The Next Generation: New Genes and Panels at PGXL Kristen K. Reynolds, PhD VP Laboratory Operations Copyright 2012 PGXL Laboratories, Louisville KY All materials herein are the exclusive property of PGXL Laboratories

2012 Q4 New Genes CYP3A4/3A5: Statins, benzodiazepines, Ca ++ channel blockers CYP1A2: Antidepressants, antipsychotics SLCO1B1: Statin-induced myopathy risk SLC6A4 (Serotonin transporter): SSRI antidepressant sensitivity/resistance SULT4A1: Olanzapine OPRM1: Opioid sensitivity/resistance (expected December 2012)

CYP3A4 and CYP3A5

CYP3A4 and 3A5 Together metabolize 50% of all medications 80% redundancy of function Genetic variants in each – decrease enzyme function (clearance) – Increased risk of dose-dependent adverse events

CYP3A4/5 master drug list

CYP3A4/5 significant variants CYP3A4*22 – Decreased dose requirements for tacrolimus, cyclosporin, simvastatin, atorvastatin, lovastatin, midazolam – 4-8% frequency CYP3A5*3 – Decreased dose requirements vincristine, tacrolimus, cyclosporin – 90% freq Cauc, 50% AA, 60% Asians

3A4 Interpretation CYP3A4 Phenotype THERAPEUTIC IMPLICATIONS (adapted from published resources) Extensive Metabolizer Normal metabolic clearance expected. Common CYP3A4 medications below. CYP3A4 Phenotype THERAPEUTIC IMPLICATIONS (adapted from published resources) Partially Decreased Metabolizer Decreased metabolic clearance expected with increased risk of dose-dependent side effects. Common CYP3A4 medications below. CYP3A4 Phenotype THERAPEUTIC IMPLICATIONS (adapted from published resources) Decreased Metabolizer Decreased metabolic clearance expected with increased risk of dose-dependent side effects. Common CYP3A4 medications below. CYP3A4 Phenotype THERAPEUTIC IMPLICATIONS (adapted from published resources) *22 Decreased Metabolizer Decreased metabolic clearance expected with increased risk of dose-dependent side effects. Adjust DosageAdjustment Simvastatin max mg, or consider alternative statin if also SLCO1B1 *5/*5 genotype Atorvastatinmax mg Lovastatinmax mg Tacrolimusdecrease by up to 40%

3A5 Interpretation CYP3A5 Phenotype THERAPEUTIC IMPLICATIONS (adapted from published resources) Extensive Metabolizer Genotype consistent with the highest baseline enzymatic activity for CYP3A5. Patients with this genotype represent only 1% of the population. Maintenance dosages for most CYP3A5 drugs may be at the higher end of the typical dose range. Common CYP3A5 medications below. CYP3A5 Phenotype THERAPEUTIC IMPLICATIONS (adapted from published resources) Partially Decreased Metabolizer Genotype consistent with intermediate CYP3A5 enzymatic activity and represents approximately 20% of the population. For PDMs, maintenance dosages for most CYP3A5 drugs are lower than extensive metabolizers and are higher than decreased metabolizers. CYP3A5 Phenotype THERAPEUTIC IMPLICATIONS (adapted from published resources) Decreased Metabolizer Genotype consistent with reduced CYP3A5 enzymatic activity and represents the majority (60-80%) of the population. For DMs, maintenance dosages for most CYP3A drugs are lower than extensive metabolizers. Common CYP3A5 medications below.

SLCO1B1 statin myopathy risk

Statin therapy reduces risk of CV events Statin therapy can lead to muscle weakness and ultimately muscle breakdown with rhabdomyolysis GWAS studies revealed a single genetic determinant of statin induced myopathy

N Engl J Med 2008;359:

~35% of population are carriers of the SLC01B1*5 allele – Myalgia/muscle cramps Myopathy on 40mg/day: – SLCO1B1 *1/*5, OR = 2.6 – SLCO1B1 *5/*5, OR = 5.2 Most frequently associated with simvastatin > atorvastatin > pravastatin SLC01B1 OATP1B1

Vanderbilt Algorithm Wilke et al. Clin Pharmaco Ther 2012;92(1).

SLCO1B1 Interpretation SLCO1B1 Phenotype THERAPEUTIC IMPLICATIONS (adapted from published resources) No Increased Risk Normal OATP1B1 transporter function. No increased risk of statin-induced myopathy expected at low to moderate doses (10-40 mg). Consider mg dose if also CYP3A4*22 carrier. SLCO1B1 Phenotype THERAPEUTIC IMPLICATIONS (adapted from published resources) 2.6 Fold Increased Myopathy Risk Reduced OATP1B1 transporter function. Increased risk of statin-induced myopathy. Adjust DosageAdjustment Simvastatin max mg and consider monitoring CK levels, or consider alternative statin if also taking verapamil or diltiazem. Consider low mg dose of alternative statin if patient also CYP3A4*22 carrier. Atorvastatin max mg SLCO1B1 Phenotype THERAPEUTIC IMPLICATIONS (adapted from published resources) >5 Fold Increased Myopathy Risk Avoid Alternative Consideration Adjust DosageAdjustment Simvastatin pravastatin, lovastatin, fluvastatin, rosuvastatin, mevastatin Atorvastatinmax mg

SLC6A4 serotonin transporter

SLC6A4 Serotonin Transporter

SLC6A % depressed patients have recurrence and 20% fail 1 st line Rx (SSRIs) – TRD  increased # of Rx, hospitalization risk, costs (19x higher) 75% people carry S or LG S/S, S/LG, or LG/LG should be considered for non-SSRI therapies

Antidepressants SSRIsSNRIs 2C19citalopramCelexa2D6,1A2duloxetineCymbalta 2C19escitalopramLexapro2D6venlafaxineEffexor 2D6fluoxetineProzac3A4/5desvenlafaxinePristiq 2D6,1A2fluvoxamineLuvoxrenalmilnacipranSavella 2D6paroxetinePaxil2D6,1A2,3A4/5mirtazapineRemeron 2C19sertralineZoloft 3A4/5vilazodoneViibryd TCAs 2D6,1A2,3A4/5amitriptylineElavilAtypicals (NRIs, NDRIs) 2D6,1A2clomipramineAnafranil2B6,1A2bupropionWellbutrin 2D6,2C19desipramineNorpramin3A4/5trazadoneDesyrel 2D6doxepinSinequan3A4/5nefazadoneSerzone 2D6imipramineTofranil2D6maprotilineLudiomil 2D6,3A4/5nortriptylinePamelor, Aventyl2D6,1A2mianserin 2D6,3A4/5,2C19trimipramineSurmontil3A4/5reboxetineEdronax MAOIs phenelzineNardil tranylcyromineParnate isocarboxazidMarplan 2C19moclobemide Black indicates major pathway; Gray indicates minor pathway

SLC6A4 interpretations SLC6A4 PhenotypeTHERAPEUTIC IMPLICATIONS (adapted from published resources) Normal Responder Normal serotonin transporter expression expected. Patients with the LA/LA genotype are more likely to respond within the first 4 weeks of therapy, achieve remission, and are less likely to have adverse effects when treated with SSRIs. SLC6A4 PhenotypeTHERAPEUTIC IMPLICATIONS (adapted from published resources) Intermediate Responder Carriers of S or LG alleles may have decreased serotonin transporter expression compared to LA/LA subjects. Possible risk of decreased or slower response to SSRIs or increased risk of adverse events. SLC6A4 PhenotypeTHERAPEUTIC IMPLICATIONS (adapted from published resources) Poor Responder Decreased serotonin transporter expression expected. Risk of decreased response to SSRI-based therapies and increased risk of adverse events. Consider non-SSRI antidepressant therapies, such as SNRIs or tricyclic antidepressants alternatives.

CYP1A2

Metabolizes many antidepressants and antipsychotics Inducible by several medications and smoking Variants cause altered enzymatic activity, particularly in the presence of an inducer Increased risk of having adverse drug reactions or therapeutic failure to standard dosages of CYP1A2 medications

CYP1A2 master drug list CYP1A2 Other Psychiatry RopivicaineVarious brandsOlanzapineZyprexa LidocaineVarious brandsClozapineClozaril TheophyllineAerolateImipramineTofranil ZolmipitranZomigClomipramineAnafranil TriamtereneDyreniumMirtazapineRemeron FlutamideEulexinBupropionWellbutrin TizanidineZanaflexDuloxetineCymbalta TacrineCognexPromazineSparine CyclobenzaprineFlexarilAsenapineSaphris Caffeine 17-beta estradiol

1A2 Interpretation CYP1A2 Phenotype THERAPEUTIC IMPLICATIONS (adapted from published resources) Normal Inducer Normal metabolic clearance expected. Common CYP1A2 medications below. This patient’s genotype is consistent with normal CYP1A2 enzymatic activity and normal induction in the presence of an inducer, such as tobacco smoke. CYP1A2*1A/*1A patients with inducers have 30% lower plasma concentrations of CYP1A2 substrates such as olanzapine. CYP1A2*1A*1A patients without inducers have a 30% increased plasma concentration over those who have inducers present. CYP1A2 Phenotype THERAPEUTIC IMPLICATIONS (adapted from published resources) HyperinducerRapid metabolism expected, especially in smokers. Consider dose increases for medications inactivated by CYP1A2 particularly in smokers, or alternative medications not metabolized by CYP1A2. Common CYP1A2 medications below. CYP1A2 Hyperinducer: Presence of the CYP1A2*1F allele results in the hyperinduction phenotype. Hyperinduction may yield 20-40% higher CYP1A2 activity compared to the normal *1A allele in the presence of an inducer, such as tobacco smoke. Patients who are homozygous for the CYP1A2*1F/*1F genotype may exhibit even higher rates of CYP1A2 enzymatic activity and have been described as ultra-rapid metabolizers for olanzapine. As an example, carriers of CY1A2*1F with the hyperinduction phenotype may exhibit as much as 50% lower than expected plasma levels of olanzapine, clozapine, and haloperidol, which could lead to sub-therapeutic response. Hyperinducers may require increased dosages of CYP1A2 substrates due to higher than normal rates of drug metabolism in the presence of an inducer. CYP1A2 Phenotype THERAPEUTIC IMPLICATIONS (adapted from published resources) Non-InducerNormal metabolic clearance not affected by inducers. Consider dose decreases for medications inactivated by CYP1A2 or alternative medications not metabolized by CYP1A2. Common CYP1A2 medications below.

SULT4A1 psychosis

PGXL exclusive provider of SULT4A1 marker (schizophrenia, bipolar disorder)

SULT4A1 Brain enzyme that interacts with neurochemicals Efficacy advantage with olanzapine EfficacyHospitalization

SULT4A1 Interpretations GeneTHERAPEUTIC IMPLICATIONS (adapted from published resources) SULT4A1-1 POSITIVE Consider olanzapine. SULT4A1-1 positive patients have been shown to demonstrate enhanced treatment efficacy and reduced hospitalization risk when treated with olanzapine compared to both SULT4A1-1 negative patients treated with olanzapine and SULT4A1-1 positive patients treated with risperidone. SULT4A1-1 NEGATIVE SULT4A1-1 negative patients treated with olanzapine do not display the expected efficacy advantage compared to other atypical antipsychotics.

How do we implement these new genes? Panels and specialty-specific focus

Panels* PGXL Core Panel: CYP2D6 CYP2C9 CYP2C19 CYP3A4 CYP3A5 CYP1A2 Thrombophilia Panel: Factor V Leiden Factor II MTHFR Panel Add-Ons (build specialty- specific uses): VKORC1 (warfarin) SLC6A4 (SSRIs) SLCO1B1 (statins) OPRM1 (opioids) *All genes always orderable a la carte

Specialty Requisition Forms

General Practice - DRAFT

Cardiology - DRAFT

Pain Management - DRAFT

OB/GYN - DRAFT

Psychiatry - DRAFT Depression Psychosis

PGXL Depression Panel DRAFT (Panel + SLC6A4 add-on) CONFIDENTIAL COPYRIGHT PGXL LABORATORIES 2012

STA 2 R Panel Report

2D6 master drug List CYP2D6 Pain Management Psychiatry Codeine**Various brandsAntidepressants Antipsychotics Oxycodone**Oxycontin, variousFluoxetineProzacHaloperidolHaldol Hydrocodone**Various brandsFluvoxamineLuvoxRisperidoneRisperidol Tramadol**Ultram, variousParoxetinePaxilAripiprazoleAbilify VenlafaxineEffexorZuclopenthixolVarious brands Cardiology DuloxetineCymbaltaPerphenazineTrilafon CarvedilolCoregMaprotilineLudiomilThioridazineMellaril MetoprololToprol-XLMirtazapineRemeronIloperidineFanapt PropanololInderal, variousAmitriptyline Various brands ChlorpromazineThorazine TimololBlocadrenClomipramineAnanfranilAtomoxetineStrattera PropafenoneRythmolDesipramineNorpraminAmphetamineAdderall FlecainideTambocorDoxepinSinequan ImipramineTofranil Other Nortriptyline Pamelor, Aventyl LoratadineClaritinTrimipramineSurmontil DonepezilAricept DextromethorphanVarious brands Tamoxifen**Various brands ** indicates prodrug

2C19 and 2C9 master drug lists CYP2C19CYP2C9 Clopidogrel**PlavixWarfarinCoumadin CitalopramCelexaCelecoxibCelebrex EscitalopramLexapro, variousIbuprofenAdvil, Motrin ImipramineTofranilNaproxenAleve SertralineZoloftGlyburideDiabeta DiazepamValiumGlipizideGlucotrol OmeprazolePrilosecTolbutamideOrinase EsomeprazoleNexiumGlimepirideAmaryl PantoprazoleProtonixPhenytoinDilantin RabeprazoleAciphexFluvastatinLescol LansoprazolePrevacidRosuvastatinCrestor NelfinavirViraceptLosartanCozaar MethadoneVarious brands Carisoprodol**Soma VoriconazoleVfend

Cliff Notes on the Portal

Questions?

Thank You!

*Lack of efficacy due to failure to produce active metabolite; † Increased risk of adverse events due to diminished drug clearance. CYP2D6 Poor Metabolizer (PM): This patient’s genotype is consistent with a lack of CYP2D6 enzymatic activity. PMs are at increased risk of drug-induced side effects due to diminished drug elimination of active drugs or lack of therapeutic effect resulting from failure to generate the active form of the drug, as is the case with pro-drugs. CONFIDENTIAL COPYRIGHT PGXL LABORATORIES 2012

*Lack of efficacy due to failure to produce active metabolite; † Increased risk of adverse events due to diminished drug clearance. CYP2C19 Intermediate Metabolizer (IM): This patient’s genotype is consistent with reduced CYP2C19 enzymatic activity. IMs are at slightly increased risk of drug-induced side effects due to diminished drug elimination of active drugs. Patients with reduced CYP2C19 function (IMs) taking clopidogrel may exhibit suboptimal drug activation and may have increased risk for cardiovascular events compared to CYP2C19 extensive metabolizers. 2C19

2C19 all

CONFIDENTIAL COPYRIGHT PGXL LABORATORIES 2012 CYP2C9 Intermediate Metabolizer (IM): This patient’s genotype is consistent with reduced CYP2C9 enzymatic activity. Reduced CYP2C9 activity leads to lower warfarin dose requirement due to decreased clearance, increased elimination half-life, and increased time to reach steady-state blood concentrations. The time to reach steady-state affects the timing of INR measurement for optimal interpretation. Time to reach steady-state is the time period required for the dosage to consistently yield reproducible blood concentrations of warfarin. INR measurements are most reliable when measured after steady-state has been achieved. INR measurements before steady-state blood concentrations have been achieved should be interpreted with caution, as they may not be indicative of stable therapy. VKORC1 Low Warfarin Sensitivity: This patient’s genotype is consistent with higher VKORC1 enzyme expression and higher warfarin dose requirement. ‡The warfarin maintenance dose estimate was derived using a published formula that accounts for age, gender, weight, and CYP2C9 and VKORC1 genotypes. This estimate should be viewed as an example of how this information can be taken into consideration by the physician as part of the overall patient management strategy.

All warf possible

Factor V Leiden High Thrombosis Risk: This genotype result revealed that the patient is homozygous for (has two copies of) the Factor V Leiden (1691 G>A) variant, which has been associated with an increased risk of thromboembolic events. This variant is found in approximately 4% of individuals in the U.S. Presence of the Factor V Leiden variant increases the risk of venous thromboembolism (VTE) by 3-8 fold in heterozygous carriers and >9 fold in homozygous carriers. Factor II Moderate Thrombosis Risk: This genotype result revealed that the patient is heterozygous for (has one copy of) the Factor II (Prothrombin) G>A variant, which has been associated with an increased risk of thromboembolic events. This variant is found in approximately 2% of individuals in the U.S. Presence of the Factor II 20210G>A variant increases the risk of venous thromboembolism (VTE) by 2-3 fold in heterozygous carriers and >3 fold in homozygous carriers. MTHFR Increased Risk: Presence of the 677 C>T polymorphism of MTHFR leads to decreased MTHFR enzymatic activity and elevated homocysteine. This patient’s genotype is consistent with an increased risk of hyperhomocysteinemia, atherosclerotic heart disease, myocardial infarction, cerebrovascular disease, and venous thrombosis. Additionally, associations between the 677 C>T polymorphism and increased risk for methotrexate toxicity, increased 5-fluorouracil chemosensitivity, and increased risk of fetal neural tube defects in pregnant women have also been reported in states of folate deficiency.