
enantiomers, the dose and dose titration of metoprolol, and to influence heart rate—
Metoprolol Therapy and CYP2D6 Genotype 247
CYP2D6 poor metabolizers have an increased risk of bradycardia (13-16). However,

CYP2D6 does not appear to influence the efficacy of metoprolol when used to treat
hypertension (17).
Variants within the beta1 receptor have also been found to influence the treatment
response to specific beta blockers. The most commonly studied is a reduced function
variant, Arg389Gly, which leads to reduced levels of cAMP and diminished beta1 receptor
signaling cascades (18). Individuals who are homozygous Arg389 carriers may have a
more favorable response to metoprolol treatment than individuals who are homozygous
for Gly389 (18-21).

activity.
Gene: CYP2D6
Decreased function *9, *10, *17, *29, *36, *41
No function *3-*8, *11-*16, *19-*21, *38, *40, *42
“ultrarapid metabolizers,” whereas individuals who carry two normal or one normal and
one decreased function allele are classified as “normal metabolizers.”
Individuals with one normal and one no function allele or two decreased function alleles
are categorized as “normal metabolizers” by recent nomenclature guidelines (23), but have
also been categorized as “intermediate metabolizers” in the literature. Subjects with one
decreased and one no function allele are predicted to be intermediate metabolizers and
those with two no function alleles, poor metabolizers.
The most common no function alleles include CYP2D6*3, *4, *5, and *6 (24-27), and the
most common decreased function alleles include CYP2D6*9, *10, *17, *29 and *41 (28-32)
(Table 1).
There are large inter-ethnic differences in the frequency of these alleles. For example,
CYP2D6*4 is the most common no function allele in Caucasians, but is less abundant in
subjects with African ancestry, and is rare in Asians. In contrast, the decreased function
exclusively found in individuals with African ancestry (33).
Consequently, the phenotype frequencies also vary substantially among the major
ethnicities and may vary among populations. Approximately 6-8% of European
Caucasians and their descendants are poor metabolizers, mainly due to the prevalent no
function CYP2D6*4 and *5 alleles (34, 35).
Genetic Testing
The NIH’s Genetic Testing Registry provides examples of the genetic tests that are
currently available for metoprolol response and the CYP2D6 gene.

2016 Statement from the US Food and Drug Administration (FDA): Metoprolol is
metabolized predominantly by CYP2D6, an enzyme that is absent in about 8% of
Caucasians (poor metabolizers) and about 2% of most other populations. CYP2D6 can be
inhibited by a number of drugs. Poor metabolizers and extensive metabolizers who
concomitantly use CYP2D6 inhibiting drugs will have increased (several-fold) metoprolol
blood levels, decreasing metoprolol's cardioselectivity.
the Royal Dutch Association for the Advancement of Pharmacy (KNMP):
CYP2D6 Poor Metabolizers:
The gene variation reduces the conversion of metoprolol to inactive metabolites. However,
the clinical consequences are limited mainly to the occurrence of asymptomatic
bradycardia.
generic drug.
Recommendation:
If a gradual reduction in heart rate is desired, or in the event of symptomatic bradycardia:
1 Increase the dose in smaller steps and/or prescribe no more than 25% of the
standard dose
Other cases:
1 No action required
CYP2D6 Intermediate Metabolizers:
The gene variation reduces the conversion of metoprolol to inactive metabolites. However,
the clinical consequences are limited mainly to the occurrence of asymptomatic
bradycardia.
Recommendation:
If a gradual reduction in heart rate is desired, or in the event of symptomatic bradycardia:
1 Increase the dose in smaller steps and/or prescribe no more than 50% of the
standard dose
Other cases:
1 No action required
CYP2D6 Ultrarapid Metabolizers:
The gene variation increases the conversion of metoprolol to inactive metabolites. This
can increase the dose requirement. However, with a target dose of 200 mg/day, there was
no effect on the blood pressure and hardly any effect on the reduction of the heart rate.
Recommendation:
1. Use the maximum dose for the relevant indication as a target dose
2. If the effectiveness is still insufficient: increase the dose based on effectiveness and
side effects to 2.5 times the standard dose or select an alternative
Possible alternatives include:
• Heart failure: bisoprolol or carvedilol. Bisoprolol: advantage: not metabolised by
CYP2D6; disadvantage: elimination depends on the kidney function. Carvedilol:
advantage: elimination does not depend on the kidney function; disadvantage: is
metabolised (to a lesser extent than metoprolol) by CYP2D6.
• Other indications: atenolol or bisoprolol. Neither is metabolised by CYP2D6.

Coding Protein
identifier for
allele location
frameshift)
Trp152Gly 454delT
CYP2D6T
(Pro34Ser) 100C>T
(Thr107Ile) 320C>T
(Cys296Arg) 886T>C
(Cys296Arg) 886T>C
[2] In the literature, 2850C>T is also referred to as 2938C>T.
Acknowledgments
The author would like to thank Larisa H. Cavallari, Pharm.D., Associate Professor,
Department of Pharmacotherapy and Translational Research & Director, Center for
Pharmacogenomics, University of Florida; Mandy van Rhenen, secretary of the Dutch
Dutch Pharmacists Association (KNMP); and John Wikstrand, Professor of Clinical
Physiology, Wallenberg Laboratory, University of Gothenburg, Sweden, for reviewing this
summary.
References
1. TOPROL XL- metoprolol succinate tablet, extended release [Package insert].
Wilmington, DE: AstraZeneca; 2016. Available from: https://dailymed.nlm.nih.gov/
dailymed/drugInfo.cfm?setid=4a5762c6-d7a2-4e4c-10b7-8832b36fa5f4
Group (DPWG). Pharmacogenetic Guidelines [Internet]. Netherlands. Metoprolol –
CYP2D6 [Cited March 2017]. Available from: http://kennisbank.knmp.nl/ [Access is
3. Effect of metoprolol CR/XL in chronic heart failure: Metoprolol CR/XL Randomised
Intervention Trial in Congestive Heart Failure (MERIT-HF). Lancet. 1999;353(9169):
2001–7. PubMed PMID: 10376614.
4. Kotecha D., Manzano L., Krum H., Rosano G., et al. Effect of age and sex on efficacy
and tolerability of beta blockers in patients with heart failure with reduced ejection
fraction: individual patient data meta-analysis. BMJ. 2016;353:i1855. PubMed PMID:
27098105.
5. Bristow M.R. beta-adrenergic receptor blockade in chronic heart failure. Circulation.
2000;101(5):558–69. PubMed PMID: 10662755.
6. Sackner-Bernstein J.D., Mancini D.M. Rationale for treatment of patients with
chronic heart failure with adrenergic blockade. JAMA. 1995;274(18):1462–7.
7. Yoshikawa T., Handa S., Anzai T., Nishimura H., et al. Early reduction of
neurohumoral factors plays a key role in mediating the efficacy of beta-blocker
therapy for congestive heart failure. Am Heart J. 1996;131(2):329–36. PubMed PMID:
8579029.
8. Gilbert E.M., Abraham W.T., Olsen S., Hattler B., et al. Comparative hemodynamic,
left ventricular functional, and antiadrenergic effects of chronic treatment with
metoprolol versus carvedilol in the failing heart. Circulation. 1996;94(11):2817–25.
9. Rau T., Wuttke H., Michels L.M., Werner U., et al. Impact of the CYP2D6 genotype
on the clinical effects of metoprolol: a prospective longitudinal study. Clin Pharmacol
Ther. 2009;85(3):269–72. PubMed PMID: 19037197.
10. Blake C.M., Kharasch E.D., Schwab M., Nagele P. A meta-analysis of CYP2D6
metabolizer phenotype and metoprolol pharmacokinetics. Clin Pharmacol Ther.
2013;94(3):394–9. PubMed PMID: 23665868.
11. Jin S.K., Chung H.J., Chung M.W., Kim J.I., et al. Influence of CYP2D6*10 on the
pharmacokinetics of metoprolol in healthy Korean volunteers. J Clin Pharm Ther.
2008;33(5):567–73. PubMed PMID: 18834373.
12. Wuttke H., Rau T., Heide R., Bergmann K., et al. Increased frequency of cytochrome
P450 2D6 poor metabolizers among patients with metoprolol-associated adverse
effects. Clin Pharmacol Ther. 2002;72(4):429–37. PubMed PMID: 12386645.
13. Baudhuin L.M., Miller W.L., Train L., Bryant S., et al. Relation of ADRB1, CYP2D6,
and UGT1A1 polymorphisms with dose of, and response to, carvedilol or metoprolol
therapy in patients with chronic heart failure. Am J Cardiol. 2010;106(3):402–8.

14. Batty J.A., Hall A.S., White H.L., Wikstrand J., et al. An investigation of CYP2D6
genotype and response to metoprolol CR/XL during dose titration in patients with
heart failure: a MERIT-HF substudy. Clin Pharmacol Ther. 2014;95(3):321–30.
15. Hamadeh I.S., Langaee T.Y., Dwivedi R., Garcia S., et al. Impact of CYP2D6
polymorphisms on clinical efficacy and tolerability of metoprolol tartrate. Clin
16. Bijl M.J., Visser L.E., van Schaik R.H., Kors J.A., et al. Genetic variation in the
CYP2D6 gene is associated with a lower heart rate and blood pressure in beta-blocker
users. Clin Pharmacol Ther. 2009;85(1):45–50. PubMed PMID: 18784654.
17. Zineh I., Beitelshees A.L., Gaedigk A., Walker J.R., et al. Pharmacokinetics and
CYP2D6 genotypes do not predict metoprolol adverse events or efficacy in
hypertension. Clin Pharmacol Ther. 2004;76(6):536–44. PubMed PMID: 15592325.
18. Parvez B., Chopra N., Rowan S., Vaglio J.C., et al. A common beta1-adrenergic
receptor polymorphism predicts favorable response to rate-control therapy in atrial
fibrillation. J Am Coll Cardiol. 2012;59(1):49–56. PubMed PMID: 22192668.
19. Lymperopoulos A., Bathgate A. Pharmacogenomics of the heptahelical receptor
regulators G-protein-coupled receptor kinases and arrestins: the known and the
unknown. Pharmacogenomics. 2012;13(3):323–41. PubMed PMID: 22304582.
20. Huntgeburth M., La Rosee K., ten Freyhaus H., Bohm M., et al. The Arg389Gly
beta1-adrenoceptor gene polymorphism influences the acute effects of beta-
adrenoceptor blockade on contractility in the human heart. Clin Res Cardiol.
2011;100(8):641–7. PubMed PMID: 21311897.
21. Liu J., Liu Z.Q., Tan Z.R., Chen X.P., et al. Gly389Arg polymorphism of beta1-
adrenergic receptor is associated with the cardiovascular response to metoprolol. Clin
22. Malhotra N., Abunassar J., Wells G.A., McPherson R., et al. A pharmacodynamic
comparison of a personalized strategy for anti-platelet therapy versus ticagrelor in
achieving a therapeutic window. Int J Cardiol. 2015;197:318–25. PubMed PMID:
26151596.
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223. PubMed PMID: 27441996.
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[Access is restricted to KNMP membership.]
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treatment. Pharmgenomics Pers Med. 2017;10:29–38. PubMed PMID: 28203102.
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Metoprolol response

CYP2D6 gene
255

Laura Dean, MD1
Created: October 1, 2012; Updated: March 8, 2016.
Introduction
Omeprazole blocks the secretion of gastric acid and belongs to the drug class of proton
pump inhibitors. It is used to treat gastroesophageal reflux disease (GERD), gastric ulcers,
duodenal ulcers, erosive esophagitis, and other acid-related disorders. It is also used in the
treatment of hypersecretory conditions, such as Zollinger-Ellison syndrome, and is used
in combination with antibiotics to eradicate Helicobacter pylori (H. pylori) infection (1).
CYP2C19 is the principal enzyme that metabolizes omeprazole to inactive metabolites.
Approximately 3% of Caucasians and 15 to 20% of Asians have reduced or absent
CYP2C19 enzyme activity (“poor metabolizers”). In these individuals, standard doses of
omeprazole may lead to higher exposure to the drug and improved treatment outcomes
(2). In contrast, individuals with increased CYP2C19 activity (“ultrarapid metabolizers”)
may have an insufficient response to treatment as the active drug is inactivated at a faster
rate.
The FDA-approved drug label for omeprazole states that a dose reduction should be
considered in the Asian population, particularly for the maintenance of healing of erosive
esophagitis (1). The Pharmacogenetics Working Group of the Royal Dutch Association for
the Advancement of Pharmacy (KNMP) has published dose alterations based on
CYP2C19 genotype. For CYP2C19 poor metabolizers, they do not recommend altering
the dose; however for ultrarapid metabolizers, they recommend being extra alert to an
insufficient response to treatment. For the eradication of H. pylori in ultrarapid
metabolizers, they recommend increasing the dose of omeprazole by 100–200%, and to
consider the same dose increase for other conditions (see Table 1) (3, 4).

Table 1. CYP2C19 phenotypes and the therapeutic recommendations for omeprazole therapy, adapted from
the Pharmacogenetics Working Group of the Royal Dutch Association for the Advancement of Pharmacy
(KNMP).
Phenotype Phenotype details Examples of Therapeutic (dose)
diplotypes recommendations for
omeprazole
Ultrarapid metabolizer Normal or increased *17/*17 Be extra alert to insufficient
CYP2C19 activity response. For the eradication of
H. pylori, increase dose by 100–
200%.
For other conditions, consider
dose increase by 100–200%.
Extensive metabolizer Normal CYP2C19 *1/*1 No recommendations
activity
Intermediate Decreased CYP2C19 *1/*2 No recommendations
metabolizer activity *1/*3
*2/*17
*3/*17
Poor metabolizer Markedly reduced or *2/*2 No recommendations
absent CYP2C19 *2/*3
activity *3/*3
Good quality evidence supports the dose recommendations for poor and intermediate metabolizers;
moderate quality evidence supports the dose recommendations for ultrarapid metabolizers.
Drug class: Proton Pump Inhibitors

Proton pump inhibitors (PPIs) are inhibitors of gastric acid secretion that are used in the
treatment of stomach-acid related disorders. PPIs are also used to prevent and treat ulcers
associated with nonsteroidal anti-inflammatory drugs (NSAIDs), and can be used in
combination with antibiotics to eradicate H. pylori infection.
Six PPIs are currently FDA-approved for clinical use: esomeprazole, dexlansoprazole,
lansoprazole, omeprazole, pantoprazole, and rabeprazole. All PPIs are similarly potent at
inhibiting gastric acid secretion and are thought to be similarly efficacious (5, 6).
PPIs are metabolized and inactivated by a number of CYP enzymes, including CYP2C19,
which has a principal role in the metabolism of omeprazole. The increased function
CYP2C19*17 variant allele may enhance PPI clearance (7) resulting in less active PPI
available to inhibit gastric acid secretion. In contrast, the CYP2C19*2 loss-of-function
allele is associated with decreased PPI clearance, resulting in more active PPI available
and enhanced treatment. For several PPIs, including omeprazole and lansoprazole, higher
drug levels in patients with low or absent CYP2C19 activity have been associated with
increased drug efficacy and improved treatment outcomes (2, 8).
Omeprazole Therapy and CYP2C19 Genotype 257
Drug: Omeprazole
Omeprazole was the first PPI to be introduced to the US market in 1989. Today,
omeprazole is one of the PPIs that are available both as prescription and over-the-counter
(OTC) medications.
In adults, omeprazole is used in the treatment of ulcers (gastric and duodenal), GERD,
and to maintain healing of erosive esophagitis. Omeprazole is also used in the long-term
treatment of hypersecretory conditions such as Zollinger-Ellison syndrome, multiple
endocrine adenomas, and systemic mastocytosis. In children, omeprazole is used in the
treatment of GERD and erosive esophagitis (1).
The human stomach contains approximately one billion parietal cells that secrete
hydrochloric acid (HCl) into the gastric lumen. Gastric acid aids digestion by hydrolyzing
dietary protein and facilitating the absorption of calcium, iron, and vitamin B. Gastric
acid also helps maintain a sterile environment by suppressing the growth of bacteria (9).
Hydrogen ions (H+) are actively secreted in to the gastric lumen in exchange for
potassium ions (K+) via an H+/K+-ATPase, which is also known as a “proton pump”.
Located on the surface of gastric parietal cells, the proton pump controls the last step in
acid secretion, and by targeting this step, omeprazole and the other PPIs are able to
potently inhibit gastric acid secretion.
Omeprazole is metabolized and inactivated in the liver by the cytochrome P450 system.
CYP2C19 is the principal enzyme involved, although other enzymes such as CYP3A4 may
also contribute. Omeprazole is metabolized to hydroxy and desmethyl metabolites, which
have no effect on gastric acid secretion (10).
Individuals with reduced CYP2C19 enzyme activity may experience twice the exposure to
omeprazole compared to individuals with normal enzyme function. This reduced enzyme
activity has a positive effect on clinical outcomes, and because PPIs are generally regarded
as safe drugs, especially in the short-term (less than 6 months), this can have a beneficial
effect without an increased risk of omeprazole toxicity (11, 12).
One study reported that when using omeprazole as part of the treatment to eradicate H.
pylori, success was achieved in all patients who had little or no CYP2C19 activity, but in
only 29% of patients who had “normal” CYP2C19 activity. Similar results were found in
another study that evaluated lansoprazole in the treatment of GERD: the cure rate was
85% for patients with little or no CYP2C19 activity, compared to 16% for patients with
normal CYP219 activity (13-15).
The FDA-approved drug label for omeprazole does not comment on dose adjustments
based on CYP2C19 status. However, guidelines from KNMP recommend that patients
with increased CYP2C19 activity (“ultrarapid metabolizers”) should receive an increased
dose of omeprazole for the eradication of H. pylori, and that an increased dose should be
considered for other indications (Table 1).
The long-term use of PPIs has been associated with several adverse effects. Daily
treatment with any PPI for longer than three years may lead to malabsorption of vitamin
B12, caused by hypochlorhydria. Because prolonged hypochlorhydria also increases the
risk of Clostridium difficile infection, and may increase the risk for osteoporosis-related
fractures, the FDA recommends that patients should use the lowest dose and shortest
duration of PPI therapy appropriate to the condition being treated (1).
Gene: CYP2C19
metabolism.
drugs, such as antidepressants, benzodiazepines, and some of the PPIs, including
omeprazole.
CYP2C19 is highly polymorphic, as 35 variant star (*) alleles are currently catalogued at
the Human Cytochrome P450 (CYP) Allele Nomenclature Database (http://
normal enzyme activity and the “extensive metabolizer” phenotype (16).
Caucasians and Africans, and ~29–35% in Asians (17). “Intermediate metabolizers” carry
one copy of an allele that encodes reduced or absent function (e.g. *1/*2), whereas “poor
metabolizers” are homozygous or compound heterozygous for two loss-of-function alleles
(e.g., *2/*2, *2/*3).
CYP2C19*4-*8 (17, 18).
In contrast to non-functional alleles, the CYP2C19*17 allele (c.-806C>T) is associated
with increased enzyme activity. Allele frequencies range from 3 to 21% across different
populations (19). Individuals who are homozygous for the *17 allele are known as
“ultrarapid metabolizers”, and it is this patient group who may benefit from an increased
dose of omeprazole. However, not all studies have identified a significant effect
of CYP2C19*17 on the metabolism of PPIs and treatment outcomes (15, 20, 21).
Genetic Testing
Currently, the FDA does not provide recommendations about the use of CYP2C19 genetic
testing for omeprazole treatment (1).
Clinical genotyping tests are available for several CYP2C19 alleles, and a list of some test
extensive, intermediate, or poor).
Table 1 summarizes common CYP2C19 phenotypes with recommendations developed by
the Pharmacogenetics Working Group of the Royal Dutch Association for the
Advancement of Pharmacy (KNMP).

2014 Statement from the US Food and Drug Administration (FDA): Asian Population:
In pharmacokinetic studies of single 20 mg omeprazole doses, an increase in AUC of
approximately four-fold was noted in Asian subjects compared with Caucasians. Dose
reduction, particularly where maintenance of healing of erosive esophagitis is indicated,
for Asian subjects should be considered.
the Royal Dutch Association for the Advancement of Pharmacy (KNMP): For
individuals who are ultrarapid metabolizers, an increase in the dose of omeprazole by
100–200% is recommended for the eradication of H.pylori, and the physician should be
extra alert to an insufficient response. For other conditions, the physician should remain
extra alert to an insufficient response, and consider a dose increase by 100–200%.
There are no therapeutic (dose) recommendations for individuals who are either poor or
intermediate metabolizers.
generic drug.
Nomenclature
Coding Protein
identifier for
allele location
Pro227Pro
Trp212Ter
region
Acknowledgments
Genomic Sciences, Icahn School of Medicine at Mount Sinai; and Mia Wadelius, Senior
Lecturer, Uppsala University; for reviewing this summary.
Version History
To view an earlier version of this summary (update: 18 March 2013), please click here.
References
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healing of gastroesophageal reflux disease is unrelated to the genotype of CYP2C19:
evidence from clinical and pharmacokinetic data. Clinical pharmacology and
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10901708.
11. Desta Z., Zhao X., Shin J.G., Flockhart D.A. Clinical significance of the cytochrome
P450 2C19 genetic polymorphism. Clinical pharmacokinetics. 2002;41(12):913–58.
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pharmacokinetics. European journal of clinical pharmacology. 2008;64(10):935–51.
13. Furuta T., Shirai N., Watanabe F., Honda S., et al. Effect of cytochrome P4502C19
genotypic differences on cure rates for gastroesophageal reflux disease by
lansoprazole. Clin Pharmacol Ther. 2002;72(4):453–60. PubMed PMID: 12386647.
14. Furuta T., Ohashi K., Kamata T., Takashima M., et al. Effect of genetic differences in
omeprazole metabolism on cure rates for Helicobacter pylori infection and peptic
ulcer. Ann Intern Med. 1998;129(12):1027–30. PubMed PMID: 9867757.
15. Furuta T., Shirai N., Takashima M., Xiao F., et al. Effect of genotypic differences in
CYP2C19 on cure rates for Helicobacter pylori infection by triple therapy with a
proton pump inhibitor, amoxicillin, and clarithromycin. Clinical pharmacology and
PMID: 22027650.
23698643.
18. Lee S.J., Kim W.Y., Kim H., Shon J.H., et al. Identification of new CYP2C19 variants
exhibiting decreased enzyme activity in the metabolism of S-mephenytoin and
omeprazole. Drug Metab Dispos. 2009;37(11):2262–9. PubMed PMID: 19661214.
2011;90(2):328–32. PubMed PMID: 21716271.
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[Cited 2016 March 02]. Available from: http://www.pharmgkb.org/haplotype/
PA165816533
21. Baldwin R.M., Ohlsson S., Pedersen R.S., Mwinyi J., et al. Increased omeprazole
metabolism in carriers of the CYP2C19*17 allele; a pharmacokinetic study in healthy
volunteers. British journal of clinical pharmacology. 2008;65(5):767–74. PubMed
PMID: 18294333.



Omeprazole response

CYP2C19 gene
263
Pertuzumab Therapy and ERBB2 (HER2)

Genotype
Laura Dean, MD1
Introduction
Pertuzumab is a monoclonal antibody used in the treatment of breast cancer. It targets a
receptor in the epidermal growth factor family encoded by the ERBB2 gene, which is
commonly referred to as the HER2 gene.
The HER2 gene is overexpressed in 15-20% of breast cancers and is also overexpressed in
some cases of other cancer types (gastric, colon, head and neck). Overall, “HER2 positive”
tumors are associated with a faster rate of growth and a poorer prognosis. The use of
pertuzumab in treatment regimens for breast cancer improves outcomes, but adverse
effects of therapy include cardiac toxicity.
The FDA-approved drug label for pertuzumab states that pertuzumab should only be used
to treat patients with tumors which have either HER2 protein overexpression or HER2
gene amplification, as determined by an accurate and validated FDA-approved assay. This
is because these are the only patients studied for whom benefit has been shown (1) .
A guideline from ASCO/CAP states that oncologists must request HER2 testing on every
primary invasive breast cancer (and on a metastatic site, if stage IV and if specimen
available) from a patient with breast cancer to guide decision to pursue HER2-targeted
therapy. This should be especially considered for a patient who previously tested HER2
negative in a primary tumor and presents with disease recurrence with clinical behavior
suggestive of HER2-positive or triple-negative disease (2).
Drug: Pertuzumab
Pertuzumab (brand name, Perjeta) is a monoclonal antibody that targets ERBB2 (a
tyrosine kinase receptor, also known as HER2 or HER-2/neu). Pertuzumab is only used to
treat specific tumors that overexpress ERBB2; these tumors are known as “HER2-positive”
tumors.
Pertuzumab is used in the treatment of HER2-positive metastatic breast cancer to increase
the chance of long-term disease-free survival. Pertuzumab is used in combination with
trastuzumab (another monoclonal antibody that targets ERBB2) and docetaxel (a
chemotherapy drug) (1).

Recently, HER2 targeted therapy has been approved by the FDA for use in the
neoadjuvant setting. Neoadjuvant therapy is given before surgical therapy in women with
early stage breast cancer. In the neoadjuvant setting, pertuzumab, along with trastuzumab
and docetaxel, is used to treat HER2-positive breast cancer, which may be at an early
stage, locally advanced, or inflammatory (1, 3, 4).
Before treatment with pertuzumab begins, overexpression of the HER-2 protein or
amplification of the HER-2 gene must first be determined. In clinical studies of
pertuzumab, patients with breast cancer were required to have evidence of HER-22
overexpression defined as 3+ IHC or FISH amplification ratio of 2 or greater (see Genetic
Testing) (1). The FDA recommends that testing be performed using an FDA-approved
test, in a laboratory with demonstrated proficiency with the technology being used. This is
because the benefits of pertuzumab have only been proven in patients with tumors that
overexpress HER2. In addition, although pertuzumab is generally well tolerated, the risks
of treatment include infusion reactions, and rarely pulmonary toxicity, and
cardiomyopathy that can result in cardiac failure.
Pertuzumab targets the HER2 receptor by binding to a specific region in its extracellular
domain. The HER2 receptor is an epidermal growth factor receptor, consisting of an
intracellular tyrosine kinase domain, a single transmembrane spanning region, and an
extracellular domain, comprised of four subdomains (I – IV). Pertuzumab binds to
subdomain II and trastuzumab binds to subdomain IV. This binding limits the receptor’s
ability to activate its intrinsic kinase, which in turn, limits the activation of numerous
signaling pathways that can promote cell growth.
A number of proposed mechanisms may underlie the anti-tumor effects of pertuzumab
and trastuzumab. One such mechanism is that these drugs block the HER3 receptor from
binding to HER2. The HER2-HER3 dimerized receptor is thought to be highly active,
triggering many signaling cascades in the absence of a “true” ligand (5-8).
Another proposed mechanism is antibody-dependent cellular cytotoxicity (ADCC). Once
pertuzumab or trastuzumab have bound to a cancer cell, immune cells (typically activated
natural killer cells) bind to the drug and initiate lysis of the cancer cell (9). Trastuzumab
may also mediate the enhanced internalization and degradation of the HER2 receptor,
inhibit angiogenesis, and inhibit HER2 shedding by preventing the cleavage of HER2 and
the subsequent release of its extracellular domain (10, 11).
Unfortunately, breast cancer may start to progress again during HER2 targeted therapy.
Possible mechanisms that may facilitate drug resistance and disease progression during
treatment include increased signaling from the HER family of receptors, an upregulation
of downstream signaling pathways, and an increased level of insulin growth factor -1
receptor (12, 13).
At the time of writing, four drugs have been approved to target HER2 (pertuzumab,
trastuzumab, lapatinib, and T-DM1), with more drugs in clinical trials.
Pertuzumab Therapy and ERBB2 (HER2) Genotype 265
Gene: ERBB2 (HER2)

The human epidermal growth factor receptor (HER) family consists of four members: the
epidermal growth factor receptor (EGFR), HER2, HER3, and HER4 (see Nomenclature).
All four members are transmembrane tyrosine kinase receptors, and they regulate a
number of important cellular processes, such as cell growth, survival, and differentiation
(14).
HER2, along with EGFR, are proto-oncogenes. Proto-oncogenes are a group of genes that,
when mutated or expressed at abnormally high levels, can contribute to abnormal cell
growth. The mutated version of the proto-oncogene is called an oncogene. Proto-
oncogenes typically encode proteins that stimulate cell division, inhibit cell
differentiation, and halt cell death. All these are important biological processes. However,
the increased production of these proteins, caused by oncogenes, can lead to the
proliferation of poorly differentiated cancer cells (15).
The official gene symbol for HER2 is ERBB2, which is derived from a viral oncogene with
which the receptor shares homology; “v-erb-b2 avian erythroblastic leukemia viral
oncogene homolog 2.” However, clinicians commonly refer to the ERBB2 gene as “HER2”
(Human Epidermal growth factor Receptor 2) or “HER2/neu” (neu was the name given to
the gene that caused cancer derived from a rodent neuro/glioblastoma). HER2 is an
alternate gene symbol for ERBB2 and is more commonly used by the community in
clinical care.
One unique feature of ERBB2 compared to the other receptors in the HER family is the
absence of a known ligand. It is therefore thought that this receptor may permanently be
in an activated state, or it may become activated during heterodimerization with one of
the other members of the HER family (11). And, one unique feature of HER3 is that it has
very little enzymatic activity compared to the other tyrosine kinase receptors in the HER
family. It is therefore thought that an important role of HER3 is to act as a
heterodimerization partner for ERBB2 (16, 17).
When a partner such as HER3 binds to ERBB2, the heterodimer undergoes activation,
which stimulates the intrinsic tyrosine kinase activity of the receptor.
Autophosphorylation of several key residues of the receptor triggers the downstream
activation of many commonly used growth factor signaling pathways, such as the
PI3K/AKT/mTOR pathway and the RAS/RAF/MEK/ERK pathway (18, 19). Impaired
ERBB2 signaling is associated with the development of neurodegenerative diseases, such
as multiple sclerosis and Alzheimer disease, whereas excessive ERBB2 signaling is
associated with the development of cancers.
ERBB2 is overexpressed in approximately 15-20% of breast tumors, as a result of
amplification of the ERBB2 gene, and tumors with increased ERBB2 usually have a higher
growth rate and more aggressive clinical behavior (2, 20-22). Although gene amplification
is frequently seen in cancer and other degenerative disorders, the underlying basis for
amplification remain largely unknown (23). And in the case of ERBB2, although sequence
variants have been identified, it is nearly always the wildtype ERBB2 gene that is
overexpressed in tumors (24). In about 1% of breast cancers, activating mutations in
ERBB2 can be identified that are likely to drive tumorigenesis, without ERBB2
amplification (25).
Tumor Testing for ERBB2 (HER2)

There are two main methods used for HER2 testing: testing for overexpression of the
HER2 protein using immunohistochemistry (IHC), or testing for gene amplification using
in-situ hybridization (ISH). Each assay type has diagnostic pitfalls that must be avoided,
and so the pathologist who reviews the histologic findings should determine the optimal
assay (IHC or ISH) for the determination of HER2 status (2, 22).
In an IHC assay, a slice of tumor tissue is stained, along with a control sample that
contains high levels of HER2. The tumor sample is then examined by light microscopy to
assess the intensity of membrane staining—the amount of staining correlates with the
quantity of HER2 protein and is typically graded from 0 to 3+:
• IHC 0 means no visible staining and is an “HER2 negative” result
• IHC 1+ is also an “HER2 negative” result—there is a staining pattern with weak and
incomplete staining, or weak and complete staining of very few tumor cells
• IHC 2+ is an “HER2 equivocal result”—there is a staining pattern with moderately
intense staining, or intense staining of very few tumor cells
• IHC 3+ is an “HER2 positive result”—there is a staining pattern with intense
membrane staining on more than 10% of tumor cells, indicating a higher than
normal level of HER2
For an equivocal (IHC 2+) result, either a reflex test must be ordered (same specimen
using ISH), or a new test must be ordered (using a new specimen, if available, using IHC
or ISH) to confirm the results.
The ISH assay, or FISH assay (fluorescence in situ hybridization), measures HER2 gene
amplification by measuring HER2 DNA—the actual number of copies of the HER2 genes
are counted. Under the microscope, the genes appear as red signals or dots, in a blue-
stained cancer cell nucleus. The result is usually either FISH negative (normal level of
HER2 gene) or FISH positive (at least twice as much as normal level of HER2 gene), but in
a small number of cases the FISH result will be equivocal due to a low level of HER2
amplification. The use of a control helps distinguish between a negative result and a non-
informative result caused by an error. Approximately 25% of patients who have an IHC 2+
result will have a FISH positive result (26).
For the complete algorithms for evaluation of HER2 protein expression using IHC or
ISH, please see the American Society of Clinical Oncology (ASCO) guidelines, located
here: (27)

Detection of HER2 protein overexpression is necessary for selection of patients
appropriate for pertuzumab therapy because these are the only patients studied and for
whom benefit has been shown. Patients with breast cancer were required to have evidence
of HER2 overexpression defined as 3+ IHC or FISH amplification ratio ≥ 2.0 in the
clinical studies. Only limited data were available for patients whose breast cancer was
positive by FISH, but did not demonstrate protein overexpression by IHC.
Assessment of HER2 status should be performed by laboratories using FDA-approved
tests with demonstrated proficiency in the specific technology being utilized. Improper
assay performance, including use of sub-optimally fixed tissue, failure to utilize specified
reagents, deviation from specific assay instructions, and failure to include appropriate
controls for assay validation, can lead to unreliable results.
FDA-approved medical devices for HER2 are listed here.
Excerpted recommendations from the American Society of Clinical Oncology /
College of American Pathologists 2013 clinical practice guideline update:
Key Recommendations for Oncologists
• Must request HER2 testing on every primary invasive breast cancer (and on
metastatic site, if stage IV and if specimen available) from a patient with breast
cancer to guide decision to pursue HER2-targeted therapy. This should be especially
considered for a patient who previously tested HER2 negative in a primary tumor
and presents with disease recurrence with clinical behavior suggestive of HER2-
positive or triple-negative disease.
• Should recommend HER2-targeted therapy if HER2 test result is positive, if there is
no apparent histopathologic discordance with HER2 testing and if clinically
appropriate.
• Must delay decision to recommend HER2-targeted therapy if initial HER2 test
result is equivocal. Reflex testing should be performed on the same specimen using
generic drug.
the alternative test if initial HER2 test result is equivocal or on an alternative

specimen.
• Must not recommend HER2-targeted therapy if HER2 test result is negative and if
there is no apparent histopathologic discordance with HER2 testing.
• Should delay decision to recommend HER2-targeted therapy if HER2 status cannot
be confirmed as positive or negative after separate HER2 tests (HER2 test result or
results equivocal). The oncologist should confer with the pathologist regarding the
need for additional HER2 testing on the same or another tumor specimen.
• If the HER2 test result is ultimately deemed to be equivocal, even after reflex testing
with an alternative assay (i.e., if neither test is unequivocally positive), the
oncologist may consider HER2-targeted therapy. The oncologist should also
consider the feasibility of testing another tumor specimen to attempt to definitely
establish the tumor HER2 status and guide therapeutic decisions. A clinical
decision to ultimately consider HER2-targeted therapy in such cases should be
individualized on the basis of patient status (comorbidities, prognosis, and so on)
and patient preferences after discussing available clinical evidence.
Please review the complete therapeutic recommendations, including Key
Recommendations for Pathologists that are located here (2).
Nomenclature
Common gene symbols Alternative gene symbols
EGFR ERBB1
ERBB
HER1
ERBB2 HER2
HER-2
HER-2/neu
NEU
ERBB3 HER3
ERBB4 HER4
Acknowledgments
The author would like to thank Professor Andreas Schneeweiss, Head of Division
Gynecologic Oncology, National Center for Tumor Diseases, Heidelberg University
Hospital, Germany; and Jo Anne Zujewski, Head of Breast Cancer Therapeutics, Clinical
Investigation Branch, Cancer Therapy Evaluation Program, Division of Cancer Treatment
and Diagnosis, National Cancer Institute; for reviewing this summary.
References
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Trastuzumab (Herceptin) Therapy and ERBB2 (HER2) Genotype

Trastuzumab (Herceptin) Therapy and ERBB2 (HER2) Genotype

Pertuzumab response

ERBB2 gene
273
Phenytoin Therapy and HLA-B*15:02 and

CYP2C9 Genotypes
Laura Dean, MD1
Introduction
Phenytoin is an antiseizure medication used for the prevention of focal seizures and
generalized tonic-clonic convulsions (1).
Phenytoin has a narrow therapeutic index—patients that have toxic blood concentrations
of phenytoin have inreased risks of acute side effects. Dosing can be complex due to
pharmacokinetic factors, including patient weight, age, sex, concomitant medications,
plasma binding protein stats, the presence of uremia or hyperbilirubinemia, and specific
pharmacogenetic variants. As such, therapeutic drug monitoring is often used to adjust
dose and maintain serum concentrations within the therapeutic range (10–20 μg/mL).
CYP2C9 is one of the main enzymes involved in the metabolism of phenytoin, and variant
CYP2C9 alleles are known to influence phenytoin drug levels. Individuals who carry
decreased activity CYP2C9 variants may have reduced clearance rates of phenytoin and be
at greater risk for dose-related side effects (2).
An individual’s human leukocyte antigen B (HLA-B) genotype is a known risk factor for
drug-induced hypersensitivity reactions. HLA-B has an important immunological role in
pathogen recognition and response, as well as to non-pathogens such as drugs. Carriers of
the variant HLA-B*15:02 allele are at high risk of developing potentially life-threatening
phenytoin-induced Stevens-Johnson syndrome (SJS) and the related toxic epidermal
necrolysis (TEN).
The HLA-B*15:02 variant is most commonly found among individuals of Southeast Asian
descent, where there is a strong association between SJS/TEN and exposure to
carbamazepine. Carbamazepine is an antiseizure medication used to treat the same types
of seizures as phenytoin, as well as trigeminal neuralgia and bipolar disorder.
The FDA-approved drug label for phenytoin states that consideration should be given to
avoiding phenytoin as an alternative for carbamazepine in patients positive for HLA-
B*15:02. The label also mentions that variant CYP2C9 alleles may contribute to unusually
high levels of phenytoin (1).
The Clinical Pharmacogenetics Implementation Consortium (CPIC) recommends the use
of an antiseizure medication other than carbamazepine, phenytoin (or its prodrug

fosphenytoin) for any HLA-B*15:02 carrier regardless of CYP2C9 genotype, patient

ancestry or age. CPIC also recommends consideration of at least a 25% reduction in the
starting maintenance dose for patients who are CYP2C9 intermediate metabolizers and
HLA-B*15:02 negative, and at least a 50% reduction for CYP2C9 poor metabolizers and
HLA-B*15:02 negative, with subsequent maintenance doses adjusted based on therapeutic
drug monitoring and response (Table 1) (2).
Table 1. 2014 Therapeutic recommendations for phenytoin therapy based on HLA-B and CYP2C9
genotypes, adapted from Clinical Pharmacogenetics Implementation Consortium (CPIC)
Phenotype HLA-B*15:02 positive HLA-B*15:02 negative
Implication Therapeutic Implication Therapeutic
recommendation recommendation
CYP2C9 normal Increased risk of If patient is phenytoin Normal phenytoin Initiate therapy with
metabolizer phenytoin- naive,A do not use metabolism recommended
induced SJS/ phenytoin/ maintenance dose C
TEN fosphenytoinB
CYP2C9 Increased risk of If patient is phenytoin Reduced phenytoin Consider 25%
intermediate phenytoin- naive,A do not use metabolism. Higher reduction of
metabolizer induced SJS/ phenytoin/ plasma recommended starting
TEN fosphenytoinB concentrations will maintenance dose.C
increase probability Subsequent
of toxicities maintenance doses
should be adjusted
according to
therapeutic drug
monitoring and
response
CYP2C9 poor Increased risk of If patient is phenytoin Reduced phenytoin Consider 50%
metabolizer phenytoin- naive,A do not use metabolism. Higher reduction of
induced SJS/ phenytoin/ plasma recommended starting
TEN fosphenytoinB concentrations will maintenance dose.C
Subsequent
The strength of the therapeutic recommendations is classified as “strong” for all recommendations, with the
exception of the recommendation for CYP2C9 intermediate metabolizers who are HLA-B*15:02 non
carriers, which is classified as “moderate”.
A If the patient has previously used phenytoin for longer than 3 months without incidence of cutaneous
adverse reactions, reinitiate phenytoin with caution. Adjust dose based on CYP2C9 genotype if known.
B Carbamazepine should not be used as an alternative. Alternative medications such as oxcarbazepine,
eslicarbazepine acetate, and lamotrigine have some evidence linking SJS/TEN with the HLA-B*15:02 allele,
and thus caution should be used in choosing alternatives to phenytoin).
C Recommended maintenance dose based on patient’s clinical characteristics.
Table is adapted from Caudle KE, Rettie AE, Whirl-Carrillo M, Smith LH, Mintzer S, Lee MT, Klein TE,
Callaghan JT. Clinical pharmacogenetics implementation consortium guidelines for CYP2C9 and HLA-B
genotypes and phenytoin dosing. Clinical pharmacology and therapeutics. 2014:96(5):542-8 (2).
Note: The nomenclature used in this table reflects the standardized pharmacogenetic terms proposed by
CPIC (3).
Phenytoin Therapy and HLA-B*15:02 and CYP2C9 Genotypes 275
Phenotype HLA-B*15:02 positive HLA-B*15:02 negative

Implication Therapeutic Implication Therapeutic
recommendation recommendation
increase probability maintenance doses
of toxicities should be adjusted
according to
therapeutic drug
monitoring and
response
The strength of the therapeutic recommendations is classified as “strong” for all recommendations, with the
exception of the recommendation for CYP2C9 intermediate metabolizers who are HLA-B*15:02 non
carriers, which is classified as “moderate”.
A If the patient has previously used phenytoin for longer than 3 months without incidence of cutaneous
adverse reactions, reinitiate phenytoin with caution. Adjust dose based on CYP2C9 genotype if known.
B Carbamazepine should not be used as an alternative. Alternative medications such as oxcarbazepine,
eslicarbazepine acetate, and lamotrigine have some evidence linking SJS/TEN with the HLA-B*15:02 allele,
and thus caution should be used in choosing alternatives to phenytoin).
C Recommended maintenance dose based on patient’s clinical characteristics.
Note: The nomenclature used in this table reflects the standardized pharmacogenetic terms proposed by
CPIC (3).
Drug: Phenytoin
Phenytoin is a generic antiseizure drug that is rarely prescribed to newly diagnosed
patients due to its propensity for long-term side effects. Nevertheless, it continues to be
used by many patients who initiated treatment prior to the availability of newer
medications that have fewer side effects and drug-drug interactions. Phenytoin is used for
the control of partial seizures and generalized tonic-clonic convulsions. It is also used in
the treatment of status epilepticus and may be used to prevent or treat seizures that occur
during and following neurosurgery (1).
Phenytoin belongs to the sodium channel blockers class of antiseizure drugs, which are
thought to suppress seizure activity by blocking voltage-gated sodium channels that are
responsible for the upstroke of action potentials (4, 5). The block by phenytoin and other
members of this class of antiseizure drugs occurs in a state-dependent fashion, with
preferential binding and block of the inactivated state of the channel. This results in
voltage- and frequency-dependent block in which high frequency action potential firing,
which occurs during epileptic activity, is preferentially inhibited (1, 6)
The dosing of phenytoin can be complex, as treatment is typically initiated at a low
starting dose, which considers patient age, weight, and the presence of concomitant
medications that may influence phenytoin metabolism or protein binding. The dose is
then carefully escalated to obtain the desired therapeutic effect. There is a wide variation
in how individuals respond to phenytoin (2). Therapeutic drug monitoring is often used
to adjust the dose to ensure that plasma levels are within therapeutic range (10–20 μg/dl
in adults). Measurement of plasma levels is useful when adding or discontinuing
concomitant medications that effect phenytoin levels. Periodic measurement of plasma
phenytoin concentrations may also be valuable in pregnancy, because altered phenytoin
pharmokinetics increases the risk of seizures.
Phenytoin use during pregnancy has been associated with an 11% risk in the offspring of
the fetal hydantoin syndrome, in which there is dysmorphism, hypoplasia and irregular
ossification of the distal phalanges. Facial dysmorphism includes epicanthal folds,
hypertelorism, broad flat nasal bridges, an upturned nasal tip, wide prominent lips, and, in
addition, distal digital hypoplasia, intrauterine growth retardation, and mental
retardation. An additional 30% of the in utero-exposed children express fetal hydantoin
effects, in which there is a more limited pattern of dysmorphic characteristics. Some
studies have found significant associations between in utero exposure to phenytoin and
major congenital abnormalities (mainly, cardiac malformations and cleft palate) whereas
others have failed to find such associations (7, 8).
The adverse effects of phenytoin fall into two categories, types A and B. Type A adverse
drug reactions account for up to 90% of reactions. They are predictable and can occur in
any individual if their drug exposure is high enough. Some of these reactions occur
rapidly and are reversible when the dose is reduced. These include acute central nervous
system adverse effects such as sedation, nystagmus, and ataxia. Other common side effects
occur with long-term exposure and include changes to the physical appearance, such as
gingival hyperplasia, coarsening of the facial features, hirsuitism, and acne.
Type B adverse drug reactions include idiosyncratic hypersensitivity reactions. Such
reactions can occur at any dose and develop through a mechanism that is unrelated to the
mechanism of action of the drug.
A rare but life-threatening hypersensitivity reaction associated with phenytoin treatment
is Stevens-Johnson syndrome (SJS) and the related toxic epidermal necrolysis (TEN). Both
are severe cutaneous reactions to specific drugs, and are characterized by fever and lesions
of the skin and mucous membranes, with a mortality rate of up to 30% (9).
It is difficult to predict in whom a drug-induced hypersensitivity reaction is likely to
occur. For phenytoin, however, carriers of a specific HLA variant are known to be
susceptible to phenytoin-induced SJS/TEN. HLA testing of patients can identify those at-
risk individuals so that an alternative drug can be used.
HLA gene family

The human leukocyte antigen (HLA) genes are members of the Major Histocompatability
Complex (MHC) gene family, which includes more than 200 genes. The MHC family has
been subdivided into three subgroups based on the structure and function of the encoded
proteins: Class I, Class II, and Class III. The class I region contains the genes encoding the
HLA molecules HLA-A, HLA-B, and HLA-C. These molecules are expressed on the
surfaces of almost all cells and play an important role in processing and presenting
antigens. The class I gene region also contains a variety of other genes, many of which are
not known to be involved in immune function.
cellular proteins (“self ”). However, if foreign peptide fragments are presented, e.g., from a
pathogen, CD8+T cells will recognize the peptides as “non-self ” and will be activated to
pathogen (or foreign body).
HLA-B alleles have been identified (10). HLA allele nomenclature includes the HLA
prefix, followed by the gene, an asterisk and a two digit number that corresponds to
antigen specificity, and the assigned allele number (11). For example, the HLA-B*15:02
allele is composed of:
• B: the B gene (a particular HLA gene in this region)
analysis).
Variation in HLA genes plays an important role in the susceptibility to autoimmune
better outcomes are observed if the donor and recipient are HLA-compatible.
More recently, HLA variants have been associated with susceptibility to Type B adverse
drug reactions. For example, HLA-B variants have been associated with severe
hypersensitivity reactions to abacavir (used to treat HIV), allopurinol (used to treat gout),
and the antiepileptic drugs, carbamazepine and phenytoin.
Gene: HLA-B*15:02
Individuals who carry one or two copies of the high risk HLA-B*15:02 allele are known as
HLA-B*15:02 positive (Table 2).
Table 2. 2014 Assignment of likely HLA-B phenotype based on genotype (CPIC)

Likely phenotypea Genotype Examples of diplotypes
Negative No copies of high-risk HLA- *X/*Xb
High-risk HLA-B*15:02 allele not B*15:02 allele
detected
(constitutes ~98.6% of patients)
Positive Homozygous or heterozygous for *15:02/*Xb, *15:02/*15:02
Detection of high-risk HLA-B*15:02 high-risk HLA-B*15:02 allele
allele
(constitutes ~1.4% of patients)
a Global frequencies presented in parentheses. Haplotype frequencies vary among populations; please see
(2) for individual population frequencies
b Where *X = any genotype other than *15:02.
Note: The nomenclature used in this table reflect the standardized pharmacogenetic terms proposed by
CPIC (3).
The association between the HLA-B*15:02 allele and SJS/TEN was first reported with the
use of carbamazepine in the Han Chinese population. In the initial study, all patients who
had carbamazepine-induced SJS/TEN were found to be a carrier of the HLA-B*15:02
allele (44/44, 100%), whereas the allele was much less common among carbamazepine-
tolerant patients (3/101, 3%)(12). In subsequent studies, this association was replicated,
with a HLA-B*15:02 carrier frequency of 70100% among cases of carbamazepine-induced
SJS/TEN (13).
The HLA-B*15:02 allele was later associated with phenytoin-induced hypersensitivity
reactions, including phenytoin-induced SJS in a Thai population and phenytoin-induced
SJS/TEN in Chinese Asians (14, 15).
There are fewer studies on phenytoin-induced hypersensitivity then carbamazepine, and
the strength of association between phenytoin and SJS/TEN is weaker than that of
carbamazepine and SJS/TEN. However, from the evidence available, the FDA
recommends consideration of avoiding phenytoin as an alternative treatment to
carbamazepine in individuals who are carriers of HLA-B*15:02 (2).
The prevalence of carbamazepine-induced SJS/TEN is higher in populations where HLA-
B*15:02 is more common. Of note, the HLA-B*15:02 allele frequency is highest in
Southeast Asia, as populations from Hong Kong, Thailand, Malaysia, Vietnam, and parts
of the Philippines have an allele frequency > 15%. It is slightly lower (~ 10-13%) in Taiwan
and Singapore, and around 4% in North China. South Asians, including Indians, appear
to have a HLA-B*15:02 allele frequency of ~2 to 4%, with higher frequencies in some
subpopulations (12-14, 16-27).
The HLA-B*15:02 allele is rare (< 1%) in East Asia (Japan and Korea) and among
individuals who are not of Asian descent. For example, the variant is very rare in
Europeans, Hispanics, Africans, African Americans, and Native Americans (13, 18).
Gene: CYP2C9
enzyme activity.
The CYP2C9 gene is highly polymorphic, with more than 50 known alleles. Variation in
CYP2C9 is thought to contribute to the pharmacogenetic variability in phenytoin
metabolism.
CYP2C9*1 is the wild-type allele and is associated with normal enzyme activity (2).
Individuals who have two normal-function alleles (e.g., CYP2C9 *1/*1) are classified as
“normal metabolizers” (Table 3). For individuals who are CYP2C9 normal metabolizers,
the recommended starting maintenance dose of phenytoin does not need to be adjusted
based on genotype (2).
Table 3. 2014 Assignment of likely CYP2C9 phenotype based on genotype (CPIC)
Likely phenotypea Genotype Examples of diplotypes
Normal metabolizer An individual carrying two *1/*1
(normal activity) normal-function alleles
(constitutes ~91% of patients)
Intermediate metabolizer An individual carrying one *1/*3, *1/*2
(heterozygote or intermediate normal-function allele plus one
activity) decreased-function allele
(constitutes ~8% of patients)b
Poor metabolizer An individual carrying two *2/*2, *3/*3, *2/*3
(homozygous variant, low or deficient decreased function alleles
activity)
(constitutes ~1% of patients)
a Global frequencies presented in parentheses. Haplotype frequencies vary among populations; please see
(2) for individual population frequencies
b The enzyme activity in this grouping varies widely. Please see (2) for activity ranges.
Note: The nomenclature used in this table reflect the standardized pharmacogenetic terms proposed by
CPIC (3).
Two allelic variants associated with reduced enzyme activity are CYP2C9*2 and *3. The *2
allele is more common in Caucasian (10-20%) than Asian (1-3%) or African (0-6%)
populations, whereas the *3 allele is less common (<10% in most populations) and is
extremely rare in African populations (24, 25, 28-30).
Individuals with one decreased function allele (e.g., CYP2C9*1/*2 and *1/*3) have mild to
moderately reduced clearance of phenytoin; these individuals are classified as CYP2C9
intermediate metabolizers. The CPIC recommendations for CYP2C9 intermediate
metabolizers include “to consider at least a 25% reduction of the recommended starting
maintenance dose” (2).
Individuals with two decreased function alleles (e.g., CYP2C9*2/*2, *3/*3) have reduced
clearance of phenytoin and are classified as CYP2C9 poor metabolizers. CPIC
recommendations for CYP2C9 poor metabolizers include “to consider at least a 50%
reduction of the starting maintenance dose” (2).
In African Americans, the CYP2C9*5, *6, *8 and *11 variants are more common, and
these variants are also associated with a decrease in phenytoin metabolism (31).
Genetic Testing
currently available for the phenytoin drug response, the HLA-B gene, and the CYP2C9
gene.
The genotype results for an HLA allele such as HLA-B*15:02 can either be “positive” or
“negative.” There are no intermediate phenotypes because the HLA genes are expressed in
a codominant manner.
A positive result indicates the individual is either “heterozygous” or “homozygous” for the
variant, depending upon whether they are carrying one or two copies of the *15:02 allele,
respectively.
A negative result indicates that the individual does not carry the HLA-B*15:02 allele.
However, a negative result does not rule out the possibility of a patient developing
phenytoin-induced SJS/TEN. Therefore, clinicians should carefully monitor all patients
according to standard practices.
For CYP2C9, the variants that are routinely tested for include CYP2C9*2 and *3. Results
are typically reported as a diplotype, such as CYP2C9 *1/*2.

This section contains excerpted1, 2 information on gene-based dosing
2015 Statement from the US Food and Drug Administration (FDA)
generic drug.
Regarding HLA-B:
Studies in patients of Chinese ancestry have found a strong association between the risk of
developing SJS/TEN and the presence of HLA-B*1502, an inherited allelic variant of the
HLA B gene, in patients using carbamazepine. Limited evidence suggests that HLA-
B*1502 may be a risk factor for the development of SJS/TEN in patients of Asian ancestry
taking other antiepileptic drugs associated with SJS/TEN, including phenytoin.
Consideration should be given to avoiding phenytoin as an alternative for carbamazepine
in patients positive for HLA-B*1502.
The use of HLA-B*1502 genotyping has important limitations and must never substitute
for appropriate clinical vigilance and patient management. The role of other possible
factors in the development of, and morbidity from, SJS/TEN, such as antiepileptic drug
(AED) dose, compliance, concomitant medications, comorbidities, and the level of
dermatologic monitoring have not been studied.
Regarding CYP2C9:
In most patients maintained at a steady dosage, stable phenytoin serum levels are
achieved. There may be wide interpatient variability in phenytoin serum levels with
equivalent dosages. Patients with unusually low levels may be noncompliant or
hypermetabolizers of phenytoin. Unusually high levels result from liver disease, variant
CYP2C9 and CYP2C19 alleles, or drug interactions which result in metabolic interference.
The patient with large variations in phenytoin plasma levels, despite standard doses,
presents a difficult clinical problem. Serum level determinations in such patients may be
particularly helpful. As phenytoin is highly protein bound, free phenytoin levels may be
altered in patients whose protein binding characteristics differ from normal.
(CPIC)
Regarding HLA-B: […] Therefore, regardless of the CYP2C9 genotype and the
individual’s ancestry or age, if the HLA-B*15:02 test result is positive, the
recommendation is to consider using an anticonvulsant other than carbamazepine and
phenytoin, unless the benefits of treating the underlying disease clearly outweigh the risks.
Some evidence exists linking SJS/TEN with the HLA-B*15:02 allele in association with the
use of alternative medications such as oxcarbazepine, eslicarbazepine acetate, and
lamotrigine, and thus caution should be used in choosing alternatives to phenytoin.
2 Square brackets indicate insertions by the author to reflect the standardized nomenclature for
pharmacokinetic terms proposed by CPIC in 2016 3. Caudle, K.E., H.M. Dunnenberger, R.R.
Freimuth, J.F. Peterson, et al., Standardizing terms for clinical pharmacogenetic test results:
consensus terms from the Clinical Pharmacogenetics Implementation Consortium (CPIC). Genet
Med, 2016.
Regarding CYP2C9: The recommended phenytoin maintenance dose does not need
adjustment based on genotype for CYP2C9 extensive [“normal”] metabolizers. Available
evidence does not clearly indicate the amount of dose reduction needed to prevent
phenytoin-related toxicities in CYP2C9 intermediate and poor metabolizers; thus, our
recommendations should be considered conservative estimates, given the variability
surrounding phenytoin dosing in an individual. On the basis of the doses reported in the
pharmacokinetic and pharmacogenetic studies mentioned above and in Supplementary
Table S9 online, at least a 25% reduction of the recommended starting maintenance dose
may be considered for CYP2C9 intermediate metabolizers, with subsequent maintenance
doses adjusted based on therapeutic drug monitoring and response. For CYP2C9 poor
metabolizers, consider at least a 50% reduction of starting maintenance dose, with
subsequent maintenance doses adjusted based on therapeutic drug monitoring or
response.
Nomenclature of selected HLA-B alleles

HLA-B*15:02 rs2844682 and rs3909184
For the MHC region, variations in genes such as HLA-B occur across the whole sequence of the gene, not a
single locus. Therefore, the HLA-B*15:02 allele is defined by its sequence rather than single coding or
protein variations. If there is strong linkage disequilibrium between one or more SNPs and a specific HLA
allele, the presence of these SNPs (tag SNPs) may be used for HLA typing in some populations; however,
genotyping tag SNPs should not be considered diagnostic or equivalent to actual HLA testing. For HLA-
B*15:02, rs2844682 and rs3909184 are the tag SNPs (32).
Guidelines on nomenclature of the HLA system are available from HLA Nomenclature: http://
hla.alleles.org/
Nomenclature of selected CYP2C9 alleles

Coding Protein
identifier for
allele location
CYP2C9*2 430C>T NM_000771.3:c. NP_000762.2:p.Arg144Cys rs1799853
Arg144Cys 430C>T
CYP2C9*3 1075A>C NM_000771.3:c. NP_000762.2:p.Ile359Leu rs1057910
Ile359Leu 1075A>C
CYP2C9*5 1080C>G NM_000771.3:c. NP_000762.2:p.Asp360Glu rs28371686
Asp360Glu 1080C>G

Coding Protein
identifier for
allele location
CYP2C9*6 817delA NM_000771.3:c. NP_000762.2:p.Lys273Argfs rs9332131
Lys273Argfs 817delA
CYP2C9*8 449G>A NM_000771.3:c. NP_000762.2:p.Arg150His rs7900194
Arg150His 449G>A
CYP2C9*11 1003C>T NM_000771.3:c. NP_000762.2:p.Arg335Trp rs28371685
Arg335Trp 1003C>T
Acknowledgments
The author would like to thank Mohamed Nagy, Clinical Pharmacist, Head of the
Personalised Medication Management Unit, Department of pharmaceutical Services,
Children's Cancer Hospital, Egypt; Emily K. Pauli, Director of Research, Clearview
Cancer Institute, Alabama; Michael A. Rogawski, Professor of Neurology, University of
California, Davis; and Stuart A. Scott, Assistant Professor of Genetics and Genomic
Sciences, Icahn School of Medicine at Mount Sinai; for reviewing this summary.
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b537-430fdfa4f10e
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activity are preferentially diminished by the anticonvulsant phenytoin. J
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7. Birth Defects: Data & Statistics. Centers for Disease Control and Prevention (CDC);
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antiepileptic drugs. Expert Rev Neurother. 2010;10(6):943–59. PubMed PMID:
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9. Svensson C.K., Cowen E.W., Gaspari A.A. Cutaneous drug reactions.
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10. Nomenclature for Factors of the HLA System: HLA Alleles 2016 [Cited 23 June
2016]. Available from: http://hla.alleles.org/alleles/index.html
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Stevens-Johnson syndrome. Nature. 2004;428(6982):486. PubMed PMID: 15057820.
13. Amstutz U., Shear N.H., Rieder M.J., Hwang S., et al. Recommendations for HLA-
B*15:02 and HLA-A*31:01 genetic testing to reduce the risk of carbamazepine-
induced hypersensitivity reactions. Epilepsia. 2014;55(4):496–506. PubMed PMID:
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14. Locharernkul C., Loplumlert J., Limotai C., Korkij W., et al. Carbamazepine and
phenytoin induced Stevens-Johnson syndrome is associated with HLA-B*1502 allele
in Thai population. Epilepsia. 2008;49(12):2087–91. PubMed PMID: 18637831.
15. Hung S.I., Chung W.H., Liu Z.S., Chen C.H., et al. Common risk allele in aromatic
antiepileptic-drug induced Stevens-Johnson syndrome and toxic epidermal necrolysis
in Han Chinese. Pharmacogenomics. 2010;11(3):349–56. PubMed PMID: 20235791.
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Phenytoin response

HLA-B gene
CYP2C9 gene
287

Laura Dean, MD1
Introduction
Prasugrel is a third-generation thienopyridine platelet inhibitor used in the management
of patients with acute coronary syndrome (ACS) undergoing percutaneous coronary
intervention (PCI). Prasugrel is used to reduce thrombotic cardiovascular events, such as
stent thrombosis, myocardial infarction, and stroke in these patients. Prasugrel, along
with other antiplatelet agents such as clopidogrel and ticagrelor, inhibits platelet activation
by irreversibly binding to the platelet receptor, P2RY12.
Prasugrel is metabolized to its active metabolite primarily by CYP3A5 and CYP2B6, and
to a lesser extent by CYP2C9 and CYP2C19. The FDA-approved label for prasugrel states
that genetic variations in CYP2B6, CYP2C9, CYP2C19, or CYP3A5 genes do not have a
relevant effect on prasugrel pharmacokinetics and the generation of its active metabolite
or its inhibition of platelet aggregation in healthy subjects, patients with stable
atherosclerosis, or ACS (1).
Another commonly prescribed antiplatelet is the second-generation thienopyridine
clopidogrel, which is bioactivated primarily by CYP2C19. Consequently, clopidogrel is
less effective among patients with decreased or no function variant alleles in the CYP2C19
gene. In contrast, CYP2C19 variants are not associated with a decrease in effectiveness of
prasugrel, which is a more potent antiplatelet agent than clopidogrel, but has a higher risk
of bleeding (2-5).
Drug: Prasugrel
Prasugrel is a third-generation thienopyridine antiplatelet agent that binds irreversibly to
the P2RY12 receptor and inhibits ADP-mediated platelet activation and aggregation.
Other P2RY12 receptor blockers include clopidogrel and ticagrelor.
As an antiplatelet agent, prasugrel inhibits the formation of blood clots in the coronary,
peripheral, and cerebrovascular arteries among patients with acute coronary syndrome
(ACS).
ACS reflects a decreased blood flow in the coronary arteries, and includes unstable
angina, which occurs suddenly, often at rest or with minimal exertion. Unstable angina
may be new in onset or it may occur with less exertion than previously. Another form of
ACS is a myocardial infarction (MI), which may be classified as “STEMI” or “NSTEMI”

based on EKG findings. EKG findings that include ST-segment elevation is termed “ST
segment elevation MI” (STEMI). If no ST segment elevation is present but myocardial
biomarkers such as troponin I or T are increased, the term “non-ST segment elevation
MI” (NSTEMI) is applied.
Patients with ACS are usually treated with a P2Y12 receptor blocker and aspirin (called
dual antiplatelet therapy, DAPT) to reduce the risk of developing a coronary artery
thrombus. Platelet adhesion and aggregation are early stages in the formation of a
thrombus, which may occlude the coronary artery. Patients who undergo PCI are at risk
of stent occlusion via this mechanism.
A large trial, TRITON-TMI 38, compared prasugrel with clopidogrel in 13,608 patients
with ACS who were undergoing PCI. Prasugrel was found to provide more potent platelet
inhibition than clopidogrel: after 15 months, the patients treated with prasugrel had a
lower incidence of the combined endpoint of cardiovascular death, nonfatal myocardial
infarction, or nonfatal stroke as compared with patients treated with clopidogrel (9.9% vs.
12.1%) (2, 3). However, prasugrel was associated with a higher risk of bleeding, leading to
the FDA warning that prasugrel use is contraindicated in patients with active pathological
bleeding, or a history of stroke or transient ischemic attack (TIA) (4, 5).
Prasugrel inhibits ADP-induced platelet aggregation by selectively binding to the platelet
purinergic receptor, P2RY12. Because prasugrel is a pro-drug, it requires conversion into
an active metabolite before it can act as an antiplatelet agent. Prasugrel is rapidly
metabolized to thiolactone, which is then converted to an active metabolite by CYP3A5
and CYP2B6, and to a lesser extent by CYP2C9 and CYP2C19.
The active prasugrel metabolite (R-138727) contains a reactive thiol group, which forms a
disulfide bridge with a free cysteine residue on the P2RY12 receptor. Once irreversibly
bound to prasugrel, the receptor is unable to bind ADP, and platelet activation via this
pathway is prevented for the rest of the platelet’s lifespan of about 10 days (6).
Despite the general efficacy of clopidogrel as an antiplatelet agent, interindividual
variability in metabolite levels, platelet inhibition, and clinical response has been reported.
It has been estimated that between 16˗50% of patients treated with clopidogrel have high
on-treatment platelet reactivity (HTPR), indicating that despite clopidogrel treatment, a
portion of P2RY12 receptors are not blocked (7). This is due, in part, to genetic variants in
the CYP2C19 gene, which encodes the principal hepatic enzyme involved in converting
clopidogrel to its active metabolite. Patients that carry no function CYP2C19 alleles (e.g.,
CYP2C19*2) have reduced plasma active clopidogrel metabolites and an increased risk for
HTPR.
In contrast, there is no relevant effect of genetic variation in CYP3A5, CYP2B6, CYP2C9,
or CYP2C19 on the prasugrel pharmacokinetics and generation of active metabolites, or
its inhibition of platelet aggregation (8-12). Therefore, although both clopidogrel and
prasugrel form active metabolites with similar potency, prasugrel is a more potent
Prasugrel Therapy and CYP Genotype 289
antiplatelet agent than clopidogrel due to the more efficient formation of the active
metabolite from the prodrug (13).
Although prasugrel is more effective than standard-dose clopidogrel, DAPT with
clopidogrel and aspirin remains the standard of care at some institutions for some patients
with ACS undergoing PCI (14). This is mainly because clopidogrel has a lower bleeding
risk and is less expensive (15). However, the availability of CYP2C19 genetic testing can
facilitate personalized antiplatelet therapy, as individuals with impaired CYP2C19 activity
could be identified and offered an alternative antiplatelet agent, such as prasugrel (16-19).
Recent studies have found that CYP2C19-genotype guided antiplatelet therapy results in a
higher likelihood of achieving a therapeutic level of on-treatment platelet reactivity
(20-22), which may also be cost effective among ACS patients undergoing PCI (23).

genes are highly polymorphic and can result in no, decreased, normal, or increased
enzyme activity.
CYP2C19, CYP2C9, CYP3A5, and CYP2B6 are involved in the metabolism of prasugrel,
but genetic variations in these genes do not appear to influence the pharmokinetics of
prasugrel. In contrast, genetic variation in the CYP2C19 gene may lead to decreased
effectiveness of the related drug, clopidogrel. To read more about CYP variants and the
clopidogrel drug response, please see “Clopidogrel Therapy and CYP2C19 Genotype”.
Genetic Testing
for the genes CYP2C19, CYP2C9, CYP3A5, and CYP2B6. Given that the formation of the
active metabolite of prasugrel is not known to be affected by CYP variants, genetic testing
prior to the use of prasugrel is not currently recommended.
For clopidogrel, its effectiveness is dependant on its activation to an active metabolite,
principally by CYP2C19. Therefore, the FDA states that tests that identify a patient’s
CYP2C19 genotype can be used as an aid to determining therapeutic strategy.

Statement from the US Food and Drug Administration (FDA): In healthy subjects,
patients with stable atherosclerosis, and patients with ACS receiving prasugrel, there was
no relevant effect of genetic variation in CYP2B6, CYP2C9, CYP2C19, or CYP3A5 on the

pharmacokinetics of prasugrel's active metabolite or its inhibition of platelet aggregation.
[...]
In TRITON-TIMI 38, prasugrel reduced ischemic events (mainly nonfatal MIs) and
increased bleeding events relative to clopidogrel. The findings are consistent with the
intended greater inhibition of platelet aggregation by prasugrel at the doses used in the
study. There is, however, an alternative explanation: both prasugrel and clopidogrel are
pro-drugs that must be metabolized to their active moieties. Whereas the
pharmacokinetics of prasugrel's active metabolite are not known to be affected by genetic
variations in CYP2B6, CYP2C9, CYP2C19, or CYP3A5, the pharmacokinetics of
clopidogrel's active metabolite are affected by CYP2C19 genotype, and approximately 30%
of Caucasians are reduced-metabolizers. Moreover, certain proton pump inhibitors,
widely used in the ACS patient population and used in TRITON-TIMI 38, inhibit
CYP2C19, thereby decreasing formation of clopidogrel's active metabolite. Thus, reduced-
metabolizer status and use of proton pump inhibitors may diminish clopidogrel's activity
in a fraction of the population, and may have contributed to prasugrel's greater treatment
effect and greater bleeding rate in TRITON-TIMI 38. The extent to which these factors
were operational, however, is unknown.
Acknowledgments
The author would like to thank Mohamed Nagy, Clinical Pharmacist, Head of the
Personalised Medication Management Unit, Department of Pharmaceutical Services,
Children's Cancer Hospital, Egypt; Aniwaa Owusu Obeng, PharmD, Assistant Professor,
The Charles Bronfman Institute for Personalized Medicine, Icahn School of Medicine at
Mount Sinai; and Victoria M. Pratt, Ph.D., FACMG, Director, Pharmacogenomics
Laboratory, Department of Medical and Molecular Genetics, Indiana University School of
Medicine; for reviewing this summary.
References
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clopidogrel in patients with acute coronary syndromes. N Engl J Med. 2007;357(20):
2001–15. PubMed PMID: 17982182.
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2008;371(9621):1353–63. PubMed PMID: 18377975.
4. Antman E.M., Wiviott S.D., Murphy S.A., Voitk J., et al. Early and late benefits of
prasugrel in patients with acute coronary syndromes undergoing percutaneous
coronary intervention: a TRITON-TIMI 38 (TRial to Assess Improvement in
Therapeutic Outcomes by Optimizing Platelet InhibitioN with Prasugrel-
Thrombolysis In Myocardial Infarction) analysis. J Am Coll Cardiol. 2008;51(21):
2028–33. PubMed PMID: 18498956.
5. Mariani M., Mariani G., De Servi S. Efficacy and safety of prasugrel compared with
clopidogrel in patients with acute coronary syndromes: results of TRITON-TIMI 38
trials. Expert Rev Cardiovasc Ther. 2009;7(1):17–23. PubMed PMID: 19105763.
6. Wallentin L. P2Y(12) inhibitors: differences in properties and mechanisms of action
and potential consequences for clinical use. Eur Heart J. 2009;30(16):1964–77.
7. Mallouk N., Labruyere C., Reny J.L., Chapelle C., et al. Prevalence of poor biological
response to clopidogrel: a systematic review. Thromb Haemost. 2012;107(3):494–506.
8. Brandt J.T., Close S.L., Iturria S.J., Payne C.D., et al. Common polymorphisms of
CYP2C19 and CYP2C9 affect the pharmacokinetic and pharmacodynamic response
to clopidogrel but not prasugrel. J Thromb Haemost. 2007;5(12):2429–36. PubMed
PMID: 17900275.
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Prasugrel response

CYP2C19 gene
CYP2C9 gene
CYP3A5 gene
CYP2B6 gene
295

Laura Dean, MD1
Introduction
Propafenone is an antiarrhythmic medication. It is used to prevent the reoccurrence of
atrial fibrillation in patients with episodic atrial fibrillation who do not have underlying
structural heart disease (propafenone may provoke proarrhythmic events in patients with
structural heart disease).
Propafenone belongs to class IC of antiarrhythmic agents and acts on cardiac sodium
channels to inhibit action potentials. In general, because of the lack of evidence that
antiarrhythmic agents improve survival, they should only be used to treat arrhythmias
that are thought to be life-threatening.
Propafenone is metabolized by CYP2D6, CYP3A4, and CYP1A2 enzymes. Approximately
6% of Caucasians in the US lack CYP2D6 activity, and are known as “CYP2D6 poor
metabolizers” (Table 1) (1). Standard doses of propafenone will lead to higher plasma
drug concentrations in poor metabolizers, compared to normal metabolizers. In addition,
drugs that inhibit CYP2D6, CYP3A4, and CYP1A2 may also increase propafenone levels,
which may lead to cardiac arrhythmia episodes.
The FDA-approved drug label for propafenone states that the recommended dosing
regimen of propafenone is the same for all patients (CYP2D6 poor metabolizers and
normal metabolizers). However, the label also cautions that the simultaneous use of
propafenone with both a CYP2D6 inhibitor (or in patients with CYP2D6 deficiency) and
a CYP3A4 inhibitor should be avoided, because of the increased risk of causing
arrhythmias and other adverse events (1).
A guideline from The Dutch Pharmacogenetics Working Group (DPWG) of the Royal
Dutch Pharmacists Association (KNMP) provides dosing recommendations for
propafenone, based on CYP2D6 genotype. For CYP2D6 poor metabolizers, the guideline
recommends reducing the initial dose of propafenone by 70%, ECG monitoring, and
monitoring plasma concentrations. For intermediate and ultrarapid metabolizers, the
guideline states there is insufficient data to allow for a calculation of dose adjustment.
Therefore, it is recommended to adjust the dose in response to plasma concentration and
to monitor with ECG, or select an alternative drug (e.g., sotalol, disopyramide, quinidine,
amiodarone) (2, 3) (Table 2).

Drug class: Antiarrhythmics

Antiarrhythmic agents suppress abnormal heart rhythms (cardiac arrhythmias), which
can originate from the atria (e.g., atrial fibrillation, atrial flutter) or the ventricles (e.g.,
ventricular tachycardia, ventricular fibrillation).
There are five main classes of antiarrhythmic agents, based on their primary site of action:
• Class I: block sodium (Na+) channels e.g., quinidine (class IA), lidocaine (class IB),
propafenone (class IC)
• Class II: block beta adrenoreceptors e.g., carvedilol, metoprolol, propranolol
• Class III: block potassium (K+) channels e.g., amiodarone, sotalol
• Class IV: block calcium (Ca2+) channels e.g., verapamil, diltiazem
• Class V: work by other or unknown mechanisms e.g., adenosine, digoxin
Drug: Propafenone
Propafenone is an antiarrhythmic used to prevent the recurrence of atrial fibrillation in
patients who have episodic atrial fibrillation and no underlying structural heart disease.
Propafenone is also used in the management of paroxysmal supraventricular tachycardia
and atrial flutter (1).
Because there are no well-controlled studies in pregnant women, the FDA-approved drug
label states that propafenone should only be used during pregnancy if the benefit justifies
the potential risk to the fetus. The label also states that the safety and effectiveness of
propafenone in pediatric patients have not been established.
Atrial fibrillation is the most common type of harmful cardiac arrhythmias. It is more
common in men than women, and the risk of developing atrial fibrillation increases with
age. Atrial fibrillation may be paroxysmal (intermittent), persistent (persists for at least 7
days), long-standing (more than 12 months), or permanent.
The symptoms of atrial fibrillation range from no symptoms, to feeling dizzy, short of
breath, and experiencing palpitations. The pulse feels irregular, and an ECG will show an
absence of P waves and an irregular QRS complex. Atrial fibrillation can lead to reduced
cardiac output, increase the risk of thrombosis and stroke, and affected patients may be at
an increased risk for mortality (4). Management typically includes antithrombotic therapy
and rhythm control.
Propafenone is a class IC antiarrhythmic agent. All class I agents have a "membrane
stabilizing effect"—by reducing the fast influx of sodium ions into the cardiac muscle cells,
they inhibit the propagation of action potentials. Propafenone also has some Class II
activity—it can act as a beta blocker. Side effects of this action include bradycardia and
bronchospasm (5, 6).
The class IC agents encainide and flecainide have been associated with increasing the risk
of cardiac arrest or death, compared to placebo. Consequently all class IC agents,
Propafenone Therapy and CYP2D6 Genotype 297
including propafenone, are considered to have a significant risk of provoking

proarrhythmic events in patients with structural heart disease. Therefore, propafenone
should not be used in patients with underlying structural heart disease. Its use is
contraindicated in a number of conditions, including heart failure, conduction disorders,
bradycardia, and recent myocardial infarction (within the last 3 months) (1, 7-9).
Propafenone is metabolized into two active metabolites: 5-hydroxypropafenone, which is
formed by CYP2D6, and norpropafenone, which is formed by both CYP3A4 and
CYP1A2. Multiple studies have found that genetic variants in the CYP2D6 gene influence
the plasma drug levels of propafenone (10-13).
In patients who lack CYP2D6 activity, metabolism of propafenone is slower, so the 5-
hydroxy metabolite is not formed or is formed at very slow rates. In these patients, high
doses of propafenone (850mg daily) lead to plasma concentrations of propafenone that
are about twice those of patients who have normal CYP2D6 activity. At lower initial
doses, the difference between propafenone and 5-hydroxy metabolite concentrations is
even greater (1, 14).
However, the FDA recommends that the dosing regimen of propafenone should be the
same for all patients, regardless of their CYP2D6 activity levels. This is because even at
high doses, the effects of high propafenone levels are mitigated by the lack of the active 5-
hydroxy metabolite in the slow metabolizers, and also because steady-state conditions are
achieved after 4 to 5 days of titrating the dose in all patients. But the FDA also
recommends that because of the large variation in plasma drug levels between
individuals, the dose of propafenone should be individually titrated on the basis of
response and tolerance, with close attention paid to clinical and ECG evidence of toxicity
(1).
The FDA-approved drug label for propafenone cautions against the simultaneous use of
propafenone with both a CYP2D6 inhibitor and a CYP3A4 inhibitor. This is because the
combination of CYP3A4 inhibition and either CYP2D6 inhibition or deficiency may
increase propafenone exposure, which may trigger new cardiac arrhythmias and
exaggerate beta adrenoreceptor blockage (1).

activity.
Gene: CYP2D6

No function *3-*8, *11-*16, *19-*21, *38, *40, *42
Individuals who have more than two normal function copies of

the CYP2D6 (CYP2D6*xN) gene are “ultrarapid metabolizers,” whereas individuals who
carry two normal or one normal and one decreased function allele are classified as
“normal metabolizers.”
are categorized as “normal metabolizers” by recent nomenclature guidelines (16), but have
also been categorized as “intermediate metabolizers” in the literature. Subjects with one
decreased and one no function allele are predicted to be intermediate metabolizers and
those with two no function alleles are classified as poor metabolizers.
most common decreased function alleles include CYP2D6*9, *10, *17, *29 and *41 (5, 6,
18, 20, 21) (Table 1).
There are large inter-ethnic differences in the frequency of these alleles. For example,
CYP2D6*4 is the most common no function allele in Caucasians, but is less abundant in
subjects with African ancestry, and is rare in Asians. In contrast, the decreased function
exclusively found in individuals with African ancestry (22).
Consequently, the phenotype frequencies vary substantially among the major ethnicities
and may vary among populations. Approximately 6-10% of European Caucasians and
their descendants are poor metabolizers, mainly due to the prevalent no function
CYP2D6*4 and *5 alleles (17, 23).
Genetic Testing
The NIH’s Genetic Testing Registry (GTR) lists genetic tests currently available for
propafenone response and the CYP2D6 gene.
Results are typically reported as a diplotype, such as CYP2D6 *1/*1 (wild type). A result
for copy number, if available, is also important when interpreting CYP2D6 results (19).

2016 Statement from the US Food and Drug Administration (FDA): Propafenone is
metabolized by CYP2D6, CYP3A4, and CYP1A2 isoenzymes. Approximately 6% of
Caucasians in the US population are naturally deficient in CYP2D6 activity and other
demographic groups are deficient to a somewhat lesser extent. Drugs that inhibit these
CYP pathways (such as desipramine, paroxetine, ritonavir, sertraline for CYP2D6;
ketoconazole, erythromycin, saquinavir, and grapefruit juice for CYP3A4; and
amiodarone and tobacco smoke for CYP1A2) can be expected to cause increased plasma
levels of propafenone.
Increased exposure to propafenone may lead to cardiac arrhythmias and exaggerated
beta-adrenergic blocking activity. Because of its metabolism, the combination of CYP3A4
inhibition and either CYP2D6 deficiency or CYP2D6 inhibition in users of propafenone is
potentially hazardous. Therefore, avoid simultaneous use of propafenone with both a
CYP2D6 inhibitor and a CYP3A4 inhibitor.
2016 Summary of recommendations from The Dutch Pharmacogenetics Working
Group (DPWG) of the Royal Dutch Pharmacists Association (KNMP): For CYP2D6
poor metabolizers (PMs), defined as patients carrying two defective alleles, dose
reductions are recommended for clomipramine, flecainide, haloperidol, zuclopenthixol
(all 50%); doxepin, nortriptyline (both 60%); imipramine, propafenone (both 70%); and
metoprolol (75%).
[…].
For CYP2D6 intermediate metabolizers (IMs), defined as patients carrying two
decreased-activity alleles or one active/decreased-activity allele and one inactive allele,
dose reductions ranging from 20 to 50% are advised for doxepin, amitriptyline,
zuclopenthixol, imipramine, nortriptyline, and metoprolol. There were insufficient data to
calculate dose adjustments for clomipramine, oxycodone, propafenone, risperidone, and
venlafaxine (Table 2).
generic drug.
Table 2. CYP2D6 phenotypes and the therapeutic recommendations for propafenone therapy, from The
CYP2D6 Phenotype Recommendations for propafenone therapy
Ultrarapid metabolizer Insufficient data to allow calculation of dose adjustment. Adjust
dose in response to plasma concentration and record ECG or
select alternative drug (e.g., sotalol, disopyramide, quinidine,
amiodarone).
Intermediate metabolizer Insufficient data to allow calculation of dose adjustment. Adjust
dose in response to plasma concentration and record ECG or
select alternative drug (e.g., sotalol, disopyramide, quinidine,
amiodarone).
Poor metabolizer Reduce dose by 70%, record ECG, monitor plasma concentration
The level of evidence for the therapeutic (dose) recommendations is 4/4 (“good quality”) for poor
metabolizers, and 3/4 (“moderate quality”) for intermediate and ultrarapid metabolizer types. The Table is
adapted from Swen J.J., Nijenhuis M., de Boer A., Grandia L. et al. Pharmacogenetics: from bench to byte -
an update of guidelines. Clinical pharmacology and therapeutics. 2011;89(5):662–73 (2, 3).

Coding Protein
identifier for
allele location
frameshift)
Trp152Gly 454delT
CYP2D6T
(Pro34Ser) 100C>T
(Thr107Ile) 320C>T
(Cys296Arg) 886T>C
(Cys296Arg) 886T>C
Acknowledgments
The author would like to thank the following individuals for reviewing this summary: JT
Callaghan, M.D., Ph.D., Associate Dean of Veterans Affairs Research, Associate Professor
of Medicine, and Pharmacology and Toxicology, Department of Veterans Affairs, and
Indiana University School of Medicine; Ben Kong, PharmD, BCPS, Clinical Pharmacist,
Oregon Health & Science University, Oregon; Gouri Mukerjee, Scientific Officer at
Geneyouin Inc., Toronto, Canada; Mohamed Nagy, Clinical Pharmacist, Head of the
Personalised Medication Management Unit, Department of Pharmaceutical Services,
Children's Cancer Hospital, Egypt; Mandy van Rhenen, Secretary of the Dutch
Dutch Pharmacists Association (KNMP); and DeeAnn Visk, PhD, a medical writer,
editor, and member of the Clinical Pharmacogenetics Implementation Consortium
(CPIC).
References
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– CYP2D6 2016 [Cited March 2017]. Available from: http://kennisbank.knmp.nl
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patients receiving encainide, flecainide, or placebo. The Cardiac Arrhythmia
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8. Vaughan Williams E.M. Significance of classifying antiarrhythmic actions since the
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10. Cai W.M., Xu J., Chen B., Zhang F.M., et al. Effect of CYP2D6*10 genotype on
propafenone pharmacodynamics in Chinese patients with ventricular arrhythmia.
Acta Pharmacol Sin. 2002;23(11):1040–4. PubMed PMID: 12421483.
11. Chen B., Cai W.M. Influence of CYP2D6*10B genotype on pharmacokinetics of
propafenone enantiomers in Chinese subjects. Acta Pharmacol Sin. 2003;24(12):
1277–80. PubMed PMID: 14653957.
12. Zhou S.F. Polymorphism of human cytochrome P450 2D6 and its clinical
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13. Su Y., Liang B.Q., Feng Y.L., Zhan Y., et al. Assessment of 25 CYP2D6 alleles found in
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genetically determined polymorphic drug metabolism in the beta-blockade produced
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11972444.


Propafenone response

CYP2D6 gene
305

Laura Dean, MD1
Introduction
Risperidone is the most commonly prescribed antipsychotic medication in the US. It is an
atypical (second generation) antipsychotic used in the treatment of schizophrenia, bipolar
disorder, severe dementia, and irritability associated with autism.
Risperidone is metabolized to the active metabolite 9-hydroxyrisperidone by the enzyme
CYP2D6 and to a lesser extent by CYP3A4. Individuals who carry two inactive copies of
the CYP2D6 gene are termed “poor metabolizers” and may have a decreased capacity to
metabolize risperidone. These individuals may be at a higher risk of adverse effects
because of increased exposure to plasma risperidone, compared to normal metabolizers,
who carry two active copies of CYP2D6. Individuals who are CYP2D6 ultrarapid
metabolizers (who carry more than two functional copies of CYP2D6) may have a
decreased response to therapy, resulting from lower steady-state risperidone
concentrations.
The FDA-approved drug label states that analysis of clinical studies involving a modest
number of poor metabolizers (n=70) does not suggest that poor and extensive (normal)
metabolizers have different rates of adverse effects (1). In addition, the Dutch
Pharmacogenetics Working Group (DPWG) recently changed its dosing
recommendations to “no action is needed” for CYP2D6 poor metabolizers taking
risperidone (2).
Drug: Risperidone
Risperidone is an atypical antipsychotic primarily used in the treatment of schizophrenia
and manic or mixed episodes in bipolar disorder. Risperidone may also be used as part of
the management of aggression and/or psychosis in severe dementia and irritability
associated with autistic disorder in children and adolescents (1).
chlorpromazine. Known as “first-generation” or “typical” antipsychotics, these drugs are
used to treat psychosis (regardless of the underlying cause), chronic psychotic disorders
(e.g., schizophrenia), and other psychiatric conditions.
All antipsychotics, with the exception of aripiprazole, are dopamine receptor antagonists.
Blockade of the D2 dopamine receptor in the brain’s limbic system is thought to improve

the “positive” symptoms of schizophrenia, such as delusions and hallucinations, which are
signs of psychosis.
However, typical antipsychotics also block dopamine receptors in the nigrostriatal
pathway. This can cause movement disorders known as extrapyramidal side effects. These
disorders include akathisia (motor restlessness), dystonia (abnormal muscle tone), and
tardive dyskinesia (involuntary and repetitive movements).
lower risk of extrapyramidal side effects. Risperidone is an atypical antipsychotic. The
most common side effects of risperidone therapy are sedation and dry mouth, but the
rates of both appear to be low, at around 5% (3). Other atypical antipsychotics approved
by the FDA include aripiprazole, asenapine, brexpiprazole, cariprazine, clozapine,
lurasidone, olanzapine, quetiapine, and ziprasidone.
Atypical antipsychotics, such as risperidone, are thought to transiently occupy D2
receptors and then rapidly dissociate, to allow for normal dopamine neurotransmission
(4). Because risperidone has high affinity for the D2 receptor but binds it “loosely”, it does
not block dopamine receptors in the nigrostriatal pathway and extrapyramidal side effects
are less likely (5).
Risperidone also blocks serotonin receptors, alpha 1 adrenergic receptors, and, to a lesser
extent, histamine H1 and alpha 2 adrenergic receptors.
The main route of risperidone metabolism is in the liver by the enzyme CYP2D6. The
major active metabolite, 9-hydroxyrisperidone, contributes to the pharmacological effects
of this drug (5). While risperidone and 9-hydroxyrisperidone are often regarded as
equipotent, they display different affinities towards the two target receptors (D2 and
5HT2A), where risperidone appears to be approximately 2-fold more potent than 9-
hydroxyrisperidone. There is also a difference in brain distribution; risperidone is
distributed more to the CNS (6).
Genetic variations in the CYP2D6 gene may contribute to an increased risk of adverse
events associated with risperidone therapy (7). Individuals who are “CYP2D6 poor
metabolizers” carry two no function copies of the CYP2D6 gene. In these individuals,
standard doses of risperidone may lead to increased plasma levels of risperidone and
decreased levels of 9-hydoxyrisperidone.
However, it is unclear to the extent to which CYP2D6 genotype influences the efficacy and
safety of risperidone therapy. One small study of 76 patients with schizophrenia reported
that CYP2D6 poor metabolism was associated with greater clinical improvement in the
total Positive and Negative Syndrome Scale (PANSS) (8). Other studies have reported a
higher rate of adverse reactions and drug discontinuations in CYP2D6 poor metabolizers
compared to normal metabolizers (5, 9, 10).
The ratio of risperidone to 9-hdroxyrisperidone, which largely reflects CYP2D6
phenotype, may be a risk factor for different side effects (11). Because prolactin levels
Risperidone Therapy and CYP2D6 Genotype 307
mainly correlate with 9-hydroxyrisperidone levels, CYP2D6 ultrarapid metabolizers may

experience different side effects than normal metabolizers (12). In addition, because
elderly patients accumulate 9-hydroxyrisperidone due to reduced renal function, older
patients who are CYP2D6 poor metabolizers (and others with reduced renal function) are
at particular risk of side effects during risperidone treatment (5).
Individuals who are “CYP2D6 ultrarapid metabolizers” may have decreased plasma levels
of risperidone, due to increased CYP2D6 activity—these individuals carry more than two
functional copies of the CYP2D6 gene. A small study of 85 patients taking long-lasting
risperidone showed that the plasma concentrations of risperidone and its active
metabolite were subtherapeutic in three individuals who were CYP2D6 ultrarapid
metabolizers. The study, however, did not report whether these changes affected the
effectiveness or tolerability of the drug in these patients (13).
Overall, it remains unclear whether the accurate determination of an individual’s CYP2D6
genotype, together with therapeutic drug monitoring, has the potential to optimize the
response of CYP2D6 poor metabolizers and ultrarapid metabolizers to antipsychotic
therapy (9, 14).

form the major system for metabolizing or detoxifying lipids, hormones, toxins, and
drugs. The CYP450 genes are very polymorphic and can result in reduced, absent, or
increased enzyme activity.
Gene: CYP2D6
the reference (or wild-type) allele encoding an enzyme with normal activity. The
CYP2D6*2, *33, and *35 alleles are also considered to confer normal enzyme activity
(Table 1).
No function *3, *4, *5, *6, *7, *8, *11, *12, *13, *14, *15, *16, *19, *20, *21, *38, *40, *42
classified as “ultrarapid metabolizers,” whereas individuals who carry two normal or one
normal and one decreased function allele are classified as “normal metabolizers” (also
referred to as “extensive metabolizers”).
are also categorized as “normal metabolizers” by recent nomenclature guidelines (16), but
have also been categorized as “intermediate metabolizers” elsewhere in the literature.
Subjects with one decreased and one no function allele are predicted to be “intermediate
metabolizers” and those with two no function alleles are considered to be “poor
metabolizers” (Table 2).
patients)a
or combinations of
2.0
patients)
patients) *3/*4
*5/*5
*5/*6
laboratories.
most common decreased function alleles include CYP2D6*9, *10, *17, *29 and *41 (19,
21-24). There are large inter-ethnic differences in the frequency of these alleles. For
example, CYP2D6*4 is the most common no function allele in Caucasians, but is less
abundant in subjects with African ancestry and is rare in Asians. In contrast, the
decreased function allele CYP2D6*10 is the most common allele in Asians, and
CYP2D6*17 is almost exclusively found in individuals with African ancestry (25).
ethnicities and may vary among populations. Approximately 6–10% of European
Genetic Testing
currently available for risperidone response and for the CYP2D6 gene.
number, if available, is also important when interpreting CYP2D6 genotyping results (28).
However, it is important to note that the number of variants tested can vary among
laboratories, which can result in diplotype result discrepancies between testing platforms
and laboratories (29).
score to each allele (e.g., 0 for no function, 0.5 for decreased function, and 1 for each copy
of a normal function allele). The phenotype is defined by the sum of the two scores:

2016 Statement from the US Food and Drug Administration (FDA): Risperidone is
extensively metabolized in the liver. The main metabolic pathway is through
hydroxylation of risperidone to 9-hydroxyrisperidone by the enzyme, CYP 2D6. A minor
metabolic pathway is through N-dealkylation. The main metabolite, 9-
generic drug.
hydroxyrisperidone, has similar pharmacological activity as risperidone. Consequently,

the clinical effect of the drug results from the combined concentrations of risperidone
plus 9-hydroxyrisperidone.
CYP 2D6, also called debrisoquin hydroxylase, is the enzyme responsible for metabolism
of many neuroleptics, antidepressants, antiarrhythmics, and other drugs. CYP 2D6 is
subject to genetic polymorphism (about 6%–8% of Caucasians, and a very low percentage
of Asians, have little or no activity and are "poor metabolizers") and to inhibition by a
variety of substrates and some non-substrates, notably quinidine. Extensive2 CYP 2D6
metabolizers convert risperidone rapidly into 9-hydroxyrisperidone, whereas poor CYP
2D6 metabolizers convert it much more slowly. Although extensive metabolizers have
lower risperidone and higher 9-hydroxyrisperidone concentrations than poor
metabolizers, the pharmacokinetics of risperidone and 9-hydroxyrisperidone combined,
after single and multiple doses, are similar in extensive and poor metabolizers.
2017 Summary of recommendations from the Dutch Pharmacogenetics Working
Group (DPWG) of the Royal Dutch Association for the Advancement of Pharmacy
(KNMP):
CYP2D6 Poor metabolizers:
No action is needed for this gene-drug interaction.
The genetic variation can result in both an increase in side effects and a stronger decrease
in schizophrenia symptoms. In addition to this, the genetic variation may lead to a
decrease in the required maintenance dose. However, as the effect on the dose is smaller
than that of the normal biological variation, action is not useful.
CYP2D6 intermediate metabolizers:
There is little evidence to support an increase in side effects caused by the genetic
variation. The genetic variation may lead to a decrease in the required maintenance dose.
However, as the effect on the dose is smaller than that of the normal biological variation,
action is not useful.
2 The FDA statement uses the term “extensive metabolizer.” CPIC recently introduced
standardized nomenclature for pharmacogenetic terms, which included replacing the term
“extensive metabolizer” with the term “normal metabolizer.” More details can be found in the
2016 paper, “Standardizing terms for clinical pharmacogenetic test results: consensus terms from
the Clinical Pharmacogenetics Implementation Consortium (CPIC)” 16. Caudle, K.E., H.M.
Dunnenberger, R.R. Freimuth, J.F. Peterson, et al., Standardizing terms for clinical
pharmacogenetic test results: consensus terms from the Clinical Pharmacogenetics
Implementation Consortium (CPIC). Genet Med, 2016.
CYP2D6 ultrarapid metabolizers:

Genetic variation may lead to an increase in the required maintenance dose. However, as
the effect is smaller than that of the normal biological variation, action is not useful.
Nomenclature
allele name names / Major reference
Coding Protein
SNP identifier for
allele location
Trp152Gly 454delT
Pro34Ser 100C>T
1023C>T 886T>C
(Thr107Ile)
2850C>T
(Cys296Arg)
SNP= Single Nucleotide Polymorphism
*In the literature, 1023C>T is also referred to as 1111C>T, and 2850C>T is also referred to 2938C>T.
Acknowledgments
John T. Callaghan, M.D., Ph.D., Associate Dean of Veterans Affairs Research, Associate
Professor of Medicine, and Adjunct Associate Professor of Pharmacology and Toxicology,
Department of Veterans Affairs, and Indiana University School of Medicine; Houda

Hachad, PharmD, M.Res, Chief Science Officer, Translational Software, Seattle, WA; Ben
Kong, PharmD, BCPS, Clinical Pharmacist, Oregon Health & Science University; Mark W.
Linder, Ph.D., Professor, and Assistant Director, Clinical Chemistry and Toxicology,
University of Louisville Hospital, and Associate Director, Pharmacogenetics Diagnostic
Laboratory, Department of Pathology and Laboratory Medicine, University of Louisville
School of Medicine; Espen Molden, Ph.D., Research Leader, Diakonhjemmet Hospital,
and Professor, University of Oslo, Norway; Mohamed Nagy, RPh, MSc, Clinical
Pharmaceutical Services, Children's Cancer Hospital, Egypt; George P. Patrinos, Ph.D.,
Associate Professor, University of Patras School of Health Sciences, Greece; Mandy van
Rhenen, MSc, Secretary, Dutch Pharmacogenetics Working Group (DPWG), Centre for
Information on Medicines, Royal Dutch Pharmacists Association (KNMP); Chonlaphat
Sukasem, B. Pharm, Ph.D, Associate Professor and Head, Division of Pharmacogenomics
and Personalized Medicine, Faculty of Medicine, Ramathibodi Hospital, Mahidol
University, Bangkok, Thailand.
References
1. RISPERDAL CONSTA- risperidone [Package Insert]. Titusville, NJ: Janssen
Pharmaceuticals, I.; 2016. Available from: https://dailymed.nlm.nih.gov/dailymed/
drugInfo.cfm?setid=bb34ee82-d2c2-43b8-ba21-2825c0954691
Group (DPWG). Pharmacogenetic Guidelines [Internet]. Netherlands. Risperidone –
CYP2D6 [Cited March 2017]. Available from: http://kennisbank.knmp.nl/ [Access is
3. Mahmoud R.A., Pandina G.J., Turkoz I., Kosik-Gonzalez C., et al. Risperidone for
treatment-refractory major depressive disorder: a randomized trial. Ann Intern Med.
2007;147(9):593–602. PubMed PMID: 17975181.
4. Seeman P. Atypical antipsychotics: mechanism of action. Canadian journal of
psychiatry. Revue canadienne de psychiatrie. 2002;47(1):27–38. PubMed PMID:
11873706.
5. Molden E., Waade R.B., Hoff M., Haslemo T. Impact of Ageing on Serum
Concentrations of Risperidone and Its Active Metabolite in Patients with Known
CYP2D6 Genotype. Basic Clin Pharmacol Toxicol. 2016;119(5):470–475. PubMed
PMID: 27145399.
6. Hendset M., Haslemo T., Rudberg I., Refsum H., et al. The complexity of active
metabolites in therapeutic drug monitoring of psychotropic drugs.
Pharmacopsychiatry. 2006;39(4):121–7. PubMed PMID: 16871467.
7. de Leon J., Susce M.T., Pan R.M., Fairchild M., et al. The CYP2D6 poor metabolizer
phenotype may be associated with risperidone adverse drug reactions and
discontinuation. J Clin Psychiatry. 2005;66(1):15–27. PubMed PMID: 15669884.
8. Almoguera B., Riveiro-Alvarez R., Lopez-Castroman J., Dorado P., et al. CYP2D6
poor metabolizer status might be associated with better response to risperidone
treatment. Pharmacogenet Genomics. 2013;23(11):627–30. PubMed PMID:

24026091.
9. Lisbeth P., Vincent H., Kristof M., Bernard S., et al. Genotype and co-medication
dependent CYP2D6 metabolic activity: effects on serum concentrations of
aripiprazole, haloperidol, risperidone, paliperidone and zuclopenthixol. Eur J Clin
10. Patteet L., Haufroid V., Maudens K., Sabbe B., et al. Erratum to: Genotype and co-
medication dependent CYP2D6 metabolic activity: effects on serum concentrations
of aripiprazole, haloperidol, risperidone, paliperidone and zuclopenthixol. Eur J Clin
Pharmacol. 2016. PubMed PMID: 27738718.
11. Cartwright A.L., Wilby K.J., Corrigan S., Ensom M.H. Pharmacogenetics of
risperidone: a systematic review of the clinical effects of CYP2D6 polymorphisms.
Ann Pharmacother. 2013;47(3):350–60. PubMed PMID: 23463739.
12. Knegtering R., Baselmans P., Castelein S., Bosker F., et al. Predominant role of the 9-
hydroxy metabolite of risperidone in elevating blood prolactin levels. Am J
13. Ganoci L., Lovric M., Zivkovic M., Sagud M., et al. The Role Of Cyp2d6, Cyp3a4/5,
And Abcb1 Polymorphisms In Patients Using Long-Acting Injectable Risperidone.
Clin Ther. 2016;38(10S):e10–e11. PubMed PMID: 27673605.
14. Vanwong N., Ngamsamut N., Hongkaew Y., Nuntamool N., et al. Detection of
CYP2D6 polymorphism using Luminex xTAG technology in autism spectrum
disorder: CYP2D6 activity score and its association with risperidone levels. Drug
Metab Pharmacokinet. 2016;31(2):156–62. PubMed PMID: 26944100.
PMID: 27441996.
Ther. 2016.
18. Mayo Clinic Mayo Medical Laboratories. Test ID: AMTRP: Amitriptyline and
Nortriptyline, Serum. Mayo Clinic Mayo Medical Laboratories [19 August 2016];
Available from: http://www.mayomedicallaboratories.com/test-catalog/Clinical+and
+Interpretive/63506.
20. Ulrich S., Lauter J. Comprehensive survey of the relationship between serum
concentration and therapeutic effect of amitriptyline in depression. Clin
Pharmacokinet. 2002;41(11):853–76. PubMed PMID: 12190332.
21. Steimer W., Zopf K., von Amelunxen S., Pfeiffer H., et al. Amitriptyline or not, that is
the question: pharmacogenetic testing of CYP2D6 and CYP2C19 identifies patients
with low or high risk for side effects in amitriptyline therapy. Clin Chem. 2005;51(2):
376–85. PubMed PMID: 15590749.
22. van der Weide J., van Baalen-Benedek E.H., Kootstra-Ros J.E. Metabolic ratios of
psychotropics as indication of cytochrome P450 2D6/2C19 genotype. Ther Drug
Monit. 2005;27(4):478–83. PubMed PMID: 16044105.
23. Stern S.L., Ribner H.S., Cooper T.B., Nelson L.D., et al. 2-Hydroxydesipramine and
desipramine plasma levels and electrocardiographic effects in depressed younger
adults. J Clin Psychopharmacol. 1991;11(2):93–8. PubMed PMID: 2056147.
24. Schneider L.S., Cooper T.B., Severson J.A., Zemplenyi T., et al. Electrocardiographic
changes with nortriptyline and 10-hydroxynortriptyline in elderly depressed
outpatients. J Clin Psychopharmacol. 1988;8(6):402–8. PubMed PMID: 3069881.
PMID: 27388693.
11972444.
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2014;15(2):218–32. PubMed PMID: 24524666.




Risperidone response

CYP2D6 gene
317
Simeprevir Therapy and IFNL3 Genotype

Laura Dean, MD1
Introduction
Simeprevir is a hepatitis C virus (HCV) protease inhibitor used in combination with other
drugs to treat chronic hepatitis genotype 1 or 4 infection (1).
Previously, the standard care of patients with HCV infection was peginterferon alfa and
ribavirin, but ~40-50% of patients with HCV genotype 1 infection had a suboptimal
sustained virological response (SVR) (2).
A SVR is defined as undetectable HCV RNA by the end of treatment and at a specific
number of weeks after the end of treatment. The addition of simeprevir increased the SVR
in patients with HCV genotype 1 infection who were previously untreated. However, there
were reports of treatment failure, most commonly in adults, who failed to respond to
previous peginterferon and ribavirin treatment (3).
The FDA-approved drug label for simeprevir contains information regarding a genetic
variant near the IFNL3 gene (a C to T change; rs12979860), which is a strong predictor of
response to peginterferon alfa and ribavirin treatment. The label states that in phase 3
clinical trials, SVR rates were lower in patients with CT and TT genotypes, compared to
patients with the CC genotype. However, patients of all IFNL3 genotypes had highest SVR
rates when being treated with regimens that included simeprevir.
In addition, the label strongly recommends patients with HCV genotype 1a infection
should be screened for the presence of virus with the S3 Q80K polymorphism. If Q80K is
detected, the label strongly recommends that alternative therapy be considered (4).
Drug class: HCV Protease Inhibitors

The treatment of hepatitis C virus (HCV) has evolved over the years. Initially, interferon
(IFN) was used as monotherapy. This was followed by the addition of the antiviral agent
ribavirin (a nucleoside analogue) to peginterferon (PEG-IFN), and more recently, the
addition of antiviral protease inhibitors such as simeprevir.
Protease inhibitors are the first direct-acting antivirals to be approved for the treatment of
HCV, and simeprevir is the first second-generation agent to become available. Simeprevir
has largely replaced the use of the first-generation protease inhibitors, boceprevir and
telaprevir, which have less favorable side effect profiles.

Successful treatment of hepatitis C is confirmed when no trace of HCV can be found after
treatment has finished. This is referred to as the SVR, which is defined as undetectable
HCV RNA by a quantification assay at the end of treatment, and typically 12 (SVR12) or
24 weeks (SVR24) after the end of treatment.
The addition of simeprevir to a PEG-IFN and ribavirin treatment regimen increases the
SVR in patients with chronic hepatitis caused by genotype type 1 or 4 hepatitis C virus,
and the response to treatment is influenced by the patient’s IFNL3 genotype.
The FDA-approved drug label for simeprevir states that simeprevir should only be used in
combination with other antiviral drugs, such as in combination with PEG-IFN and
ribavirin; or in combination with sofosbuvir (HCV nucleotide-analogue NS5B
polymerase inhibitor) (1). However, because IFN-free regimes are fast becoming the
current standard of care for hepatitis C, simeprevir tends to be prescribed with sofosbuvir
rather than IFNs.
Drug: Simeprevir
Acute infection with HCV is usually asymptomatic, and about 15-45% of people who are
infected clear the virus within 6 months of infection without any treatment. The
remaining 55-85% of people will develop chronic HCV infection, which may also be
asymptomatic for many years. It is thought that over 180 million people are infected with
HCV worldwide (5).
The HCV is classified by genotype, based on the RNA viral strands. There are 6 classes of
genotype, numbered 1-6, with multiple subtypes e.g., 1a, 1b, 2a, 2b. In the US,
approximately 70% of people with HCV infection have genotype 1, with genotype 1a
more common than 1b (6). Genotype 1 is the most difficult to treat, as it is less likely than
genotypes 2 and 3 to respond to therapy.
Simeprevir has been FDA-approved for use in combination with other drugs, for the
treatment of adults with chronic hepatitis C, caused by an infection with genotype 1 or 4
HCV.
During the natural course of HCV infection, patients develop liver fibrosis, which,
without treatment, can progress to liver cancer (hepatocellular carcinoma).
Approximately 45% of patients with chronic hepatitis C will develop liver cancer within
20 years from the initial infection.
Until recently, the standard of care for hepatitis C infection was based on therapy with
peginterferon and ribavirin. Approximately half of the patients cleared the HCV infection,
as shown by a SVR, but adverse effects were common and sometimes life-threatening (2).
Treatment was expensive and inconvenient, lasting up to 48 weeks.
Protease inhibitors such as simeprevir were specifically developed to improve the
effectiveness of peginterferon and ribavirin therapy. Teleprevir was the first drug to be
developed, but severe dermatological adverse effects and liver toxicity limited its use.
Simeprevir Therapy and IFNL3 Genotype 319
Simeprevir belongs to the second generation of drugs, and has an improved therapeutic
index.
Simeprevir prevents maturation of the HCV by blocking viral protein synthesis.
Specifically, simeprevir inhibits the viral protease NS3/4A which is responsible for
cleaving and processing the HCV polyprotein precursor (7). Several mutations in this
viral NS3/4A protease are associated with a reduced susceptibility to simeprevir. One of
the most common and clinically significant mutations is the Q80K polymorphism. The
FDA-approved drug label states that patients with HCV genotype 1a infection should be
screened for the presence of virus with the Q80K polymorphism. If Q80K is detected, the
label strongly recommends that alternative therapy be considered (1).
The combination of protease inhibitors such as simeprevir with peginterferon and
ribavirin therapy has led to a much more effective treatment of hepatitis C in patients who
were “treatment naïve” (no history of HCV treatment) and among “relapsers” (patients
who had relapsed after previous HCV therapy). This was evidenced by improvement in
the SVR and reduction of treatment from 48 to 24 weeks, without any increase in
peginterferon and ribavirin adverse effects (3, 8).
The treatment options for hepatitis C continue to evolve. Currently, IFN-free treatment
regimes for hepatitis C are considered to be the standard of care. The IFN-free
combination of simeprevir plus sofosbuvir has been found to be a highly effective
treatment, with studies reporting high SVR12 rates for the majority of patients with
chronic HCV infection (from about 84% to 94%) (9-11).
Genetic variants in the IFNL3 gene have been shown to strongly influence treatment
response to PEG interferon-alpha-based regimens (including regimens with simeprevir)
in previously untreated patients with HCV genotype 1 infection (4). However, data are
currently lacking on how IFNL3 variants influence an individual’s response to simeprevir
when used with sofosbuvir in an IFN-free regimen.
Gene: IFNL3
The IFNL3 gene, previously known as IL28B, encodes interferon lambda-3 (IFN-λ3) and
is involved in the immune response to hepatitis C.
When a person is infected by a virus, their immune response includes the production of
interferons. These signaling proteins induce changes in infected and uninfected cells to
block viral replication and stop the spread of virus. Interferons are given as part of
treatment for HCV to strengthen this innate response.
There are three classes of IFNs: type I (IFN-α/β), type II (IFN-γ) and type III (IFN-λ). The
IFNL3 is a type III interferon, and as such, induces a strong antiviral state in responsive
cells with a higher risk of viral infection, such as mucosal cells (12).
IFNL3 is only highly expressed in hepatocytes and epithelial cells, in contrast to other
similar interferons, such as IFN-α, which are expressed in most cell types. IFNL3 exerts its
actions by interacting with a cytokine receptor complex, which is composed of the IL10RB
and IL28RA receptor chains (4).
The first two IFNL3 variants to be commonly tested for are rs12979860 and rs8099917.
These variants are in close proximity to each other near the IFNL3 gene, and are in strong
linkage disequilibrium. HCV genotype 1 patients with the “favorable” genotypes (CC for
rs12979860 and TT for rs8099917) respond better to treatment as they are associated with
an approximate 2-fold increase in SVR. However, the exact mechanism how these variants
influence treatment outcome is not yet known (4).
In a US cohort of mixed ethnicity, variants in rs12979860 predicted treatment response in
HCV genotype 1 infection patients: CC genotype individuals were more likely to
spontaneously clear acute HCV infection and TT genotype individuals had the poorest
response to treatment. Accordingly, CT genotype individuals had an intermediate
response that was between those of the CC and TT genotype patients (4).
The response to HCV treatment varies across different populations, which can be largely
explained by differences in allele frequencies. The rs12979860 ‘C’ allele is commonly
found in East Asians (allele frequency nearly 0.9), followed by Caucasians (0.63) and
Hispanics (0.55), and is the least common among individuals of African origin (0.39) (4).
Among Asians and individuals of European descent, the rs8099917 variant best predicts
treatment response (13-15). Moreover, recently a variant in the IFNL4 gene
(rs368234815), was found to be superior to rs12979860 in predicting treatment outcome
in individuals of African ancestry. Together with another IFNL4 variant (rs117648444),
the combination of these two variants was found to have greater treatment response
prediction compared to testing for single variants (12).
Genetic Testing
Genetic testing for IFNL3 is available, and is used to predict response to peg-IFN and
RBV in HCV genotype 1 patients. The results can help clinicians and patients make
informed decisions on how to best manage their HCV infection.
The rs12979860 variant is most commonly tested, and the results are typically reported in
the following format:
rs12979860 CC, favorable genotype
rs12979860 CT, unfavorable genotype
rs12979860 TT, unfavorable genotype (4).
Before starting a treatment regimen with simeprevir in patients with HCV genotype 1a
infection, the FDA strongly recommends screening patients for the presence of virus with
the “NS3 Q80K” polymorphism. The FDA states that an alternative therapy to simeprevir
should be considered if Q80K is detected (1).

2015 Statement from the US Food and Drug Administration (FDA): A genetic variant
near the gene encoding interferon-lambda-3 (IL28B rs12979860, a C [cytosine] to T
[thymine] substitution) is a strong predictor of response to Peg-IFN-alfa and RBV (PR).
In the Phase 3 trials, IL28B genotype was a stratification factor.
Overall, SVR rates were lower in subjects with the CT and TT genotypes compared to
those with the CC genotype. Among both treatment-naïve subjects and those who
experienced previous treatment failures, subjects of all IL28B genotypes had the highest
SVR rates with simeprevir-containing regimens.
Nomenclature
Common allele name Alternative names HGVS reference sequence dbSNP reference
identifier for allele
Coding Protein
location
rs12979860 / NM_001276254.2:c. N/A rs12979860
151-152G>A
rs8099917 / N/A N/A rs8099917
Acknowledgments
The author would like to thank Jitesh Kawedia, Pharmaceutical/Pharmacy Research
Specialist at the University of Texas MD Anderson Cancer Center; Stuart Scott, Assistant
Professor of Genetics and Genomic Sciences, Icahn School of Medicine at Mount Sinai;
and Professor Alex Thompson, Director of the Department of Gastroenterology at St
Vincent's Hospital, Melbourne, Senior Research Fellow at the Victorian Infectious
Diseases Reference Laboratory, and Adjunct Assistant Professor of the Department of
Gastroenterology, Duke University Medical Centre, USA; for reviewing this summary.
generic drug.
References
1. OLYSIO- simeprevir capsule [package insert]. Titusville, NJ: Janssen Products LP;
2015. Available from: https://dailymed.nlm.nih.gov/dailymed/drugInfo.cfm?
setid=1816fd68-0ed7-4a37-84bb-e298c5ab6e28
2. Nakayama M., Kobayashi H., Fukushima K., Ishido M., et al. Predictive factors for 24
weeks sustained virologic response (SVR24) and viral relapse in patients treated with
simeprevir plus peginterferon and ribavirin. Hepatol Int. 2016;10(1):158–68. PubMed
PMID: 26264253.
3. Manns M., Marcellin P., Poordad F., de Araujo E.S., et al. Simeprevir with pegylated
interferon alfa 2a or 2b plus ribavirin in treatment-naive patients with chronic
hepatitis C virus genotype 1 infection (QUEST-2): a randomised, double-blind,
placebo-controlled phase 3 trial. Lancet. 2014;384(9941):414–26. PubMed PMID:
24907224.
4. Muir A.J., Gong L., Johnson S.G., Lee M.T., et al. Clinical Pharmacogenetics
Implementation Consortium (CPIC) guidelines for IFNL3 (IL28B) genotype and
PEG interferon-alpha-based regimens. Clin Pharmacol Ther. 2014;95(2):141–6.
5. Messina J.P., Humphreys I., Flaxman A., Brown A., et al. Global distribution and
prevalence of hepatitis C virus genotypes. Hepatology. 2015;61(1):77–87. PubMed
PMID: 25069599.
6. Muir A.J. The rapid evolution of treatment strategies for hepatitis C. Am J
Gastroenterol. 2014;109(5):628–35quiz 636. PubMed PMID: 24732866.
7. Lin, C., HCV NS3-4A Serine Protease, in Hepatitis C Viruses: Genomes and Molecular
Biology, S. Tan, Editor. 2006, Horizon Bioscience: Norfolk (UK). Available from:
http://www.ncbi.nlm.nih.gov/books/NBK1623/
8. Forns, X., E. Lawitz, S. Zeuzem, E. Gane, et al., Simeprevir with peginterferon and
ribavirin leads to high rates of SVR in patients with HCV genotype 1 who relapsed after
previous therapy: a phase 3 trial. Gastroenterology, 2014. 146(7): p. 1669-79 e3.
9. Sulkowski M.S., Vargas H.E., Di Bisceglie A.M., Kuo A., et al. Effectiveness of
Simeprevir Plus Sofosbuvir, With or Without Ribavirin, in Real-World Patients With
HCV Genotype 1 Infection. Gastroenterology. 2016;150(2):419–29. PubMed PMID:
26497081.
10. Lawitz E., Sulkowski M.S., Ghalib R., Rodriguez-Torres M., et al. Simeprevir plus
sofosbuvir, with or without ribavirin, to treat chronic infection with hepatitis C virus
genotype 1 in non-responders to pegylated interferon and ribavirin and treatment-
naive patients: the COSMOS randomised study. Lancet. 2014;384(9956):1756–65.
11. Yee B.E., Nguyen N.H., Jin M., Lutchman G., et al. Lower response to simeprevir and
sofosbuvir in HCV genotype 1 in routine practice compared with clinical trials. BMJ
Open Gastroenterol. 2016;3(1):e000056. PubMed PMID: 26966547.
12. Wack A., Terczynska-Dyla E., Hartmann R. Guarding the frontiers: the biology of
type III interferons. Nat Immunol. 2015;16(8):802–9. PubMed PMID: 26194286.
13. Rauch, A., Z. Kutalik, P. Descombes, T. Cai, et al., Genetic variation in IL28B is
associated with chronic hepatitis C and treatment failure: a genome-wide association
study. Gastroenterology, 2010. 138(4): p. 1338-45, 1345 e1-7.
14. Thomas D.L., Thio C.L., Martin M.P., Qi Y., et al. Genetic variation in IL28B and
spontaneous clearance of hepatitis C virus. Nature. 2009;461(7265):798–801.
15. Urban T.J., Thompson A.J., Bradrick S.S., Fellay J., et al. IL28B genotype is associated
with differential expression of intrahepatic interferon-stimulated genes in patients
with chronic hepatitis C. Hepatology. 2010;52(6):1888–96. PubMed PMID: 20931559.

IFNL3 gene
325
Sofosbuvir Therapy and IFNL4 Genotype

Laura Dean, MD1
Created: January 25, 2017.
Introduction
Sofosbuvir is an antiviral agent used in the treatment of chronic hepatitis C virus (HCV)
infection. Sofosbuvir is FDA-approved to treat patients infected with HCV genotypes 1, 2,
3, and 4, as part of a combination antiviral treatment regimen (1). HCV genotype 1 is the
most prevalent worldwide and HCV genotype 3 is the next most prevalent (2). Sofosbuvir
may also be used as part of the treatment regimen of HCV genotypes 5 or 6 (3).
About 180 million people worldwide are infected with chronic hepatitis C, which is a
major cause of chronic liver disease, cirrhosis, and liver cancer. Viral eradication is
suboptimal with peginterferon plus ribavirin-based therapy, with only about half of
patients with HCV genotype 1 infection achieving a sustained virological response (SVR)
after 24 weeks (4). A SVR is defined as undetectable HCV RNA by the end of treatment or
at a specific number of weeks after the initiation of treatment, e.g., undetectable HCV
RNA at 12 weeks is annotated (SVR12).
Direct-acting antivirals (DAAs), such as sofosbuvir, were developed to improve viral
eradication rates. They target HCV-encoded proteins involved in viral replication and
infection. Sofosbuvir, the first and thus far only DAA, targets NS5B polymerase, the viral
enzyme required for HCV RNA replication.
Sofosbuvir may be used in combination with peginterferon. The genetic variant
rs12979860, located in the INFL4 gene, is a strong predictor of response to peginterferon-
based therapies. The variant is a C to T change—individuals with the favorable “C/C”
genotype have about a 2-fold higher likelihood of achieving SVR compared to individuals
with CT or TT genotypes (5). (Note, because the association of rs12979860 with
treatment response was reported several years before the discovery of IFNL4, the variant
is commonly, but mistakenly, referred to as IL28B, which is the previous name for the
IFNL3 gene.)
For specific treatment regimens that include sofosbuvir, although the IFNL4 variant still
influences treatment outcomes, the SVR remains relatively high for all IFNL4 genotypes.
For example in the NEUTRINO study, which is referred to in the FDA-approved drug
label for sofosbuvir, the SVR12 rate was 99% in individuals with baseline C/C alleles and
87% in individuals with baseline non-C/C alleles. The individuals in this study had HCV
genotype 1 or 4 infection, and were receiving sofosbuvir plus peginterferon plus ribavirin
therapy (1, 6).

The drug label for sofosbuvir also discusses viral resistance. In cell culture, the amino acid
substitution S282T in the viral NS5B polymerase is associated with reduced susceptibility
to sofosbuvir (7). During the ELECTRON trial, this substitution was transiently detected
in one individual who relapsed during sofosbuvir monotherapy. However, the clinical
significance of such substitutions remains unknown (1).
Drug Class: Direct Acting Antivirals for HCV

The treatment of hepatitis C virus (HCV) has evolved over the years. Initially, interferon
(IFN) was used as monotherapy. This was followed by the addition of the antiviral agent
ribavirin (a nucleoside analogue) to peginterferon. However, only about half of the HCV
genotype 1-infected patients cleared their infection, and adverse effects were common and
sometimes life-threatening (4). Treatment was also expensive and inconvenient, lasting up
to 48 weeks.
Direct-acting antivirals (DDAs) improved the effectiveness of peginterferon and ribavirin
therapy. These agents target specific viral proteins required for viral replication and
infection.
HCV is a single-stranded RNA virus that encodes structural proteins (to encode the viral
capsid and envelope) and non-structural proteins (required for viral replication). The
DDAs target several of the non-structural proteins, the viral protease (NS3/NS4A), the
viral RNA polymerase (NS5B), and a viral protein thought to regulate replication and
viral assembly (NS5A).
Currently, there are four classes of drugs in clinical use or in development, which are
classified by their therapeutic target:
• Protease inhibitors e.g., simeprevir, grazoprevir, paritaprevir
• Nucleoside polymerase inhibitors e.g., sofosbuvir
• Non-nucleoside polymerase inhibitors
• NS5A inhibitors e.g., ledipasvir
Successful treatment of hepatitis C is confirmed when no trace of HCV can be found after
treatment has finished. This is referred to as the SVR, which is defined as undetectable
HCV RNA by a quantification assay at the end of treatment, and typically 12 (SVR12) or
24 weeks (SVR24) after the end of treatment.
Drug: Sofosbuvir
Sofosbuvir is a nucleotide analogue used in the treatment of chronic HCV infection as
part of a combination antiviral treatment regimen.
The early stages of infection with HCV are usually asymptomatic—about 15-45% of
people spontaneously clear the virus within 6 months of infection without any treatment.
The remaining 55-85% of people will develop chronic HCV infection, which may also be
asymptomatic for many years (8).
Sofosbuvir Therapy and IFNL4 Genotype 327
However, during the natural course of HCV infection, patients develop liver fibrosis,
which, without treatment, can progress to liver cirrhosis and liver cancer (hepatocellular
carcinoma). The risk of developing liver cancer for a patient with HCV-related cirrhosis is
approximately 2-6% per year (9).
HCV is classified by genotype, based on the nucleotide sequence of the viral RNA. There
are six major classes of genotype, numbered 1-6, with multiple subtypes e.g., 1a, 1b, 2a, 2b.
In the US, approximately 70% of people with HCV infection have genotype 1, with
genotype 1a more common than 1b (8). Genotype 1 was formerly the most difficult to
cure with interferon-based therapies, as it was less likely than genotypes 2 and 3 to
respond to therapy. With the introduction of DAA-based, interferon-free treatments, this
is no longer the case.
Sofosbuvir is indicated for the treatment of genotype 1, 2, 3 or 4 chronic HCV infection
and is generally considered to have moderate to high efficacy for all six genotypes (10).
For the treatment of genotype 1 or 4 infections, the drug label recommends a combination
therapy of sofosbuvir plus peginterferon alfa plus ribavirin. For the treatment of genotype
2 or 3 infections, the combination therapy of sofosbuvir plus ribavirin is recommended
(1).
Sofosbuvir is a NS5B nucleotide analogue and a prodrug. Once inside a liver cell,
sofosbuvir is activated by phosphorylation to a nucleoside triphosphate that competes
with nucleotides during viral replication. Binding of the analogue to the viral NS5B
polymerase results in RNA chain termination, thus inhibiting the virus from replicating
its genome (11).
The safety and efficacy of sofosbuvir has been established in several clinical trials. The
usual dose of sofosbuvir is a 400mg tablet, taken once a day for 12 weeks, in combination
with other antiviral agents. Sofosbuvir is generally well tolerated, with no side effects
beyond those associated with placebo therapy (10, 12).
Sofosbuvir forms the backbone of a several treatment regimens including DAA such as
sofosbuvir/velpatasvir and sofosbuvir/velpatasvir/voxilaprevir. The regimen sofosbuvir/
ledipasvir has been found to result in high SVR rates in shorter periods of time, but costs
may be prohibitive (7).
Genetic variants in the IFNL4 gene have been shown to strongly influence treatment
response to peginterferon-based regimens in previously untreated patients with HCV
genotype 1 infection (5, 13). Such variants also appear to influence the outcomes of
treatment regimens that include sofosbuvir. For example, the rs12979860 genotype
predicts the response to 8 weeks of treatment with sofosbuvir/ledipasvir (14).
In addition, several substitutions that occur with the viral NS5B polymerase have been
reported. Most notably, a S282T polymorphism has been associated with sofosbuvir
resistance (15). In cell cultures, the S282T substitution is associated with a reduced
susceptibility to sofosbuvir. However, the clinical significance of such substitutions is not
yet known, as they appear to be detrimental to viral fitness. So far, the S282T substitution
has only been detected in one patient who experienced a relapse while being treated with
sofosbuvir monotherapy in a trial, and the substitution was no longer detectable at week
12 post-treatment (1).
Gene: IFNL4
The IFNL4 gene encodes interferon lambda-4 (IFN-λ4) and is involved in the immune
response to hepatitis C.
When a person is infected by viruses, including HCV, their immune response includes the
production of interferons. These signaling proteins induce changes in infected and
uninfected cells to block the viral replication cycle and stop the spread of virus.
Interferons are given as part of treatment for HCV to strengthen this innate response.
Three classes of IFNs exist: type I (IFN-α/β), type II (IFN-γ), and type III (IFN-λ). The
most recent interferon to be discovered, IFNL4, belongs to the type III class. It is located
upstream of IFNL3 and is a functional gene in the majority (>95%) of the African
population. But in about 50% of the European population and in most of the east Asian
population, IFNL4 is a pseudogene, created by a frameshift-causing deletion
polymorphism (rs368234815) (16-18).
As a type III interferon, IFNL4, induces an antiviral state in responsive cells with a higher
risk of viral infection, such as mucosal cells (17). IFNL4 exerts its actions by interacting
with a cytokine receptor complex, which is composed of the IL10RB and IFNLR1 receptor
chains (5). Expression of IFNLR1 is largely restricted to cells of epithelial origin, which
includes hepatocytes. In contrast, receptors for type I interferons, such as IFN-α, are
expressed in most cell types.
The first two variants to be commonly tested for are rs12979860 (located in IFNL4) and
rs8099917, which lies proximate to IFNL4. These variants are in close proximity to each
other and are in strong linkage disequilibrium (5). Linkage disequilibrium means that the
variants are linked to treatment response more than would be expected in the general
population.
HCV genotype 1 patients with the “favorable” genotypes (CC for rs12979860 and TT for
rs8099917) respond better to interferon-based treatment—favorable genotypes are
associated with an approximate 2-fold increase in SVR (5). However, for specific
treatment regimens which include sofosbuvir, although an individual’s IFNL4 genotype
still influences treatment outcomes, the SVR for non-favorable genotypes remains
relatively high (1).
In the NETURINO study, patients with HCV genotype 1 or 4 who had not received
previous treatments for HCV infection were treated with a regimen of sofosbuvir plus
peginterferon plus ribavirin for 12 weeks. The SVR12 rate was 99% (89/90) in subjects
with baseline rs12979860 C/C alleles and 87% (200/230) in subjects with baseline
rs12979860 non-C/C alleles (6).
Similarly, in the PHOTON trial, patients with HCV genotype 1 infection and co-infection
with HIV were treated with a combination of sofosbuvir and ribavarin. The SVR12 rates
were 80% (24/30) in subjects with baseline rs12979860 C/C allele and 75% (62/83) in
subjects with baseline rs12979860 non-C/C alleles (1).
The frequency of the rs12979860 ‘C’ allele varies globally across different populations—it
is commonly found in East Asians (allele frequency nearly 0.9), followed by Caucasians
(0.63) and Hispanics (0.55), and is the least common among individuals of African origin
(0.39) (5).
In individuals of African ancestry, the rs368234815 variant is superior to rs12979860, and
together with another IFNL4 variant (rs117648444), the combination of testing these two
variants gives a greater treatment response prediction compared to testing for single
variants (16, 17).
Genetic Testing
Genetic testing for IFNL4 is used to predict response to peginterferon and ribavarin in
HCV genotype 1 patients. The results can help clinicians and patients make informed
decisions on how to manage HCV infection.
The rs12979860 variant is most commonly tested, and the results are typically reported in
the following format:
rs12979860 CC, favorable genotype
rs12979860 CT, unfavorable genotype
rs12979860 TT, unfavorable genotype (5).

Statement from the US Food and Drug Administration (FDA): NEUTRINO was an
open-label, single-arm trial that evaluated 12 weeks of treatment with sofosbuvir in
combination with peginterferon alfa 2a and ribavirin in treatment-naïve subjects with
genotype 1, 4, 5 or 6 HCV infection compared to pre-specified historical control. [...]
SVR12 rates were 99% (89/90) in subjects with genotype 1 or 4 HCV and baseline IL28B
C/C allele and 87% (200/230) in subjects with genotype 1 or 4 HCV and baseline IL28B
non-C/C alleles2.
generic drug.
It is estimated that the SVR12 in patients who previously failed pegylated interferon and
ribavirin therapy will approximate the observed SVR12 in NEUTRINO subjects with
multiple baseline factors traditionally associated with a lower response to interferon-based
treatment. The SVR12 rate in the NEUTRINO trial in genotype 1 subjects with IL28B
non-C/C alleles, HCV RNA greater than 800,000 IU/mL and Metavir F3/F4 fibrosis was
71% (37/52).
[…]
In a pooled analysis of 982 subjects who received sofosbuvir in Phase 3 trials, 224 subjects
had post- baseline NS5B genotypic data from next generation nucleotide sequencing
(assay cutoff of 1%).
Treatment-emergent substitutions L159F (n=6) and V321A (n=5) were detected in post-
baseline samples from GT3a-infected subjects across the Phase 3 trials. No detectable shift
in the phenotypic susceptibility to sofosbuvir of subject isolates with L159F or V321A
substitutions was seen. The sofosbuvir-associated resistance substitution S282T was not
detected at baseline or in the failure isolates from Phase 3 trials. However, an S282T
substitution was detected in one genotype 2b subject who relapsed at Week 4 post-
treatment after 12 weeks of sofosbuvir monotherapy in the Phase 2 trial P7977-0523
[ELECTRON]. The isolate from this subject displayed a mean 13.5-fold reduced
susceptibility to sofosbuvir. For this subject, the S282T substitution was no longer
detectable at Week 12 post-treatment by next generation sequencing with an assay cutoff
of 1%.
Nomenclature
Common allele Alternative HGVS reference sequence dbSNP reference identifier
name names for allele location
Coding Protein
rs12979860 / NM_001276254.2:c. N/A rs12979860
151-152G>A
rs8099917 / N/A N/A rs8099917
2 Note: Recent studies report that the rs12979860 variant is in the IFNL4 gene, and not the
IFNL3 gene (previously called IL28B). Therefore, a more accurate term for describing an
individual’s genotype would be “rs12979860 C/C”, instead of “IL28B C/C”.
Acknowledgments
The author would like to thank Teresa Beam, Ph.D., Chair, Department of Pharmaceutical
Sciences, Manchester University, Indiana; David Kisor, B.S., Pharm.D., Professor and
Director of Pharmacogenomics Education, Pharmacogenomics Program, Manchester
University, Indiana; Martin Lagging, MD, PhD, Professor, Department of Infectious
Medicine / Virology, Institute of Biomedicine, Sahlgrenska Academy, University of
Gothenburg, Sweden; and Thomas R. O’Brien, M.D., M.P.H., Senior Investigator, National
Cancer Institute, Division of Cancer Epidemiology & Genetics, Infections and
Immunoepidemiology Branch; for reviewing this summary.
References
1. SOVALDI- sofosbuvir tablet, film coated [package insert]. Foster City, CA: Gilead
Sciences, I.; 2015. Available from: https://dailymed.nlm.nih.gov/dailymed/
drugInfo.cfm?setid=80beab2c-396e-4a37-a4dc-40fdb62859cf
2. Messina J.P., Humphreys I., Flaxman A., Brown A., et al. Global distribution and
prevalence of hepatitis C virus genotypes. Hepatology. 2015;61(1):77–87. PubMed
PMID: 25069599.
3. Panel A.I.H.G. Hepatitis C guidance: AASLD-IDSA recommendations for testing,
managing, and treating adults infected with hepatitis C virus. Hepatology.
2015;62(3):932–54. PubMed PMID: 26111063.
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weeks sustained virologic response (SVR24) and viral relapse in patients treated with
simeprevir plus peginterferon and ribavirin. Hepatol Int. 2016;10(1):158–68. PubMed
PMID: 26264253.
5. Muir A.J., Gong L., Johnson S.G., Lee M.T., et al. Clinical Pharmacogenetics
Implementation Consortium (CPIC) guidelines for IFNL3 (IL28B) genotype and
PEG interferon-alpha-based regimens. Clin Pharmacol Ther. 2014;95(2):141–6.
6. Lawitz E., Mangia A., Wyles D., Rodriguez-Torres M., et al. Sofosbuvir for previously
untreated chronic hepatitis C infection. N Engl J Med. 2013;368(20):1878–87.
7. HARVONI- ledipasvir and sofosbuvir tablet, film coated Foster City, CA: Gilead
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drugInfo.cfm?setid=f4ec77e4-bae8-4db0-b3d5-bde09c5fa075
8. Muir A.J. The rapid evolution of treatment strategies for hepatitis C. Am J
Gastroenterol. 2014;109(5):628–35quiz 636. PubMed PMID: 24732866.
9. Sangiovanni A., Del Ninno E., Fasani P., De Fazio C., et al. Increased survival of
cirrhotic patients with a hepatocellular carcinoma detected during surveillance.
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sofosbuvir plus ribavirin for the treatment of HCV genotype 2 infection: results of the
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chronic hepatitis C infection. J Pharmacol Pharmacother. 2014;5(4):278–84. PubMed
PMID: 25422576.
12. Cortez K.J., Kottilil S. Beyond interferon: rationale and prospects for newer treatment
paradigms for chronic hepatitis C. Ther Adv Chronic Dis. 2015;6(1):4–14. PubMed
PMID: 25553238.
13. Rembeck K., Lagging M. Impact of IL28B, ITPA and PNPLA3 genetic variants on
therapeutic outcome and progression of hepatitis C virus infection.
14. O'Brien T.R., Lang Kuhs K.A., Pfeiffer R.M. Subgroup differences in response to 8
weeks of ledipasvir/sofosbuvir for chronic hepatitis C. Open Forum Infect Dis.
2014;1(3):ofu110. PubMed PMID: 25734178.
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23291588.
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IFNL4 gene
333

Laura Dean, MD1
Created: October 7, 2014; Updated: May 3, 2016.
Introduction
Tamoxifen is a selective estrogen receptor modulator (SERM) which is used in the
treatment and prevention of breast cancer (1).
The CYP2D6 enzyme metabolizes a quarter of all prescribed drugs, and is one of the main
enzymes responsible for converting tamoxifen into its major active metabolite, endofixen.
Variants in the CYP2D6 allele may lead to reduced (“intermediate metabolizer”) or absent
(“poor metabolizer”) enzyme activity. Individuals who carry these variant alleles may have
reduced plasma concentrations of endoxifen and benefit less from tamoxifen therapy.
At this time, the FDA-approved drug label for tamoxifen does not discuss genetic testing
for CYP2D6. The National Comprehensive Cancer Network (NCCN) does not
recommend CYP2D6 testing as a tool to determine the optimal adjuvant endocrine
strategy (2), and this recommendation is consistent with the 2010 guidelines from the
American Society of Clinical Oncology (ASCO) (2, 3).
In contrast, the Dutch Pharmacogenetics Working Group has made recommendations for
tamoxifen therapy based on CYP2D6 genotypes. For both poor and intermediate
metabolizers, their recommendation is to consider using aromatase inhibitors for
postmenopausal women due to an increased risk for relapse of breast cancer with
tamoxifen. They also recommend that intermediate metabolizers avoid the concomitant
use of CYP2D6 inhibitors (Table 1) (4).
Table 1. CYP2D6 phenotypes and the therapeutic recommendations for tamoxifen therapy, adapted from
the Dutch Pharmacogenetics Working Group
Phenotype Genotype Therapeutic recommendation for
tamoxifen
Ultrarapid metabolizer More than two copies of None
functional alleles
Intermediate metabolizer One active allele and one Increased risk for relapse of breast
inactive allele, or two decreased cancer. Avoid concomitant use of
The strength of the tamoxifen therapeutic recommendations scored a maximum of 4/4 (the highest quality
of evidence). Table is adapted from Swen J.J., Nijenhuis M., de Boer A., Grandia L. et al. Pharmacogenetics:
from bench to byte - an update of guidelines. Clinical pharmacology and therapeutics. 2011;89(5):662–73
(4).
Phenotype Genotype Therapeutic recommendation for

tamoxifen
activity alleles, or one decreased CYP2D6 inhibitors. Consider aromatase
activity allele and one inactive inhibitor for postmenopausal women
allele
Poor metabolizer Two inactive alleles Increased risk for relapse of breast
cancer. Consider aromatase inhibitor for
postmenopausal women
The strength of the tamoxifen therapeutic recommendations scored a maximum of 4/4 (the highest quality
of evidence). Table is adapted from Swen J.J., Nijenhuis M., de Boer A., Grandia L. et al. Pharmacogenetics:
from bench to byte - an update of guidelines. Clinical pharmacology and therapeutics. 2011;89(5):662–73
(4).

Allele type Alleles
Active *1, *2, *33, *35
Inactive *3, *4, *5, *6, *7, *8, *11-*16, *19-*21, *38, *40, *42
Note: The most clinically significant variants are highlighted in bold.
Drug: Tamoxifen
Tamoxifen is a selective estrogen receptor modulator (SERM) that is used in the treatment
and prevention of breast cancer. In both men and women, tamoxifen is used to treat
metastatic breast cancer—patients with tumors that are estrogen receptor positive (ER+)
are more likely to benefit. In post-menopausal women with breast cancer, tamoxifen is
used as an adjuvant treatment following surgery and radiation—patients with four or
more positive axillary nodes may benefit the most. And tamoxifen is also used to prevent
breast cancer in women who have an increased risk, and to reduce the risk of invasive
breast cancer in women with ductal carcinoma in situ (DCIS) (1).
Tamoxifen acts on the estrogen receptor (ER) and has both estrogenic and anti-estrogenic
actions, depending on the target tissue. In the breast tissue, it acts as an anti-estrogen
(inhibitory effect) and competitively inhibits cancerous ER+ cells from receiving the
estrogen they need to grow (5, 6).
In other tissues, such as the endometrium, tamoxifen acts as an estrogen agonist
(stimulatory effect) leading to some of the adverse effects associated with tamoxifen
therapy. These include endometrial hyperplasia, endometrial polyps, and about a 2.5 times
higher risk of developing endometrial cancer. Hot flashes are the most common side effect

Tamoxifen Therapy and CYP2D6 Genotype 335
associated with tamoxifen use, which affect up to 80% of women, and there is also an
increased risk of depression (5, 7).
Tamoxifen increases the risk of thromboembolic events, such as deep vein thrombosis
(DVT) and pulmonary embolism. The risk of tamoxifen-associated thromboembolic
events (TTE) is further increased when tamoxifen is coadministered with chemotherapy.
The drug label for tamoxifen states that the risks and benefits of tamoxifen therapy should
be carefully considered in women with a history of thromboembolic events.
Some studies suggest that clinicians should consider screening breast cancer patients
before prescribing adjuvant tamoxifen to identify women who are at risk of thrombotic
embolic disease because of Factor V Leiden (R506Q in the F5 gene); or have an increased
risk of TTE because of a variant in the estrogen receptor gene (ESR1) (8-11). However, a
small substudy (N=81) of the NSABP P-1 trial found no benefit in screening women for
Factor V Leiden or prothombin thrombophilia (G20210A in the F2 gene) as a means to
identify women who may not be appropriate candidates for tamoxifen therapy due to the
propensity of thromboembolitic side effects (1, 12).
Tamoxifen is a pro-drug that is metabolized to active metabolites in the liver. The
metabolites 4-hydroxytamoxifen and 4-hydroxy-N-desmethyltamoxifen (endoxifen) are
thought to be mainly responsible for the clinical effects of tamoxifen. Both of these
metabolites have about a 100-fold higher affinity for the ER compared to tamoxifen, but
endoxifen is thought to be the major metabolite because plasma levels of endoxifen tend
to be several-fold higher than that of 4-hydroxytamoxifen (5, 13). Endoxifen formation
mainly occurs via the conversion of the inactive primary metabolite N-
desmethyltamoxifen, mediated by CYP2D6.
The mechanism of action of tamoxifen is complex and involves tamoxifen metabolites
binding to the ER and inducing a conformational change that blocks or changes the
expression of estrogen-dependent genes. It is also likely that tamoxifen interacts with
other protein cofactors (both activators and repressors), and binds with different estrogen
receptors (ER-alpha or ER-beta), to produce estrogenic and anti-estrogenic effects in
different tissues. Certain tamoxifen metabolites such as norendoxifen have also been
found to act as aromatase inhibitors in vitro (albeit at high concentrations)—decreasing
the amount of estrogen available by inhibiting the conversion of steroids to estradiol (14).
The response to tamoxifen (i.e., clinical efficacy and side effects) varies widely between
individuals; this may be partly caused by differences in metabolism because of variations
in genes such as CYP2D6 (15).
Gene: CYP2D6
genes are often polymorphic and can result in reduced, absent, or increased enzyme
activity.

including antidepressants, antipsychotics, analgesics, and beta-blockers. CYP2D6 is the
main enzyme that catalyzes the rate-limited step in the metabolism of tamoxifen to its
potent metabolite, endoxifen. Other CYP enzymes involved in tamoxifen metabolism
include CYP2C19, CYP2B6, CYP3A4, and CYP3A5.
CYP2D6 is a particularly complex gene that is difficult to genotype because of the large
number of variants (more than 100 alleles have been described (16)), and the presence of
gene deletions, duplications, multiplications and pseudogenes. The complexity of genetic
variation complicates making a correct determination of CYP2D6 genotype.
There is substantial variation in CYP2D6 genotypes among different populations.
normal “extensive metabolizer” phenotype. The CYP2D6 alleles *2, *33, and *35 are also
considered to have near-normal activity. Other alleles include variants that produce a
non-functioning enzyme (e.g., *3, *4, *5, and *6) (17-20) or an enzyme with reduced
activity (e.g., *10, *17, and *41) (21-23) (see Table 2). There are large inter-ethnic
differences in the frequency of these alleles, with *3, *4, *5, *6, and *41 being more
common in the Caucasian population, *17 more common in Africans, and *10 more
common in Asians (24).
non-functioning CYP2D6 alleles (Table 1). Approximately 30% of Asians and individuals
of Asian descent are intermediate metabolizers. In these populations, only half of CYPD6
alleles are fully functional, with the reduced function *10 variant being very common
(~40%, compared to ~2% in Caucasians) (25). As a result, Asians are more likely to be
intermediate metabolizers than Caucasians (24). Similarly, in Africans and African
Americans, only half of CYPD6 alleles are functional. However, a wider range of variants
account for the remaining alleles (24, 26, 27).
metabolizers, mainly due to the more prevalent nonfunctional *4 and *5 alleles (24).
Notably, less than 40% are homozygous extensive metabolizers (carrying two copies of *1
allele), and more than 50% belong to a mixed group of intermediate metabolizers and
heterozygote carriers of one functional allele in combination with either a deficient or
non-functional allele (20, 28-30).
Because CYP2D6 is the main enzyme involved in converting tamoxifen into its most
potent anti-estrogenic metabolites, endoxifen and 4-hydroxytamoxifen, genetic
polymorphisms of CYP2D6 may influence tamoxifen metabolism (31). High plasma levels
of endoxifen require the presence of fully functional CYP2D6 alleles, in poor
metabolizers, endoxifen levels are decreased (13, 32).
The role of CYP2D6 in tamoxifen response has yet to be fully determined (33). Some
studies suggest that genetic polymorphisms of CYP2D6 may be important predictors of
the clinical outcomes of tamoxifen treatment for patients with metastatic breast cancer
(34) and for patients with early breast cancer who receive tamoxifen as an adjuvant
treatment following surgery (32, 35-37).
However, the high degree of inter-individual variability of tamoxifen metabolism and
treatment outcomes is not fully accounted for by CYP2D6 variation (38). Additional
contributors may include genetic variation in other metabolic pathways and the
sequestration of lipophilic tamoxifen metabolites into fat tissues (13, 32).
Genetic Testing
Genetic testing is available for many (~30) of the variant CYP2D6 alleles. Usually a
patient’s result is reported as a diplotype, such as CYP2D6 *1/*1. A result for copy number
is also important when interpreting results for this gene.
of a functional allele). The phenotype is defined by the sum of the two scores, e.g., poor
metabolizers have an activity score of 0; intermediate metabolizers have an activity score
between 0.5 and 1.5 and metabolizers have an activity score of 2 and up (39).

2013 Statement from the US Food and Drug Administration (FDA): “Tamoxifen is
extensively metabolized after oral administration. N-desmethyl tamoxifen is the major
metabolite found in patients' plasma. The biological activity of N-desmethyl tamoxifen
appears to be similar to that of tamoxifen. 4-Hydroxytamoxifen and a side chain primary
alcohol derivative of tamoxifen have been identified as minor metabolites in plasma.
Tamoxifen is a substrate of cytochrome P-450 3A, 2C9 and 2D6, and an inhibitor of P-
glycoprotein.”
2014 Statement from the National Comprehensive Cancer Network (NCCN): “The
cytochrome P-450 (CYP450) enzyme, CYP2D6, is involved in the conversion of
tamoxifen to endoxifen. Over 100 allelic variants of CYP2D6 have been reported in the
literature. Individuals with wild-type CYP2D6 alleles are classified as extensive
metabolizers of tamoxifen. Those with one or two variant alleles with either reduced or no
generic drug.
activity are designated as intermediate metabolizers and poor metabolizers, respectively.

A large retrospective study of 1325 patients found that time to disease recurrence was
significantly shortened in poor metabolizers of tamoxifen. However, the BIG 1-98 trial
reported on the outcome based on CYP2D6 genotype in a subset of postmenopausal
patients with endocrine-responsive, early invasive breast cancer. The study found no
correlation between CYP2D6 allelic status and disease outcome or between CYP2D6
allelic status and tamoxifen-related adverse effects. A genetic analysis of the ATAC trial
found no association between CYP2D6 genotype and clinical outcomes. Given the limited
and conflicting evidence at this time, the NCCN Breast Cancer Panel does not
recommend CYP2D6 testing as a tool to determine the optimal adjuvant endocrine
strategy. This recommendation is consistent with the ASCO Guidelines.”
2010 Excerpt from the American Society of Clinical Oncology (ASCO) guideline2:
“Are There Specific Patient Populations That Derive Differing Degrees of Benefit From an
AI Compared With Tamoxifen?
Recommendation: Direct evidence from randomized trials does not identify a specific
marker or clinical subset that predicted which adjuvant treatment strategy—tamoxifen,
AI monotherapy, or sequential therapy—would maximally improve outcomes for a given
patient. Among men with breast cancer, tamoxifen remains the standard adjuvant
endocrine treatment. The Update Committee recommends against using CYP2D6
genotype to select adjuvant endocrine therapy. The Committee encouraged caution with
concurrent use of CYP2D6 inhibitors (such as bupropion, paroxetine, fluoxetine; see Table
11 in the full guideline for a complete list of inhibitors) and tamoxifen because of the
known drug-drug interactions.
Comment: The adjuvant endocrine therapy recommendations in this update are for all
women, irrespective of any specific clinical subset or prognostic marker. AI therapy has
not been evaluated in men, thus the continued recommendation that men with breast
cancer receive adjuvant tamoxifen.
Data suggest that variability in tamoxifen metabolism affects the likelihood of cancer
recurrence in patients treated with tamoxifen. Factors that contribute to this variability
include concurrent use of other drugs that inhibit the CYP2D6 isoenzyme and
pharmacogenetic variation (polymorphisms) in CYP2D6 alleles. It is not yet known
whether these variations account for differences in outcomes among patients treated with
tamoxifen.
Available data on CYP2D6 pharmacogenetics are insufficient to recommend testing as a
tool to determine an adjuvant endocrine strategy. Patients who clearly benefit from
2 The 2014 ASCO practice guideline focused update does not address pharmacogenetic testing
(JCO July 20, 2014 vol. 32 no. 212255-2269).
known CYP2D6 inhibitors might consider avoiding tamoxifen because of potential

pharmacologic interactions. Conversely, patients who receive tamoxifen may prefer to
avoid concurrent use of known CYP2D6 inhibitors if suitable alternatives are available.”
the Royal Dutch Association for the Advancement of Pharmacy (KNMP): “For
CYP2D6 poor metabolizers (PMs), defined as patients carrying two defective alleles […]
With respect to tamoxifen, an increased risk for breast cancer relapse is present, and it is
advised that an aromatase inhibitor be considered for treating postmenopausal women
with breast cancer. Other recommendations included the selection of an alternative drug,
therapeutic drug monitoring, increased alertness to adverse drug events and to reduced
efficacy, and the recording of an electrocardiogram.
For CYP2D6 intermediate metabolizers (IMs), defined as patients carrying two
decreased-activity alleles or one active/decreased-activity allele and one inactive allele […]
For tamoxifen, the use of an aromatase inhibitor for treating postmenopausal women with
breast cancer and the avoidance of concomitant use of a CYP2D6 inhibitor are advised.
Other recommendations are comparable to the recommendations for PMs.”
Nomenclature
Coding Protein
identifier for
allele location
CYP2D6*4 1846G>A NM_000106.5:c. Not applicable—variant occurs rs3892097
CYP2D6*5 Not applicable—variant results in a whole gene deletion
Trp152Gly 454delT
Pro34Ser 100C>T
1023C>T 886T>C
(Thr107Ile)
2850C>T
(Cys296Arg)
CYP2D6*41 2988G>A NM_000106.5:c. Not applicable—variant occurs rs28371725
985+39G> in a non-coding region
Acknowledgments
First edition:
The author would like to thank Harold Burstein, Associate Professor of Medicine,
Harvard Medical School; and Hiltrud Brauch, Deputy Head of the Fischer-Bosch-Institute
of Clinical Pharmacology (IKP) and Head of the Breast Cancer Susceptibility and
Pharmacogenomics IKP Department, for reviewing this summary.
Version History
To view an earlier version of this summary (Created: October 7, 2014), please click here.
References
1. Tamoxifen Citrate [package insert]. Morgontown, WV: Mylan Pharmaceuticals; 2013.
Available from: http://dailymed.nlm.nih.gov/dailymed/lookup.cfm?
setid=7ee3d3d2-85d1-4018-8e70-5ed8a64ae1f0
2. National Comprehensive Cancer Network Clinical Practice Guidelines in Oncology
(NCCN Guidelines): Breast Cancer Version 3.2014. [Last accessed: 14 May 2014].
Available from: http://www.nccn.org/
3. Burstein H.J., Griggs J.J., Prestrud A.A., Temin S. American society of clinical
oncology clinical practice guideline update on adjuvant endocrine therapy for
women with hormone receptor-positive breast cancer. J Oncol Pract. 2010;6(5):243–
662–73. PubMed PMID: 21412232.
5. Osborne C.K. Tamoxifen in the treatment of breast cancer. N Engl J Med.
1998;339(22):1609–18. PubMed PMID: 9828250.
6. Jordan V.C. Tamoxifen as the first targeted long-term adjuvant therapy for breast
cancer. Endocr Relat Cancer. 2014;21(3):R235–46. PubMed PMID: 24659478.
7. Henry N.L., Stearns V., Flockhart D.A., Hayes D.F., et al. Drug interactions and
pharmacogenomics in the treatment of breast cancer and depression. Am J
8. Garber J.E., Halabi S., Tolaney S.M., Kaplan E., et al. Factor V Leiden mutation and
thromboembolism risk in women receiving adjuvant tamoxifen for breast cancer. J
Natl Cancer Inst. 2010;102(13):942–9. PubMed PMID: 20554945.
9. Onitilo A.A., McCarty C.A., Wilke R.A., Glurich I., et al. Estrogen receptor genotype
is associated with risk of venous thromboembolism during tamoxifen therapy. Breast
Cancer Res Treat. 2009;115(3):643–50. PubMed PMID: 19082882.
10. Kovac M., Kovac Z., Tomasevic Z., Vucicevic S., et al. Factor V Leiden mutation and
high FVIII are associated with an increased risk of VTE in women with breast cancer
during adjuvant tamoxifen - results from a prospective, single center, case control
study. Eur J Intern Med. 2015;26(1):63–7. PubMed PMID: 25592075.
11. Kujovich J.L. Factor V Leiden thrombophilia. Genet Med. 2011;13(1):1–16. PubMed
PMID: 21116184.
12. Abramson N., Costantino J.P., Garber J.E., Berliner N., et al. Effect of Factor V Leiden
and prothrombin G20210-->A mutations on thromboembolic risk in the national
surgical adjuvant breast and bowel project breast cancer prevention trial. J Natl
Cancer Inst. 2006;98(13):904–10. PubMed PMID: 16818854.
13. Mürdter T.E., Schroth W., Bacchus-Gerybadze L., Winter S., et al. Activity levels of
tamoxifen metabolites at the estrogen receptor and the impact of genetic
polymorphisms of phase I and II enzymes on their concentration levels in plasma.
Clin Pharmacol Ther. 2011;89(5):708–17. PubMed PMID: 21451508.
14. Lu W.J., Xu C., Pei Z., Mayhoub A.S., et al. The tamoxifen metabolite norendoxifen is
a potent and selective inhibitor of aromatase (CYP19) and a potential lead compound
for novel therapeutic agents. Breast Cancer Res Treat. 2012;133(1):99–109. PubMed
PMID: 21814747.
15. Desta Z., Ward B.A., Soukhova N.V., Flockhart D.A. Comprehensive evaluation of
tamoxifen sequential biotransformation by the human cytochrome P450 system in
vitro: prominent roles for CYP3A and CYP2D6. J Pharmacol Exp Ther. 2004;310(3):
1062–75. PubMed PMID: 15159443.
16. CYP2D6 allele nomenclature. 2014 [Last accessed: 14 May 2014]. Available from:
[Cited 14 May 2014]. Available from: http://www.pharmgkb.org/haplotype/
PA165816578
PA165816579
PA165948092
PA165816581
PA165816582
PA165816583
PA165816584
11972444.
17301689.
8287064.
4468–77. PubMed PMID: 20515869.
496–526. PubMed PMID: 18001838.
31. ter Heine R., Binkhorst L., de Graan A.J., de Bruijn P., et al. Population
pharmacokinetic modelling to assess the impact of CYP2D6 and CYP3A metabolic
phenotypes on the pharmacokinetics of tamoxifen and endoxifen. Br J Clin
32. Saladores P., Murdter T., Eccles D., Chowbay B., et al. Tamoxifen metabolism predicts
drug concentrations and outcome in premenopausal patients with early breast cancer.
33. Johnson J.A., Hamadeh I.S., Langaee T.Y. Loss of heterozygosity at the CYP2D6 locus
in breast cancer: implications for tamoxifen pharmacogenetic studies. J Natl Cancer
Inst. 2015;107(2) PubMed PMID: 25638249.
34. Lim H.S., Ju Lee H., Seok Lee K., Sook Lee E., et al. Clinical implications of CYP2D6
genotypes predictive of tamoxifen pharmacokinetics in metastatic breast cancer. J
Clin Oncol. 2007;25(25):3837–45. PubMed PMID: 17761971.
35. Jung J.A., Lim H.S. Association between CYP2D6 genotypes and the clinical
outcomes of adjuvant tamoxifen for breast cancer: a meta-analysis.
36. Province M.A., Goetz M.P., Brauch H., Flockhart D.A., et al. CYP2D6 genotype and
adjuvant tamoxifen: meta-analysis of heterogeneous study populations. Clin
37. Brauch H., Schwab M. Prediction of tamoxifen outcome by genetic variation of
CYP2D6 in post-menopausal women with early breast cancer. Br J Clin Pharmacol.
2014;77(4):695–703. PubMed PMID: 24033728.
38. de Vries Schultink A.H., Zwart W., Linn S.C., Beijnen J.H., et al. Effects of
Pharmacogenetics on the Pharmacokinetics and Pharmacodynamics of Tamoxifen.
Clin Pharmacokinet. 2015;54(8):797–810. PubMed PMID: 25940823.


Tamoxifen response

CYP2D6 gene
345

Laura Dean, MD1
Created: September 20, 2012; Updated: May 3, 2016; Revised: May 3, 2016.
Introduction
Thioguanine is an antineoplastic agent that belongs to the drug class of thiopurines. It is
used in the treatment of acute myeloid leukemia (1).
Thioguanine is a prodrug that must first be activated to form thioguanine nucleotides
inactivates thioguanine, leaving less parent drug available to form TGNs.
An adverse effect of thioguanine therapy is bone marrow suppression, which can occur in
any patient, is dose-dependent, and may be reversed by reducing the dose of thioguanine.
However, patients who carry two nonfunctional TPMT alleles universally experience life-
threatening myelosuppression when treated with thioguanine, due to high levels of TGNs.
Patients who carry one nonfunctional TPMT allele may also be unable to tolerate
conventional doses of thioguanine (2, 3).
The FDA-approved drug label for thioguanine states that there are individuals with an
inherited deficiency of the thiopurine methyltransferase (TPMT) enzyme who may be
unusually sensitive to the myelosuppressive effects of thioguanine and prone to
developing rapid bone marrow suppression following treatment initiation. Substantial
dosage reductions may be required to avoid the development of life-threatening bone
marrow suppression in these patients. Prescribers should be aware that some laboratories
offer testing for TPMT deficiency.
recommendations for TPMT genotype-based thioguanine dosing. These
Start with reduced doses of thioguanine for patients with one nonfunctional TPMT allele,
or drastically reduced doses for patients with malignancy and two nonfunctional alleles;
adjust dose based on degree of myelosuppression and disease-specific guidelines.
Consider alternative nonthiopurine immunosuppressant therapy for patients with
nonmalignant conditions and two nonfunctional alleles (see Table 1) (2-4).

Table 1. TPMT phenotypes and the therapeutic recommendations for thioguanine therapy, adapted from
CPIC
Phenotype Phenotype details TPMT Genotype Examples of Therapeutic recommendations
diplotypes for thioguanine (TG)
Homozygous High enzyme Two or more *1/*1 Start with normal starting dose.
wild-type activity. functional TPMT Adjust doses of TG and of other
(“normal”) Found in alleles myelosuppressive therapy
approximately 86– without any special emphasis
97% of patients. on TG.
Allow 2 weeks to reach steady
state after each dose
adjustment.
Heterozygous Intermediate One functional *1/*2 Start with reduced doses
enzyme activity. TPMT allele plus *1/*3A (reduce by 30–50%) and adjust
Found in one *1/*3B doses of TG based on degree of
approximately 3– nonfunctional *1/*3C myelosuppression and disease-
14% of patients. TPMT allele *1/*4 specific guidelines.
adjustment.
and depending on other
therapy, emphasis should be on
reducing TG over other agents.
Homozygous Low or deficient Two *3A/*3A Start with drastically reduced
variant enzyme activity. nonfunctional *2/*3A doses (reduce daily dose by 10-
Found in TPMT alleles *3C/*3A fold and dose thrice weekly
approximately 1 in *3C/*4 instead of daily) and adjust
178 to 1~3736 *3C/*2 doses of TG based on degree of
patients. *3A/*4 myelosuppression and disease-
specific guidelines.
adjustment.
emphasis should be on
reducing TG over other agents.
For nonmalignant conditions,
consider alternative
nonthiopurine
immunosuppressant therapy.
The strength of therapeutic recommendations is “moderate” for heterozygous individuals, and “strong” for
the other phenotypes.
2011;89(3):387–91 (2, 3).
Thioguanine Therapy and TPMT Genotype 347

Drug: Thioguanine
Thioguanine is a neoplastic agent used in the treatment of acute myeloid leukemia (AML).
AML is the most common acute leukemia in adults, accounting for approximately 80% of
cases, and the incidence increases with age. It is a less common cause of acute leukemia in
children accounting for less than 10% of cases.
AML is characterized by a proliferation of the myeloid lineage of blood cells, causing an
accumulation of abnormal and immature cells in the blood, bone marrow, and sometimes
other tissues. This causes a disruption in the production of normal red blood cells,
platelets, and mature granulocytes, leading to anemia, bleeding, and an increased risk of
infection.
Combination chemotherapy for AML, which includes thioguanine, more frequently
induces remission and a longer duration of remission than using thioguanine alone, but
because of the high risk of liver toxicity, thioguanine is not recommended for long-term
use. Younger patients with AML tend to have a better response to thioguanine than older
patients (1).
Like all thiopurines, thioguanine is a purine analogue, and acts as an antimetabolite.
Thioguanine is metabolized by two main pathways—it is either activated by HPRT1
(hypoxanthine phosphoribosyltransferase) and metabolized to form TGNs, or deactivated
by TPMT. The cytotoxicity of thioguanine is due, in part, to the incorporation of TGNs
into DNA. In addition to inhibiting de novo purine synthesis, thioguanine may also
inhibit purine nucleotide interconversions (1).
The most frequent adverse reaction to thioguanine is myelosuppression, which can occur
in any patient, and can usually be reversed by decreasing the dose of thioguanine.
However, all patients who carry two nonfunctional TPMT alleles (approximately 0.3%)
experience life-threatening myelosuppression after starting treatment with conventional

doses of thioguanine.
Individuals who are heterozygous for nonfunctional TPMT alleles (approximately 3–14%)
are at an increased risk of moderate to severe bone marrow suppression, whereas
individuals who are homozygous for wild-type TPMT alleles have a lower risk of bone
marrow suppression. However, all individuals receiving thioguanine require close
monitoring (2, 3, 5, 6).
The FDA-approved drug label for thioguanine states that substantial dosage reductions
may be required to avoid the development of life-threatening bone marrow suppression in
patients with an inherited deficiency of TPMT. A concern among oncologists may be that
a reduced dose of thioguanine will have less anti-tumor efficacy. However, CPIC
recommendations (table 1) state that “dose adjustments based on TPMT genotype have
reduced thiopurine-induced adverse effects without compromising desired antitumor and
immunosuppressive therapeutic effects in several clinical settings”.
Another adverse effect of thioguanine treatment is hyperuricemia, which frequently
occurs because of the rapid lysis of tumor cells. In addition, liver toxicity associated with
vascular endothelial damage has been reported when thioguanine is used for
maintenance, or for similar long-term continuous therapy. Liver toxicity usually presents
as the clinical syndrome of hepatic veno-occlusive disease (hyperbilirubinemia, tender
hepatomegaly, weight gain due to fluid retention, and ascites) or with signs of portal
hypertension (splenomegaly, thrombocytopenia, and oesophageal varices). For this
reason, the long-term use of thioguanine is not recommended (1).
Gene: TPMT
metabolism of thiopurines, such as thioguanine. TPMT activity is inherited as a co-
alleles (7-10).
typical response to thioguanine and a lower risk of myelosuppression. This accounts for
the majority of patients (~86–97%) (2, 3).
• TPMT*2 (c.238G>C)
frequently (7, 13).
Genetic Testing
red blood cells directly (5). In adult patients taking thioguanine as an immunosuppressive
agent, there is strong evidence of a near 100% concordance between phenotype and
genotype testing. Inflammatory disease processes do not interfere with the accuracy of
TPMT activity measurements if the blood sample is taken under standard conditions (e.g.,
not within two months of a blood transfusion).
However in patients with leukemia, the concordance between TPMT phenotype and
genotype is poor (19). By the time of diagnosis, red cell TPMT activity is typically greatly
reduced because of atypical hematopoiesis. Therefore, phenotype testing may wrongly
identify an individual as having a TPMT deficiency, e.g., a patient who has two functional
copies of the TPMT gene (homozygous wild-type) may be determined as having only one
functional copy and one nonfunctional variant (TPMT heterozygous); and a patient who
is TPMT heterozygous may be wrongly determined to be TPMT homozygous (two copies
of nonfunctional TPMT variants). In addition, during the course of chemotherapy, TPMT
phenotype testing may reveal excessively high TPMT activity. This is thought to be due to
an excess of young red blood cells with their associated higher level of TPMT enzyme
activity. Therefore, to avoid an incorrect TPMT status, genotype testing is recommended
for patients with leukemia (19).
Finally, one study reported that TPMT genotyping was more reliable than phenotyping in
identifying patients at risk of adverse reactions from thiopurine treatment (20), and
several studies reported that the TPMT genotype is a better indicator than TPMT activity
for predicting TGN accumulation or treatment outcome (6, 21-23).

2013 Statement from the US Food and Drug Administration (FDA): There are
individuals with an inherited deficiency of the enzyme thiopurine methyltransferase
(TPMT) who may be unusually sensitive to the myelosuppressive effects of thioguanine
and prone to developing rapid bone marrow suppression following the initiation of
treatment. Substantial dosage reductions may be required to avoid the development of
life-threatening bone marrow suppression in these patients. Prescribers should be aware
that some laboratories offer testing for TPMT deficiency. Since bone marrow suppression
may be associated with factors other than TPMT deficiency, TPMT testing may not
identify all patients at risk for severe toxicity. Therefore, close monitoring of clinical and
hematologic parameters is important. Bone marrow suppression could be exacerbated by
coadministration with drugs that inhibit TPMT, such as olsalazine, mesalazine, or
sulphasalazine.
(CPIC): Testing for TPMT status is recommended prior to starting thioguanine therapy
so that the starting dosages can be adjusted accordingly—see Table 1 for dosing
recommendations. In homozygous variant individuals, consider an alternative agent for
nonmalignant conditions and drastically reduce doses in malignant conditions. In
heterozygous individuals, the starting doses should be reduced. In both patient groups, a
longer period of time should be left after each dose adjustment to allow for a steady state
to be reached.
Nomenclature
Coding Protein
location
Ala80Pro 238G>C
generic drug.

Coding Protein
location
Ala154Thr 460G>A
Tyr240Cys 719A>G
Acknowledgments
The author would like to thank Lynne Lennard, PhD, Reader in Pharmacology and Senior
Lecturer, University of Sheffield, UK; Malin Lindqvist Appell, Associate Professor in
Pharmacogenetics and Program Director at the Biomedical Laboratory Science Program,
Linköping University, Sweden; and Stuart A. Scott, Assistant Professor of Genetics and
First edition:
page/cpic
Version History
References
1. TABLOID - thioguanine tablet [package insert]. Mauritius: Aspen Global Inc.; 2013.
setid=4490128b-e73f-4849-9d6e-e8591639d771
Ther. 2013;93(4):324–5. PubMed PMID: 23422873.
4. PharmGKB [Internet]. Palo Alto (CA): Stanford University. Chemical: Drug -
thioguanine. [Cited 2016 January 11]. Available from: https://www.pharmgkb.org/
chemical/PA451663
8. Katara P., Kuntal H. TPMT Polymorphism: When Shield Becomes Weakness.
Interdiscip Sci. 2015. PubMed PMID: 26297310.
9. Schaeffeler E., Fischer C., Brockmeier D., Wernet D., et al. Comprehensive analysis of
thiopurine S-methyltransferase phenotype-genotype correlation in a large population
of German-Caucasians and identification of novel TPMT variants.
Pharmacogenetics. 2004;14(7):407–17. PubMed PMID: 15226673.
10. TPMT Nomenclature Committee [Internet]. Sweden: Linköping University. Table of
TPMT alleles. [Cited 2016 February 02]. Available from: http://www.imh.liu.se/
tpmtalleles/tabell-over-tpmt-alleler?l=en
PMID: 11966406.
12. PharmGKB [Internet]. Palo Alto (CA): Stanford University. Gene: TPMT thiopurine
S-methyltransferase (TPMT). [Cited 2016 January 11]. Available from: https://
13. PharmGKB [Internet]. Palo Alto (CA): Stanford University. Haplotype TPMT *3A.
[Cited 2016 Apr 28]. Available from: http://www.pharmgkb.org/haplotype/
PA165819270
2014;24(6):320–3. PubMed PMID: 24710034.
2011;17(6):1441–2. PubMed PMID: 20945351.
PMID: 11736862.
2012;6(6):655–9. PubMed PMID: 22398041.
2013;76(1):125–36. PubMed PMID: 23252716.



Thioguanine response

TPMT gene
355

Laura Dean, MD1
Created: February 9, 2017.
Introduction
Thioridazine is an antipsychotic used in the treatment of schizophrenia and psychosis. Its
use is reserved for patients who have failed to respond to or cannot tolerate other
antipsychotics.
Thioridazine has been shown to prolong the QT interval (the time taken for the heart
ventricles to depolarize and repolarize) in a dose related manner. Drugs with this
potential have been associated with the life-threatening ventricular tachycardia, “torsades
de pointes”.
The CYP2D6 enzyme is involved in metabolizing thioridazine. About 7% of the
population has reduced enzyme activity because of variants in the CYP2D6 gene. In
individuals with low CYP2D6 activity, standard doses of thioridazine may lead to higher
drug levels in the plasma, and increase the risk of cardiac arrhythmias.
The FDA-approved drug label for thioridazine states that thioridazine is contraindicated
in individuals who are known to have reduced levels of CYP2D6 activity. The label also
states it is contraindicated to coadminister thioridazine with drugs that inhibit CYP2D6
(e.g., fluoxetine, paroxetine) or inhibit the metabolism of thioridazine (e.g., fluvoxamine,
propranolol, and pindolol) (1).
Drug Class: Antipsychotics

chlorpromazine, followed by other agents, including fluphenazine, loxapine,
pherphenazine, pimozide, thioridazine, thiothixene, and trifluoperazine.
Known as “first generation” or “typical” antipsychotics, these drugs were used to treat
psychosis (regardless of the cause), chronic psychotic disorders (e.g., schizophrenia), and
other psychiatric conditions. However, prominent adverse effects included extrapyramidal
side effects such as tardive dyskinesia, muscle rigidity, and tremors, i.e., Parkinsonian-like
symptoms.
lower risk of extrapyramidal side effects. However, many have serious metabolic effects.

These antipsychotics include aripiprazole, clozapine, iloperidone, olanzapine, and

risperidone.
Drug: Thioridazine
Thioridazine is a first generation “typical” antipsychotic used in the treatment of
schizophrenia. Schizophrenia is a severe neurodevelopmental disorder with a worldwide
prevalence of around 0.3˗0.7% (2). The etiology of schizophrenia is unknown, but it is
thought to result from a combination of complex genetic and environmental factors.
Before the discovery of the first antipsychotics in the 1950s, the management of
schizophrenia relied heavily upon sedation, electroconvulsive therapy, and
institutionalization.
The symptoms of schizophrenia fall into three main categories: positive, negative, and
without moving or with a monotonous voice) and avolition (a lack of motivation to start
The use of thioridazine is reserved for patients who have failed to respond to or cannot
tolerate the side effects of other antipsychotics. The FDA-approved drug label for
thioridazine strongly recommends that prior to starting thioridazine, a patient should be
given at least two trials, each with a different antipsychotic drug product, at an adequate
dose, for an adequate duration of time. The label also states that for patients who do
require chronic treatment with thioridazine, the smallest dose and the shortest duration of
treatment should be sought and the need for continued treatment should be reassessed
periodically; and cautions that the efficacy of thioridazine in treating patients with
refractory schizophrenia is unknown (1).
The main action of both first-generation and second-generation antipsychotics appears to
be the post-synaptic blockade of D2 dopamine receptors in the brain. (An exception is
aripiprazole, which is a D2 partial agonist.) Blockade of the D2 receptor in the brain’s
limbic system is thought to improve the “positive” symptoms of schizophrenia (3).
However, because the first-generation antipsychotics also block dopamine receptors in the
nigrostriatal pathway, they cause movement disorders known as extrapyramidal side
effects. These disorders include akathisia (motor restlessness), dystonia (abnormal muscle
tone), and tardive dyskinesia (involuntary and repetitive movements).
Thioridazine Therapy and CYP2D6 Genotypes 357
Compared to other first generation antipsychotics, thioridazine shares a similar efficacy,

but has a lower risk of extrapyramidal side effects (4-6). However, a higher level of EKG
changes is associated with thioridazine therapy (6).
Antipsychotics, and thioridazine in particular, can inhibit cardiac ion channels. Most first
generation antipsychotics block the cardiac potassium channel KCNH2, previously
known as the human ether-a-go-go-related gene (hERG) (7, 8). Blockade of this channel
reduces inward potassium current, resulting in longer cardiac repolarization times. On
the EKG, this manifests as a prolonged QT interval. In extreme cases, this can lead to a
life-threatening ventricular tachycardia known as torsades de pointes (“twisting of the
points”) (9-11).
At one point, thioridazine was one of the most commonly used medications for major
mental health disorders. However, numerous case reports of sudden, unexpected death
led to label changes in 2000, which recommended that thioridazine be used as a last resort
(12). In 2005, the manufacturer Novartis discontinued the branded form of thioridazine
because of its association with QT prolongation, but generic forms are still available in the
US (13, 14).
Thioridazine is metabolized by CYP2D6 to the active metabolite mesoridazine, which is
further metabolized to sulforidazine, both of which are more potent than thioridazine. In
addition, both thioridazine and mesoridazine have similar effects on the QT interval (15,
16).
Recent research has found that thioridazine is active against multidrug resistant
tuberculosis, when used in combination with other antituberculosis drugs. Thioridazine
increases the permeability of the cell-envelope, enabling the enhanced uptake of
antibiotics (17).
The FDA drug label states that no teratogenic effect has been shown with thioridazine to
date. However, all drugs should be kept to a minimum during pregnancy, so thioridazine
should be given only when the benefits exceed the possible risks to mother and fetus. Of
note, neonates exposed to antipsychotic drugs during the third trimester are at risk for
extrapyramidal and/or withdrawal symptoms following delivery which vary in severity;
while in some cases symptoms have been self-limited, in other cases neonates have
required intensive care unit support and prolonged hospitalization.

activity.
Gene: CYP2D6
CYP2D6 is highly polymorphic; over 100 star (*) alleles are described and currently
CYP2D6*1 is the reference (or wild-type) allele encoding enzyme with normal activity.
The CYP2D6*2, *33, and *35 alleles are also considered to confer normal activity (Table
1).
Decreased function *9, *10, *17, *29, *41
No function *3-*8, *11-*16, *19-*21, *38, *40, *42
An activity score can be assigned to each CYP2D6 allele, e.g., 1 for each functional allele,
0.5 for a decreased function allele, and 0 for a no function allele. Individuals who carry
more than two normal function copies (e.g., multiple copies) of the CYP2D6 gene are
“ultrarapid metabolizers”, whereas individuals who are “normal metabolizers” either carry
two normal function copies of CYP2D6, or a combination of normal/decreased/no
function alleles that result in an activity score between 1.0 and 2.0. Individuals who are
intermediate or poor metabolizers carry copies of decreased or no function CYP2D6
alleles, respectively (Table 2).
Table 2. 2016 Assignment of CYP2D6 phenotypes by CPIC
CYP2D6 Ultrarapid Greater than 2.0 An individual carrying (*1/*1)xN
(approximately 1-20% of alleles (*2/*2)xNb
patients)a
CYP2D6 Normal 1.0 – 2.0c An individual carrying two *1/*1
(approximately 72-88% of or two decreased function *2/*2
a For population-specific allele and phenotype frequencies, please see
laboratories.

or combinations of
2.0
CYP2D6 Intermediate 0.5 An individual carrying one *4/*41
(approximately 1-13% of no function allele *4/*10
patients)
CYP2D6 Poor metabolizer 0 An individual carrying two *4/*4
(approximately 1-10% of no function alleles *4/*4xN
patients) *3/*4
*5/*5
*5/*6
a For population-specific allele and phenotype frequencies, please see
laboratories.
most common decreased function alleles include CYP2D6*9, *10, *17, *29 and *41
(24-28) .There are large inter-ethnic differences in the frequency of these alleles. For
example, CYP2D6*4 is the most common no function allele in Caucasians, but is less
abundant in subjects with African ancestry, and is rare in Asians. In contrast, the
decreased function allele CYP2D6*10 is the most common allele in Asians, and
CYP2D6*17 is almost exclusively found in individuals with African ancestry (29).
ethnicities and may vary among populations. Approximately 6-10% of European
In individuals who are CYP2D6 poor metabolizers, standard doses of thioridazine may
lead to the drug accumulating in the plasma. Since a dose-related side effect of
thioridazine is prolongation of the QTc interval, which is a potentially life threatening
event, the FDA has stated that the use of thioridazine is contraindicated in individuals
who are known to have reduced CYP2D6 activity (1, 32). In addition, the label also states
it is contraindicated to coadminister thioridazine with other drugs that inhibit CYP2D6

activity (e.g., the antidepressants fluoxetine and paroxetine) or inhibit the metabolism of
thioridazine (e.g., the beta-blockers propranolol and pindolol, and the antidepressant
fluvoxamine) (1).
Genetic Testing
The NIH’s Genetic Testing Registry, GTR, provides examples of the genetic tests that are
currently available for the thioridazine response and the CYP2D6 gene.
needs to be noted that the number of variants tested varies substantially among
laboratories and there is no standardized way to report results (34).
score to each allele (e.g., 0 for no function, 0.5 for decreased function, and 1 for each copy
of a normal function allele). The phenotype is defined by the sum of the two scores:
• An ultrarapid metabolizer has an activity score of greater than 2 (19, 35)

2016 Statement from the US Food and Drug Administration (FDA): Reduced
cytochrome P450 2D6 isozyme activity drugs that inhibit this isozyme (e.g., fluoxetine
and paroxetine) and certain other drugs (e.g., fluvoxamine, propranolol, and pindolol)
appear to appreciably inhibit the metabolism of thioridazine. The resulting elevated levels
of thioridazine would be expected to augment the prolongation of the QTc interval
associated with thioridazine and may increase the risk of serious, potentially fatal, cardiac
arrhythmias, such as Torsades de pointes type arrhythmias. Such an increased risk may
result also from the additive effect of coadministering thioridazine with other agents that
prolong the QTc interval. Therefore, thioridazine is contraindicated with these drugs as
generic drug.
well as in patients, comprising about 7% of the normal population, who are known to
have a genetic defect leading to reduced levels of activity of P450 2D6.
Nomenclature
Coding Protein
identifier for
allele location
frameshift)
Trp152Gly 454delT
• CYP2D6T
(Pro34Ser) 100C>T
(Thr107Ile) 320C>T
(Cys296Arg) 886T>C
(Cys296Arg) 886T>C
Acknowledgments
The author would like to thank David Kisor, B.S., Pharm.D., Professor and Director of
Pharmacogenomics Education, Pharmacogenomics Program, Manchester University,
Indiana; Mohamed Nagy, Clinical Pharmacist, Head of the Personalised Medication
Management Unit, Department of Pharmaceutical Services, Children's Cancer Hospital,
Egypt; and Yolande Saab, Pharm.D., Ph.D., Associate Professor of Pharmacogenomic,
School of Pharmacy, Lebanese American University, Lebanon; for reviewing this

summary.
References
1. THIORIDAZINE HYDROCHLORIDE- thioridazine hydrochloride tablet, film
coated [packet insert]. Morgantown, WV: Mylan Pharmaceuticals, I.; 2016. Available
from: https://dailymed.nlm.nih.gov/dailymed/drugInfo.cfm?setid=2479bf9f-
e5ec-4bf8-b177-169107fc7763
2. van Os J., Kapur S. Schizophrenia. Lancet. 2009;374(9690):635–45. PubMed PMID:
19700006.
3. Goodnick P.J., Jerry J.M. Aripiprazole: profile on efficacy and safety. Expert Opin
4. Yang S.Y., Kao Yang Y.H., Chong M.Y., Yang Y.H., et al. Risk of extrapyramidal
syndrome in schizophrenic patients treated with antipsychotics: a population-based
study. Clin Pharmacol Ther. 2007;81(4):586–94. PubMed PMID: 17235331.
5. Thanacoody H.K. Thioridazine: resurrection as an antimicrobial agent? Br J Clin
6. Fenton M., Rathbone J., Reilly J., Sultana A. Thioridazine for schizophrenia.
Cochrane Database Syst Rev. 2007;(3):CD001944. PubMed PMID: 17636691.
7. Oshiro C., Thorn C.F., Roden D.M., Klein T.E., et al. KCNH2 pharmacogenomics
summary. Pharmacogenet Genomics. 2010;20(12):775–7. PubMed PMID: 20150828.
8. Reilly J.G., Ayis S.A., Ferrier I.N., Jones S.J., et al. QTc-interval abnormalities and
psychotropic drug therapy in psychiatric patients. Lancet. 2000;355(9209):1048–52.
9. Crumb W.J. Jr, Ekins S., Sarazan R.D., Wikel J.H., et al. Effects of antipsychotic drugs
on I(to), I (Na), I (sus), I (K1), and hERG: QT prolongation, structure activity
relationship, and network analysis. Pharm Res. 2006;23(6):1133–43. PubMed PMID:
16715368.
10. Berling I., Isbister G.K. Prolonged QT Risk Assessment in Antipsychotic Overdose
Using the QT Nomogram. Ann Emerg Med. 2015;66(2):154–64. PubMed PMID:
25639523.
11. Kongsamut S., Kang J., Chen X.L., Roehr J., et al. A comparison of the receptor
binding and HERG channel affinities for a series of antipsychotic drugs. Eur J
12. Ray W.A., Meador K.G. Antipsychotics and sudden death: is thioridazine the only
bad actor? Br J Psychiatry. 2002;180:483–4. PubMed PMID: 12042224.
13. THIORIDAZINE - Withdrawn due to poor benefit/risk profile. Essential Medicines and
Health Products Information Portal. Essential Medicines and Health Products
Information Portal 2005 [cited 2016 September 2016]; Available from: http://
apps.who.int/medicinedocs/en/d/Js8116e/1.7.html.
14. Purhonen M., Koponen H., Tiihonen J., Tanskanen A. Outcome of patients after
market withdrawal of thioridazine: a retrospective analysis in a nationwide cohort.
Pharmacoepidemiol Drug Saf. 2012;21(11):1227–31. PubMed PMID: 22941581.
15. Dorado P., Penas L.E.M., de la Rubia A. -1584C>G polymorphism for

thioridazine:mesoridazine plasma concentration ratio in psychiatric patients.
Pharmacogenomics. 2009;10(7):1083–9. and L.L. A, Relevance of CYP2D6. p.
16. Salih I.S., Thanacoody R.H., McKay G.A., Thomas S.H. Comparison of the effects of
thioridazine and mesoridazine on the QT interval in healthy adults after single oral
doses. Clin Pharmacol Ther. 2007;82(5):548–54. PubMed PMID: 17410120.
17. de Keijzer J., Mulder A., de Haas P.E., de Ru A.H., et al. Thioridazine Alters the Cell-
Envelope Permeability of Mycobacterium tuberculosis. J Proteome Res. 2016;15(6):
1776–86. PubMed PMID: 27068340.
Ther. 2016.
PA165816578
PA165816579
PA165948092
PA165816581
PA165948317
PA165816582
PA165816583
PA165948318
PA165816584
PMID: 27388693.
11972444.
32. Kannankeril P., Roden D.M., Darbar D. Drug-induced long QT syndrome.
Pharmacol Rev. 2010;62(4):760–81. PubMed PMID: 21079043.
Ther. 2015;98(2):127–34. PubMed PMID: 25974703.
2014;15(2):218–32. PubMed PMID: 24524666.


Thioridazine response

CYP2D6 gene
367

Laura Dean, MD1
Introduction
Tramadol is an analgesic used to treat moderate to moderately severe pain. It is a synthetic
opioid, related to codeine, and is used to treat both acute and chronic pain. Tramadol is
often prescribed for post-operative pain, and pain caused by cancer, osteoarthritis, and
other musculoskeletal diseases (1).
The CYP2D6 enzyme metabolizes a quarter of all prescribed drugs, including tramadol.
Individuals who carry two inactive copies of CYP2D6 are known as poor metabolizers and
have higher plasma concentrations of tramadol compared with individuals who have two
copies of normal activity alleles (1). Individuals who carry one or more reduced or
inactive copies of CYP2D6 are known as intermediate metabolizers, and individuals who
carry more than two active copies of CYP2D6 are known as ultrarapid metabolizers.
The FDA states that the levels of tramadol are approximately 20% higher in poor
metabolizers compared to extensive (“normal”) metabolizers, while concentrations of the
tramadol metabolite, M1, are 40% lower. Inhibitors of CYP2D6, such as fluoxetine and
amitriptyline, also inhibit the metabolism of tramadol, and the full pharmacological
impact of these alterations of tramadol dose in terms of either efficacy or safety is
unknown (1).
A guideline from the Dutch Pharmacogenetics Working Group includes dose
recommendations for poor metabolizers (either select an alternative drug—not
oxycodone or codeine—or be alert to the symptoms of insufficient pain relief). It also
contains dose recommendations for intermediate metabolizers (be alert to decreased
efficacy of tramadol, consider increasing the dose and if the response is still inadequate,
either select an alternative drug—not oxycodone or codeine, or be alert to the symptoms
of insufficient pain relief) and ultrarapid metabolizers (either reduce the dose of tramadol
by 30% and be alert to adverse drug events, or select an alternative drug e.g.,
acetaminophen, NSAID, morphine—not oxycodone or codeine) (see Table 1) (2).

Table 1. CYP2D6 phenotypes and the therapeutic recommendations for tramadol therapy
Phenotype Genotype Therapeutic recommendation for tramadol
Ultrarapid metabolizer More than two copies of Reduce dose by 30% and be alert to ADEs
functional alleles (e.g., nausea, vomiting, constipation,
respiratory depression, confusion, urinary
retention) or select alternative
drug (e.g., acetaminophen, NSAID, morphine
—not oxycodone or codeine)
Intermediate metabolizer One active allele and one Be alert to decreased efficacy. Consider dose
inactive allele, or two increase. If response is still inadequate, select
decreased activity alleles, or alternative drug—not oxycodone or codeine—
one decreased activity allele or be alert to symptoms of insufficient pain
and one inactive allele relief
Poor metabolizer Two inactive alleles Select alternative drug—not oxycodone or
codeine—or be alert to symptoms of
insufficient pain relief
ADE: Adverse Drug Event
The strength of the tramadol therapeutic recommendations scored a maximum of 4/4 (the highest quality of
evidence) for poor and intermediate metabolizers, and a score of 3/4 for ultrarapid metabolizers. Table is
adapted from Swen J.J., Nijenhuis M., de Boer A., Grandia L. et al. Pharmacogenetics: from bench to byte -
an update of guidelines. Clinical pharmacology and therapeutics. 2011;89(5):662–73 (2).
Allele type Alleles
Active *1, *2, *33, *35
Inactive *3-*8, *11-*16, *19-*21, *38, *40, *42
Note: The most clinically significant variants are highlighted in bold.
Drug: Tramadol
Tramadol is an analgesic that is used to treat moderate to moderately severe pain.
Tramadol is commonly prescribed for postoperative, cancer, and musculoskeletal pain. In
the US, tramadol is classified as a Schedule IV controlled substance (1, 3).
Tramadol is a centrally acting analgesic that is structurally related to codeine and
morphine, and belongs to the same drug class of opiate drugs. Tramadol, however, is a
synthetic opioid, and it is administered as a racemic mixture of two enantiomers, (+) and
(-) tramadol (4).
Although opiates have been used for pain control for several thousands of years, the
receptors upon which they act were discovered relatively recently, in the 1960s. The exact
mechanism of action of tramadol is not known, but it is thought that both enantiomers
contribute to its analgesic effect in different ways. Tramadol has some activity at mu-
Tramadol Therapy and CYP2D6 Genotype 369
opioid receptor (less than codeine) and it also inhibits the synaptic reuptake of serotonin
and norepinephrine which inhibits pain transmission at the spinal cord (4, 5).
Tramadol is extensively metabolized within the liver and has one main major metabolite,
O-desmethyltramadol, known as M1. Both the parent drug and M1 contribute to the
analgesic effect, but M1 has a significantly higher affinity for opioid receptors than
tramadol (6). The enzyme CYP2D6 catalyzes the production of M1, and other CYP
enzymes (CYP2B6 and CYP3A4) catalyze the production of M2, an inactive metabolite
(7).
The adverse effects of tramadol therapy are similar to that of other weak opioids.
Common side effects include dizziness, nausea, constipation, and headache. But an
additional risk of tramadol therapy is the risk of seizures, especially in patients who are
already taking antidepressants or other drugs that decrease the seizure threshold. There is
also an increased risk of suicide, and therefore tramadol should not be prescribed for
patients who are suicidal or prone to addictions—the use of non-narcotic analgesics
should be considered instead (1).
Because tramadol has mu-opioid agonist activity, there is a risk of abuse and addiction,
even under appropriate medical use. Therefore, as for all patients treated with opioids,
there should be careful monitoring of patients taking tramadol. In addition, the longer a
patient is on continuous tramadol therapy, the greater the risk of tolerance (the need to
increase the dose of drug to maintain a defined level of analgesia in the absence of disease
progression). Physical dependence upon tramadol is manifested by withdrawal symptoms
after the use of tramadol is stopped abruptly. Symptoms include restlessness, rhinorrhea,
lacrimation, and chills (1).
Serotonin syndrome is a potentially life-threatening syndrome that may occur with the
use of tramadol, especially if other medications such as antidepressants or other drugs
that impair the metabolism of tramadol (CYP2D6 and CYP3A4 inhibitors) are used
concurrently. Symptoms include changes in mental status (e.g., agitation, hallucinations,
coma), autonomic instability (e.g., tachycardia, labile blood pressure, hyperthermia),
neuromuscular aberrations (e.g., hyperreflexia, incoordination) and/or gastrointestinal
symptoms (e.g., nausea, vomiting, diarrhea) (1, 8).
Gene: CYP2D6
activity.
“extensive metabolizer” phenotype. The CYP2D6 alleles *2, *33, and *35 are also
considered to have near-normal activity.
Other alleles include variants that produce a non-functioning enzyme (e.g., *3, *4, *5, and
*6) (10-13) or an enzyme with reduced activity (e.g., *10, *17, and *41) (2, 14, 15) (see
Table 2). There are large inter-ethnic differences in the frequency of these alleles, with *3,
*4, *5, *6, and *41 being more common in Caucasians, *17 more common in Africans,
and *10 more common in Asians (16).
Individuals who are intermediate or poor metabolizers carry copies of decreased-
functioning and inactive CYP2D6 alleles (see Table 1 and 2). In these individuals, the
metabolic capacity of CYP2D6 is decreased which may result in higher levels of tramadol.
The FDA-approved drug label for tramadol includes a study where concentrations of
tramadol were approximately 20% higher in "poor metabolizers" versus "extensive
metabolizers", while M1 concentrations were 40% lower. The label also states that other
factors, such as the concurrent use of CYP2D6 inhibitors (e.g., fluoxetine and its
metabolite norfluoxetine, amitriptyline and quinidine) could also result in increases in
tramadol concentrations and decreased concentrations of M1, and that the “full
pharmacological impact of these alterations in terms of either efficacy or safety is
unknown” (1).
The Dutch Pharmacogenetics Working Group recommendations state that for poor
metabolizers, “either select an alternative drug (not oxycodone or codeine) or be alert to
the symptoms of insufficient pain relief ” (2).
Poor metabolizers are commonly found in European Caucasians (6-10%). The most
common allele in this population is the functional CYP2D6*1 (70%), and the most
common nonfunctional alleles include CYP2D6*4 and *5, which largely account for the
poor metabolizer phenotype in these populations (16). About 2% of African Americans
are poor metabolizers, due to a wide ranges of variants that include the nonfunctional *4
and *5 alleles (17-19).
For intermediate metabolizers, the Dutch Pharmacogenetics Working Group
recommendations state to be alert to decreased efficacy of tramadol. Consider increasing
the dose of tramadol and if the response is still inadequate, either select an alternative
drug (not oxycodone or codeine), or be alert to the symptoms of insufficient pain relief
(2).
Approximately 30% of Asians and individuals of Asian descent are intermediate
metabolizers. In these populations, only half of CYPD6 alleles are fully functional, with
the reduced function *10 variant being very common (~40%, compared to ~2% in
Caucasians) (20). As a result, Asians are more likely to be intermediate metabolizers than
Caucasians (16).
Individuals who have multiple functional copies of the CYP2D6 gene are “ultrarapid
metabolizers” (UM). Each allele contributes to the metabolism of venlafaxine to the active
metabolite, M1. The Dutch Pharmacogenetics Working Group recommendations state
that for ultrarapid metabolizers, either reduce the dose of tramadol by 30% and be alert to
adverse drug events (e.g., nausea, vomiting, constipation, respiratory depression,
confusion, urinary retention), or select an alternative drug (e.g., acetaminophen, NSAID,
morphine—not oxycodone or codeine).
The ultrarapid metabolizer phenotype is estimated to be present in up to 28% of North
Africans, Ethiopians, and Arabs; up to 10% in Caucasians; 3% in African Americans, and
up to 1% in Hispanics, Chinese, and Japanese (16).
Genetic Testing
Genetic testing is available for many of the more common variant CYP2D6 alleles. Results
are typically reported as a diplotype, such as CYP2D6 *1/*1 (21). A result for copy
number, if available, is also important when interpreting CYP2D6 results.

Statement from the US Food and Drug Administration (FDA): Approximately 7% of
the population has reduced activity of the CYP2D6 isoenzyme of cytochrome P- 450.
These individuals are "poor metabolizers" of debrisoquine, dextromethorphan, tricyclic
antidepressants, among other drugs. Based on a population PK [pharmacokinetic]
analysis of Phase I studies in healthy subjects, concentrations of tramadol were
approximately 20% higher in "poor metabolizers" versus "extensive metabolizers", while
M1 [tramadol metabolite] concentrations were 40% lower. Concomitant therapy with
drug labels in this excerpt and may have inserted text in brackets, to explain some of the terms
used. The FDA may not have labeled all formulations containing the generic drug.
inhibitors of CYP2D6 such as fluoxetine, paroxetine and quinidine could result in

significant drug interactions. In vitro drug interaction studies in human liver microsomes
indicate that inhibitors of CYP2D6 such as fluoxetine and its metabolite norfluoxetine,
amitriptyline and quinidine inhibit the metabolism of tramadol to various degrees,
suggesting that concomitant administration of these compounds could result in increases
in tramadol concentrations and decreased concentrations of M1. The full pharmacological
impact of these alterations in terms of either efficacy or safety is unknown. Concomitant
use of SEROTONIN re-uptake INHIBITORS and MAO INHIBITORS may enhance the
risk of adverse events, including seizure and serotonin syndrome.
Royal Dutch Association for the Advancement of Pharmacy (KNMP): For ultrarapid
metabolizers, either reduce the dose of tramadol by 30% and be alert to adverse drug
events (e.g., nausea, vomiting, constipation, respiratory depression, confusion, urinary
retention), or select an alternative drug (e.g., acetaminophen, NSAID, morphine—not
oxycodone or codeine).
For intermediate metabolizers, be alert to decreased efficacy of tramadol. Consider
increasing the dose of tramadol and if the response is still inadequate, either select an
alternative drug (not oxycodone or codeine), or be alert the symptoms of insufficient pain
relief.
For poor metabolizers, either select an alternative drug (not oxycodone or codeine) or be
alert to the symptoms of insufficient pain relief.
Nomenclature
Coding Protein
identifier
for allele
location
CYP2D6*4 1846G>A NM_000106.4:c.506-1G>A Not applicable—variant rs3892097
region
CYP2D6*5 CYP2D6,DEL NC_000022.10:g. Not applicable—variant results in a
(42534124_42531353)_(42521970_42519196)del whole gene deletion
CYP2D6*6 1707 del T NM_000106.4:c.454delT NP_000097.2:p.Trp152Glyfs rs5030655
Trp152Gly

Coding Protein
identifier
for allele
location
CYP2D6*10 100C>T NM_000106.4:c.100C>T NP_000097.2:p.Pro34Ser rs1065852
Pro34Ser
CYP2D6*17 Includes at NM_000106.4:c.320C>T NP_000097.2:p.Thr107Ile rs28371706
least two NM_000106.4:c.886T>C NP_000097.2:p.Cys296Arg rs16947
functional
variants*:
1023C>T
(Thr107Ile)
2850C>T
(Cys296Arg)
CYP2D6*41 2988G>A NM_000106.4:c.985+39G>A Not applicable—variant rs28371725
region
Acknowledgments
The author would like to thank Professor Stefan Grond, Chief Physician of the Clinic for
Anesthesiology and Operative Intensive Care Medicine at Klinikum Lippe, Germany; and
Alan D. Kaye, Professor and Chairman of the Department of Anesthesiology at Louisiana
State University Health Sciences Center, New Orleans, and Editor-in-Chief, Pain Physician
Journal, for reviewing this summary.
References
1. TRAMADOL- tramadol hydrochloride tablet [package insert]. North Carolina, USA:
Accord Healthcare, I.; 2014. Available from: http://dailymed.nlm.nih.gov/dailymed/
drugInfo.cfm?setid=052d06ef-4186-4ac1-9099-af05fa37c2f8
662–73. PubMed PMID: 21412232.
3. Drug Enforcement Administration, Department of Justice. Schedules of Controlled
Substances: Placement of Tramadol Into Schedule IV. Federal Register 2014 [Last
accessed: 3 June 2015]. Available from: https://www.federalregister.gov/articles/
2014/07/02/2014-15548/schedules-of-controlled-substances-placement-of-tramadol-
into-schedule-iv
4. Grond S., Sablotzki A. Clinical pharmacology of tramadol. Clin Pharmacokinet.
2004;43(13):879–923. PubMed PMID: 15509185.
5. Reeves R.R., Burke R.S. Tramadol: basic pharmacology and emerging concepts.
Drugs Today (Barc). 2008;44(11):827–36. PubMed PMID: 19180260.
6. Gillen C., Haurand M., Kobelt D.J., Wnendt S. Affinity, potency and efficacy of
tramadol and its metabolites at the cloned human mu-opioid receptor. Naunyn
Schmiedebergs Arch Pharmacol. 2000;362(2):116–21. PubMed PMID: 10961373.
7. Subrahmanyam V., Renwick A.B., Walters D.G., Young P.J., et al. Identification of
cytochrome P-450 isoforms responsible for cis-tramadol metabolism in human liver
microsomes. Drug Metab Dispos. 2001;29(8):1146–55. PubMed PMID: 11454734.
8. Beakley B.D., Kaye A.M., Kaye A.D. Tramadol, Pharmacology, Side Effects, and
Serotonin Syndrome: A Review. Pain Physician. 2015;18(4):395–400. PubMed PMID:
26218943.
9. CYP2D6 allele nomenclature. 2015 [Last accessed: 3 June 2015]. Available from:
[Cited 3 June 2015]. Available from: http://www.pharmgkb.org/haplotype/
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8287064.


Tramadol response

CYP2D6 gene
377
Trastuzumab (Herceptin) Therapy and ERBB2

(HER2) Genotype
Laura Dean, MD1
Introduction
Trastuzumab (brand name, Herceptin) is a monoclonal antibody used in the treatment of
breast and gastric/gastroesophageal cancer. It targets an epidermal growth factor receptor
encoded by the ERBB2 gene, which is commonly referred to as the HER2 gene.
The HER2 gene is overexpressed in 15-20% of breast cancers and is also overexpressed in
some cases of gastric cancer. Overall, “HER2 positive” tumors are associated with a faster
rate of growth and a poorer prognosis. The use of trastuzumab in treatment regimes
improves outcomes, but adverse effects of therapy include cardiac toxicity.
The FDA-approved drug label for trastuzumab states that trastuzumab should only be
used to treat patients with tumors that have either HER2 protein overexpression or HER2
gene amplification, as determined by an accurate and validated FDA-approved assay,
specific for the type of tumor tested (breast or gastric). This is because these are the only
patients studied for whom benefit has been shown (1).
A guideline from ASCO/CAP states that oncologists must request HER2 testing on every
primary invasive breast cancer (and on a metastatic site, if stage IV and if specimen
available) from a patient with breast cancer to guide decision to pursue HER2-targeted
therapy. This should be especially considered for a patient who previously tested HER2
negative in a primary tumor and presents with disease recurrence with clinical behavior
suggestive of HER2-positive or triple-negative disease (2).
Drug: Trastuzumab (Herceptin)

Trastuzumab (brand name, Herceptin) is a monoclonal antibody that targets ERBB2 (a
tyrosine kinase receptor, also known as HER2 or HER-2/neu). Trastuzumab is only used
to treat specific tumors that overexpress ERBB2; these tumors are known as “HER2-
positive” tumors.
Trastuzumab is typically used as an adjuvant treatment of early-stage HER2-positive
breast cancer. Adjuvant therapies are used after primary treatment (such as surgery) to
increase the chance of long-term disease-free survival. An example chemotherapy
treatment regime is "AC→TH", which stands for Adriamycin, Cytoxan, then Taxol and

Herceptin. Trastuzumab is also used in the treatment of HER2-positive metastatic breast

cancer and HER2-positive metastatic gastric cancer (1).
Recently, HER2 targeted therapy has been approved by the FDA for use in the
neoadjuvant setting. Neoadjuvant therapy is given before primary therapy, for example, to
shrink a tumor to an operable size or to allow for breast-conserving surgery, and to
increase the chance of long-term, disease-free survival. In the neoadjuvant setting,
pertuzumab, along with trastuzumab and docetaxel (a chemotherapy agent) can be given
pre-operatively (3-5).
Before treatment with trastuzumab begins, overexpression of the ERBB2 protein or
amplification of the ERBB2 gene must first be determined. The FDA recommends that
testing be performed using an FDA-approved test for the specific tumor type (breast or
gastric tumor), in a laboratory with demonstrated proficiency with the technology being
used. This is because the benefits of trastuzumab have only been proven in patients with
tumors that overexpress ERBB2. In addition, although trastuzumab is generally well
tolerated, the risks of treatment include infusion reactions, pulmonary toxicity, and
cardiomyopathy that can result in cardiac failure (1).
Trastuzumab targets the ERBB2 receptor by binding to the juxtamembrane portion of the
extracellular domain. This binding limits the receptor’s ability to activate its intrinsic
tyrosine kinase, which in turn, limits the activation of numerous signaling pathways that
can promote the growth of cancerous cells.
A number of proposed mechanisms may underlie the anti-tumor effects of trastuzumab.
One such mechanism is that trastuzumab blocks the HER3 receptor from binding to
ERBB2. The ERBB2-HER3 dimerized receptor is thought to be highly active, triggering
many signaling cascades in the absence of a “true” ligand (6).
Another proposed mechanism is antibody-dependent cellular cytotoxicity (ADCC). Once
trastuzumab has bound to a cancer cell, immune cells (typically activated natural killer
cells) bind to trastuzumab and initiate lysis of the cancer cell (7). Trastuzumab may also
mediate the enhanced internalization and degradation of the ERBB2 receptor, inhibit
angiogenesis, and inhibit ERBB2 shedding by preventing the cleavage of ERBB2 and the
subsequent release of its extracellular domain (8, 9).
Unfortunately, breast cancer may start to progress again during trastuzumab therapy.
Possible mechanisms that may facilitate disease progression during treatment include
increased signaling from the HER family of receptors, an upregulation of downstream
signaling pathways, and an increased level of insulin growth factor -1 receptor (10, 11).
At the time of writing, four drugs have been approved to target ERBB2 (trastuzumab,
lapatinib, pertuzumab, and T-DM1), with more drugs in clinical trials.
Trastuzumab (Herceptin) Therapy and ERBB2 (HER2) Genotype 379
Gene: ERBB2 (HER2)

The human epidermal growth factor receptor (HER) family consists of four members: the
epidermal growth factor receptor (EGFR), HER2, HER3, and HER4 (see Nomenclature).
All four members are transmembrane tyrosine kinase receptors, and they regulate a
number of important cellular processes, such as cell growth, survival, and differentiation
(12).
HER2, along with EGFR, are proto-oncogenes. Proto-oncogenes are a group of genes that,
when mutated or expressed at abnormally high levels, can contribute to normal cells
becoming cancerous cells. The mutated version of the proto-oncogene is called an
oncogene. Proto-oncogenes typically encode proteins that stimulate cell division, inhibit
cell differentiation, and halt cell death. All these are important biological processes.
However, the increased production of these proteins, caused by oncogenes, can lead to the
proliferation of poorly differentiated cancer cells (13).
The official gene symbol for HER2 is ERBB2, which is derived from a viral oncogene with
which the receptor shares homology; “v-erb-b2 avian erythroblastic leukemia viral
oncogene homolog 2.” However, clinicians commonly refer to the ERBB2 gene as “HER2”
(Human Epidermal growth factor Receptor 2) or “HER2/neu” (neu was the name given to
the gene that caused cancer derived from a rodent neuro/glioblastoma). HER2 is an
alternate gene symbol for ERBB2 and is more commonly used by the community.
One unique feature of ERBB2 compared to the other receptors in the HER family is the
absence of a known ligand. It is therefore thought that this receptor may permanently be
in an activated state, or it may become activated during heterodimerization with one of
the other members of the HER family (9). And, one unique feature of HER3 is that it has
very little enzymatic activity compared to the other tyrosine kinase receptors in the HER
family. It is therefore thought that an important role of HER3 is to act as a
heterodimerization partner for ERBB2 (14, 15).
When a partner such as HER3 binds to ERBB2, the heterodimer undergoes activation,
which stimulates the intrinsic tyrosine kinase activity of the receptor.
Autophosphorylation of several key residues of the receptor triggers the downstream
activation of many commonly used growth factor signaling pathways, such as the
PI3K/AKT/mTOR pathway and the RAS/RAF/MEK/ERK pathway (16, 17). Impaired
ERBB2 signaling is associated with the development of neurodegenerative diseases, such
as multiple sclerosis and Alzheimer disease, whereas excessive ERBB2 signaling is
associated with the development of cancers.
ERBB2 is overexpressed in approximately 15-20% of breast tumors, as a result of
amplification of the ERBB2 gene, and tumors with increased ERBB2 usually have a higher
growth rate and more aggressive clinical behavior (2, 18-20). Although gene amplification
is frequently seen in cancer and other degenerative disorders, the underlying basis for
amplification remains largely unknown (21). And in the case of ERBB2, although
sequence variants have been identified, it is nearly always the wildtype ERBB2 gene that is
overexpressed in tumors (22). In about 1% of breast cancers, activating mutations in

ERBB2 can be identified that are likely to drive tumorigenesis, without ERBB2
amplification (23).
Tumor Testing for ERBB2 (HER2)

There are two main methods used for HER2 testing: testing for overexpression of the
HER2 protein using immunohistochemistry (IHC), or testing for gene amplification using
in-situ hybridization (ISH). Each assay type has diagnostic pitfalls that must be avoided,
and so the pathologist who reviews the histologic findings should determine the optimal
assay (IHC or ISH) for the determination of HER2 status (2, 20).
In an IHC assay, a slice of tumor tissue is stained, along with a control sample that
contains high levels of HER2. The tumor sample is then examined by light microscopy to
assess the intensity of membrane staining—the amount of staining correlates with the
quantity of HER2 protein and is typically graded from 0 to 3+:
• IHC 0 means no visible staining and is an “HER2 negative” result
• IHC 1+ is also an “HER2 negative” result—there is a staining pattern with weak and
incomplete staining, or weak and complete staining of very few tumor cells
• IHC 2+ is an “HER2 equivocal result”—there is a staining pattern with moderately
intense staining, or intense staining of very few tumor cells
• IHC 3+ is an “HER2 positive result”—there is a staining pattern with intense
membrane staining on more than 10% of tumor cells, indicating a higher than
normal level of HER2
For an equivacol (IHC 2+) result, either a reflex test must be ordered (same specimen
using ISH), or a new test must be ordered (using a new specimen, if available, using IHC
or ISH) to confirm the results.
The ISH assay, or FISH assay (fluorescence in situ hybridization), measures HER2 gene
amplification by measuring HER2 DNA—the actual number of copies of the HER2 genes
are counted. Under the microscope, the genes appear as red signals or dots, in a blue-
stained cancer cell nucleus. The result is usually either FISH negative (normal level of
HER2 gene) or FISH positive (at least twice as much as normal level of HER2 gene), but in
a small number of cases the FISH result will be equivocal due to a low level of HER2
amplification. The use of a control helps distinguish between a negative result and a non-
informative result caused by an error. Approximately 25% of patients who have an IHC 2+
result will have a FISH positive result (24).
For the complete algorithms for evaluation of HER2 protein expression using IHC or
ISH, please see the American Society of Clinical Oncology (ASCO) / College of
American Pathologists (CAP) clinical practice guideline update, located here (2)
Therapeutic Recommendations based on HER2 Testing

Detection of HER2 protein overexpression is necessary for selection of patients
appropriate for trastuzumab therapy because these are the only patients studied and for
whom benefit has been shown. Due to differences in tumor histopathology, use FDA-
approved tests for the specific tumor type (breast or gastric/gastroesophageal
adenocarcinoma) to assess HER2 protein overexpression and HER2 gene amplification.
Tests should be performed by laboratories with demonstrated proficiency in the specific
technology being utilized. Improper assay performance, including use of suboptimally
fixed tissue, failure to utilize specified reagents, deviation from specific assay instructions,
and failure to include appropriate controls for assay validation, can lead to unreliable
results.
Several FDA-approved commercial assays are available to aid in the selection of breast
cancer and metastatic gastric cancer patients for trastuzumab therapy. Users should refer
to the package inserts of specific assay kits for information on the Intended Use, and the
validation and performance of each assay.
Limitations in assay precision make it inadvisable to rely on a single method to rule out
potential Herceptin benefit.
FDA-approved medical devices for HER2 are listed here.
Excerpted recommendations from the American Society of Clinical Oncology /
College of American Pathologists 2013 clinical practice guideline update:
Key Recommendations for Oncologists
• Must request HER2 testing on every primary invasive breast cancer (and on
metastatic site, if stage IV and if specimen available) from a patient with breast
cancer to guide decision to pursue HER2-targeted therapy. This should be especially
considered for a patient who previously tested HER2 negative in a primary tumor
and presents with disease recurrence with clinical behavior suggestive of HER2-
positive or triple-negative disease.
generic drug.
• Should recommend HER2-targeted therapy if HER2 test result is positive, if there is

no apparent histopathologic discordance with HER2 testing and if clinically
appropriate.
• Must delay decision to recommend HER2-targeted therapy if initial HER2 test
result is equivocal. Reflex testing should be performed on the same specimen using
the alternative test if initial HER2 test result is equivocal or on an alternative
specimen.
• Must not recommend HER2-targeted therapy if HER2 test result is negative and if
there is no apparent histopathologic discordance with HER2 testing.
• Should delay decision to recommend HER2-targeted therapy if HER2 status cannot
be confirmed as positive or negative after separate HER2 tests (HER2 test result or
results equivocal). The oncologist should confer with the pathologist regarding the
need for additional HER2 testing on the same or another tumor specimen.
• If the HER2 test result is ultimately deemed to be equivocal, even after reflex testing
with an alternative assay (i.e., if neither test is unequivocally positive), the
oncologist may consider HER2-targeted therapy. The oncologist should also
consider the feasibility of testing another tumor specimen to attempt to definitely
establish the tumor HER2 status and guide therapeutic decisions. A clinical
decision to ultimately consider HER2-targeted therapy in such cases should be
individualized on the basis of patient status (comorbidities, prognosis, and so on)
and patient preferences after discussing available clinical evidence.
Please review the complete therapeutic recommendations, including Key
Recommendations for Pathologists that are located here (2).
Nomenclature
Common gene symbols Alternative gene symbols
EGFR ERBB1
ERBB
HER1
ERBB2 HER2
HER-2
HER-2/neu
NEU
ERBB3 HER3
ERBB4 HER4
Acknowledgments
Clifford Hudis, Chief, Breast Medicine Service, Vice President for Government Relations
and Chief Advocacy Officer at Memorial Sloan Kettering Cancer Center, and Professor of
Medicine, Weill Cornell Medical College
David G. Hicks, Director of Surgical Pathology and Professor of Pathology and

Laboratory Medicine at the University of Rochester Medical Center
Stanley Lipkowitz, Chief of the Women’s Malignancies Branch, National Cancer Institute
Tracy G. Lively, Deputy Associate Director of the Cancer Diagnosis Program, National
Cancer Institute
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3. PERJETA- pertuzumab injection, solution, concentrate [package insert]. Genetech, I.;
setid=17f85d17-ab71-4f5b-9fe3-0b8c822f69ff
4. Gianni L., Pienkowski T., Im Y.H., Roman L., et al. Efficacy and safety of neoadjuvant
pertuzumab and trastuzumab in women with locally advanced, inflammatory, or
early HER2-positive breast cancer (NeoSphere): a randomised multicentre, open-
label, phase 2 trial. Lancet Oncol. 2012;13(1):25–32. PubMed PMID: 22153890.
5. FDA approves Perjeta for neoadjuvant breast cancer treatment: First drug approved
for use in preoperative breast cancer. [Last accessed: July 2015]. Available from:
http://www.fda.gov/NewsEvents/Newsroom/PressAnnouncements/ucm370393.htm
6. Lane H.A., Motoyama A.B., Beuvink I., Hynes N.E. Modulation of p27/Cdk2
complex formation through 4D5-mediated inhibition of HER2 receptor signaling.
Ann Oncol. 2001;12 Suppl 1:S21–2. PubMed PMID: 11521716.
7. Cooley S., Burns L.J., Repka T., Miller J.S. Natural killer cell cytotoxicity of breast
cancer targets is enhanced by two distinct mechanisms of antibody-dependent
cellular cytotoxicity against LFA-3 and HER2/neu. Exp Hematol. 1999;27(10):1533–
41. PubMed PMID: 10517495.
8. Izumi Y., Xu L., di Tomaso E., Fukumura D., et al. Tumour biology: herceptin acts as
an anti-angiogenic cocktail. Nature. 2002;416(6878):279–80. PubMed PMID:
11907566.
9. Valabrega G., Montemurro F., Aglietta M. Trastuzumab: mechanism of action,
resistance and future perspectives in HER2-overexpressing breast cancer. Ann Oncol.
2007;18(6):977–84. PubMed PMID: 17229773.
10. Baselga J., Cortes J., Kim S.B., Im S.A., et al. Pertuzumab plus trastuzumab plus
docetaxel for metastatic breast cancer. N Engl J Med. 2012;366(2):109–19. PubMed
PMID: 22149875.
11. Gajria D., Chandarlapaty S. HER2-amplified breast cancer: mechanisms of

trastuzumab resistance and novel targeted therapies. Expert Rev Anticancer Ther.
2011;11(2):263–75. PubMed PMID: 21342044.
12. Hudis C.A. Trastuzumab--mechanism of action and use in clinical practice. N Engl J
Med. 2007;357(1):39–51. PubMed PMID: 17611206.
14. Cho H.S., Mason K., Ramyar K.X., Stanley A.M., et al. Structure of the extracellular
region of HER2 alone and in complex with the Herceptin Fab. Nature.
2003;421(6924):756–60. PubMed PMID: 12610629.
15. Dr Dang, D.C. The HER2 Pathway in Breast Cancer. 2013 [Last accessed: January 16,
2015]. Available from: http://am.asco.org/her2-pathway-breast-cancer
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dimerization/oligomerization. Oncogene. 2000;19(53):6093–101. PubMed PMID:
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Pertuzumab Therapy and ERBB2 (HER2) Genotype

Pertuzumab Therapy and ERBB2 (HER2) Genotype

ERBB2 gene
387
Vemurafenib Therapy and BRAF and NRAS

Genotype
Laura Dean, MD1
Introduction
Vemurafenib is a kinase inhibitor used in the treatment of patients with unresectable or
metastatic melanoma with the BRAF V600E variant.
BRAF is an intracellular kinase in the mitogen-activated protein kinases (MAPK)
pathway. BRAF is involved in regulating important cell functions such as cell growth,
division, differentiation, and apoptosis. BRAF is also a proto-oncogene—when mutated it
has the ability to transform normal cells into cancerous cells.
Variation in the kinase domain of BRAF have been associated with various cancers. The
most common BRAF variant, V600E, constitutively activates the kinase, and causes cell
proliferation in the absence of growth factors that would normally be required. The
V600E variant is detected in approximately 50% of melanomas (1, 2).
The FDA-approved drug label for vemurafenib states that the presence of BRAF V600E
mutation in tumor specimens should be confirmed, using an FDA-approved test, before
starting treatment with vemurafenib. The label also states that vemurafenib is not
indicated for treatment of patients with wild-type BRAF melanoma (3).
Variations in NRAS, also an oncogene, are found in up to 30% of all malignancies and in
approximately 15-20% of melanomas. NRAS variants activate MAPK and have been
implicated in in acquired resistance to BRAF inhibitors. Vemurafenib’s label warns that
one adverse effect associated with therapy may be the progression of pre-existing chronic
myelomonocytic leukemia with NRAS mutation (3). Other adverse effects include
arthralgia, rash, alopecia, photosensitivity reaction, pruritus, and skin papilloma.
Drug: Vemurafenib
Vemurafenib is a BRAF kinase inhibitor indicated for the treatment of patients with
unresectable or metastatic melanoma with the BRAF V600E variant, as detected by an
FDA-approved test. It was one of the first molecularly targeted agents to receive FDA
approval for advanced melanoma (3). Off-label uses of vemurafenib include the treatment
of other BRAF V600E positive tumors that are not responding to traditional treatments,
e.g., refractory hairy cell leukemia (4).

Skin cancer is the most common of all cancers. Although melanoma is the least common
type of skin cancer, accounting for approximately 1% of cases, it is responsible for the
majority of deaths from skin cancer. In the US, the lifetime risk of melanoma is
approximately 2.5% for whites, 0.5% for Hispanics, and 0.1% for blacks (5).
Most cases of malignant melanoma are diagnosed at an early stage, when the tumor is
localized and surgical excision can be curative. However, the 5-year survival rate drops
from 98% for localized disease, to only 16% for patients with metastatic disease.
For patients with advanced metastatic or unresectable malignant melanoma, treatment
options typically include immunotherapy and targeted therapy. Although chemotherapy
was once widely used, it does not increase survival and therefore its use is now limited to
patients who are not candidates for further treatment with either immunotherapy or
targeted therapy, and for whom there is no appropriate clinical trial.
High-dose interleukin2 (IL2) therapy may be successful in a minority of cases, but can
only be used in select patients with good organ function because of the risk of severe
toxicity. Immunotherapy drugs include antibodies that target programmed cell death
protein 1 (PD1), e.g., nivolumab and pembrolizumab (6); and ipilimumab, a monoclonal
antibody that targets cytotoxic T-lymphocyte-associated protein 4 (CTLA4). Oncolytic
virus therapy with T-VEC (talimogene laherparepvec) is one of the newer
immunotherapy drugs approved for melanoma.
Targeted therapies are designed to inhibit components of the MAPK signaling pathway,
primarily when it is constitutively activated in melanomas with the activating BRAF
mutation, V600E. Drugs in this category include vemurafenib and dabrafenib, which
inhibit BRAF, and trametinib and cobimetinib, which target downstream kinases MEK1
and MEK2, respectively.
Vemurafenib is a potent inhibitor of the kinase domain of the variant BRAF V600E. It acts
by decreasing signaling through the MAPK pathway, leading to the reduced transcription
of genes involved in various cellular responses. Combining vemurafenib with MEK
inhibitors may potentiate these effects and has been shown to extend survival (7, 8).
Both targeted therapy with vemurafenib and immunotherapy regimens (e.g., nivolumab
plus ipilimumab) have been shown to improve overall survival in patients with metastatic
melanoma compared with chemotherapy (9, 10). However, at this time there are no
randomized trials that compare targeted therapy with immunotherapy, and there are little
data regarding the appropriate combinations and sequencing of these therapies for
patients with a BRAF V600E variant.
In the BRIM3 trial, vemurafenib improved overall survival (13.6 versus 9.7 months) and
progression-free survival (6.9 versus 1.6 months) when compared to cytotoxic
chemotherapy (dacarbazine)(11). However, virtually every patient treated with a BRAF
inhibitor eventually demonstrated disease progression (12). Most patients developed
mechanisms of acquired resistance, which is sometimes associated with NRAS variants,
and approximately15% of patients did not achieve tumor regression at all (11, 13-17).
Vemurafenib Therapy and BRAF and NRAS Genotype 389
The most common adverse events associated with vemurafenib are skin lesions (benign
and malignant), fever, arthralgiab, and fatigue. Skin lesions, such as cutaneous squamous
cell carcinoma, tend to occur during the first 8 weeks of treatment. Regular evaluation of
the skin is recommended, with excision of suspicious lesions (18). Liver enzymes
(transaminases, alkaline phosphatase, and bilirubin) should also be monitored because of
the risk of liver injury. Combining BRAF with MEK inhibitors helps reduce the odds of
these side effects.
Approximately 50% of cases of metastatic melanoma are found to have the BRAF V600E
activating variant (1, 2). Because vemurafenib targets the kinase with this variant, patients
without BRAF variants or with a different type of BRAF variant (e.g., V600K) should not
be treated with vemurafenib; they will not benefit from vemurafenib therapy and will be
needlessly exposed to adverse events. In addition, the FDA drug label warns that BRAF
inhibitors have been shown to increase cell proliferation in BRAF wild-type cells in vitro.
Gene: BRAF
RAF is a family of intracellular kinases within the MAPK signaling pathway. The RAF
family has three members, ARAF, BRAF, and CRAF (19). RAF, along with RAS (see
below), are proto-oncogenes.
Proto-oncogenes are genes that, when mutated or expressed at abnormally high levels, can
transform normal cells into cancerous cells. Proto-oncogenes typically encode proteins
that stimulate cell division, inhibit cell differentiation, and halt cell death. The increased
production of oncogenic proteins can lead to the proliferation of poorly differentiated
cancer cells (20).
Germline mutations in BRAF, as well as other components of the MAPK signaling
pathway, are associated with birth defects, such as cardiofaciocutaneous syndrome,
characterized by heart defects, mental retardation, and a distinctive facial dysmorphology.
Somatic BRAF mutations are also associated with several malignancies, including lung
adenocarcinoma, mucinous adenoma, ductal carcinoma of the pancreas, colorectal
carcinoma, and malignant melanoma.
Variations in BRAF are detectable in approximately 50% of malignant melanomas, and
drive progression of the disease (1, 2). The BRAF variant V600E accounts for
approximately 90% of variants. This variant is a substitution of adenine for thymine at
position 1799 and results in the substitution of valine for glutamate at codon 600. The
variant BRAF protein kinase is constitutively active and a highly potent oncogene, with an
increase in kinase activity by as much as 500-fold compared to the wild-type (21). The
second most common BRAF variant is V600K. Substitutions at other sites are rarer (22,
23).
Several drugs are being developed to target BRAF mutations, and so far, two drugs have
been FDA- approved: vemurafenib and dabrafenib. Unfortunately, less progress has been
made in developing targeted therapies for melanoma with wild-type BRAF. There are
fewer treatment options available, but these include immunotherapy and MEK inhibitors
(6, 24).
Gene: NRAS
The RAS family contains three genes, HRAS, NRAS, and KRAS, which are essential
components of a number of signaling pathways. They act as signal transducers, coupling
cell surface receptors to intracellular signaling pathways.
RAS proteins have intrinsic GTPase activity, they are activated by a guanine nucleotide-
exchange factor, and inactivated by a GTPase activating protein. RAS proteins regulate
cell signal transduction by acting as a switch; they cycle between "on" (GTP-bound) or
"off" (GDP-bound) conformations. In the "on" position, RAS proteins transmit
extracellular growth signals to the nucleus, primarily via the MAPK pathway. Cells are
subsequently stimulated to grow, divide, mature, and differentiate.
Variations in RAS genes lead to RAS proteins that are resistant to GTPase, so that GTP-
remains permanently bound and the receptor remains "on" providing a continual growth
stimulus to cells. Such activating RAS variants are common, having been detected in
colorectal cancer, lung cancer, pancreatic cancer, and melanoma.
Variations in NRAS are detectable in 15–30% of melanomas, clustering at codons 12, 13,
and 61 (25, 26). These NRAS variants are the second most common oncogenic “driver”
mutation in malignant melanomas, behind alternations in BRAF (26).
NRAS variants are associated with more aggressive melanomas, and generally a poorer
prognosis (26). Currently, no therapies that specifically target NRAS have been approved.
However, in the near future newer targeted therapies will likely provide effective
treatment options for NRAS-variant melanoma (26, 27). Off-label, MEK inhibitors,
especially in combination with other agents, have exhibited some efficacy in NRAS-
variant melanoma.
NRAS variants are also associated with a number of other conditions, including Noonan
syndrome (type 6), somatic rectal cancer, follicular thyroid cancer, autoimmune
lymphoproliferative syndrome, and juvenile myelomonocytic leukemia.
Genetic Testing
for the genes BRAF and NRAS.
The FDA-approved label for vemurafenib states that the presence of the BRAF V600E
mutation should be confirmed in tumor specimens using an FDA-approved test before
starting treatment with vemurafenib. The label also states that vemurafenib is not
indicated for treatment of patients with wild-type BRAF melanoma.

Vemurafenib is indicated for the treatment of patients with unresectable or metastatic
melanoma with BRAF V600E mutation as detected by an FDA-approved test.
Limitation of Use: Vemurafenib is not indicated for treatment of patients with wild-type
BRAF melanoma.
Patient Selection: Confirm the presence of BRAF V600E mutation in tumor specimens
prior to initiation of treatment with Vemurafenib. Information on FDA-approved tests for
the detection of BRAF V600 mutations in melanoma is available at http://www.fda.gov/
CompanionDiagnostics.
Nomenclature
Selected BRAF variants
allele name names identifier for
Coding Protein
allele location
V600E p.Val600Glu NM_004333.4:c.1799T>A NP_004324.2:p.Val600Glu rs113488022
V600K p.Val600Lys NM_004333.4:c. NP_004324.2:p.Val600Lys rs121913227
1798_1799delGTinsAA
V600R p.Val600Arg NM_004333.4:c. NP_004324.2:p.Val600Arg rs121913227
1798_1799delGTinsAG
V600D p.Val600Asp NM_004333.4:c. NP_004324.2:p.Val600Asp rs121913377
1799_1800delTGinsAT
Selected NRAS variants

name names identifier for allele
Coding Protein
location
NRAS G12V p.Gly12Val NM_002524.4:c. NP_002515.1:p.Gly12Val rs121913237
35G>T
NRAS G13R p.Gly13Arg NM_002524.4:c. NP_002515.1:p.Gly13Arg rs121434595
37G>C

name names identifier for allele
Coding Protein
location
NRAS Q61R p.Gln61Arg NM_002524.4:c. NP_002515.1:p.Gln61Arg rs11554290
182A>G
NRAS Q61K p.Gln61Lys NM_002524.4:c. NP_002515.1:p.Gln61Lys rs121913254
181C>A
Acknowledgments
The author would like thank Paul B. Chapman, MD, Medical Oncologist and Head of the
Melanoma Section Clinical Immunology Service, Memorial Sloan Kettering Cancer
Center, New York; Avadhut Joshi, PhD, Clinical Pharmacogenomics Lead, Translational
Software, Bellevue, Washington; Matthew Hardison, PhD, FACMG, Director of
BioPharma Laboratory, Aegis Sciences Corporation, Nashville, TN; and Pamala A.
Pawloski, PharmD, Research Investigator, HealthPartners Institute, Bloomington, MN; for
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advanced melanoma and its potential in other malignancies. Drugs. 2012;72(17):
2207–22. PubMed PMID: 23116250.
19. Orlandi A., et al. BRAF in metastatic colorectal cancer: the future starts now.
21. Mandal R., Becker S., Strebhardt K. Stamping out RAF and MEK1/2 to inhibit the
ERK1/2 pathway: an emerging threat to anticancer therapy. Oncogene. 2016;35(20):
2547–61. PubMed PMID: 26364606.
22. Puerta-Garcia E., Canadas-Garre M., Calleja-Hernandez M.A. Molecular biomarkers
in colorectal carcinoma. Pharmacogenomics. 2015;16(10):1189–222. PubMed PMID:
26237292.
23. Ekedahl H., et al. The clinical significance of BRAF and NRAS mutations in a clinic-
based metastatic melanoma cohort. Br J Dermatol. 2013;169(5):1049–55. PubMed
PMID: 23855428.
24. Fedorenko I.V., et al. Beyond BRAF: where next for melanoma therapy? Br J Cancer.
2015;112(2):217–26. PubMed PMID: 25180764.
25. Edlundh-Rose E., et al. NRAS and BRAF mutations in melanoma tumours in relation
to clinical characteristics: a study based on mutation screening by pyrosequencing.
Melanoma Res. 2006;16(6):471–8. PubMed PMID: 17119447.
26. Johnson D.B., Puzanov I. Treatment of NRAS-mutant melanoma. Curr Treat Options
Oncol. 2015;16(4):15. PubMed PMID: 25796376.
27. Johnson D.B., et al. Impact of NRAS mutations for patients with advanced melanoma
treated with immune therapies. Cancer Immunol Res. 2015;3(3):288–95. PubMed
PMID: 25736262.

Dabrafenib Therapy and BRAF and G6PD Genotype

Dabrafenib Therapy and BRAF and G6PD Genotype

NRAS gene
BRAF gene
395

Laura Dean, MD1
Created: July 27, 2015.
Introduction
Venlafaxine is an antidepressant used in the treatment of major depressive order, anxiety,
and panic disorders. Venlafaxine belongs to the drug class of serotonin and
norepinephrine reuptake inhibitors (SNRIs) (1).
The CYP2D6 enzyme metabolizes a quarter of all prescribed drugs, including venlafaxine.
This enzyme converts venlafaxine to the active metabolite, O-desmethylvenlafaxine
(ODV). Individuals who carry two inactive copies of CYP2D6 (“poor metabolizers”) may
have decreased capacity to metabolize venlafaxine, resulting in less active metabolites in
their system. In contrast, individuals who carry more than two copies of functional
CYP2D6 alleles (“ultrarapid metabolizers”) may have an enhanced capacity to metabolize
venlafaxine, resulting in more increased active metabolites in their system.
The FDA states that because the total exposure of venlafaxine and ODV is similar in poor
and extensive (normal) metabolizers, there is no need for different venlafaxine dosing
regimens for these individuals (1). However, the Dutch Pharmacogenetics Working Group
recommends that both poor and intermediate metabolizer genotypes should be treated
with an alternative drug, or lower doses of venlafaxine based on clinical response and
drug levels. For ultrarapid metabolizer genotypes, they recommend that either the dose of
venlafaxine be increased up to 150% of the normal dose, or an alternative drug used (see
Table 1 and 2) (2).
Table 1. CYP2D6 phenotypes and therapeutic recommendations for venlafaxine therapy
Phenotype Genotype Recommendations for venlafaxine therapy
Ultrarapid metabolizer More than two copies of Be alert to decreased venlafaxine and increased O-
functional alleles desmethylvenlafaxine plasma concentration. Titrate
dose to a maximum of 150% of the normal dose or
select alternative drug (e.g., citalopram, sertraline).
Intermediate One active allele and one Insufficient data to allow calculation of dose
metabolizer inactive allele, or two adjustment. Select alternative drug (e.g., citalopram,
decreased activity alleles, sertraline) or adjust dose to clinical response and
or one decreased activity monitor O-desmethylvenlafaxine plasma
concentration

Phenotype Genotype Recommendations for venlafaxine therapy

allele and one inactive
allele
Poor metabolizer Two inactive alleles Insufficient data to allow calculation of dose
adjustment. Select alternative drug (e.g., citalopram,
sertraline) or adjust dose to clinical response and
monitor O-desmethylvenlafaxine plasma
concentration.
Allele type Alleles
Active *1, *2, *33, *35
Inactive *3-*8, *11-*16, *19-*21, *38, *40, *42
Drug: Venlafaxine
Venlafaxine is an antidepressant that is used for the treatment of a range of psychiatric
disorders that include major depressive disorder, generalized anxiety disorder (GAD),
social anxiety disorder, and panic disorder (1).
Venlafaxine is thought to exert its antidepressant effect by blocking the transporter
reuptake proteins for key neurotransmitters affecting mood, thereby leaving more active
neurotransmitters in the synapse. This is known as the “potentiation of
neurotransmission.”
Venlafaxine belongs to the drug class of serotonin-norepinephrine reuptake
inhibitors (SNRIs). However, because venlafaxine also weakly inhibits dopamine reuptake,
it is also referred to as a serotonin-norepinephrine-dopamine reuptake inhibitor (SNDRI).
Venlafaxine is metabolized in the liver to its major active metabolite, O-
desmethylvenlafaxine (ODV). Venlafaxine and ODV are both potent inhibitors of
neuronal serotonin and norepinephrine reuptake and weak inhibitors of dopamine
reuptake. The formation of ODV is catalyzed by the enzyme CYP2D6. A high ratio of
venlafaxine to ODV is a marker of low CYP2D6 activity. Other hepatic enzymes
(CYP3A4, CYP2C19, and CYP2C9) metabolize venlafaxine and ODV to minor, less active
metabolites (1).
As for all antidepressants, the FDA-approved drug label for venlafaxine includes a black
box warning about the risk of suicide: “Antidepressants increased the risk compared to
placebo of suicidal thinking and behavior (suicidality) in children, adolescents, and young
adults in short-term studies of Major Depressive Disorder (MDD) and other psychiatric
Venlafaxine Therapy and CYP2D6 Genotype 397
disorders. Anyone considering the use of venlafaxine or any other antidepressant in a

child, adolescent, or young adult must balance this risk with the clinical need.” (1)
The toxicity of venlafaxine appears to be higher than for other drugs of the same class.
Adverse events include an increase in anxiety, insomnia, and nervousness; the
precipitation of mania or hypomania in patients with bipolar disorder; weight loss,
reduced appetite, hyponatremia, seizures, cardiac conduction abnormalities, and an
increased risk of bleeding events. There is also a risk of discontinuation syndrome, which
may occur if therapy is stopped abruptly (a gradual reduction in the dose of venlafaxine is
recommended whenever possible) (1, 3).
Gene: CYP2D6
activity.
“extensive metabolizer” phenotype. The CYP2D6 *2, *33, and *35 alleles are also
considered to have near-normal activity. Other alleles include variants that produce a
non-functioning enzyme (e.g., *3, *4, *5, and *6) (5-8) or an enzyme with reduced activity
(e.g., *10, *17, and *41) (9-11) (see Table 2). There are large inter-ethnic differences in the
frequency of these alleles, with *3, *4, *5, *6, and *41 being more common in Caucasians,
*17 more common in Africans, and *10 more common in Asians (12).
Individuals who are intermediate or poor metabolizers carry copies of decreased-function
and inactive CYP2D6 alleles (see Table 1 and 2). In these individuals, the metabolic
capacity of CYP2D6 is decreased, which may result in higher levels of venlafaxine and
lower levels of ODV.
The FDA-approved drug label for venlafaxine states that although poor metabolizers have
increased levels of venlafaxine and decreased levels of ODV compared to individuals with
normal CYP2D6 activity, the differences between poor and extensive (normal)
metabolizers are not thought to be clinically important because “the sum of venlafaxine
and ODV is similar in the two groups and venlafaxine and ODV are pharmacologically
approximately equiactive and equipotent.” (1) However, the results of some reported
studies suggest that side effects are more common in poor metabolizers, and that CYP2D6
genotyping prior to the initiation of venlafaxine may prevent potential side effects (13,
14). Some of the adverse effects of venlafaxine therapy that have been reported to occur
more frequently in poor metabolizers include gastrointestinal side effects, such as
vomiting and diarrhea; and cardiovascular side effects, such as hypertension, tachycardia,
and prolonged QTc interval (14, 15).
The Dutch Pharmacogenetics Working Group recommendations state that for poor and
intermediate metabolizers, there is insufficient data to calculate the dose adjustment for
venlafaxine, and an alternative drug should be used (e.g., citalopram, sertraline). Or, the
dose of venlafaxine should be adjusted according to the clinical response, and ODV
plasma levels should be monitored (2).
Poor metabolizers are commonly found in European Caucasians. The functional
CYP2D6*1 allele is the most common (~70%), and the most common nonfunctional
alleles include CYP2D6*4 and *5, which largely account for the poor metabolizer
phenotype in these populations (16, 17).
In individuals of Asian descent, only about 50% of CYPD6 alleles are functional, with the
reduced function CYP2D6*10 variant being very common (~40%). As a result, Asians are
more likely to be intermediate metabolizers than Caucasians (12). Similarly, in Africans
and African Americans, only 50% of CYPD6 alleles are functional; however, a wider range
of variants account for the remaining alleles (18, 19).
Individuals who have multiple functional copies of the CYP2D6 gene are “ultrarapid
metabolizers” (UM). Each allele contributes to the metabolism of venlafaxine to the active
metabolite, ODV. Data suggest that the ultrarapid metabolizer phenotype does not have a
significant effect on treatment with venlafaxine (efficacy or side effects) but as a
precaution, drug levels should be monitored and an increased dose of venlafaxine may be
required (13, 14, 20). The Dutch Pharmacogenetics Working Group recommendations
state that for ultrarapid metabolizers, there is a need to be alert to decreased venlafaxine
and increased ODV concentrations. The dose of venlafaxine should be titrated to a
maximum of 150% of the normal dose, or an alternative drug (e.g., citalopram, sertraline)
should be considered (2), in patients with normal renal clearance (21).
The ultrarapid metabolizer phenotype is estimated to be present in up to 28% of North
Africans, Ethiopians, and Arabs; ~10% in Caucasians; 3% in African Americans, and up
to 1% in Hispanics, Chinese, and Japanese (22).
Genetic Testing
Genetic testing is available for many of the more common variant CYP2D6 alleles. Results
are typically reported as a diplotype, such as CYP2D6 *1/*1 (23). A result for copy
number, if available, is also important when interpreting CYP2D6 results.


Statement from the US Food and Drug Administration (FDA): Plasma concentrations
of venlafaxine were higher in CYP2D6 poor metabolizers than extensive metabolizers.
Because the total exposure (AUC) of venlafaxine and ODV was similar in poor and
extensive metabolizer groups, however, there is no need for different venlafaxine dosing
regimens for these two groups.
Royal Dutch Association for the Advancement of Pharmacy (KNMP): For individuals
who are poor or intermediate metabolizers, there are insufficient data to calculate a dose
adjustment for venlafaxine. Select an alternative drug (e.g., citalopram, sertraline), or
adjust the dose of venlafaxine based on the clinical response, and monitor (O-
desmethyl)venlafaxine plasma concentration. For individuals who are ultrarapid
metabolizers, physicians should be alert to decreased venlafaxine and increased (O-
desmethyl)venlafaxine plasma concentration. The dose of venlafaxine should be titrated
up to a maximum of 150% of the normal dose or an alternative drug used (e.g.,
citalopram, sertraline).
Nomenclature
Coding Protein
identifier for
allele location
generic drug.

Coding Protein
identifier for
allele location
Trp152Gly 454delT
Pro34Ser 100C>T
1023C>T 886T>C
(Thr107Ile)
2850C>T
(Cys296Arg)
985+39G> in a non-coding region
Acknowledgments
Sciences, Icahn School of Medicine at Mount Sinai; and Bruce G. Pollock, Vice President
of Research and Director of the Campbell Family Mental Health Research Institute,
CAMH and Professor of Psychiatry & Pharmacology at the University of Toronto; for
References
1. VENLAFAXINE HYDROCHLORIDE tablet Morgantown, WV: Mylan
Pharmaceuticals Inc.; 2012. Available from: http://dailymed.nlm.nih.gov/dailymed/
lookup.cfm?setid=2c3f8268-ef43-d58c-7da6-dd44f8feb3be
662–73. PubMed PMID: 21412232.
Venlafaxine [Cited 2015 April 30]. Available from: http://www.pharmgkb.org/drug/
PA451866
4. CYP2D6 allele nomenclature. 2014 30 April 2015]; Available from: http://

www.cypalleles.ki.se/cyp2d6.htm
[Cited 2015 April 30]. Available from: http://www.pharmgkb.org/haplotype/
PA165816578
PA165816579
PA165948092
PA165816581
PA165816582
PA165816583
PA165816584
11972444.
13. Waade R.B., Hermann M., Moe H.L., Molden E. Impact of age on serum
concentrations of venlafaxine and escitalopram in different CYP2D6 and CYP2C19
genotype subgroups. Eur J Clin Pharmacol. 2014;70(8):933–40. PubMed PMID:
24858822.
14. Shams M.E., Arneth B., Hiemke C., Dragicevic A., et al. CYP2D6 polymorphism and
clinical effect of the antidepressant venlafaxine. Journal of clinical pharmacy and
15. Johnson E.M., Whyte E., Mulsant B.H., Pollock B.G., et al. Cardiovascular changes
associated with venlafaxine in the treatment of late-life depression. Am J Geriatr
496–526. PubMed PMID: 18001838.

17301689.
8287064.
20. Veefkind A.H., Haffmans P.M., Hoencamp E. Venlafaxine serum levels and CYP2D6
genotype. Therapeutic drug monitoring. 2000;22(2):202–8. PubMed PMID:
10774634.
21. Whyte E.M., Romkes M., Mulsant B.H., Kirshne M.A., et al. CYP2D6 genotype and
venlafaxine-XR concentrations in depressed elderly. Int J Geriatr Psychiatry.
2006;21(6):542–9. PubMed PMID: 16642541.


Venlafaxine response

CYP2D6 gene
405
Warfarin Therapy and the Genotypes CYP2C9

and VKORC1
Laura Dean, MD1
Created: March 8, 2012; Updated: June 8, 2016.
Introduction
Warfarin is an anticoagulant that acts by reducing the activity of vitamin K-dependent
clotting factors. It is used in the prevention and treatment of thrombotic disorders. The
dose of warfarin must be tailored for each patient according to the patient’s INR response
and the condition being treated.
A patient’s CYP2C9 and VKORC1 genotype can be used to help determine the optimal
starting dose of warfarin. The CYP2C9 gene encodes one of the main enzymes involved in
the metabolism of warfarin. Several variant CYP2C9 alleles are associated with reduced
enzyme activity and lower clearance rates of warfarin. Patients who carry at least one copy
of such a variant allele (such as CYP2C9*2 and CYP2C9*3) have reduced metabolism
leading to higher warfarin concentrations. On average, they require a lower daily warfarin
dose than patients who are homozygous for the wild-type CYP2C9*1 allele.
The VKORC1 gene encodes the vitamin K epoxide reductase enzyme, the target of
warfarin. Patients who carry the -1639G>A polymorphism in the promoter region of the
VKORC1 gene are more sensitive to warfarin and require lower doses.
The FDA-approved warfarin drug label provides a dosing table based on CYP2C9 and
VKORC1 genotypes (Table 1). The label states if the patient’s CYP2C9 and/or VKORC1
genotype are known, to consider these ranges in choosing the initial doses, but whether
this strategy reduces warfarin-related adverse events is controversial. The label also states
that patients with CYP2C9 *1/*3, *2/*2, *2/*3, and *3/*3 may require more time (longer
than 2 to 4 weeks) to achieve maximum INR effect for a given dosage regimen than
patients without these CYP variants (1).
However, the Clinical Pharmacogenetics Implementation Consortium (CPIC)
recommends that this dosing table should only be used when electronic access is not
possible. Instead, CPIC recommends that whenever possible, the pharmacogenetic
algorithms available on http://www.warfarindosing.org should be used to predict the
optimal warfarin dose (2). Although one randomized trial found that genotype-guided
dosing might improve INR control after warfarin initiation (3), the largest completed trial
found no benefit. (4). The largest trial of pharmacogenetic dosing of warfarin

(ClinicalTrials.gov Identifier: NCT01006733) is expected to have results in December

2016.
Table 1. Three Ranges of Expected Maintenance Warfarin Doses based on CYP2C9 and VKORC1
Genotypes, adapted from the FDA drug label.
VKORC1 CYP2C9
*1/*1 *1/*2 *1/*3 *2/*2 *2/*3 *3/*3
GG 5-7 mg 5-7 mg 3-4 mg 3-4 mg 3-4 mg 0.5-2 mg
AG 5-7 mg 3-4 mg 3-4 mg 3-4 mg 0.5-2 mg 0.5-2 mg
AA 3-4 mg 3-4 mg 0.5-2 mg 0.5-2 mg 0.5-2 mg 0.5-2 mg
Ranges are derived from multiple published clinical studies. VKORC1 –1639G>A (rs9923231) variant is
used in this table. Other co-inherited VKORC1 variants may also be important determinants of warfarin
dose. This table is adapted from the FDA-approved drug label for Coumadin (warfarin) (1).
Drug: Warfarin
Warfarin is an anticoagulant used in the prevention and treatment of venous thrombosis,
pulmonary embolism, and the complications associated with atrial fibrillation and/or
cardiac valve replacement. Warfarin is sometimes prescribed to reduce the risk of stroke
after a myocardial infarction (MI).
Warfarin has no direct effect on an established thrombus. However, once a thrombus has
occurred (e.g., deep venous thrombosis), the goal of warfarin therapy is to prevent further
extension of the formed clot and to prevent secondary thromboembolic complications
that may be fatal (e.g., pulmonary embolism).
Warfarin exerts its anticoagulant effect by inhibiting the enzyme encoded by VKORC1,
which catalyzes the conversion of vitamin K epoxide to the active reduced form of
vitamin K, vitamin K hydroquinone. Vitamin K hydroquinone is an essential cofactor in
the synthesis of several clotting factors—it promotes the synthesis of γ-carboxyglutamic
acid residues in the proteins essential for biological activity. The decreased availability of
vitamin K hydroquinone leads to decreased activity of the clotting factors II, VII, IX, and
X, and the anticoagulant proteins C and S (5).
Warfarin is administered as a racemic mixture of the R and S stereoisomers. (S)-warfarin
is two to five times more potent than (R)-warfarin, and is mainly metabolized by
CYP2C9. (R)-warfarin is mainly metabolized via CYP3A4, with involvement of several
other cytochrome P450 enzymes (6).
The initial and maintenance dosing of warfarin must be individualized for each patient.
The goal of warfarin therapy is to achieve an international normalized ratio (INR) in a
target range for the condition being treated (most commonly 2-3). This involves selecting
an initial starting dose, followed by regular testing of the INR so that the dose of warfarin
can be adjusted until the appropriate daily maintenance dose is determined. In general,
Warfarin Therapy and the Genotypes CYP2C9 and VKORC1 407
the duration of anticoagulant therapy varies by clinical indication and should be

continued until the danger of thrombosis and embolism has passed.
Selecting the initial dose of warfarin should be based on the expected maintenance dose,
having taken into account the factors known to influence warfarin dose. Using an optimal
starting dose for an individual may reduce the time taken to reach a stable INR, and
reduce the risk of having either a high INR (with a risk of bleeding) or a low INR (with a
risk of thrombosis) (2). Appropriate dosing of warfarin varies widely between individuals,
and not all factors responsible for the variability in warfarin dose are known or easily
quantified.
Known factors that influence an individual’s response to the first dose of warfarin include
clinical factors (e.g., age, race, body weight, sex, concomitant medications—including
those that compete for binding to albumin, comorbidities, diet, nutritional status) and
genetic factors (e.g., CYP2C9 and VKORC1 genotypes). Therefore, the initial dose should
be modified to take into account these and any additional patient-specific factors that may
influence warfarin response.
The FDA-approved drug label for warfarin suggests considering a lower initial and
maintenance dose of warfarin for elderly and/or debilitated patients, and in Asian
patients. The drug label recommends against the routine use of loading doses because this
practice may increase hemorrhagic and other complications and does not offer more
rapid protection against clot formation.
Warfarin can cause major or fatal bleeding. Bleeding is more likely to occur within the
first month, and the risk factors include a high intensity of anticoagulation (INR greater
than 4), age greater than or equal to 65, and a history of highly variable INRs. Other
serious adverse events associated with warfarin therapy include necrosis of the skin and
other tissues, particularly when used prematurely to manage thrombosis associated with
heparin-induced thrombocytopenia (HIT).
Gene: CYP2C9
enzyme activity.
CYP450 isozymes involved in the metabolism of warfarin include CYP2C9 and CYP3A4.
The more potent warfarin S-enantiomer is metabolized by CYP2C9 while the R-
enantiomer is metabolized by CYP1A2 and CYP3A4. The FDA-drug label for warfarin
states that drugs that inhibit or induce CYP2C9, CYP1A2, and/or CYP3A4 have the
potential to alter the effect (INR) of warfarin by altering the exposure of warfarin.
CYP2C9*1 is the wild-type allele and is associated with normal enzyme activity and the
normal metabolizer phenotype.
Two common allelic variants associated with reduced enzyme activity are CYP2C9*2
(Arg144Cys) and CYP2C9*3 (Ile359Leu). Compared to normal metabolizers, patients
who inherit one or two copies of *2 or *3 are more sensitive to warfarin—they require
lower doses and are at a greater risk of bleeding during warfarin initiation (7-10).
The frequencies of the CYP2C9 alleles vary between different ethnic groups (11-13). The
*2 allele is more common in Caucasian (10-20%) than Asian (1-3%) or African (0-6%)
populations (14). The *3 allele is less common (<10% in most populations) and extremely
rare in African populations (15). In African Americans, it is likely that other CYP2C9
variants such as CYP2C9*5, *6, *8, and *11 contribute to the variability in patient response
to warfarin (2).
Gene: VKORC1
The VKORC1 gene encodes the vitamin K epoxide reductase enzyme. It catalyzes the rate-
limiting step in vitamin K recycling, and it is the target of the drug warfarin.
A common non-coding variant, -1639G>A, is associated with an increased sensitivity to
warfarin (16). The polymorphism occurs in the promoter region of VKORC1 and is
thought to alter a transcription factor binding site, leading to lower protein expression. As
a result, patients starting warfarin therapy who are −1639A carriers require lower initial
and maintenance doses of the drug than −1639G carriers.
The −1639G>A allele frequency varies among different ethnic groups. It is the major allele
(around 90%) in Asian populations, and may be a contributing factor for lower warfarin
dosing requirements often observed in patients of Asian descent. It is also common in
Caucasians (around 40%) and African Americans (around 14%) (17-19).
Less commonly, missense mutations in VKORC1 can lead to warfarin resistance (20, 21).
Genetic Testing
VKORC1 and CYP2C9 genotypes are the most important genetic determinants
of warfarin dosing. The contribution of VKORC1 to the variation in dose requirement is
larger (approximately 30%) than the contribution of CYP2C9 (usually less than 10%) (22).
Individuals who are most likely to benefit from genetic testing are those who have yet to
start warfarin therapy. However, genotype-guided warfarin dosing is not the standard of
care in most healthcare systems, and most (but not all) recent studies have reported that,
in general, the use of genotype-guided dosing algorithms did not improve anticoagulation
control in the first few weeks of warfarin therapy (4, 23-27).
Genetic testing is available for CYP2C9 and VKORC1. The variants that are routinely
tested for are CYP2C9*2, CYP2C9*3, and −1639G>A. These variants are used in the FDA
table to guide therapy, and also in the International Warfarin Pharmacogenomics
Consortium (IWPC) algorithm.
Other variants that are not routinely tested for include the CYP2C9*6 and *8, alleles, the
genes CYP4F2, EPHX1, and GGX (which all have a role in the vitamin-K cycle), and the
gene CALU (a cofactor in the VKOR complex) (2, 28). Including these additional
genotypes in an expanded dosing algorithm improves warfarin dose prediction in
African-Americans, while maintaining high performance in European-Americans (29).

Dosing Recommendations without Consideration of Genotype
If the patient’s CYP2C9 and VKORC1 genotypes are not known, the initial dose of
warfarin is usually 2 to 5 mg once daily. Determine each patient’s dosing needs by close
monitoring of the INR response and consideration of the indication being treated. Typical
maintenance doses are 2 to 10 mg once daily.
Dosing Recommendations with Consideration of Genotype
Table 1 displays three ranges of expected maintenance COUMADIN doses observed in
subgroups of patients having different combinations of CYP2C9 and VKORC1 gene
variants […]. If the patient’s CYP2C9 and/or VKORC1 genotype are known, consider
these ranges in choosing the initial dose. Patients with CYP2C9 *1/*3, *2/*2, *2/*3, and
*3/*3 may require more prolonged time (>2 to 4 weeks) to achieve maximum INR effect
for a given dosage regimen than patients without these CYP variants.
(CPIC): The pharmacogenetic algorithms available on http://www.warfarindosing.org
should be used whenever possible to determine the dose of warfarin required. Such
algorithms have been derived from large studies across different ethnic populations, and
they take into account both the genetic and non-genetic factors that influence the
variability in warfarin response. The existence of rare genetic variants may be responsible
for individuals whose warfarin dosing is not well predicted. However, overall the dosing
equations are well validated and fairly precise. Only if electronic access to a
pharmacogenetic algorithm is not possible should the table-based dosing approach be
used, which is preferable to a fixed-dose approach.
generic drug.
Please review the complete therapeutic recommendations that are located here: (2,
30).
Table 2. Recommended daily warfarin doses (mg/day) to achieve a therapeutic INR based on CYP2C9 and
VKORC1 genotype using the warfarin product insert approved by the US Food and Drug Administration
VKORC1: CYP2C9*1/*1 CYP2C9*1/*2 CYP2C9*1/*3 CYP2C9*2/*2 CYP2C9*2/*3 CYP2C9*3/*3
–1639G>A
GG 5-7 5-7 3-4 3-4 3-4 0.5-2
GA 5-7 3-4 3-4 3-4 0.5-2 0.5-2
AA 3-4 3-4 0.5-2 0.5-2 0.5-2 0.5-2
Table is adapted from Johnson JA, Gong L, Whirl-Carrillo M, Gage BF, Scott SA, Stein CM, Anderson JL,
Kimmel SE, Lee MT, Pirmohamed M, Wadelius M, Klein TE, Altman RB; Clinical Pharmacogenetics
Implementation Consortium Guidelines for CYP2C9 and VKORC1 genotypes and warfarin dosing. Clinical
pharmacology and therapeutics. 2011;90(4):625–9 (2).
Nomenclature
Coding Protein
identifier for
allele location
CYP2C9*2 430C>T NM_000771.3:c.430C>T NP_000762.2:p.Arg144Cys rs1799853
Arg144Cys
CYP2C9*3 1075A>C NM_000771.3:c.1075A>C NP_000762.2:p.Ile359Leu rs1057910
Ile359Leu
VKORC1: -1639G>A NM_024006.4:c.-1639G>A Not applicable - variant occurs rs9923231
-1639G>A in a non-coding region
Acknowledgments
The author would like to thank Brian F. Gage, MD, MSC, Professor of Medicine,
Washington University, St. Louis; and Sol Schulman, MD, Clinical Fellow in Medicine,
Division of Hemostasis and Thrombosis, Department of Medicine, Beth Israel Deaconess
Medical Center, Harvard Medical School, Boston; for reviewing this summary.
First edition:

page/cpic
References
1. COUMADIN- warfarin sodium tablet) [package insert]. Princeton, NJ: Bristol-Myers
Squibb Pharma Company; 2015. Available from: http://dailymed.nlm.nih.gov/
dailymed/drugInfo.cfm?setid=d91934a0-902e-c26c-23ca-d5accc4151b6
2. Johnson J.A., Gong L., Whirl-Carrillo M., Gage B.F., et al. Clinical Pharmacogenetics
Implementation Consortium Guidelines for CYP2C9 and VKORC1 genotypes and
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3. Pirmohamed M., Burnside G., Eriksson N., Jorgensen A.L., et al. A randomized trial
of genotype-guided dosing of warfarin. N Engl J Med. 2013;369(24):2294–303.
4. Furie B. Do pharmacogenetics have a role in the dosing of vitamin K antagonists? N
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between CYP2C9 genetic variants and anticoagulation-related outcomes during
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8. Aithal G.P., Day C.P., Kesteven P.J., Daly A.K. Association of polymorphisms in the
cytochrome P450 CYP2C9 with warfarin dose requirement and risk of bleeding
complications. Lancet. 1999;353(9154):717–9. PubMed PMID: 10073515.
9. Limdi N.A., McGwin G., Goldstein J.A., Beasley T.M., et al. Influence of CYP2C9 and
VKORC1 1173C/T genotype on the risk of hemorrhagic complications in African-
American and European-American patients on warfarin. Clinical pharmacology and
10. Lindh J.D., Holm L., Andersson M.L., Rane A. Influence of CYP2C9 genotype on
warfarin dose requirements--a systematic review and meta-analysis. European
journal of clinical pharmacology. 2009;65(4):365–75. PubMed PMID: 19031075.
2004;5(7):895–931. PubMed PMID: 15469410.
2002;12(3):251–63. PubMed PMID: 11927841.
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[Cited 2012 Feb 22]. Available from: http://www.pharmgkb.org/haplotype/
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[Cited 2012 Feb 22]. Available from: http://www.pharmgkb.org/haplotype/
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[Cited 2012 Feb 24]. Available from: http://www.pharmgkb.org/rsid/rs9923231 -
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17. Geisen C., Watzka M., Sittinger K., Steffens M., et al. VKORC1 haplotypes and their
impact on the inter-individual and inter-ethnical variability of oral anticoagulation.
Thrombosis and haemostasis. 2005;94(4):773–9. PubMed PMID: 16270629.
18. Obayashi K., Nakamura K., Kawana J., Ogata H., et al. VKORC1 gene variations are
the major contributors of variation in warfarin dose in Japanese patients. Clinical
19. Ross K.A., Bigham A.W., Edwards M., Gozdzik A., et al. Worldwide allele frequency
distribution of four polymorphisms associated with warfarin dose requirements.
Journal of human genetics. 2010;55(9):582–9. PubMed PMID: 20555338.
20. Loebstein R., Dvoskin I., Halkin H., Vecsler M., et al. A coding VKORC1 Asp36Tyr
polymorphism predisposes to warfarin resistance. Blood. 2007;109(6):2477–80.
21. Rost S., Fregin A., Ivaskevicius V., Conzelmann E., et al. Mutations in VKORC1 cause
warfarin resistance and multiple coagulation factor deficiency type 2. Nature.
2004;427(6974):537–41. PubMed PMID: 14765194.
22. Verhoef T.I., Redekop W.K., Daly A.K., van Schie R.M., et al. Pharmacogenetic-
guided dosing of coumarin anticoagulants: algorithms for warfarin, acenocoumarol
and phenprocoumon. Br J Clin Pharmacol. 2014;77(4):626–41. PubMed PMID:
23919835.
23. Verhoef T.I., Ragia G., de Boer A., Barallon R., et al. A randomized trial of genotype-
guided dosing of acenocoumarol and phenprocoumon. N Engl J Med. 2013;369(24):
2304–12. PubMed PMID: 24251360.
24. Stergiopoulos K., Brown D.L. Genotype-guided vs clinical dosing of warfarin and its
analogues: meta-analysis of randomized clinical trials. JAMA Intern Med.
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Warfarin response

CYP2C9 gene
VKORC1 gene
415
Genetic variants and

disease
417
ABO Blood Group

Laura Dean, MD1
Created: October 1, 2012; Updated: July 27, 2015.
Characteristics
There are four common blood groups in the ABO system: O, A, B, and AB. The blood
groups are defined by the presence of specific carbohydrate sugars on the surface of red
blood cells, N-acetylgalactosamine for the A antigen, and D-galactose for the B antigen.
Both of these sugars are built upon the H antigen—if the H antigen is left unmodified, the
resulting blood group is O because neither the A nor the B antigen can attach to the red
blood cells.
Individuals will naturally develop antibodies against the ABO antigens they do not have.
For example, individuals with blood group A will have anti-B antibodies, and individuals
with blood group O will have both anti-A and anti-B. Before a blood transfusion takes
place, routine serological testing checks the compatibility of the ABO (and Rh) blood
groups. An ABO incompatible blood transfusion can be fatal, due to the highly
immunogenic nature of the A and B antigens, and the corresponding strongly hemolytic
antibodies (1).
Compared to other blood groups, individuals with blood group O may have a lower risk
of pancreatic cancer and thromboembolic disease (2, 3). In addition, in certain African
populations, individuals with the blood group O may be protected from life-threatening
malaria (4). However, this blood group is not more common in some regions where
malaria is endemic. This might be because individuals with blood group O are at higher
risk of cholera and severe diarrhea due to Vibrio cholerae 01, with individuals with the AB
blood group being the most protected (5, 6).
Over 80 ABO alleles have been reported. The common alleles include A1, A2, B1, O1, O1v,
and O2 (7). Whereas the A and B alleles each encode a specific glycosyl-transferring
enzyme, the O allele appears to have no function. A single-base deletion in the O allele
means that individuals with blood group O do not produce either the A or B antigens.
Blood type frequencies vary in different racial/ethnic groups. In the US, in Caucasians,
the ratio of blood group O, A, B, and AB is 45%, 40%, 11%, and 4% respectively. In
Hispanics, the distribution is 57%, 31%, 10%, and 3%; and in Blacks, 50%, 26%, 20%, and
4% (8).

Diagnosis/testing
Serological testing is sufficient to determine an individual’s blood type (e.g., blood group
A) for the purposes of blood donation and transfusion. Molecular genetic testing can be
used to determine an individual’s ABO genotype (e.g., genotype AO or AA). This may be
useful in the research setting, for example, to investigate the link between ABO blood
groups and particular diseases, and also in the forensic setting (9).
Management
Determining an individual’s blood group is important prior to blood transfusion and
prior to the donation or receiving of a kidney transplant.
Occasionally, a person’s blood type may appear to change. For example, the ABO antigens
can act as tumor markers. Their presence may be decreased in particular diseases, such as
acute myeloid leukemia, AML (10). In contrast, occasionally the B antigen may be
acquired in certain infectious diseases. A bacterial infection with specific strains of E. coli
or Clostridium tertium can generate a B-like antigen from an individual who has the A1
allele (11).
Genetic counseling
The ABO blood type is inherited in an autosomal codominant fashion. The A and B alleles
are codominant, and the O allele is recessive.
Acknowledgments
The author would like to thank Michael Murphy, Professor of Blood Transfusion
Medicine, University of Oxford, and Consultant Haematologist, NHS Blood & Transplant
and Oxford University Hospitals, Oxford, UK, for reviewing this summary.
References
1. Food and Drug Administration. Rockville (MD) Transfusion/Donation Fatalities:
Notification Process for Transfusion Related Fatalities and Donation Related Deaths.
[cited 2012 Sep 26]. Available from: http://www.fda.gov/biologicsbloodvaccines/
safetyavailability/reportaproblem/transfusiondonationfatalities/default.htm
2. Amundadottir L., Kraft P., Stolzenberg-Solomon R.Z., Fuchs C.S., et al. Genome-wide
association study identifies variants in the ABO locus associated with susceptibility to
pancreatic cancer. Nature genetics. 2009;41(9):986–90. PubMed PMID: 19648918.
3. Tregouet D.A., Heath S., Saut N., Biron-Andreani C., et al. Common susceptibility
alleles are unlikely to contribute as strongly as the FV and ABO loci to VTE risk:
results from a GWAS approach. Blood. 2009;113(21):5298–303. PubMed PMID:
19278955.
ABO Blood Group 419
4. Fry A.E., Griffiths M.J., Auburn S., Diakite M., et al. Common variation in the ABO
glycosyltransferase is associated with susceptibility to severe Plasmodium falciparum
malaria. Human molecular genetics. 2008;17(4):567–76. PubMed PMID: 18003641.
5. Faruque A.S., Mahalanabis D., Hoque S.S., Albert M.J. The relationship between ABO
blood groups and susceptibility to diarrhea due to Vibrio cholerae 0139. Clinical
infectious diseases. 1994;18(5):827–8. PubMed PMID: 8075282.
6. Rowe J.A., Handel I.G., Thera M.A., Deans A.M., et al. Blood group O protects
against severe Plasmodium falciparum malaria through the mechanism of reduced
rosetting. Proceedings of the National Academy of Sciences of the United States of
America. 2007;104(44):17471–6. PubMed PMID: 17959777.
7. Seltsam A., Hallensleben M., Kollmann A., Blasczyk R. The nature of diversity and
diversification at the ABO locus. Blood. 2003;102(8):3035–42. PubMed PMID:
12829588.
8. Garratty G., Glynn S.A., McEntire R. ABO and Rh(D) phenotype frequencies of
different racial/ethnic groups in the United States. Transfusion. 2004;44(5):703–6.
9. Johnson P.H., Hopkinson D.A. Detection of ABO blood group polymorphism by
denaturing gradient gel electrophoresis. Human molecular genetics. 1992;1(5):341–4.
10. Bianco-Miotto T., Hussey D.J., Day T.K., O'Keefe D.S., Dobrovic A. DNA methylation
of the ABO promoter underlies loss of ABO allelic expression in a significant
proportion of leukemic patients. PloS one. 2009;4(3):e4788. PubMed PMID:
19274076.
11. Roath S., Todd C.E., Shaw D. Transient acquired blood group B antigen associated
with diverticular bowel disease. Acta haematologica. 1987;77(3):188–90. PubMed
PMID: 3113163.
421
ACHOO Syndrome
Laura Dean, MD1
Created: October 15, 2012; Updated: July 27, 2015.
Characteristics
Autosomal Dominant Compelling Helioopthalmic Outburst (ACHOO) Syndrome is
characterized by uncontrollable sneezing in response to the sudden exposure to bright
light, typically intense sunlight (1). This type of sneezing is also known as photic sneezing.
About one in four individuals who already have a prickling sensation in their nose will
sneeze in response to sunlight, but “pure” photic sneezing is far less common (2).
Sneezing is usually triggered by contact with infectious agents or after inhaling irritants,
but the cause of photic sneezing is not fully understood. It may involve an over-
excitability of the visual cortex in response to light, leading to a stronger activation of the
secondary somatosensory areas (3).
Diagnosis/testing
The diagnosis of ACHOO syndrome is usually made by clinical history. Affected
individuals report a “prickling sensation” or sneezing in response to a bright light. This
response may be reproduced in the clinical setting by asking the individual to look at a
bright light, although findings are unreliable.
The genetic basis of this syndrome is not yet known.
Management
Recommendations for management of ACHOO syndrome include using a hat or
sunglasses to shield the eyes from direct sunlight whenever possible. Potential hazards
include the possibility of drivers having an accident caused by sneezing brought on by, for
example, exiting a road tunnel on a bright day. Similarly, airline pilots may be at risk (4).
Genetic counseling
ACHOO syndrome is inherited in an autosomal dominant manner (1). As such, if one
parent is affected, their child has a 50% chance of inheriting the syndrome.

Acknowledgments
The author would like to thank Nicolas Langer, Endeavor Scientist at the Child Mind
Institute, New York, for reviewing this summary.
References
1. Forrester J.M. Sneezing on exposure to bright light as an inherited response. Human
heredity. 1985;35(2):113–4. PubMed PMID: 3988295.
2. Breitenbach R.A., Swisher P.K., Kim M.K., Patel B.S. The photic sneeze reflex as a risk
factor to combat pilots. Military medicine. 1993;158(12):806–9. PubMed PMID:
8108024.
3. Langer N., Beeli G., Jancke L. When the sun prickles your nose: an EEG study
identifying neural bases of photic sneezing. PloS one. 2010;5(2):e9208. PubMed
PMID: 20169159.
4. Benbow E.W. Practical hazards of photic sneezing. The British journal of
ophthalmology. 1991;75(7):447. PubMed PMID: 1854707.
423
McCune-Albright Syndrome
Laura Dean, MD1
Created: March 8, 2012; Updated: March 6, 2017.
Characteristics
McCune-Albright Syndrome (MAS) is a rare genetic disorder originally characterized as
the triad of polyostotic fibrous dysplasia of bone, precocious puberty, and café-au-lait skin
pigmentation (1-3). With time other associated endocrinopathies have been recognized,
including hyperthyroidism, growth hormone excess, FGF23-mediated phosphate wasting,
and hypercortisolism (4, 5).
MAS is caused by an activating mutation in the GNAS gene, which encodes the alpha
subunit of the stimulatory G protein involved in G-protein signaling (6, 7). A missense
mutation, typically Arg201Cys or Arg201His (NM_001077488.3:c.604C>T, rs11554273),
impairs the intrinsic GTPase activity of the Gsα protein, resulting in the constitutive
activation of the Gsα-cAMP signaling pathway in the cells that contain the mutation.
The mutation arises early in embryogenesis and is distributed in a mosaic pattern. The
clinical phenotype is therefore highly variable, depending upon the location and timing of
the mutation during embryologic development. Skin manifestations are common and are
usually present at or shortly after birth. The café-au-lait spots typically have irregular
margins giving them a “coast of Maine” appearance, and usually show an association with
the midline of the body.
In MAS, fibrous dysplasia of bone typically occurs at several sites (polyostotic), and
commonly presents with fracture, deformity and/or bone pain (8). Radiographs show
characteristic expansile lesions with a “ground glass” appearance. Craniofacial fibrous
dysplasia can be severe in individuals who have pituitary disorders leading to
hypersecretion of growth hormone. Treatment can be challenging and should begin as
soon as possible.
In girls, precocious puberty is a common initial manifestation, with recurrent ovarian
cysts leading to episodes of vaginal bleeding and breast development. Precocious puberty
is less common in boys, presenting with penile enlargement, pubic and axillary hair, acne,
body odor, and sexual behavior. However, in both girls and boys, there is a high frequency
of gonadal pathology (ovarian abnormalities in girls, and testicular abnormalities in boys)
(9).

Diagnosis
for the GNAS gene and the McCune-Albright Syndrome.
Currently, the diagnosis of McCune-Albright syndrome is made clinically in most cases.
This is due to the mosaic nature of the disease whereby a negative genetic test result (e.g.,
in blood) does not exclude the presence of the mutation in other tissues. However, newer
techniques such as digital PCR may improve the sensitivity of genetic testing in
individuals who have clinical signs of McCune-Albright syndrome (10, 11).
Management
Treatment is individualized based on each patient’s clinical presentation. Letrozole (12)
and/or tamoxifen (13) may be effective for treatment of precocious puberty in girls.
Medications and/or surgery may be used for treatment of hyperthyroidism (14, 15),
growth hormone excess (16, 17), and hypercortisolism (18). Management of fibrous
dysplasia of bone is palliative, with surgery as needed for fracture and deformity (19, 20).
Bisphosphonates are effective for treatment of fibrous dysplasia-related pain, but have not
been shown to have any long-term effect on the course of the disease (21, 22).
Genetic Counseling
McCune-Albright syndrome is caused by a new (de novo) mutation that occurs after
conception, at an early stage of development. Individuals with McCune-Albright
syndrome have not been observed to pass the syndrome on to their children.
Acknowledgments
The author would like to thank Albert Beckers MD, PhD, and Adrian F. Daly MB BCh,
PhD, Department of Endocrinology, Centre Hospitalier Universitaire de Liège, University
of Liège, Belgium, for reviewing this summary.
Version History
To view an earlier version (8 March 2012), please click here.
References
1. Albright F, B.A., Hampton AO, Smith P. Syndrome characterized by osteitis fibrosa
disseminata, areas, of pigmentation, and endocrine dysfunction, with precocious
puberty in females: report of 5 cases. N Engl J Med. 1937;216:727–746.
2. McCune D. Osteitis fibrosa cystica: the case of a nine-year-old girl who also exhibits
precocious puberty, multiple pigmentation of the skin and hyperthyroidism. Am J
Dis Child. 1936;52:743–744.
McCune-Albright Syndrome 425
3. Boyce, A.M. and M.T. Collins, Fibrous Dysplasia/McCune-Albright Syndrome, in

GeneReviews(R), R.A. Pagon, et al., Editors. 1993: Seattle (WA).
4. Dumitrescu C.E., Collins M.T. McCune-Albright syndrome. Orphanet J Rare Dis.
2008;3:12. PubMed PMID: 18489744.
5. Collins MT. S.F., Eugster E, McCune-Albright syndrome and the extraskeletal
manifestations of fibrous dysplasia. Orphanet J Rare Dis. 2012;7 Suppl 1:S4. PubMed
PMID: 22640971.
6. Weinstein L.S., Shenker A., Gejman P.V., Merino M.J., et al. Activating mutations of
the stimulatory G protein in the McCune-Albright syndrome. The New England
7. Schwindinger W.F., Francomano C.A., Levine M.A. Identification of a mutation in
the gene encoding the alpha subunit of the stimulatory G protein of adenylyl cyclase
in McCune-Albright syndrome. Proc Natl Acad Sci U S A. 1992;89(11):5152–6.
8. Collins M, R.M., Bianco P., Fibrous dysplasia. In: Rosen C (ed.) Primer on the
metabolic bone diseases and disorders of mineral metabolism, 2008. 1(American
Society of Bone and Mineral Research, Washington, D.C.): p. 423-428.
9. Boyce A.M., Chong W.H., Shawker T.H., Pinto P.A., et al. Characterization and
management of testicular pathology in McCune-Albright syndrome. J Clin
Endocrinol Metab. 2012;97(9):E1782–90. PubMed PMID: 22745241.
10. Vasilev V., Daly A.F., Thiry A., Petrossians P., et al. McCune-Albright syndrome: a
detailed pathological and genetic analysis of disease effects in an adult patient. J Clin
Endocrinol Metab. 2014;99(10):E2029–38. PubMed PMID: 25062453.
11. Rostomyan L., Beckers A. Screening for genetic causes of growth hormone
hypersecretion. Growth Horm IGF Res. 2016;30-31:52–57. PubMed PMID:
27756606.
12. Feuillan P., Calis K., Hill S., Shawker T., et al. Letrozole treatment of precocious
puberty in girls with the McCune-Albright syndrome: a pilot study. The Journal of
clinical endocrinology and metabolism. 2007;92(6):2100–6. PubMed PMID:
17405850.
13. Eugster E.A., Rubin S.D., Reiter E.O., Plourde P., et al. Tamoxifen treatment for
precocious puberty in McCune-Albright syndrome: a multicenter trial. J Pediatr.
2003;143(1):60–6. PubMed PMID: 12915825.
14. Mastorakos G. M.N., Doufas AG, Koutras DA, Hyperthyroidism in McCune-Albright
syndrome with a review of thyroid abnormalities sixty years after the first report.
Thyroid. 1997;7(3):433–9. PubMed PMID: 9226216.
15. Celi F.S., Coppotelli G., Chidakel A., Kelly M., et al. The role of type 1 and type 2 5'-
deiodinase in the pathophysiology of the 3,5,3'-triiodothyronine toxicosis of
McCune-Albright syndrome. J Clin Endocrinol Metab. 2008;93(6):2383–9. PubMed
PMID: 18349068.
16. Akintoye S.O., Chebli C., Booher S., Feuillan P., et al. Characterization of gsp-
mediated growth hormone excess in the context of McCune-Albright syndrome. J
Clin Endocrinol Metab. 2002;87(11):5104–12. PubMed PMID: 12414879.
17. Akintoye S.O., Kelly M.H., Brillante B., Cherman N., et al. Pegvisomant for the
treatment of gsp-mediated growth hormone excess in patients with McCune-Albright
syndrome. J Clin Endocrinol Metab. 2006;91(8):2960–6. PubMed PMID: 16720661.
18. Brown R.J., Kelly M.H., Collins M.T. Cushing syndrome in the McCune-Albright
syndrome. J Clin Endocrinol Metab. 2010;95(4):1508–15. PubMed PMID: 20157193.
19. Stanton RP. I.E., Springfield D, Lindaman L, Wientroub S, Leet A., The surgical
management of fibrous dysplasia of bone. Orphanet J Rare Dis. 2012;7 Suppl 1:S1.
20. Lee J, F.E., Chen Y, Kim H, Lustig L, Akintoye S, Collins M, Kaban L., Clinical
guidelines for the management of craniofacial fibrous dysplasia. 2012. 7(Suppl 1): p.
S2.
21. Plotkin H., Rauch F., Zeitlin L., Munns C., et al. Effect of pamidronate treatment in
children with polyostotic fibrous dysplasia of bone. J Clin Endocrinol Metab.
2003;88(10):4569–75. PubMed PMID: 14557424.
22. Collins M.T., Kushner H., Reynolds J.C., Chebli C., et al. An instrument to measure
skeletal burden and predict functional outcome in fibrous dysplasia of bone. J Bone
Miner Res. 2005;20(2):219–26. PubMed PMID: 15647815.

McCune-Albright Syndrome

GNAS gene
427
Methylenetetrahydrofolate Reductase Deficiency

Laura Dean, MD1
Created: March 8, 2012; Updated: October 27, 2016.
Characteristics
Methylenetetrahydrofolate Reductase (MTHFR) Deficiency is the most common genetic
cause of elevated levels of homocysteine in the plasma (hyperhomocysteinemia).
The MTHFR enzyme plays an important role in processing amino acids, specifically, the
conversion of homocysteine to methionine. Genetic variations in the MTHFR gene can
lead to impaired function or inactivation of this enzyme, which results in mildly elevated
levels of homocysteine, especially in individuals who are also deficient in folate (1). In
these individuals, a daily supplement of low dose folic acid may reduce and often
normalize their homocysteine levels, but this has not been demonstrated to improve
health outcomes (2, 3).
A common genetic variant in the MTHFR gene is a 677C>T polymorphism
(NM_005957.4:c.665C>T, rs1801133). This variant encodes a thermolabile enzyme that is
less active at higher temperatures. Individuals who carry two copies of this variant (“TT
homozygous”) tend to have higher homocysteine levels and lower serum folate levels
compared to controls.
More than 25% of Hispanics and around 10-15% of North America Caucasians are
estimated to be homozygous for the “thermolabile” variant (TT genotype) (4). The TT
genotype is least common in individuals of African descent (6%) (5, 6).
Another common MTHFR variant, 1298A>C (NM_005957.4:c.1286A>C, rs1801131),
does not cause increased homocysteine levels in heterozygous or homozygous individuals,
but combined heterozygosity of 1298A>C and 677C>T results in an outcome similar to
TT homozygous individuals (7).
Until recently, it was thought that MTHFR deficiency, by causing elevated homocysteine
levels, led to an increased risk of venous thrombosis, coronary heart disease, and
recurrent pregnancy loss (8-11). However, more recent analysis has not found an
association between elevated homocysteine levels and the risk of venous thrombosis or
the risk of coronary heart disease (12).
MTHFR polymorphism genotyping should not be ordered as part of the clinical
evaluation for thrombophilia, recurrent pregnancy loss, or for at-risk family members (4).

Rarely, more severe variants in the MTHFR gene can be a cause of an autosomal recessive
inborn error or metabolism where extremely high levels of homocysteine accumulate in
the urine and plasma. This can cause developmental delay, eye disorders, thrombosis, and
osteoporosis. But more commonly, homocystinuria is caused by variants in a different
gene (cystathionine beta-synthase, CBS). To read more about homocystinuria caused by
CBS deficiency, please see GeneReviews.
Diagnosis
A blood test that measures total homocysteine levels can diagnose
hyperhomocysteinemia.
Genetic testing of the MTHFR gene may be used to confirm the diagnosis of an inherited
hyperhomocysteinemia caused by MTHFR deficiency. However, a 2013 Practice
Guideline from the American College of Medical Genetics and Genomics (ACMG) states
that there is growing evidence that “MTHFR polymorphism testing has minimal clinical
utility and, therefore should not be ordered as a part of a routine evaluation for
thrombophilia” (4).
In an infant or child in whom autosomal recessive severe MTHFR deficiency is suspected,
tests for plasma homocysteine and serum amino acids levels would be expected to show a
pattern of extremely elevated homocysteine and low methionine. MTHFR full gene
sequencing (as opposed to targeted polymorphism testing) can confirm the suspected
clinical diagnosis.
Management
2013 Statement from the American College of Medical Genetics and Genomics (ACMG)
includes the following recommendations:
• MTHFR polymorphism genotyping should not be ordered as part of the clinical
evaluation for thrombophilia or recurrent pregnancy loss
• MTHFR polymorphism genotyping should not be ordered for at-risk family
members
• A clinical geneticist who serves as a consultant for a patient in whom an MTHFR
polymorphism(s) is found should ensure that the patient has received a thorough
and appropriate evaluation for his or her symptoms
• If the patient is homozygous for the “thermolabile” variant c.665C→T, the geneticist
may order a fasting total plasma homocysteine, if not previously ordered, to provide
more accurate counseling
• MTHFR status does not change the recommendation that women of childbearing
age should take the standard dose of folic acid supplementation to reduce the risk of
neural tube defects as per the general population guidelines
For the complete guideline, please see ACMG Practice Guideline: lack of evidence for
MTHFR polymorphism testing. Genetics in Medicine. 2013;15(4):153-6. (4)
Methylenetetrahydrofolate Reductase Deficiency 429
The management of severe autosomal recessive MTHFR deficiency is outside the scope of
this review.
Genetic Testing
for the MTHFR gene and for homocysteinemia due to MTHFR deficiency.
Biochemical genetic tests may also be used, which assess the level of activity of the
MTHFR enzyme or the level of analyte in the blood. GTR provides a list of biochemical
tests that assess the level of homocysteine analytes and the activity of the MTHFR
enzyme.
Genetic Counseling
The MTHFR polymorphism has been associated with many different medical
complications. Individuals who are “MTHFR positive” carry one or two copies of variants
in the MTHFR gene. However, in general, the following genotypes are unlikely to be of
clinical significance:
• 677C>T heterozygote
• c.1286A→C homozygote
• (677C>T);(c.1286A→C) compound heterozygote
Individuals who are TT homozygous with normal homocysteine levels do not have an
increased risk of venous thrombosis or recurrent pregnancy loss, according to recent
evidence. However, women do have a modestly increased risk of having a child with a
neural tube defect and this risk increases if the fetus is also homozygous.
If homocysteine levels are elevated, TT homozygotes may have a mildly increased risk of
venous thrombosis or recurrent pregnancy loss, but not other previously associated
conditions, such as cardiovascular disease.
Less is known about the c.1286A→C variant, but current evidence suggests that it is milder
than the “thermolabile” c.665C→T variant (4).
For all individuals, it is important to determine whether medical disorders have been
incorrectly attributed to their positive MTHFR status. Referral to a hematologist or
maternal–fetal medicine specialist may be needed. And patients should provide their
MTHFR genotype status to their physician before starting chemotherapy agents that
require folate (e.g., methotrexate).
Finally, MTHFR positive individuals may decide to take vitamin B and folic acid
supplements. Although safe (toxicity is rare), evidence is lacking on whether such
supplements reduce the risks associated with hyperhomocysteinemia or MTHFR
genotype status (4).
Acknowledgments
The author would like to thank Scott Hickey, MD, Assistant Professor of Clinical
Pediatrics, The Ohio State University, Program Director, Medical Genetics Residency
Program, Division of Molecular & Human Genetics, Nationwide Children's Hospital, for
References
1. Holmes M.V., Newcombe P., Hubacek J.A., Sofat R., et al. Effect modification by
population dietary folate on the association between MTHFR genotype,
homocysteine, and stroke risk: a meta-analysis of genetic studies and randomised
trials. Lancet. 2011;378(9791):584–94. PubMed PMID: 21803414.
2. Guttormsen A.B., Ueland P.M., Nesthus I., Nygard O., et al. Determinants and
vitamin responsiveness of intermediate hyperhomocysteinemia (> or = 40 micromol/
liter). The Hordaland Homocysteine Study. J Clin Invest. 1996;98(9):2174–83.
3. Shiran A., Remer E., Asmer I., Karkabi B., et al. Association of Vitamin B12
Deficiency with Homozygosity of the TT MTHFR C677T Genotype,
Hyperhomocysteinemia, and Endothelial Cell Dysfunction. Isr Med Assoc J.
2015;17(5):288–92. PubMed PMID: 26137654.
4. Hickey S.E., Curry C.J., Toriello H.V. ACMG Practice Guideline: lack of evidence for
MTHFR polymorphism testing. Genet Med. 2013;15(2):153–6. PubMed PMID:
23288205.
5. Wilcken B., Bamforth F., Li Z., Zhu H., et al. Geographical and ethnic variation of the
677C>T allele of 5,10 methylenetetrahydrofolate reductase (MTHFR): findings from
over 7000 newborns from 16 areas world wide. Journal of medical genetics.
2003;40(8):619–25. PubMed PMID: 12920077.
6. Schneider J.A., Rees D.C., Liu Y.T., Clegg J.B. Worldwide distribution of a common
methylenetetrahydrofolate reductase mutation. American journal of human genetics.
1998;62(5):1258–60. PubMed PMID: 9545406.
7. van der Put N.M., Gabreels F., Stevens E.M., Smeitink J.A., et al. A second common
mutation in the methylenetetrahydrofolate reductase gene: an additional risk factor
for neural-tube defects? American journal of human genetics. 1998;62(5):1044–51.
8. Humphrey L.L., Fu R., Rogers K., Freeman M., et al. Homocysteine level and
coronary heart disease incidence: a systematic review and meta-analysis. Mayo Clinic
proceedings. 2008;83(11):1203–12. PubMed PMID: 18990318.
9. den Heijer M., Rosendaal F.R., Blom H.J., Gerrits W.B., et al. Hyperhomocysteinemia
and venous thrombosis: a meta-analysis. Thrombosis and haemostasis. 1998;80(6):
874–7. PubMed PMID: 9869152.
10. Kupferminc M.J., Eldor A., Steinman N., Many A., et al. Increased frequency of
genetic thrombophilia in women with complications of pregnancy. The New England
Methylenetetrahydrofolate Reductase Deficiency 431
11. Kelly P.J., Rosand J., Kistler J.P., Shih V.E., et al. Homocysteine, MTHFR 677C-->T
polymorphism, and risk of ischemic stroke: results of a meta-analysis. Neurology.
2002;59(4):529–36. PubMed PMID: 12196644.
12. Clarke R., Bennett D.A., Parish S., Verhoef P., et al. Homocysteine and coronary heart
disease: meta-analysis of MTHFR case-control studies, avoiding publication bias.
PLoS Med. 2012;9(2):e1001177. PubMed PMID: 22363213.

MTHFR deficiency, thermolabile type
Homocysteinemia due to MTHFR deficiency
Homocystinuria due to MTHFR deficiency

MTHFR gene
433
Pitt-Hopkins Syndrome
Laura Dean, MD1
Characteristics
Pitt-Hopkins syndrome is characterized by mental retardation, a wide mouth, and
intermittent hyperventilation. In infancy, hypotonia is typical leading to feeding problems
and a delay in reaching developmental motor milestones. In older children, an abnormal
breathing pattern often develops, such as a period of hyperpnea followed by apnea.
Epilepsy is less common but in children who do have seizures, their ECG is abnormal.
Many children have a happy disposition, flapping their hands when excited and laughing
without a clear reason. Their gait looks stiff, due to a combination of hypotonia and ataxia.
Most adults with Pitt-Hopkins syndrome have moderate to severe cognitive impairment
and will not be able to speak.
Pitt-Hopkins syndrome is a genetically heterogeneous condition caused by an autosomal
dominant mutation in TCF4. Many different mutations have been found in the TCF4 gene
of affected children and adults, including heterozygous stop, splice, and missense
mutations (1, 2).
Diagnosis
The diagnosis of Pitt-Hopkins syndrome is based on clinical features and the exclusion of
other conditions with similar symptoms, such as Angelman syndrome, Rett syndrome,
and Mowat-Wilson syndrome.
Molecular genetic testing of TCF4 can be used to confirm the diagnosis.
Management
Treatment: Manifestations of Pitt-Hopkins syndrome are treated by a multidisciplinary
team specializing in the care of children with cognitive and motor impairment, including
physical therapists, speech therapists, and specialists who treat epilepsy.
Genetic Counseling
Almost all mutations in the TCF4 gene occur de novo (3). Prenatal testing may be offered
to unaffected parents who have had a child with Pitt-Hopkins syndrome.

References
1. Zweier C., Peippo M.M., Hoyer J., Sousa S., et al. Haploinsufficiency of TCF4 causes
syndromal mental retardation with intermittent hyperventilation (Pitt-Hopkins
syndrome). American journal of human genetics. 2007;80(5):994–1001. PubMed
PMID: 17436255.
2. Amiel J., Rio M., de Pontual L., Redon R., et al. Mutations in TCF4, encoding a class I
basic helix-loop-helix transcription factor, are responsible for Pitt-Hopkins syndrome,
a severe epileptic encephalopathy associated with autonomic dysfunction. American
3. de Pontual L., Mathieu Y., Golzio C., Rio M., et al. Mutational, functional, and
expression studies of the TCF4 gene in Pitt-Hopkins syndrome. Human mutation.
2009;30(4):669–76. PubMed PMID: 19235238.
435
Schizophrenia
Laura Dean, MD1
Created: March 8, 2012; Updated: February 6, 2017.
Characteristics
Schizophrenia is a severe neurodevelopmental disorder with a worldwide prevalence of
around 0.3-0.7% (1). The etiology of schizophrenia is unknown, but it is thought to result
from a combination of complex genetic and environmental factors. This includes physical
factors e.g., complications during pregnancy and birth, infection, and autoimmune
disease; as well as psychological factors that may trigger psychosis, such as stress and drug
abuse (2). Several neurotransmitter systems are thought to be involved in the
pathogenesis, including dopamine, glutamate, GABA, and acetylcholine.
Schizophrenia is associated with substantial morbidity and mortality. Antipsychotics are
the mainstay of treatment, however, their efficacy is poor for many patients.
Antipsychotics are thought to exert their therapeutic effects by the post-synaptic blockade
of D2 dopamine receptors in the brain.
The symptoms of schizophrenia fall in to three main categories: positive, negative, and
without moving or with a monotonous voice) and avolition (a lack of motivation to start
Genetics
Schizophrenia is highly heritable, as shown by family, twin, and adoption studies. For
example, for identical twins, if one twin develops schizophrenia, the other twin has about
a 50% chance of also developing the disease. The risk of the general population developing
the schizophrenia is about 0.3-0.7% worldwide (3).

The search for “schizophrenia genes” has been elusive. Initial linkage studies looked at
parts of the genome associated with schizophrenia, and many candidate genes were
identified, including APOE, COMT, DAO, DRD1, DRD2, DRD4, DTNBP1, GABRB2,
GRIN2B, HP, IL1B, MTHFR, PLXNA2, SLC6A4, TP53, and TPH1 (4). However, some of
these have later been questioned (5).
Microdeletions and microduplications have been found to be three times more common
in individuals with schizophrenia, compared to controls. Because these deletions and
duplications are in genes that are overexpressed in pathways related to brain development,
it is possible that the inheritance of multiple rare variants may contribute to the
development of schizophrenia (6).
Several genetic disorders feature schizophrenia as a clinical feature. The 22q11.2 Deletion
Syndrome comprises many different syndromes, of which one of the most serious is
DiGeorge syndrome. Children born with DiGeorge syndrome typically have heart defects,
cleft palate, learning difficulties, and immune deficiency. Schizophrenia is a late
manifestation, affecting around 30% of individuals (7). Microdeletions and duplications
in chromosome 1, 2, 3, 7, 15 and 16 have also been associated with schizophrenia (8).
In 2014, a genome-wide association study looked at the genomes of over 35,000 patients
and 110,00 controls. The study identified 108 SNPs that were associated with
schizophrenia, 83 of which had not been previously reported. As expected, many of these
loci occurred in genes that are expressed in the brain. For example, the SNPs included a
gene that encodes the dopamine D2 receptor, DRD2 (the target of antipsychotic drugs),
and many genes involved in glutamine neurotransmitter pathways and synaptic plasticity
(e.g., GRM3, GRIN2A, SRR, GRIA1). More surprisingly, however, associations were also
enriched among genes expressed in tissues with important immune functions (9).
In 2016, a study based on nearly 65,000 people investigated the association between
schizophrenia and variation in the Major Histocompatibility Complex (MHC) locus—a
region on chromosome 6 that is important for immune function. The study focused on
the C4 gene (complement component 4) that exists as two distinct genes: C4A and C4B,
which encode particularly structurally diverse alleles.
The study found that the alleles which promoted greater expression of C4A in the brain
were associated with a greater risk of schizophrenia. By using mice models, the study
showed that C4 is involved in the elimination of synapses during brain maturation. In
humans, “synaptic pruning” is most active during late adolescence, which coincides with
the typical onset of symptoms of schizophrenia. It is therefore possible that the
inheritance of specific C4A alleles could lead to “run away” synaptic pruning, increasing
the risk of schizophrenia. Further research may even determine C4 as a potential
therapeutic target (10).
Schizophrenia 437
Diagnosis
Currently, the diagnosis of schizophrenia is made via a psychiatric assessment using the
criteria presented in the American Psychiatric Association Manual of Psychiatric
Diseases, which is now in its 5th edition, and is known as DSM-V. To make a diagnosis,
specific characteristic symptoms of schizophrenia must be present for at least 6 months,
together with a disruption in social or occupational function, in the absence of another
diagnosis that could account for the symptoms.
The use of chromosome microarray analysis has been suggested as a diagnostic test for
schizophrenia. Microarray analysis can detect copy number variants (CNVs), which are
large regions of the genome that have been deleted or duplicated. The prevalence of
clinically significant CNVs in schizophrenia is around 5%. For autism and intellectual
disability, the prevalence is around 10-20%, and CNV testing with microarray analysis is
now a routine first-line diagnostic test for these conditions.
For an individual with schizophrenia, a positive test result for CNV may have implications
for medical management, because of the association of CNVs with physical diseases and
genetic counseling, and because offspring have a 50% risk of inheriting the CNV (3, 11).
Management
Treatment of manifestations: Antipsychotic medications are the mainstay of treatment and
help reduce symptoms and improve behaviors in patients with schizophrenia. The type,
dose, and route of administration of antipsychotic medications depends upon the clinical
scenario. Adverse effects are common, and may require the dose or type of drug to be
altered.
Antipsychotics may be given with counseling and other types of psychosocial
interventions. For refractory (treatment-resistant) symptoms, an alternative antipsychotic
or an additional antipsychotic may be required.
During pregnancy, antipsychotic drugs should be given only when the benefits derived
from treatment exceed the possible risks to mother and fetus. Neonates exposed during
the third trimester are at risk for extrapyramidal and/or withdrawal symptoms following
delivery. There have been reports of agitation, hypertonia, hypotonia, tremor, somnolence,
respiratory distress, and feeding disorder. While in some cases symptoms have been self-
limited, in others neonates have required intensive care unit support and prolonged
hospitalization.
Surveillance: Routine monitoring for the symptoms and signs of extrapyramidal adverse
effects is needed in individuals taking antipsychotics. These adverse effects include
akathisia (feeling of restlessness that may be accompanied with motor restlessness),
dystonias (involuntary contraction of large muscle groups), and parkinsonian syndrome.
Patients should also be monitored for signs of tardive dyskinesia (involuntary facial
movements) and drug-specific adverse effects. For clozapine, because of the risk of
neutropenia, the patient’s white blood cell count and absolute neutrophil count must be
regularly monitored. For thioridazine, the risk of prolonged QT interval may lead to
Torsades de pointes.
Prevention of secondary complications: Patients should be regularly monitored for weight
gain and metabolic problems such as hyperglycemia and hyperlipidemia, which are
common side effects of antipsychotic medications.
Genetic Testing
Genetic testing is available for several of the susceptibility loci for schizophrenia,
including clinical and research tests registered in the NIH Genetic Testing Registry
(GTR). Additional tests may be found in the ‘Related section’ of the main GTR record for
schizophrenia.
GTR also has registered tests for genetic conditions with schizophrenia as a clinical
feature.
Genetic Counseling
Genetic counseling is recommended for people who have a family member with
schizophrenia. Recurrence risk counseling is based on empiric familial risk for families
with individuals with schizophrenia (12).
The lifetime risk of schizophrenia for the general population is estimated to be 0.2 to 0.7%
(13).
The recurrence risk of schizophrenia in the siblings of a patient is 10%, and in the children
of patients, the risk is approximately 10%. The risk for second-degree relatives is
approximately 3-4% (14, 15).
Acknowledgments
The author would like to thank Professor Erik Jönsson, Research Team Leader, Center for
Psychiatric Research, Department of Clinical Neuroscience, Karolinksa Institutet, Sweden,
for reviewing this summary.
Version History
To view an earlier version (8 March 2012), please click here.
References
1. van Os, J. and S. Kapur, Schizophrenia. Lancet, 2009. 374(9690): p. 635-45.
2. Dean, K. and R.M. Murray, Environmental risk factors for psychosis. Dialogues
Clin Neurosci, 2005. 7(1): p. 69-80.
Schizophrenia 439
3. Vita, A., S. Barlati, L. De Peri, G. Deste, et al., Schizophrenia. Lancet, 2016.

388(10051): p. 1280.
4. Allen, N.C., S. Bagade, M.B. McQueen, J.P. Ioannidis, et al., Systematic meta-
analyses and field synopsis of genetic association studies in schizophrenia: the
SzGene database. Nature genetics, 2008. 40(7): p. 827-34.
5. Farrell, M.S., T. Werge, P. Sklar, M.J. Owen, et al., Evaluating historical candidate
genes for schizophrenia. Mol Psychiatry, 2015. 20(5): p. 555-62.
6. Walsh, T., J.M. McClellan, S.E. McCarthy, A.M. Addington, et al., Rare structural
variants disrupt multiple genes in neurodevelopmental pathways in schizophrenia.
Science, 2008. 320(5875): p. 539-43.
7. Baker, K.D. and D.H. Skuse, Adolescents and young adults with 22q11 deletion
syndrome: psychopathology in an at-risk group. Br J Psychiatry, 2005. 186: p.
115-20.
8. Cnv, C. Schizophrenia Working Groups of the Psychiatric Genomics, and C.
Psychosis Endophenotypes International, Contribution of copy number variants to
schizophrenia from a genome-wide study of 41,321 subjects. Nat Genet, 2016.
9. Schizophrenia Working Group of the Psychiatric Genomics, C., Biological insights
from 108 schizophrenia-associated genetic loci. Nature, 2014. 511(7510): p. 421-7.
10. Sekar, A., A.R. Bialas, H. de Rivera, A. Davis, et al., Schizophrenia risk from
complex variation of complement component 4. Nature, 2016. 530(7589): p. 177-83.
11. Baker, K., G. Costain, W.L. Fung, and A.S. Bassett, Chromosomal microarray
analysis-a routine clinical genetic test for patients with schizophrenia. Lancet
Psychiatry, 2014. 1(5): p. 329-31.
12. Papadimitriou, G.N. and D.G. Dikeos, How does recent knowledge on the heredity
of schizophrenia affect genetic counseling? Current psychiatry reports, 2003. 5(4): p.
239-40.
13. Kendler, K.S., T.J. Gallagher, J.M. Abelson, and R.C. Kessler, Lifetime prevalence,
demographic risk factors, and diagnostic validity of nonaffective psychosis as
assessed in a US community sample. The National Comorbidity Survey. Archives of
general psychiatry, 1996. 53(11): p. 1022-31.
14. Lichtenstein, P., C. Bjork, C.M. Hultman, E. Scolnick, et al., Recurrence risks for
schizophrenia in a Swedish national cohort. Psychol Med, 2006. 36(10): p. 1417-25.
15. Lichtenstein, P., B.H. Yip, C. Bjork, Y. Pawitan, et al., Common genetic
determinants of schizophrenia and bipolar disorder in Swedish families: a
population-based study. Lancet, 2009. 373(9659): p. 234-9.

Schizophrenia
22q11 Deletion Syndrome
DiGeorge sequence
441
Authoring and Peer Review

Created: May 11, 2017.
Medical Genetics Summaries (MGS) for pharmacogenetics is a freely available collection

of articles describing how genetics plays a role in an individual’s response to drugs or
predisposition to disease. The structured format of each summary makes accessing
information such as genetic testing or therapeutic recommendations quick and easy to
use. Medical Genetics Summaries use authoritative sources, are guideline-driven and
actionable, and are subject to an extensive review process as described below.
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The editors of Medical Genetics Summaries advise on subject matter, guide the project
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summary, and assist in recruiting reviewers and in resolution of key issues which may be
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Selection of Topics
The selection of topics for new MGS chapters is guided by two factors. First, the author
consults the FDA’s “Table of Pharmacogenomic Biomarkers in Drug Labeling” to select
new drugs that have not yet been covered in MGS. Second, to prioritize the order of new
MGS chapters, the author checks the Genetic Testing Registry (GTR) for drug response
records which contain information about genetic testing, but lack summary information
about the drug response. After a new MGS chapter is released to the production site, an
excerpt from the chapter is displayed in the relevant GTR drug response record.
Additional reciprocal links between MGS, GTR, and MedGen are also added.
Structured Format
Each MGS drug response chapter follows a structured format. Each summary has one
drug section, but may have one or more gene sections, depending on how many genetic
factors have been identified.
1. Introductory paragraphs detail the drug and its uses, how the genetic variants
influence an individual’s response to the drug, and displays dosing
recommendations from the FDA and practice guidelines from authoritative
professional societies.
2. The drug section begins with a description of the drug, the drug class, its
mechanism of action, the indications for its use, and common side effects. This is
followed by a discussion on the factors which influence the drug response.
3. The gene section reviews important facts about the gene — what role it plays in the
drug metabolism or action, and the nature of the gene variants and how they
impact the drug response. The common or clinically significant variants are then
discussed, including their prevalence across different ethnic populations.
4. “Genetic Testing” section is a key part of the summary. Here, the summary clearly
describes the genetic testing options that are available, linking to genetic test
providers listed in GTR.
5. “Therapeutic Recommendations based on Genotype” excerpts clinically actionable
information, e.g. dosing recommendations from the FDA drug label; and
therapeutic recommendations from pharmacogenetic societies such as CPIC,
CPNDS and DPWG and medical societies, such as ASCO, ACMG, NCCN.
6. Nomenclature table provides information about the different terms used for
genetic variants. Terms that are commonly used in the literature and historic terms
are linked to the official HGVS terms and rs identifiers when available.
7. Expert reviewers are acknowledged, and information about previous versions of
the summary is given.
Writing Process
Each summary is written by our in-house senior medical writer, who is an MD. All phases
from authoring to production are tracked in an internal ticket management system. To
create the first draft of a summary:
1. The author consults the most recent FDA drug label for the drug. To gain a better
understanding for the context of the drug use and impact of genetic factors, the
author will use NIH resources and other clinical sites, such as UpToDate.
2. The author then identifies key guidelines and primary papers, using PubMed
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Each summary undergoes internal review involving one or two NCBI staff members.
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Following internal review, each summary goes through a scientific peer-review process
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reviewers comments are tracked so that the evolution of the summary can be seen, and
Authoring and Peer Review 443
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Once all the review comments are reconciled, the summary is copyedited in-house and
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445
Medical Genetics Summaries Expert Reviewers

Laura Dean, MD1
Created: June 29, 2017; Updated: April 9, 2018.
Alzghari, Saeed, MS, MBA, PharmD; Gulfstream Genomics, TX, USA

• Warfarin Therapy and VKORC1 and CYP Genotype
Amstutz, Ursula, PhD; University of Bern, Switzerland
• Carbamazepine Therapy and HLA Genotype
Appell, Malin Lindqvist, PhD; Linköping University, Sweden
• Thioguanine Therapy and TPMT Genotype
Beam, Teresa, PhD; Manchester University, North Manchester, IN, USA
• Sofosbuvir Therapy and IFNL4 Genotype
Beckers, Albert, MD, PhD; University of Liège, Belgium
• McCune-Albright Syndrome
Bitner-Glindzicz, Maria, PhD, FRCP; University College London, UK
• Gentamicin Therapy and MT-RNR1 Genotype
Brauch, Hiltrud, PhD; Fischer-Bosch-Institute of Clinical Pharmacology (IKP), Germany
• Tamoxifen Therapy and CYP2D6 Genotype
Burstein, Harold, MD, PhD; Harvard Medical School, MA, USA
• Tamoxifen Therapy and CYP2D6 Genotype
Callaghan, John, MD, PhD; Indiana University School of Medicine, Indianapolis, IN, USA
• Carisoprodol Therapy and CYP2C19 Genotype
• Propafenone Therapy and CYP2D6 Genotype
• Risperidone Therapy and CYP2D6 Genotype
Carpenter, William, MD; University of Maryland School of Medicine, Baltimore, MD,
USA
• Clozapine Therapy and CYP2D6, CYP1A2, and CYP3A4 Genotypes
Cavallari, Lisa, PharmD; University of Florida, Gainesville, FL, USA

• Clopidogrel Therapy and CYP2C19 Genotype

• Metoprolol Therapy and CYP2D6 Genotype
Chapman, Paul, MD; Memorial Sloan Kettering Cancer Center, New York, NY, USA
• Vemurafenib Therapy and BRAF and NRAS Genotype
Crews, Kristine, PharmD; St. Jude Children’s Research Hospital, Memphis, TN, USA
• Codeine Therapy and CYP2D6 Genotype
Daly, Adrian, MBBch, PhD; University of Liège, Belgium
• McCune-Albright Syndrome
Ehret, Megan, MS, PharmD; Fort Belvoir Community Hospital, Fort Belvoir, VA, USA
• Aripiprazole Therapy and CYP2D6 Genotype
• Diazepam Therapy and CYP2C19 Genotype
Esquivel, Bernard, MD, MHA, PhD; Latin American Association for Personalized
Medicine, Mexico
Formea, Christine, PharmD, BCPS, FCCP, FASHP; Mayo Clinic College of Medicine and
Science, MN, USA
Gaedigk, Andrea, MS, PhD; University of Missouri, Kansas City, MO, USA
• Atomoxetine Therapy and CYP2D6 Genotype
Gage, Brian, MD, MSc; Washington University, St. Louis, MO, USA
Grond, Stefan, MD; Klinikum Lippe, Germany
• Tramadol Therapy and CYP2D6 Genotype
Gupta, Anita, DO, PharmD; Drexel University College of Medicine, Philadelphia, PA,
USA
• Celecoxib Therapy and CYP2C9 Genotype
Hachad, Houda, PharmD; Oregon Health & Science University, Portland, OR, USA
Hardison, Matthew, PhD, FACMG; Aegis Sciences Corporation, Nashville, TN, USA
Medical Genetics Summaries Expert Reviewers 447
• Dabrafenib Therapy and BRAF and G6PD Genotype

Henrich, Timothy, MD; Brigham and Women’s Hospital, Cambridge, MA, USA
• Maraviroc Therapy and CCR5 Genotype
Henricks, Linda, PharmD; The Netherlands Cancer Institute, Amsterdam, Netherlands
• Capecitabine Therapy and DPYD Genotype
Hickey, Scott, MD; Ohio State University, Columbus, OH, USA
• Methylenetetrahydrofolate Reductase Deficiency
Holsappel, Inge, MSc; Royal Dutch Pharmacists Association (KNMP), Netherlands
• Abacavir Therapy and HLA-B*57:01 Genotype
Hicks, David, MD; University of Rochester Medical Center, Rochester, NY, USA
• Trastuzumab (Herceptin) Therapy and ERBB2 (HER2) Genotype
Hudis, Clifford, MD; Weill Cornell Medical College, New York, NY, USA
Iwuchukwu, Otito F., RPh, PhD; Fairleigh Dickinson University School of Pharmacy,
Florham Park, NJ, USA
• Irinotecan Therapy and UGT1A1 Genotype
Johnson, Douglas, MD; Vanderbilt University Medical Center, Nashville, TN, USA
Jönsson, Erik, MD, PhD; Karolinksa Institutet, Sweden
• Schizophrenia
Joshi, Avadhut, PhD; Translational Software, Bellevue, WA, USA
Kawedia, Jitesh, PhD; University of Texas MD Anderson Cancer Center, Houston, TX,
USA
• Simeprevir Therapy and IFNL3 Genotype
Kaye, Alan, MD, PhD; Louisiana State University Health Sciences Center, New Orleans,
LA, USA
• Tramadol Therapy and CYP2D6 Genotype

Kisor, David, PharmD; Manchester University, North Manchester, IN, USA
• Amitriptyline Therapy and CYP2D6 and CYP2C19 Genotype
• Imipramine Therapy and CYP2D6 and CYP2C19 Genotype
• Thioridazine Therapy and CYP2D6 Genotype
Kong, Ben, PharmD; Oregon Health & Science University, Portland, OR, USA
Lagging, Martin, MD, PhD; University of Gothenburg, Sweden
Langer, Nicolas, PhD; Child Mind Institute, New York, NY, USA
• ACHOO Syndrome
Leeder, Steven, PharmD, PhD; Children’s Mercy Hospital, Kansas City, MO, USA
Lennard, Lynne, PhD; University of Sheffield, UK
Linder, Mark, PhD; University of Louisville, Louisville, KY, USA
Lipkowitz, Stanley, MD, PhD; National Cancer Institute, USA
Lively, Tracy, PhD; National Cancer Institute, Bethesda, MD, USA
Malhotra, Anil, MD; Hofstra Northwell School of Medicine, Hempstead, NY, USA
Merl, Man Yee, PharmD, BCOP; Yale-New Haven Hospital, New Haven, CT, USA
Molden, Espen, PhD; University of Oslo, Norway

Mukerjee, Gouri, PhD; Geneyouin Inc., Toronto, Canada
Müller, Daniel, MD, PhD; University of Toronto, Canada
Murphy, Michael, MD; University of Oxford, UK
• ABO Blood Group
Nagy, Mohamed, BPharm; Children's Cancer Hospital, Egypt
• Fluorouracil Therapy and DPYD Genotype
• Phenytoin Therapy and HLA-B*15:02 and CYP2C9 Genotypes
O’Brien, Thomas, MD, MPH; National Cancer Institute, Bethesda, MD, USA
Obeng, Aniwaa Owusu, PharmD; Icahn School of Medicine at Mount Sinai, New York,
NY, USA
Ostrov, David A., PhD; University of Florida College of Medicine, FL, USA
Patel, Jai N., PharmD, BCOP; Levine Cancer Institute, Charlotte, NC, USA
Patrinos, George, PhD; University of Patras, Greece
Pauli, Emily, PharmD; Clearview Cancer Institute, Huntsville, AL, USA
Pawloski, Pamala, PharmD; HealthPartners Institute, Bloomington, MN, USA

Phillips, Elizabeth, MD, FIDSA; Vanderbilt University Medical Center, Nashville, TN,
USA
Pirmohamed, Munir, MD, PhD; University of Liverpool, UK
Pollock, Bruce, MD, PhD; University of Toronto, Canada
• Venlafaxine Therapy and CYP2D6 Genotype
Pratt, Victoria, PhD, FACMG; Indiana University School of Medicine, Indianapolis, IN,
USA
Purcell, Anthony, PhD; Monash University, Australia
Rahman, Shamima, PhD, FRCP; University College London, UK
Rashed, Rashed, BCNSP, MSc; Children’s Cancer Hospital, Egypt
Rogawski, Michael, MD, PhD; University of California, Davis, CA, USA
• Carbamazepine Therapy and HLA Genotype
• Phenytoin Therapy and HLA-B*15:02 and CYP2C9 Genotype
Ross, Lisa, MS; ViiV Healthcare, Durham, NC, USA
Saab, Yolande, PharmD, PhD; Lebanese American University, Lebanon
Schellens, Jan, MD, PhD; The Netherlands Cancer Institute, Amsterdam, Netherlands

Schneeweiss, Andreas, MD; Heidelberg University Hospital, Germany
• Pertuzumab Therapy and ERBB2 (HER2) Genotype
Schulman, Sol, MD; Harvard Medical School, Boston, MA, USA
Scott, Stuart, PhD, ABMGG; Icahn School of Medicine at Mount Sinai, New York, NY,
USA
• Allopurinol Therapy and HLA-B*58:01 Genotype
• Azathioprine Therapy and TPMT Genotype
• Esomeprazole Therapy and CYP2C19 Genotype
• Mercaptopurine Therapy and TPMT Genotype
• Omeprazole Therapy and CYP2C19 Genotype
• Venlafaxine Therapy and CYP2D6 Genotype
Siasos, Gerasimos, MD, PhD, FCCP, FACC; Brigham and Women’s Hospital, Boston, MA,
USA
Skaar, Todd, PhD; Indiana University, Bloomington, IN, USA
• Codeine Therapy and CYP2D6 Genotype
Sukasem, Chonlaphat, PhD; Mahidol University, Bangkok, Thailand
Thirumaran, Ranjit, MPharm, PhD; Genelex Labs, Seattle, WA, USA
Thompson, Alex, MD, PhD; Duke University Medical Centre, Durham, NC, USA
Trenk, Dietmar, PhD; Albert Ludwig University of Freiburg, Germany

Tsunedomi, Ryouichi, PhD; Yamaguchi University Graduate School of Medicine, Japan
Uppugunduri, Chakradhara, PhD; University of Geneva, Switzerland
van Rhenen, Mandy, MSc; Royal Dutch Pharmacists Association (KNMP), Netherlands
Visk, DeeAnn, PhD; San Diego, CA, USA
Wadelius, Mia, PhD; Uppsala University, Sweden
• Allopurinol Therapy and HLA-B*58:01 Genotype
• Atomoxetine Therapy and CYP2D6 Genotype
• Esomeprazole Therapy and CYP2C19 Genotype
• Omeprazole Therapy and CYP2C19 Genotype
Wainberg, Mark, PhD, OC, OQ, FRSC; McGill University, Quebec, Canada
Wikistrand, John, MD, PhD; University of Gothenburg, Sweden
Yin, Ji-Ye; Xiangya Hospital, Central South University, Changsha, Hunan Province, China
Zujewski, Jo Anne, MD; National Cancer Institute, Bethesda, MD, USA
• Pertuzumab Therapy and ERBB2 (HER2) Genotype

Medical Genetics Summaries

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Victoria Pratt • Howard McLeod • Laura Dean • Adriana Malheiro

National Center for Biotechnology Information (US)

Copy Editor: Stacy Lathrop

Book Cover Image Credit: Aynex Mercado

Medical Genetics Summaries is a growing collection of summaries

Genetic variants and drug responses ................................................................................ 5

Allopurinol Therapy and HLA-B*58:01 Genotype ....................................................................................... 15

Amitriptyline Therapy and CYP2D6 and CYP2C19 Genotype.................................................................. 25

Aripiprazole Therapy and CYP2D6 Genotype ............................................................................................. 47

Atomoxetine Therapy and CYP2D6 Genotype.............................................................................................. 57

Azathioprine Therapy and TPMT Genotype .................................................................................................. 67

Capecitabine Therapy and DPYD Genotype ................................................................................................. 77

Carbamazepine Therapy and HLA Genotypes ............................................................................................. 87

Carisoprodol Therapy and CYP2C19 Genotype .......................................................................................... 99

Celecoxib Therapy and CYP2C9 Genotype................................................................................................... 105

Clopidogrel Therapy and CYP2C19 Genotype............................................................................................. 111

Codeine Therapy and CYP2D6 Genotype ..................................................................................................... 133

Dabrafenib Therapy and BRAF and G6PD Genotype................................................................................. 147

Diazepam Therapy and CYP2C19 Genotype ............................................................................................... 157

Esomeprazole Therapy and CYP2C19 Genotype ........................................................................................ 165

Fluorouracil Therapy and DPYD Genotype .................................................................................................... 175

Gentamicin Therapy and MT-RNR1 Genotype.............................................................................................. 185

Imipramine Therapy and CYP2D6 and CYP2C19 Genotype .................................................................... 193

Irinotecan Therapy and UGT1A1 Genotype.................................................................................................. 213

Maraviroc Therapy and CCR5 Genotype....................................................................................................... 229

Mercaptopurine Therapy and TPMT Genotype ............................................................................................. 235

Metoprolol Therapy and CYP2D6 Genotype................................................................................................. 245

Omeprazole Therapy and CYP2C19 Genotype ........................................................................................... 255

Pertuzumab Therapy and ERBB2 (HER2) Genotype..................................................................................... 263

Phenytoin Therapy and HLA-B*15:02 and CYP2C9 Genotypes............................................................... 273

Prasugrel Therapy and CYP Genotype............................................................................................................ 287

Propafenone Therapy and CYP2D6 Genotype ............................................................................................. 295

Risperidone Therapy and CYP2D6 Genotype ............................................................................................... 305

Simeprevir Therapy and IFNL3 Genotype...................................................................................................... 317

Sofosbuvir Therapy and IFNL4 Genotype ...................................................................................................... 325

Tamoxifen Therapy and CYP2D6 Genotype .................................................................................................. 333

Thioguanine Therapy and TPMT Genotype.................................................................................................... 345

Thioridazine Therapy and CYP2D6 Genotypes ............................................................................................ 355

Tramadol Therapy and CYP2D6 Genotype.................................................................................................... 367

Trastuzumab (Herceptin) Therapy and ERBB2 (HER2) Genotype.............................................................. 377

Vemurafenib Therapy and BRAF and NRAS Genotype .............................................................................. 387

Venlafaxine Therapy and CYP2D6 Genotype ............................................................................................... 395

Warfarin Therapy and the Genotypes CYP2C9 and VKORC1................................................................. 405

Genetic variants and disease ......................................................................................................415

ACHOO Syndrome ............................................................................................................................................. 421

McCune-Albright Syndrome .............................................................................................................................. 423

Methylenetetrahydrofolate Reductase Deficiency.......................................................................................... 427

Pitt-Hopkins Syndrome........................................................................................................................................ 433

Schizophrenia ....................................................................................................................................................... 435

Authoring and Peer Review ...................................................................................................................................441

Medical Genetics Summaries Expert Reviewers................................................................................................445

National Institute of General Medical Sciences

Pharmacogenomics Knowledge Database (PharmGKB) and

CPIC Consortium Members

Julie A. Johnson, PharmD, FCCP, BCPS

Genetic variants and disease

Genetic variants and drug responses

1 NCBI; Email: dean@ncbi.nlm.nih.gov.

Genetic testing can help optimize the drug dose

The use of genetic testing is often not clear-cut