1. Copyright 2010 PGXL Laboratories, Louisville KY All materials herein are the exclusive property of PGXL Laboratories Cardiology Panels Kristen K. Reynolds, PhD VP Laboratory Operations

2. Panels* Core: CYP2D6 CYP2C9 CYP2C19 CYP3A4 CYP3A5 CYP1A2 Thromobophilia: FVL FII MTHFR Cardio Panel Add-Ons: VKORC1 (warfarin) SLCO1B1 (statins) *All genes always orderable a la carte

3. Cardiology Med List **indicates prodrug

4. CAD/Stents/TIA: Plavix (2C19) Afib/Valve: Warfarin (2C9+VKORC1) DVT/MI/Ischemic Stroke: thromobophilia risk (FVL, FII, MTHFR) Hypertension/Arrhythmia: Beta blockers, Ca Ch Blockers, ARBs (2D6, 2C9, 3A4/5) Hyperlipidemia: Statins (CYP2C9, CYP3A4, CYP3A5, SLCO1B1) Multi-drug use/ADR/Non-response: 2D6, 2C19, 2C9, VKORC1, 3A4, 3A5, 1A2, SLCO1B1

5. Genotype Frequency % GeneEMIMPMUM 2D65335102 2C193632428 2C957403NA 3A487121NA 3A511881NA

6. The Problem Reynolds et al. Pers Med 2007;4(1):11-31.

7. 40% 2C9 deficient >70% VKOR sensitivity variant

8. Warfarin Genotyping CYP2C9 sets the rate, affects time to SS (accumulation and elimination) 2.7 ± 1.2 mg 4.2 ± 2.2 mg 6.7 ± 3.3 mg VKORC1 sets the target concentration (predicts warfarin sensitivity)

9. Warfarin Genotyping Guides dose selection – Estimates Maintenance Dose Requirement Guides optimal INR interpretation – Estimates Time to Reach Steady-State

10. CONFIDENTIAL COPYRIGHT PGXL LABORATORIES 2012 CYP2C9 Poor Metabolizer (PM): This patient’s genotype is consistent with significantly reduced CYP2C9 enzymatic activity. Reduced CYP2C9 activity leads to lower dose requirement (e.g., warfarin) due to decreased clearance, increased elimination half-life, and increased time to reach steady-state blood concentrations. VKORC1 Intermediate Warfarin Sensitivity: ‡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.

11. CYP2C9 CelecoxibCelebrex IbuprofenAdvil, Motrin NaproxenAleve GlyburideDiabeta GlipizideGlucotrol TolbutamideOrinase GlimepirideAmaryl PhenytoinDilantin FluvastatinLescol RosuvastatinCrestor LosartanCozaar CONFIDENTIAL COPYRIGHT PGXL LABORATORIES 2012

12. Anti-platelet therapy

13. CYP2C19 - Plavix Clopidogrel (Plavix) is a PRODRUG Active metabolite elicits the desired antiplatelet response ~ 30% of patients have deficiency in CYP2C19 – Decreased amount of active metabolite – High on-treatment platelet reactivity

14. Influence of CYP2C19 on Clopidogrel Response

15. Mega et al. JAMA 2011;23/30; 306(20) Gene-Dose dependency of therapeutic platelet inhibition

16. TreatmentCV EventsBleed EventsICER Genotype guided813340 Clopidogrel1210380$ 6,790 Prasugrel990500$ 11,710 Cost-effectiveness Reese, E.S. et. al., Pharmacotherapy 2012;32(4):323–332 $2.9M $3.9M Cost model based on event occurrence in TRITON-TIMI 38 Genotype-guided therapy selection may be more cost effective and lead to fewer adverse outcomes

17. 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. 2C19 CYP2C19 Poor Metabolizer (PM): This patient’s genotype is consistent with significantly reduced CYP2C19 enzymatic activity. PMs are at increased risk of drug-induced side effects due to diminished drug elimination of active drugs. Patients with no CYP2C19 function (PMs) taking clopidogrel lack adequate antiplatelet response and remain at risk for cardiovascular events, including thrombosis, myocardial infarction, stroke, and death.

18. 2C19 all RESULTSTHERAPEUTIC IMPLICATIONS (adapted from published resources) GenePhenotypeAvoidAlternative ConsiderationAdjust DosageAdjustment

19. CONFIDENTIAL COPYRIGHT PGXL LABORATORIES 2012 CYP2C19 ClopidogrelPlavix CitalopramCelexa EscitalopramLexapro, various ImipramineTofranil SertralineZoloft DiazepamValium OmeprazolePrilosec EsomeprazoleNexium PantoprazoleProtonix RabeprazoleAciphex LansoprazolePrevacid NelfinavirViracept

20. Statin Therapy

21. Statin therapy reduces risk of CV events Statin therapy can lead to muscle weakness – Myalgia – Myopathy – Rhabdomyolysis Genotyping can guide statin choice and dose

22. 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

23. CYP3A4/5 master drug list

24. 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

25. 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 10-20 mg, or consider alternative statin if also SLCO1B1 *5/*5 genotype Atorvastatinmax 10-20 mg Lovastatinmax 10-20 mg Tacrolimusdecrease by up to 40%

26. 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.

27. ~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

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

29. Statin Combo Interpretation 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 10-20 mg 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 10-20 mg, or consider alternative statin if also SLCO1B1 *5/*5 genotype Atorvastatinmax 10-20 mg Lovastatinmax 10-20 mg Tacrolimusdecrease by up to 40%

30. Anti-arrhythmics and Anti-hypertensives

31. 3A4: Ca ++ Channel Blockers 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.

32. **Lack of efficacy due to failure to produce active metabolite; † Increased risk of adverse events due to diminished drug clearance. CONFIDENTIAL COPYRIGHT PGXL LABORATORIES 2012 CYP2D6

34. CONFIDENTIAL COPYRIGHT PGXL LABORATORIES 2012 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, variousAmitriptylineVarious brandsChlorpromazineThorazine TimololBlocadrenClomipramineAnanfranilAtomoxetineStrattera PropafenoneRythmolDesipramineNorpraminAmphetamineAdderall FlecainideTambocorDoxepinSinequan ImipramineTofranil Other Nortriptyline Pamelor, Aventyl LoratadineClaritinTrimipramineSurmontil DonepezilAricept DextromethorphanVarious brands Tamoxifen**Various brands

35. Thrombophilia panel

36. Thrombophilia Panel Factor V Leiden Factor II (prothrombin) MTHFR

37. 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) 20210 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.

38. Thank You! kreynolds@pgxlab.com