UM = ultrarapid metabolizer, EM = extensive metabolizer, IM = intermediate metabolizer, PM = poor metabolizer
| Drug | SNP | Types | Effect | Race | Misc | |
| Ivacaftor | CFTR | |||||
| amitriptyline | CYP 2C19 | UM (R), EM, IM, PM | PM = increased conc, side effects, UM = decreased concen | PM =Common in Asians UM=Common in Caucasions | UM – Avoid or lower dose, IM/EM same, PM avoid or start at 50% dose. Must calculate activity score | |
| citalopram | CYP 2C19 | UM (R), EM, IM, PM | PM = increased conc, side effects, UM = decreased concen | PM =Common in Asians UM=Common in Caucasions | UM – Avoid or lower dose, IM/EM same, PM avoid or start at 50% dose. Must calculate activity score | |
| escitalopram | CYP 2C19 | UM (R), EM, IM, PM | PM = increased conc, side effects, UM = decreased concen | PM =Common in Asians UM=Common in Caucasions | UM – Avoid or lower dose, IM/EM same, PM avoid or start at 50% dose. Must calculate activity score | |
| Plavix | CYP2C19 | UM (R), EM, IM, PM | Prodrug – PM have decreased levels, UM have increased drug levels | PM =Common in Asians UM=Common in Caucasions | IM and PM should use alternative. Prasugrel is a prorug, but not CYP related. Ticagrelor is not prodrug. | |
| SSRIs | CYP2C19 | UM (R), EM, IM, PM | PM = increased conc, side effects, UM = decreased concen | PM =Common in Asians UM=Common in Caucasions | UM – Avoid or lower dose, IM/EM same, PM avoid or start at 50% dose. Must calculate activity score | see specific drugs |
| Tricylics | CYP2C19 | UM (R), EM, IM, PM | PM = increased conc, side effects, UM = decreased concen | PM =Common in Asians UM=Common in Caucasions | UM – Avoid or lower dose, IM/EM same, PM avoid or start at 50% dose. Must calculate activity score | see specific drugs |
| PPI | CYP2C19 | UM (R), EM, IM, PM | PM =Common in Asians UM=Common in Caucasions | |||
| voriconazole | CYP2C19 | UM (R), EM, IM, PM New Terms: | Plasma 3-4 times higher in PMS compared to Ems. UM may have sub-thera levels (not as clear) | PM =Common in Asians UM=Common in Caucasions | 2C19 polymorphism explains 50% of the variability. Adult specific and peditric specifif tables for this one. | NTI. Exposure can cause hepatotoxity, visual distburances, neurological side effects, etc.Also 2C9 and 3A4. (Ultra rapid, Rapid (this has been split into two groups now, one is homozygous and one is not), Normal Metabolizer, Intermediate Metabolizer, Poor Metabolizer). must still monitor drugs. |
| Warfarin | CYP2C9 | EM, IM, PM | IM and PM associated with lower doses | Some variants more common in AA | dosage calculators available | |
| Phenytoin | CYP2C9 | EM, IM, PM | IM, decrease dose, PM decreased more | PM= Mostly caucasiun | Phenytoin needs 2 tests. EM as usualy, IM decrease by 25%, PM decrease by 50%. | |
| Phenytoin | CYP2C9 | EM, IM, PM | EM as normal, IM = 25% of dose, PM 50% of dose | Phenytoin needs 2 tests | ||
| NSAIDs | CYP2C9 | EM, IM, PM | ||||
| Glyburide | CYP2C9 | EM, IM, PM | ||||
| SSRIs | CYP2D6 | UM, EM, IM, PM | UM =decreased concentrations, PM = increased concentrations | PM= Mostly caucasiun | UM – Avoid or lower dose, IM/EM same, PM avoid or start at 50% dose. Must calculate activity score | watch for 2d6 inhibitors, see specific drugs |
| Tricylics | CYP2D6 | UM, EM, IM, PM | UM =decreased concentrations, PM = increased concentrations | PM= Mostly caucasiun | UM – Avoid or lower dose, IM/EM same, PM avoid or start at 50% dose. Must calculate activity score | watch for 2d6 inhibitors, see specific drugs |
| nortriptyline | CYP2D6 | UM, EM, IM, PM | UM =decreased concentrations, PM = increased concentrations | PM= Mostly caucasiun | UM – Avoid or lower dose, IM/EM same, PM avoid or start at 50% dose. Must calculate activity score | watch for 2d6 inhibitors |
| amitriptyline | CYP2D6 | UM, EM, IM, PM | UM =decreased concentrations, PM = increased concentrations | PM= Mostly caucasiun | UM – Avoid or lower dose, IM/EM same, PM avoid or start at 50% dose. Must calculate activity score | watch for 2d6 inhibitors, also applies to imipramine and desipramine too |
| paroxetine | CYP2D6 | UM, EM, IM, PM | UM =decreased concentrations, PM = increased concentrations | PM= Mostly caucasiun | UM – Avoid or lower dose, IM/EM same, PM avoid or start at 50% dose. Must calculate activity score | watch for 2d6 inhibitors |
| fluvoxamine | CYP2D6 | UM, EM, IM, PM | UM =decreased concentrations, PM = increased concentrations | PM= Mostly caucasiun | UM – Avoid or lower dose, IM/EM same, PM avoid or start at 50% dose. Must calculate activity score | watch for 2d6 inhibitors |
| Codeine | CYP2D6 | UM, EM, IM, PM | Prodrug, PM – lower concentration, UM = higher | PM= Mostly caucasiun | Beware of adding 2D6 inhibitors.Must calculate activity score | Do not use in breastfeeding moms with known CYP2D6 UM. Can harm baby. Alternatives: morphine, non-opiod |
| tramadol | CYP2D6 | UM, EM, IM, PM | Prodrug, PM = decresed response, UM = increased response and adverse effects. | PM= Mostly caucasiun | UM – Avoid, EM – As usual, IM – Consider alternative if it doesn’t work, PM avoid. Not as much evidence | Do not use in breastfeeding moms with known CYP2D6 UM. Can harm baby. Alternatives: morphine, non-opiod |
| hydrocodone | CYP2D6 | UM, EM, IM, PM | Prodrug, PM – lower concentration, UM = higher | PM= Mostly caucasiun | UM – Avoid, EM – As usual, IM – Consider alternative if it doesn’t work, PM avoid | Do not use in breastfeeding moms with known CYP2D6 UM. Can harm baby. Alternatives: morphine, non-opiod |
| oxycodone | CYP2D6 | UM, EM, IM, PM | Prodrug, PM – lower concentration, UM = higher | PM= Mostly caucasiun | UM – Avoid, EM – As usual, IM – Consider alternative if it doesn’t work, PM avoid | Do not use in breastfeeding moms with known CYP2D6 UM. Can harm baby. Alternatives: morphine, non-opiod |
| Codeine | CYP3a4 | not as much evidence | alternatives: morphine, non-opiod | |||
| tegafur | DPYD | Normal, intermediate or low function | IM – increased conc, Low – much increased concen | Normal – label recs, IM – decrase dose by 50%, titrate based on toxicity, low – DO NOT USE | DPYD metabolizes to inactive form | |
| 5-FU | DPYD | Normal, intermediate or low function | IM – increased conc, Low – much increased concen | Normal – label recs, IM – decrase dose by 50%, titrate based on toxicity, low – DO NOT USE | DPYD metabolizes to inactive form | |
| capecitabine | DPYD | Normal, intermediate or low function | IM – increased conc, Low – much increased concen | Normal – label recs, IM – decrase dose by 50%, titrate based on toxicity, low – DO NOT USE | DPYD metabolizes to inactive form | |
| Rasburicase | G6PD | |||||
| Carbamazepine | HLA-B 15:02 | Not metabolism related | Presence of 15:02=increased risk for TENS/SJS. | Primarly in Asian or HAN Chinese, Vietnam, Cambodia, Runion Island, India, Hong Kong | Do not rechallenge. Do not initiate. Should be pre-screened. Also avoid phenytoin, fosphenytoin, oxcarbazepine, eslicarbazepine, lamotrigine | |
| Phenytoin | HLA-B 15:02 | Not metabolism related | Presence of 15:02=increased risk for TENS/SJS. | Primarly in Asian or HAN Chinese, Vietnam, Cambodia, Runion Island, India, Hong Kong | Do not rechallenge. Do not initiate. Should be pre-screened. Also avoid phenytoin, fosphenytoin, oxcarbazepine, eslicarbazepine, lamotrigine | Also avoid phenytoin, fosphenytoin, oxcarbazepine, eslicarbazepine, lamotrigine |
| Abacavir | HLA-B 57:01 | Not metabolism related | Presence of 57:01=increased risk for TENS/SJS. | Mostly in Southwest Asians | Do not rechallenge. Do not initiate. Should be pre-screened. | |
| Allopurinol | HLA-B 58:01 | Not metabolism related | Presence of 58:01=increased risk for TENS/SJS. | |||
| Simvastatin | SLOCO1B1 | Normal, intermediate or low function | LF = decreased effect, increase side effects | Not all statins are equally affected. OATP1b1 is affected. | ||
| repaglinide | SLOCO1B1 | Normal, intermediate or low function | LF = decreased effect, increase side effects | Not all statins are equally affected. OATP1b1 is affected. | ||
| Thiopurines | TPMT | Normal, intermediate or low function | TPMT inactives drug | Nm = normal dose, 2 week steady state, intermediate = 30-70% of dose, 2-4 weeks for SS, Low = 90% of dose, only three times a week, 4-6 weeks for steady state. Only use for low if malignency. | inherited | |
| Atazanavir | UGT1A1 | |||||
| Warfarin | VKORC1 | decreased | decreased mean less warfarin needed | Vitamin K epoxide reductase | ||
| Ondansetron | CYP2D6 | UM, EM, IM, PM | UM decreased concentration | UM should consider another choice | granisetron not metabolized by 2D6. Tripisetron is | |
| Tamoxifen | CYP2D6 | UM, EM, IM, PM | Active metabolite. PM have poorer drug response, less active metabolite. | Not as straight forward. No CPIC guideline. Don’t recommend testing as a tool. | Dutch Working Group recomends in relapse. Level A on CPIC. Most likely relevalent only postmenopausal women with ER-positive breast cancer deciding between aromatse inhib and tamoxifen. | |
| Thiopurines | NUDT15 | Normal, intermediate or low function | Asians and hispanics | Low = 90% of dose | ||
| Irinotecan | UGT1A1 | UGT1AT*28 | decresed metabolism, increased accumulation and toxicity Pro-drug, SN38 active metbolite inactivated and detoxified by a UDP-glucuronosyltransferase | No recs from CPIC. May be pertinent to genotype in high dose (>240 mg/m2) situations. Watch neutrophil count | 7 TA repeats instead of 6 TA repeats. Homozygotes – Joubert’s syndrome |
This chart was designed by Amanda Galiano, PharmD.
Sources: https://cpicpgx.org/ (CPIC Gudelines), https://www.pharmgkb.org/ (PharmGKB)