GENOTYPE/PHENOTYPE TEST RESULTS - CoreBioLabs

PATIENT:

ACCESSION:

Doe, John

DOB:

APGX-00003

GENDER: M 01/01/1950

FACILITY:

PHYSICIAN:

Access Medical Center

Jane Smith

06/12/2017COLLECTED: REPORTED:

·

REPORTED MEDICATION LISTAripiprazole(Abilify) Clopidogrel(Plavix) Loratadine(Claritin)Metoprolol(Lopressor) Naproxen(Naprosyn) Oxycodone(Percocet)Sertraline(Zoloft)

DRUG-GENE INTERACTIONS

Use with High Caution

PhenotypeMedication Evidence Level

Clopidogrel (Plavix) CYP2C19 Poor Metabolizer Actionable

Clopidogrel (Plavix) active metabolite serum levels may decrease in CYP2C19 poor metabolizers. ACS/PCI patients may be atincreased risk for myocardial infarction, stroke, or stent thrombosis. All other patients are at lower clinical risk. For ACS/PCI patientsconsider prescribing prasugrel (Effient) or ticagrelor (Brilinta) instead. For secondary prevention of stroke or for peripheral arterydisease consider prescribing aspirin or aspirin/dipyridamole (Aggrenox) instead.

Sertraline (Zoloft) CYP2C19 Poor Metabolizer Actionable

Sertraline (Zoloft) serum levels may increase in CYP2C19 poor metabolizers. Patients may be at increased risk for CNS or GI adverseeffects. Consider initiating therapy at a 50% reduction in the recommended dose and titrating to response or prescribing duloxetine(Cymbalta), bupropion (Wellbutrin), or paroxetine (Paxil) instead.

Use with Caution

PhenotypeMedication Evidence Level

Metoprolol (Lopressor) CYP2D6 Intermediate Metabolizer Actionable

Metoprolol (Lopressor) serum levels may increase in CYP2D6 intermediate metabolizers. Patients may be at increased risk for adverseeffects such as bradycardia, hypotension, or dizziness. If clinically necessary, decrease the dose or consider prescribing atenolol(Tenormin), bisoprolol (Zebeta), or nadolol (Corgard) instead.

Aripiprazole (Abilify) CYP2D6 Intermediate Metabolizer Informative

Aripiprazole (Abilify) serum levels may increase in CYP2D6 intermediate metabolizers. Patients may be at increased risk for adverseeffects. If clinically necessary, decrease the dose or consider prescribing ziprasidone (Geodon), olanzapine (Zyprexa), or lurasidone(Latuda) instead.

Oxycodone (Percocet) CYP2D6 Intermediate Metabolizer Actionable

Oxycodone (Percocet) serum levels may increase and active metabolite oxymorphone serum levels may decrease in CYP2D6intermediate metabolizers. Patients may be at increased risk for adverse effects and drug may have decreased efficacy. If clinicallynecessary, consider prescribing morphine, oxymorphone (Opana), hydromorphone (Dilaudid), or non-opioid analgesics instead.

Genetic Marker Genotype Phenotype

5HTT-rs1042173 A/A Homozygote Wild Type

GENOTYPE/PHENOTYPE TEST RESULTS

Case not SignedACCESSION: APGX-00003

Doe, JohnPATIENT:

SIGNED ON:

Page 1 of 31


5HTT-rs25531 T/T Short Form

ABCG2 A/A Homozygote Mutant

ADRA2A G/G Homozygote Wild Type

APOE E3/E3 Indeterminate Metabolizer

BDNF C/C Homozygote Wild Type

COMT G/G Homozygote Wild Type

CYP1A2 *1A/*1A Normal Metabolizer

CYP2B6 *1/*1 Normal Metabolizer

CYP2C19 *2/*2 Poor Metabolizer

CYP2C8 *1A/*1A Normal Metabolizer

CYP2C9 *1/*1 Normal Metabolizer

CYP2D6 *1/*4 Intermediate Metabolizer

CYP3A4 *1/*1 Normal Metabolizer



CYP4F2 C/C Homozygote Wild Type

DBH T/T Homozygote Mutant

DPYD *1/*1 High Activity

DRD1 C/C Homozygote Wild Type

DRD2 A2/A2 Homozygote Wild Type

FactorII A/A Homozygote Mutant

FactorV G/G Homozygote Wild Type

G6PD B/Asahi Heterozygote

GRIK1 A/C Heterozygote

GRIK4 C/C Homozygote Mutant

GRIN2B T/T Homozygote Wild Type

HTR2A C/T Heterozygote

HTR2C-rs1414334 G/G Homozygote Wild Type

HTR2C-rs3813929 T/T Homozygote Mutant

IFNL3 C/C Homozygote Wild Type

MTHFR-1298 A/A Homozygote Wild Type

MTHFR-677 C/C Homozygote Wild Type


Doe, JohnPATIENT:

SIGNED ON:

Page 2 of 31


NAT2 *4/*6 Intermediate Acetylator

OPRM1 A/A Homozygote Wild Type

SLC47A2 G/G Homozygote Wild Type

SLCO1B1 T/T Homozygote Wild Type

TPMT *1/*1 High Activity

UGT1A1 *1/*1 Normal Metabolizer

UGT2B15 *1/*1 Normal Metabolizer

UGT2B7 *1/*1 Normal Metabolizer

VKORC1 G/A Intermediate Sensitivity

ALTERNATIVE MEDICATIONS

Therapeutic Class Standard Precautions Use With Caution High Caution

Cardiology - ACEI/ARBs Irbesartan (Avapro), Losartan(Cozaar)

Cardiology - Antiarrhythmics Amiodarone (Cordarone) Mexiletine (Mexitil), Flecainide(Tambocor), Propafenone

(Rythmol), Lidocaine (Xylocaine)

Cardiology - Anticoagulants Prasugrel (Effient), Ticagrelor(Brilinta)

Warfarin (Coumadin) Clopidogrel (Plavix)

Cardiology - Antihyperlipidemics Lovastatin (Mevacor),Fluvastatin (Lescol),

Rosuvastatin (Crestor),Pitavastatin (Livalo), Fenofibrate

(Tricor), Gemfibrozil (Lopid)

Atorvastatin (Lipitor),Simvastatin (Zocor), Pravastatin

(Pravachol)

Cardiology - Beta-Blockers Bisoprolol (Zebeta) Carvedilol (Coreg), Metoprolol(Lopressor), Nebivolol (Bystolic)

Cardiology - Calcium ChannelBlockers

Diltiazem (Cardizem),Amlodipine (Norvasc),Nifedipine (Procardia),

Felodipine (Plendil), Verapamil

Cardiology - Diuretics Torsemide (Demadex),Triamterene (Component of

Dyazide)

Cardiology - Miscellaneous Clonidine (Catapres), Doxazosin(Cardura)

Hydralazine (Apresoline)

Endocrinology Metformin (Glucophage),Repaglinide (Prandin),

Rosiglitazole (Avandia),Pioglitazone (Actos), Saxagliptin

(Onglyza)

Glimepiride (Amaryl), Glyburide(Diabeta), Glipizide (Glucotrol),

Chlorpropamide (Diabinese)


Doe, JohnPATIENT:

SIGNED ON:

Page 3 of 31


Gastroenterology Promethazine (Phenergan),Ondansetron (Zofran),Palonosetron (Aloxi),

Metoclopramide (Reglan),Scopolamine (Transderm-Scop)

Esomeprazole (Nexium),Lansoprazole (Prevacid),Omeprazole (Prilosec),

Pantoprazole (Protonix),Rabeprazole (Aciphex),

Sulfasalazine (Azulfidine),MoviPrep

Gynecology Medroxyprogesterone(Provera), Desogestrel,

Levonorgestrel, Norethindrone,Etonogestrel, Estrogen

(Premarin), Estradiol (Estrace),Ethinyl Estradiol

Progesterone (Prometrium)

Immunology Sirolimus (Rapamune),Tacrolimus (Prograf),

Cyclosporine (Sandimmune),Azathioprine (Azasan),

Hydroxychloroquine (Plaquenil),Dexamethasone (Decadron),

Prednisone (Deltasone),Prednisolone (Millipred),

Methylprednisolone (Medrol)

Infectious Disease - Antibiotics Clindamycin (Cleocin),Clarithromycin (Biaxin),Metronidazole (Flagyl)

Norfloxacin (Noroxin), NalidixicAcid (NegGram), Sulfisoxazole,

Sulfadiazine (Silvadene),Sulfamethoxazole (component

of Bactrim), Trimethoprim(component of Bactrim),

Erythromycin (Erythrocin),Isoniazid, Quinine (Qualaquin),

Chloroquine (Aralan),Primaquine, Dapsone

Infectious Disease - Antifungals Itraconazole (Sporanox),Ketoconazole (Nizoral),Clotrimazole (Mycelex)

Voriconazole (Vfend)


Doe, JohnPATIENT:

SIGNED ON:

Page 4 of 31


Infectious Disease - Antivirals Efavirenz (Sustiva), Nevirapine(Viramune), Saquinavir

(Invirase), Ritonavir (Norvir),Atazanavir (Reyataz), Ribavirin

(Copegus), Boceprevir(Victrelis), Simeprevir (Olysio),Sofosbuvir (Sovaldi), Telaprevir

(Incivek), Ombitasvir(Component of Viekira),

Paritaprevir (Component ofViekira), Dasabuvir (Exviera),

Daclatasvir (Daklinza),Velpatasvir (Component of

Epclusa), Ledipasvir(Component of Harvoni),Elbasvir (Component ofZepatier), Grazoprevir

(Component of Zepatier),Peginterferon Alfa-2a (Pegasys),

Peginterferon Alfa-2b (PEG-Intron)

Miscellaneous Caffeine, Ethanol, Anti-CocaineVaccine, Naloxone (Narcan),

Naltrexone (Revia), Fluocinonide(Lidex), Triamcinolone

(Kenalog), Hydrocortisone(Cortef), Betamethasone

(Celestone)

Nicotine, Ascorbic Acid, VitaminC, Methylene Blue, Sodium

Nitrite

Disulfiram (Antabuse)

Neurology - Anticonvulsants Fosphenytoin (Cerebyx),Valproic Acid (Depakote),

Divalproex (Depakote),Carbamazepine (Tegretol),

Topiramate (Topamax),Lamotrigine (Lamictal)

Phenobarbital Phenytoin (Dilantin)

Neurology - Miscellaneous Ropinirole (Requip), Selegiline(Zelapar), Zolmitriptan (Zomig),

Eletriptan (Relpax)

Donepezil (Aricept)

Neurology - Sedatives Zolpidem (Ambien), Suvorexant(Belsomra), Eszopiclone

(Lunesta), Ramelteon(Rozerem), Triazolam (Halcion),

Fentanyl (Duragesic),Midazolam (Versed), Meperidine(Demerol), Propofol (Diprivan),

Ketamine (Ketalar)


Doe, JohnPATIENT:

SIGNED ON:

Page 5 of 31


Oncology Cyclophosphamide (Cytoxan),Ifosfamide (Ifex), Paclitaxel

(Taxol), Anastrozole (Arimidex),Letrozole (Femara),

Capecitabine (Xeloda), Cisplatin(Platinol), Fluorouracil (Adrucil),

Irinotecan (Camptosar),Mercaptopurine, Tegafur,

Thioguanine

Dabrafenib (Tafinlar) Tamoxifen

Opthamology Timolol (Timoptic)

Otolaryngology Loratadine (Claritin),Desloratadine (Clarinex)

Chlorpheniramine (Chlor-Trimeton), Dextromethorphan(Delsym), Meclizine (Antivert)

Pain Management -Miscellaneous

Ketamine (Ketalar),Cyclobenzaprine (Flexeril),

Tizanidine (Zanaflex),Duloxetine (Cymbalta)

Lidocaine (Xylocaine), Prilocaine(Emla), Nortriptyline (Pamelor)

Carisoprodol (Soma)

Pain Management - NSAIDs Flurbiprofen (Ansaid),Diclofenac (Voltaren), Naproxen

(Naprosyn), Indomethacin(Indocin), Nabumetone

(Relafen), Celecoxib (Celebrex),Ibuprofen (Motrin), Meloxicam(Mobic), Piroxicam (Feldene)

Pain Management - Opioids Fentanyl (Duragesic),Meperidine (Demerol),

Hydromorphone (Dilaudid),Oxymorphone (Opana),

Morphine, Buprenorphine(Subutex), Methadone

(Dolophine)

Codeine, Hydrocodone(Vicodin), Oxycodone

(Percocet), Tramadol (Ultram)

Psychiatry-ADHD Guanfacine (Intuniv) Atomoxetine (Strattera),Amphetamine (Component ofAdderall), Dextroamphetamine

(Component of Adderall),Lisdexamfetamine (Vyvanse)

Psychiatry-Antidepressants Duloxetine (Cymbalta),Mirtazapine (Remeron),

Vilazodone (Viibryd)

Nortriptyline (Pamelor),Bupropion (Wellbutrin),

Fluoxetine (Prozac), Paroxetine(Paxil), Fluvoxamine (Luvox),

Venlafaxine (Effexor),Trimipramine (Surmontil),Desipramine (Norpramin),

Protriptyline (Vivactil),Trazodone (Desyrel)

Sertraline (Zoloft), Citalopram(Celexa), Escitalopram

(Lexapro), Amitriptyline (Elavil),Doxepin (Sinequan), Imipramine

(Tofranil), Clomipramine(Anafranil)


Doe, JohnPATIENT:

SIGNED ON:

Page 6 of 31


Psychiatry-Antipsychotics Olanzapine (Zyprexa),Quetiapine (Seroquel),Ziprasidone (Geodon),

Lurasidone (Latuda)

Risperidone (Risperdal),Aripiprazole (Abilify),Haloperidol (Haldol)

Clozapine (Clozaril),Thioridazine (Mellaril)

Psychiatry-Anxiolytics Alprazolam (Xanax),Clonazepam (Klonopin),

Lorazepam (Ativan), Oxazepam(Serax)

Buspirone (Buspar) Diazepam (Valium)

Psychiatry-Miscellaneous Modafinil (Provigil), Armodafinil(Nuvigil)

Benztropine (Cogentin), LithiumCarbonate (Lithobid)

Pulmonology Zafirlukast (Accolate),Montelukast (Singulair),Budesonide (Pulmicort)

Rheumatology Azathioprine (Azasan),Colchicine (Colcrys), Lesinurad

(Zurampic)

Sulfasalazine (Azulfidine),Probenecid, Pegloticase

(Krystexxa), Rasburicase (Elitek)

Urology Doxazosin (Cardura),Fesoterodine (Toviaz),Oxybutynin (Ditropan),Darifenacin (Enablex),Solifenacin (Vesicare),Finasteride (Proscar),

Dutasteride (Avodart), Sildenafil(Viagra), Tadalafil (Cialis),

Vardenafil (Levitra), Avanafil(Stendra)

Tolterodine (Detrol), Tamsulosin(Flomax)


Doe, JohnPATIENT:

SIGNED ON:

Page 7 of 31

DOSING GUIDANCE FOR ALTERNATIVE MEDICATIONS

Standard Precautions

Medication Phenotype Evidence Level

Anti-Cocaine Vaccine DBH Homozygote Mutant Informative

Anti-cocaine vaccine may be efficacious in treating cocaine dependence in cocaine and opioid dependent patients.

Azathioprine (Azasan) TPMT High Activity Actionable

Patients taking azathioprine (Azasan) with high TPMT activity have lower serums levels of thioguanine metabolites and higher serumlevels of methylTIMP, which is normal. Initiate therapy at the normal starting dose (e.g. 2-3 mg/kg daily) and adjust further doses basedupon disease-specific guidelines. Allow 2 weeks to reach steady state after each dose adjustment.

Boceprevir (Victrelis) IFNL3 Homozygote Wild Type Actionable

For patients treated with pegylated-interferon alpha 2a or 2b (PEG-IFN alpha) and ribavirin (RBV) alone, approximately 70% chance forsustained virologic response (SVR) after 48 weeks of treatment. For patients treated with protease inhibitor combinations with PEG-IFNalpha and RBV therapy, approximately 90% chance for SVR after 24-48 weeks of treatment. Approximately 80-90% of patients areeligible for shortened therapy (24-28 weeks vs. 48 weeks).

Bupropion (Wellbutrin) DRD2 Homozygote Wild Type Informative

Bupropion may be efficacious in smoking cessation.

Capecitabine (Xeloda) DPYD High Activity Actionable

Capecitabine (Xeloda) may be prescribed and monitored according to standard procedures in patients with normal (high) DPD activity.

Citalopram (Celexa) GRIK4 Homozygote Mutant Informative

Citalopram may have increased efficacy in depressed patients compared to GRIK4 homozygous wild-type patients.

Clonidine (Catapres) CYP2D6 Intermediate Metabolizer Informative

Clonidine (Catapres) may be prescribed and monitored according to standard procedures in CYP2D6 intermediate metabolizers.

Clozapine (Clozaril) HTR2C-rs1414334 Homozygote Wild Type Informative

Schizophrenic and schizoaffective patients are at normal risk for clozapine-induced obesity and metabolic syndrome.

Cyclophosphamide (Cytoxan) CYP2C19 Poor Metabolizer Informative

Cyclophosphamide (Cytoxan) serum levels may increase in CYP2C19 poor metabolizers. Standard dosing regimens may be considereddue to a lack of pharmacokinetic evidence.

Daclatasvir (Daklinza) IFNL3 Homozygote Wild Type Actionable


Dasabuvir (Exviera) IFNL3 Homozygote Wild Type Actionable



Doe, JohnPATIENT:

SIGNED ON:

Page 8 of 31



Diltiazem (Cardizem) CYP2D6 Intermediate Metabolizer Informative

Diltiazem (Cardizem) may be prescribed and monitored according to standard procedures in CYP2D6 intermediate metabolizers.

Duloxetine (Cymbalta) CYP2D6 Intermediate Metabolizer Informative

Duloxetine (Cymbalta) may be prescribed and monitored according to standard procedures in CYP2D6 intermediate metabolizers.

Elbasvir (Component of Zepatier) IFNL3 Homozygote Wild Type Actionable


Fesoterodine (Toviaz) CYP2D6 Intermediate Metabolizer Informative

Fesoterodine (Toviaz) may be prescribed and monitored according to standard procedures in CYP2D6 intermediate metabolizers.

Fluorouracil (Adrucil) DPYD High Activity Actionable

Fluorouracil (Adrucil) may be prescribed and monitored according to standard procedures in patients with normal (high) DPD activity.

Fluoxetine (Prozac) CYP2D6 Intermediate Metabolizer Informative

Fluoxetine (Prozac) serum levels may increase and norfluoxetine serum levels may decrease in CYP2D6 intermediate metabolizers.Standard dosing regimens may be considered due to conflicting evidence demonstrating negative outcomes.

Grazoprevir (Component of Zepatier) IFNL3 Homozygote Wild Type Actionable


Ledipasvir (Component of Harvoni) IFNL3 Homozygote Wild Type Actionable


Mercaptopurine TPMT High Activity Actionable

Patients taking mercaptopurine with high TPMT activity have lower serum levels of thioguanine metabolites and higher serum levels ofmethylTIMP, which is normal. Initiate therapy at the normal starting dose (e.g. 75 mg/m2 daily or 1.5 mg/kg daily) and adjust furtherdoses based upon disease-specific guidelines. Allow 2 weeks to reach steady state after each dose adjustment.

Metformin (Glucophage) SLC47A2 Homozygote Wild Type Informative

Metformin (Glucophage) may be prescribed and monitored according to standard procedures in SLC47A2 homozygous wild-typepatients.


Doe, JohnPATIENT:

SIGNED ON:

Page 9 of 31



Metoclopramide (Reglan) CYP2D6 Intermediate Metabolizer Informative

Metoclopramide (Reglan) may be prescribed and monitored according to standard procedures in CYP2D6 intermediate metabolizers.

Mirtazapine (Remeron) CYP2D6 Intermediate Metabolizer Informative

Mirtazapine (Remeron) serum levels may increase in CYP2D6 intermediate metabolizers. Standard dosing regimens may be considereddue to conflicting evidence demonstrating negative outcomes.

Naltrexone (Revia) OPRM1 Homozygote Wild Type Informative

Average (normal) clinical response to naltrexone in alcoholic patients.

Olanzapine (Zyprexa) HTR2C-rs3813929 Homozygote Mutant Informative

The T allele (rs3813929) may protect against olanzapine-induced weight gain in schizophrenic patients.

Ombitasvir (Component of Viekira) IFNL3 Homozygote Wild Type Actionable


Palonosetron (Aloxi) CYP2D6 Intermediate Metabolizer Informative

Palonosetron (Aloxi) may be prescribed and monitored according to standard procedures in CYP2D6 intermediate metabolizers.

Paritaprevir (Component of Viekira) IFNL3 Homozygote Wild Type Actionable


Peginterferon Alfa-2a (Pegasys) IFNL3 Homozygote Wild Type Actionable


Peginterferon Alfa-2b (PEG-Intron) IFNL3 Homozygote Wild Type Actionable


Pitavastatin (Livalo) SLCO1B1 Homozygote Wild Type Actionable

Prescribe desired statin starting dose and adjust doses based upon disease-specific guidelines.


Doe, JohnPATIENT:

SIGNED ON:

Page 10 of 31



Prasugrel (Effient) CYP2C19 Poor Metabolizer Actionable

There is no relevant effect of genetic variation in CYP2C19 on the pharmacokinetics of prasugrel (Effient) active metabolite or itsinhibition of platelet aggregation. Prasugrel may be prescribed and monitored according to standard procedures.

Pravastatin (Pravachol) SLCO1B1 Homozygote Wild Type Actionable


Promethazine (Phenergan) CYP2D6 Intermediate Metabolizer Informative

Promethazine (Phenergan) may be prescribed and monitored according to standard procedures in CYP2D6 intermediate metabolizers.

Quetiapine (Seroquel) CYP2D6 Intermediate Metabolizer Informative

Quetiapine (Seroquel) may be prescribed and monitored according to standard procedures in CYP2D6 intermediate metabolizers.

Ribavirin (Copegus) IFNL3 Homozygote Wild Type Actionable


Risperidone (Risperdal) HTR2C-rs1414334 Homozygote Wild Type Informative

Schizophrenic and schizoaffective patients are at normal risk for risperidone-induced obesity and metabolic syndrome.

Ritonavir (Norvir) IFNL3 Homozygote Wild Type Actionable


Rosuvastatin (Crestor) ABCG2 Homozygote Mutant Informative

Preliminary evidence suggests that rosuvastatin (Crestor) may have increased efficacy in reducing LDL cholesterol in patients with theA allele.

Rosuvastatin (Crestor) SLCO1B1 Homozygote Wild Type Actionable


Simeprevir (Olysio) IFNL3 Homozygote Wild Type Actionable


Simvastatin (Zocor) SLCO1B1 Homozygote Wild Type Actionable



Doe, JohnPATIENT:

SIGNED ON:

Page 11 of 31



Sofosbuvir (Sovaldi) IFNL3 Homozygote Wild Type Actionable


Sulfamethoxazole (component ofBactrim)

NAT2 Intermediate Acetylator Informative

Sulfamethoxazole (component of Bactrim) may be prescribed and monitored according to standard procedures in NAT2 intermediateacetylators.

Tegafur DPYD High Activity Actionable

Tegafur may be prescribed and monitored according to standard procedures in patients with normal (high) DPD activity.

Telaprevir (Incivek) IFNL3 Homozygote Wild Type Actionable


Thioguanine TPMT High Activity Actionable

Patients taking thioguanine with high TPMT activity have lower serum levels of thioguanine (TGN) metabolites, but note that TGN levelsafter thioguanine are 5-10x higher than after mercaptopurine or azathioprine. Initiate therapy at the normal starting dose and adjustfurther doses based upon disease-specific guidelines. Allow 2 weeks to reach steady state after each dose adjustment.

Topiramate (Topamax) GRIK1 Heterozygote Informative

Topiramate may be prescribed and monitored according to standard procedures in GRIK1 heterozygote patients.

Velpatasvir (Component of Epclusa) IFNL3 Homozygote Wild Type Actionable


Use with Caution


Amitriptyline (Elavil) CYP2D6 Intermediate Metabolizer Actionable

Amitriptyline (Elavil) and metabolite nortriptyline serum levels may increase in CYP2D6 intermediate metabolizers. Patients may be atincreased risk for anticholinergic adverse effects. Consider prescribing a non-tricyclic antidepressant instead. If amitriptyline iswarranted, consider a 25% reduction in the recommended starting dose and utilize therapeutic drug monitoring to further guide dosageadjustment.

Amphetamine (Component of Adderall) CYP2D6 Intermediate Metabolizer Informative

Amphetamine (Component of Adderall) serum levels may increase in CYP2D6 intermediate metabolizers. Patients may be at increasedrisk for adverse effects such as decreased appetite, weight loss, xerostomia, or insomnia. If clinically necessary, decrease the dose orconsider prescribing methylphenidate (Ritalin), dexmethylphenidate (Focalin), or guanfacine (Intuniv) instead.


Doe, JohnPATIENT:

SIGNED ON:

Page 12 of 31

Use with Caution


Aripiprazole (Abilify) CYP2D6 Intermediate Metabolizer Informative

Aripiprazole (Abilify) serum levels may increase in CYP2D6 intermediate metabolizers. Patients may be at increased risk for adverseeffects. If clinically necessary, decrease the dose or consider prescribing ziprasidone (Geodon), olanzapine (Zyprexa), or lurasidone(Latuda) instead.

Ascorbic Acid G6PD Heterozygote Actionable

Ascorbic acid (vitamin C) should be used with caution in patients at unknown risk of acute hemolytic anemia.

Atomoxetine (Strattera) CYP2D6 Intermediate Metabolizer Informative

Atomoxetine (Strattera) serum levels may increase in CYP2D6 intermediate metabolizers. Patients may be at increased risk for adverseeffects. If clinically necessary, decrease the dose or consider prescribing guanfacine (Intuniv), methylphenidate (Ritalin), ordexmethylphenidate (Focalin) instead.

Benztropine (Cogentin) CYP2D6 Intermediate Metabolizer Informative

Benztropine (Cogentin) serum levels may increase in CYP2D6 intermediate metabolizers. Patients may be at increased risk foranticholinergic adverse effects. If clinically necessary, decrease the dose or consider prescribing trihexyphenidyl (Artane) instead.

Bupropion (Wellbutrin) CYP2D6 Intermediate Metabolizer Informative

Bupropion (Wellbutrin) active metabolite hydroxybupropion serum levels may increase in CYP2D6 intermediate metabolizers. Patientsmay be at increased risk for adverse effects. If clinically necessary, decrease the dose or consider prescribing escitalopram (Lexapro),sertraline (Zoloft), or varenicline (Chantix) instead.

Buspirone (Buspar) CYP2D6 Intermediate Metabolizer Informative

Buspirone (Buspar) active metabolite 1-PP serum levels may increase in CYP2D6 intermediate metabolizers. Patients may be atincreased risk for adverse effects. If clinically necessary, decrease the dose or consider prescribing an alternative instead.

Carvedilol (Coreg) CYP2D6 Intermediate Metabolizer Informative

Carvedilol (Coreg) serum levels may increase in CYP2D6 intermediate metabolizers. Patients may be at increased risk for adverseeffects such as bradycardia, hypotension, or dizziness. If clinically necessary, decrease the dose or consider prescribing an alternativeinstead.

Chloroquine (Aralan) G6PD Heterozygote Actionable

Chloroquine (Aralan) should be used with caution in patients at unknown risk of acute hemolytic anemia.

Chlorpheniramine (Chlor-Trimeton) CYP2D6 Intermediate Metabolizer Informative

Chlorpheniramine (Chlor-Trimeton) serum levels may increase in CYP2D6 intermediate metabolizers. Patients may be at increased riskfor anticholinergic adverse effects. If clinically necessary, decrease the dose or consider prescribing diphenhydramine (Benadryl)instead.

Chlorpropamide (Diabinese) G6PD Heterozygote Actionable

Chlorpropamide (Diabinese) should be used with caution in patients at unknown risk of acute hemolytic anemia. Consider prescribing anon-sulfonylurea instead.

Clomipramine (Anafranil) CYP2D6 Intermediate Metabolizer Actionable

Clomipramine (Anafranil) and metabolite desmethylclomipramine serum levels may increase in CYP2D6 intermediate metabolizers.Patients may be at increased risk for anticholinergic adverse effects. Consider prescribing a non-tricyclic antidepressant instead. If


Doe, JohnPATIENT:

SIGNED ON:

Page 13 of 31

Use with Caution


Clomipramine (Anafranil) CYP2D6 Intermediate Metabolizer Actionable

clomipramine is warranted, consider a 25% reduction in the recommended starting dose and utilize therapeutic drug monitoring tofurther guide dosage adjustment.

Codeine CYP2D6 Intermediate Metabolizer Actionable

Codeine active metabolite (morphine) serum levels may decrease in CYP2D6 intermediate metabolizers. Drug may have decreasedefficacy. If patients do not respond to recommended doses, consider prescribing morphine, oxymorphone (Opana), hydromorphone(Dilaudid), or non-opioid analgesics instead.

Dabrafenib (Tafinlar) G6PD Heterozygote Actionable

Dabrafenib (Tafinlar) should be used with caution in patients at unknown risk of acute hemolytic anemia.

Dapsone G6PD Heterozygote Actionable

Dapsone should be used with caution in patients at unknown risk of acute hemolytic anemia.

Desipramine (Norpramin) CYP2D6 Intermediate Metabolizer Actionable

Desipramine (Norpramin) serum levels may increase in CYP2D6 intermediate metabolizers. Patients may be at increased risk foranticholinergic adverse effects. Consider prescribing a non-tricyclic antidepressant instead. If desipramine is warranted, consider a 25%reduction in the recommended starting dose and utilize therapeutic drug monitoring to further guide dosage adjustment.

Dextroamphetamine (Component ofAdderall)

CYP2D6 Intermediate Metabolizer Informative

Dextroamphetamine (Component of Adderall) serum levels may increase in CYP2D6 intermediate metabolizers. Patients may be atincreased risk for adverse effects such as decreased appetite, weight loss, xerostomia, or insomnia. If clinically necessary, decrease thedose or consider prescribing methylphenidate (Ritalin), dexmethylphenidate (Focalin), or guanfacine (Intuniv) instead.

Dextromethorphan (Delsym) CYP2D6 Intermediate Metabolizer Informative

Dextromethorphan (Delsym) serum levels may increase in CYP2D6 intermediate metabolizers. Patients may be at increased risk foradverse effects. If clinically necessary, decrease the dose or consider prescribing an alternative instead.

Donepezil (Aricept) CYP2D6 Intermediate Metabolizer Informative

Donepezil (Aricept) serum levels may increase in CYP2D6 intermediate metabolizers. Patients may be at increased risk for adverseeffects such as headache, insomnia, nausea, or diarrhea. If clinically necessary, decrease the dose or consider prescribing an alternativeinstead.

Doxepin (Sinequan) CYP2D6 Intermediate Metabolizer Actionable

Doxepin (Sinequan) and metabolite nordoxepin serum levels may increase in CYP2D6 intermediate metabolizers. Patients may be atincreased risk for anticholinergic adverse effects. Consider prescribing a non-tricyclic antidepressant instead. If doxepin is warranted,consider a 25% reduction in the recommended starting dose and utilize therapeutic drug monitoring to further guide dosageadjustment.

Erythromycin (Erythrocin) G6PD Heterozygote Actionable

Erythromycin (Erythrocin) should be used with caution in patients at unknown risk of acute hemolytic anemia.

Esomeprazole (Nexium) CYP2C19 Poor Metabolizer Actionable

Esomeprazole (Nexium) serum levels may increase in CYP2C19 poor metabolizers. Patients may be at increased risk for adverseeffects. Drug may have increased efficacy. If clinically necessary, decrease the dose or consider prescribing ranitidine (Zantac) or


Doe, JohnPATIENT:

SIGNED ON:

Page 14 of 31

Use with Caution


Esomeprazole (Nexium) CYP2C19 Poor Metabolizer Actionable

famotidine (Pepcid) instead.

Flecainide (Tambocor) CYP2D6 Intermediate Metabolizer Actionable

Flecainide (Tambocor) serum levels may increase in CYP2D6 intermediate metabolizers. Patients may be at increased risk for adverseeffects such as dizziness, dyspnea, headache, or nausea. Consider reducing the dose by 25%, monitoring ECG, and adjusting basedupon flecainide serum levels. If clinically necessary, consider prescribing an alternative instead.

Fluoxetine (Prozac) CYP2C19 Poor Metabolizer Informative

Fluoxetine (Prozac) serum levels may increase and norfluoxetine serum levels may decrease in CYP2C19 poor metabolizers. Patientsmay be at increased risk for adverse effects such as anxiety, asthenia, nausea, or sleep disturbances. If clinically necessary, decreasethe dose or consider prescribing duloxetine (Cymbalta), bupropion (Wellbutrin), or paroxetine (Paxil) instead.

Fluvoxamine (Luvox) CYP2D6 Intermediate Metabolizer Informative

Fluvoxamine (Luvox) serum levels may increase in CYP2D6 intermediate metabolizers. Patients may be at increased risk for adverseeffects. If clinically necessary, decrease the dose or consider prescribing escitalopram (Lexapro), sertraline (Zoloft), or desvenlafaxine(Pristiq) instead.

Glimepiride (Amaryl) G6PD Heterozygote Actionable

Glimepiride (Amaryl) should be used with caution in patients at unknown risk of acute hemolytic anemia. Consider prescribing a non-sulfonylurea instead.

Glipizide (Glucotrol) G6PD Heterozygote Actionable

Glipizide (Glucotrol) should be used with caution in patients at unknown risk of acute hemolytic anemia. Consider prescribing a non-sulfonylurea instead.

Glyburide (Diabeta) G6PD Heterozygote Actionable

Glyburide (Diabeta) should be used with caution in patients at unknown risk of acute hemolytic anemia. Consider prescribing a non-sulfonylurea instead.

Haloperidol (Haldol) CYP2D6 Intermediate Metabolizer Informative

Haloperidol (Haldol) serum levels may increase in CYP2D6 intermediate metabolizers. Patients may be at increased risk for adverseeffects. If clinically necessary, decrease the dose or consider prescribing an alternative instead.

Hydralazine (Apresoline) NAT2 Intermediate Acetylator Informative

Hydralazine (Apresoline) serum levels may increase in NAT2 intermediate acetylators. Patients may be at increased risk for adverseeffects such as headache, tachycardia, or angina. If clinically necessary, decrease the dose or consider prescribing an alternativeinstead.

Hydrocodone (Vicodin) CYP2D6 Intermediate Metabolizer Informative

Hydrocodone (Vicodin) serum levels may increase and active metabolite hydromorphone serum levels may decrease in CYP2D6intermediate metabolizers. Patients may be at increased risk for adverse effects and drug may have decreased efficacy. If clinicallynecessary, consider prescribing morphine, oxymorphone (Opana), hydromorphone (Dilaudid), or non-opioid analgesics instead.

Imipramine (Tofranil) CYP2D6 Intermediate Metabolizer Actionable

Imipramine (Tofranil) and metabolite desipramine serum levels may increase in CYP2D6 intermediate metabolizers. Patients may be at


Doe, JohnPATIENT:

SIGNED ON:

Page 15 of 31

Use with Caution


Imipramine (Tofranil) CYP2D6 Intermediate Metabolizer Actionable

increased risk for anticholinergic adverse effects. Consider prescribing a non-tricyclic antidepressant instead. If imipramine iswarranted, consider a 25% reduction in the recommended starting dose and utilize therapeutic drug monitoring to further guide dosageadjustment.

Isoniazid NAT2 Intermediate Acetylator Informative

Isoniazid serum levels may increase in NAT2 intermediate acetylators. Patients may be at increased risk for adverse effects such asnausea, vomiting, peripheral neuropathy, or hepatotoxicity. If clinically necessary, decrease the dose or consider prescribing analternative instead.

Lansoprazole (Prevacid) CYP2C19 Poor Metabolizer Actionable

Lansoprazole (Prevacid) serum levels may increase in CYP2C19 poor metabolizers. Patients may be at increased risk for adverseeffects. Drug may have increased efficacy. If clinically necessary, decrease the dose or consider prescribing ranitidine (Zantac) orfamotidine (Pepcid) instead.

Lidocaine (Xylocaine) G6PD Heterozygote Actionable

Lidocaine (Xylocaine) should be used with caution in patients with variable (unknown) G6PD function due to increased susceptibility todrug-induced methemoglobinemia in G6PD deficient patients. Use is contraindicated in patients with congenital methemoglobinemia(cytochrome b5 reductase deficiency).

Lisdexamfetamine (Vyvanse) CYP2D6 Intermediate Metabolizer Informative

Lisdexamfetamine (Vyvanse) active metabolite dextroamphetamine serum levels may increase in CYP2D6 intermediate metabolizers.Patients may be at increased risk for adverse effects such as decreased appetite, weight loss, xerostomia, or insomnia. If clinicallynecessary, decrease the dose or consider prescribing methylphenidate (Ritalin), dexmethylphenidate (Focalin), or guanfacine (Intuniv)instead.

Meclizine (Antivert) CYP2D6 Intermediate Metabolizer Informative

Meclizine (Antivert) serum levels may increase in CYP2D6 intermediate metabolizers. Patients may be at increased risk foranticholinergic adverse effects. If clinically necessary, decrease the dose or consider prescribing dimenhydrinate (Dramamine),diphenhydramine (Benadryl), or a scopolamine patch (Transderm-Scop) instead.

Methylene Blue G6PD Heterozygote Actionable

Methylene Blue should be used with caution in patients at unknown risk of acute hemolytic anemia.

Metoprolol (Lopressor) CYP2D6 Intermediate Metabolizer Actionable

Metoprolol (Lopressor) serum levels may increase in CYP2D6 intermediate metabolizers. Patients may be at increased risk for adverseeffects such as bradycardia, hypotension, or dizziness. If clinically necessary, decrease the dose or consider prescribing atenolol(Tenormin), bisoprolol (Zebeta), or nadolol (Corgard) instead.

Mexiletine (Mexitil) CYP2D6 Intermediate Metabolizer Informative

Mexiletine (Mexitil) serum levels may increase in CYP2D6 intermediate metabolizers. Patients may be at increased risk for adverseeffects such as nausea, vomiting, heartburn, or dizziness. If clinically necessary, decrease the dose or consider prescribing an alternativeinstead.

MoviPrep G6PD Heterozygote Actionable

MoviPrep should be used with caution in patients at unknown risk of acute hemolytic anemia due to it containing vitamin C (ascorbic


Doe, JohnPATIENT:

SIGNED ON:

Page 16 of 31

Use with Caution


MoviPrep G6PD Heterozygote Actionable

acid).

Nalidixic Acid (NegGram) G6PD Heterozygote Actionable

Nalidixic acid (NegGram) should be used with caution in patients at unknown risk of acute hemolytic anemia.

Nebivolol (Bystolic) CYP2D6 Intermediate Metabolizer Informative

Nebivolol (Bystolic) serum levels may increase in CYP2D6 intermediate metabolizers. Patients may be at increased risk for adverseeffects such as bradycardia, hypotension, or dizziness. If clinically necessary, decrease the dose or consider prescribing atenolol(Tenormin), bisoprolol (Zebeta), or nadolol (Corgard) instead.

nitrofurantion G6PD Heterozygote Actionable

Nitrofurantion (Macrobid) should be used with caution in patients at unknown risk of acute hemolytic anemia.

Norfloxacin (Noroxin) G6PD Heterozygote Actionable

Norfloxacin (Noroxin) should be used with caution in patients at unknown risk of acute hemolytic anemia.

Nortriptyline (Pamelor) CYP2D6 Intermediate Metabolizer Actionable

Nortriptyline (Pamelor) serum levels may increase and metabolite 10-hydroxynortriptyline serum levels may decrease in CYP2D6intermediate metabolizers. Patients may be at increased risk for anticholinergic adverse effects. Consider prescribing a non-tricyclicantidepressant instead. If nortriptyline is warranted, consider a 25% reduction in the recommended starting dose and utilize therapeuticdrug monitoring to further guide dosage adjustment.

Omeprazole (Prilosec) CYP2C19 Poor Metabolizer Actionable

Omeprazole (Prilosec) serum levels may increase in CYP2C19 poor metabolizers. Patients may be at increased risk for adverse effects.Drug may have increased efficacy. If clinically necessary, decrease the dose or consider prescribing ranitidine (Zantac) or famotidine(Pepcid) instead.

Oxycodone (Percocet) CYP2D6 Intermediate Metabolizer Actionable

Oxycodone (Percocet) serum levels may increase and active metabolite oxymorphone serum levels may decrease in CYP2D6intermediate metabolizers. Patients may be at increased risk for adverse effects and drug may have decreased efficacy. If clinicallynecessary, consider prescribing morphine, oxymorphone (Opana), hydromorphone (Dilaudid), or non-opioid analgesics instead.

Pantoprazole (Protonix) CYP2C19 Poor Metabolizer Actionable

Pantoprazole (Protonix) serum levels may increase in CYP2C19 poor metabolizers. Patients may be at increased risk for adverseeffects. Drug may have increased efficacy. If clinically necessary, decrease the dose or consider prescribing ranitidine (Zantac) orfamotidine (Pepcid) instead.

Paroxetine (Paxil) CYP2D6 Intermediate Metabolizer Informative

Paroxetine (Paxil) serum levels may increase in CYP2D6 intermediate metabolizers. Patients may be at increased risk for adverseeffects. If clinically necessary, decrease the dose or consider prescribing escitalopram (Lexapro), sertraline (Zoloft), or desvenlafaxine(Pristiq) instead.

Pegloticase (Krystexxa) G6PD Heterozygote Actionable

In patients taking pegloticase (Krystexxa) at unknown risk of acute hemolytic anemia, G6PD enzyme activity must be measured.


Doe, JohnPATIENT:

SIGNED ON:

Page 17 of 31

Use with Caution


Phenobarbital CYP2C19 Poor Metabolizer Informative

Phenobarbital serum levels may increase in CYP2C19 poor metabolizers. Patients may be at increased risk for adverse effects. Ifclinically necessary, decrease the dose or consider prescribing an alternative instead.

Prilocaine (Emla) G6PD Heterozygote Actionable

Prilocaine should be used with caution in patients with variable (unknown) G6PD function due to increased susceptibility to drug-induced methemoglobinemia in G6PD deficient patients. Use is contraindicated in patients with congenital methemoglobinemia(cytochrome b5 reductase deficiency).

Primaquine G6PD Heterozygote Actionable

In patients taking primaquine at unknown risk of acute hemolytic anemia, G6PD enzyme activity must be measured.

Probenecid G6PD Heterozygote Actionable

Probenecid should be used with caution in patients at unknown risk of acute hemolytic anemia.

Progesterone (Prometrium) CYP2C19 Poor Metabolizer Informative

Progesterone (Prometrium) serum levels may increase in CYP2C19 poor metabolizers. Patients may be at increased risk for adverseeffects such as breast tenderness, mood changes, dizziness, headache, or abdominal bloating. If clinically necessary, decrease the doseor consider prescribing an alternative instead.

Propafenone (Rythmol) CYP2D6 Intermediate Metabolizer Actionable

Propafenone (Rythmol) serum levels may increase in CYP2D6 intermediate metabolizers. Patients may be at increased risk for adverseeffects such as altered taste perception, nausea, vomiting, or dizziness. Monitor ECG and consider adjusting the dose based uponpropafenone serum levels. If clinically necessary, consider prescribing an alternative instead.

Protriptyline (Vivactil) CYP2D6 Intermediate Metabolizer Actionable

Protriptyline (Vivactil) serum levels may increase in CYP2D6 intermediate metabolizers. Patients may be at increased risk foranticholinergic adverse effects. Consider prescribing a non-tricyclic antidepressant instead. If protriptyline is warranted, consider a 25%reduction in the recommended starting dose and utilize therapeutic drug monitoring to further guide dosage adjustment.

Quinine (Qualaquin) G6PD Heterozygote Actionable

In patients taking quinine (Qualaquin) at unknown risk of acute hemolytic anemia, G6PD enzyme activity must be measured.

Rabeprazole (Aciphex) CYP2C19 Poor Metabolizer Informative

Rabeprazole (Aciphex) serum levels may increase in CYP2C19 poor metabolizers. Patients may be at increased risk for adverse effects.Drug may have increased efficacy. If clinically necessary, decrease the dose or consider prescribing ranitidine (Zantac) or famotidine(Pepcid) instead.

Rasburicase (Elitek) G6PD Heterozygote Actionable

In patients taking rasburicase (Elitek) at unknown risk of acute hemolytic anemia, G6PD enzyme activity must be measured. If analternative is desired, consider prescribing allopurinol instead.

Risperidone (Risperdal) CYP2D6 Intermediate Metabolizer Actionable

Risperidone (Risperdal) serum levels may increase in CYP2D6 intermediate metabolizers. Patients may be at increased risk for adverseeffects. If clinically necessary, decrease the dose or consider prescribing ziprasidone (Geodon), olanzapine (Zyprexa), or lurasidone(Latuda) instead.


Doe, JohnPATIENT:

SIGNED ON:

Page 18 of 31

Use with Caution


Sodium Nitrite G6PD Heterozygote Actionable

Sodium nitrite should be used with caution in patients at unknown risk of acute hemolytic anemia. Monitor patients for an acute drop inhematocrit or consider prescribing an alternative instead.

Sulfadiazine (Silvadene) G6PD Heterozygote Actionable

Sulfadiazine (Silvadene) should be used with caution in patients at unknown risk of acute hemolytic anemia.

Sulfamethoxazole (component ofBactrim)

G6PD Heterozygote Actionable

Sulfamethoxazole (component of Bactrim) should be used with caution in patients at unknown risk of acute hemolytic anemia.

Sulfasalazine (Azulfidine) NAT2 Intermediate Acetylator Informative

Sulfasalazine (Azulfidine) active metabolite sulfapyridine serum levels may increase in NAT2 intermediate acetylators. Patients may beat increased risk for adverse effects such as nausea, dyspepsia, or dermatitis. If clinically necessary, decrease the dose or considerprescribing an alternative instead.

Sulfasalazine (Azulfidine) G6PD Heterozygote Actionable

Sulfasalazine (Azulfidine) should be used with caution in patients at unknown risk of acute hemolytic anemia.

Sulfisoxazole G6PD Heterozygote Actionable

Sulfisoxazole should be used with caution in patients at unknown risk of acute hemolytic anemia.

Tamsulosin (Flomax) CYP2D6 Intermediate Metabolizer Informative

Tamsulosin (Flomax) serum levels may increase in CYP2D6 intermediate metabolizers. Patients may be at increased risk for adverseeffects such as orthostatic hypotension, dizziness, headache, or ejaculatory dysfunction. If clinically necessary, decrease the dose orconsider prescribing an alternative instead.

Timolol (Timoptic) CYP2D6 Intermediate Metabolizer Informative

Timolol serum levels may increase in CYP2D6 intermediate metabolizers. Patients may be at increased risk for adverse effects such asbradycardia, dizziness, or fatigue. If clinically necessary, decrease the dose or consider prescribing an alternative instead.

Tolterodine (Detrol) CYP2D6 Intermediate Metabolizer Informative

Tolterodine (Detrol) serum levels may increase in CYP2D6 intermediate metabolizers. Patients may be at increased risk foranticholinergic adverse effects such as QTc prolongation. If clinically necessary, decrease the dose or consider prescribing oxybutynin(Ditropan), solifenacin (Vesicare), or mirabegron (Myrbetriq) instead.

Tramadol (Ultram) CYP2D6 Intermediate Metabolizer Actionable

Tramadol (Ultram) active metabolite M1 serum levels may decrease in CYP2D6 intermediate metabolizers. Drug may have decreasedefficacy. If clinically necessary, increase the dose or consider prescribing morphine, oxymorphone (Opana), hydromorphone (Dilaudid),or non-opioid analgesics instead.

Trazodone (Desyrel) CYP2D6 Intermediate Metabolizer Informative

Trazodone (Desyrel) active metabolite mCPP serum levels may increase in CYP2D6 intermediate metabolizers. Patients may be atincreased risk for adverse effects such as dizziness, anxiety, seizures, or exacerbation of psychiatric symptoms. If clinically necessary,decrease the dose or consider prescribing an alternative instead.


Doe, JohnPATIENT:

SIGNED ON:

Page 19 of 31

Use with Caution


Trimethoprim (component of Bactrim) G6PD Heterozygote Actionable

Trimethoprim should be used with caution in patients at unknown risk of acute hemolytic anemia.

Trimipramine (Surmontil) CYP2D6 Intermediate Metabolizer Actionable

Trimipramine (Surmontil) and metabolite desmethyltrimipramine serum levels may increase in CYP2D6 intermediate metabolizers.Patients may be at increased risk for anticholinergic adverse effects. Consider prescribing a non-tricyclic antidepressant instead. Iftrimipramine is warranted, consider a 25% reduction in the recommended starting dose and utilize therapeutic drug monitoring tofurther guide dosage adjustment.

Venlafaxine (Effexor) CYP2D6 Intermediate Metabolizer Actionable

Venlafaxine (Effexor) serum levels may increase and active metabolite desvenlafaxine serum levels may decrease in CYP2D6intermediate metabolizers. Patients may be at increased risk for adverse effects and drug may have decreased efficacy. If clinicallynecessary, consider prescribing escitalopram (Lexapro), sertraline (Zoloft), or desvenlafaxine (Pristiq) instead.

Vitamin C G6PD Heterozygote Actionable

Vitamin C (ascorbic acid) should be used with caution in patients at unknown risk of acute hemolytic anemia.

Warfarin (Coumadin) CYP4F2 Homozygote Wild Type Actionable

Patients may require lower doses of warfarin on average. These results should be taken into account with CYP2C9, VKORC1, andlifestyle factors at warfarindosing.org.

Warfarin (Coumadin) VKORC1 Intermediate Sensitivity Actionable

Patients may need lower doses of warfarin on average. These results should be taken into account with CYP2C9 and lifestyle factors atwarfarindosing.org.



Amitriptyline (Elavil) CYP2C19 Poor Metabolizer Actionable

Amitriptyline (Elavil) serum levels may increase and nortriptyline serum levels may decrease in CYP2C19 poor metabolizers. Patientsmay be at increased risk for anticholinergic adverse effects. Consider prescribing an alternative tricyclic antidepressant such asnortriptyline (Pamelor), desipramine (Norpramin), or protriptyline (Vivactil) instead. If amitriptyline is warranted, consider a 50%reduction in the recommended starting dose and utilize therapeutic drug monitoring to further guide dosage adjustment.

Carisoprodol (Soma) CYP2C19 Poor Metabolizer Actionable

Carisoprodol (Soma) serum levels may increase and meprobamate serum levels may decrease in CYP2C19 poor metabolizers. Patientsmay be at increased risk for adverse effects such as dizziness, drowsiness, or headache. If clinically necessary, consider prescribingcyclobenzaprine (Flexeril), tizanidine (Zanaflex), or baclofen (Lioresal) instead.

Citalopram (Celexa) CYP2C19 Poor Metabolizer Actionable

Citalopram (Celexa) serum levels may increase in CYP2C19 poor metabolizers. Patients may be at increased risk for adverse effectssuch as nausea, xerostomia, sleep disturbances, or QTc prolongation. Consider initiating therapy at a 50% reduction in therecommended dose and titrating to response, with a maximum dose of 20mg daily, or prescribing duloxetine (Cymbalta), bupropion(Wellbutrin), or paroxetine (Paxil) instead.


Doe, JohnPATIENT:

SIGNED ON:

Page 20 of 31



Clomipramine (Anafranil) CYP2C19 Poor Metabolizer Actionable

Clomipramine (Anafranil) serum levels may increase and desmethylclomipramine serum levels may decrease in CYP2C19 poormetabolizers. Patients may be at increased risk for anticholinergic adverse effects. Consider prescribing an alternative tricyclicantidepressant such as nortriptyline (Pamelor), desipramine (Norpramin), or protriptyline (Vivactil) instead. If clomipramine is warranted,consider a 50% reduction in the recommended starting dose and utilize therapeutic drug monitoring to further guide dosageadjustment.

Clopidogrel (Plavix) CYP2C19 Poor Metabolizer Actionable

Clopidogrel (Plavix) active metabolite serum levels may decrease in CYP2C19 poor metabolizers. ACS/PCI patients may be atincreased risk for myocardial infarction, stroke, or stent thrombosis. All other patients are at lower clinical risk. For ACS/PCI patientsconsider prescribing prasugrel (Effient) or ticagrelor (Brilinta) instead. For secondary prevention of stroke or for peripheral arterydisease consider prescribing aspirin or aspirin/dipyridamole (Aggrenox) instead.

Clozapine (Clozaril) CYP2C19 Poor Metabolizer Informative

Clozapine (Clozaril) and active metabolite norclozapine serum levels may increase in CYP2C19 poor metabolizers. Patients may be atincreased risk for adverse effects. If clinically necessary, decrease the dose or consider prescribing ziprasidone (Geodon), quetiapine(Seroquel), or lurasidone (Latuda) instead.

Diazepam (Valium) CYP2C19 Poor Metabolizer Actionable

Diazepam (Valium) serum levels may increase in CYP2C19 poor metabolizers. Patients may be at increased risk for adverse effectssuch as drowsiness, fatigue, or ataxia. If clinically necessary, decrease the dose or consider prescribing lorazepam (Ativan), clonazepam(Klonopin), or alprazolam (Xanax) instead.

Disulfiram (Antabuse) DBH Homozygote Mutant Informative

Disulfiram may be ineffective in treating cocaine dependence in cocaine- and opioid-codependent patients stabilized on methadone fortwo weeks.

Doxepin (Sinequan) CYP2C19 Poor Metabolizer Actionable

Doxepin (Sinequan) serum levels may increase in CYP2C19 poor metabolizers. Patients may be at increased risk for anticholinergicadverse effects. Consider prescribing an alternative tricyclic antidepressant such as nortriptyline (Pamelor), desipramine (Norpramin), orprotriptyline (Vivactil) instead. If doxepin is warranted, consider a 50% reduction in the recommended starting dose and utilizetherapeutic drug monitoring to further guide dosage adjustment.

Escitalopram (Lexapro) CYP2C19 Poor Metabolizer Actionable

Escitalopram (Lexapro) serum levels may increase in CYP2C19 poor metabolizers. Patients may be at increased risk for adverse effectssuch as nausea, diarrhea, sleep disturbances, or sexual dysfunction. Consider initiating therapy at a 50% reduction in the recommendeddose and titrating to response or prescribing duloxetine (Cymbalta), bupropion (Wellbutrin), or paroxetine (Paxil) instead.

Imipramine (Tofranil) CYP2C19 Poor Metabolizer Actionable

Imipramine (Tofranil) serum levels may increase and desipramine serum levels may decrease in CYP2C19 poor metabolizers. Patientsmay be at increased risk for anticholinergic adverse effects. Consider prescribing an alternative tricyclic antidepressant such asnortriptyline (Pamelor), desipramine (Norpramin), or protriptyline (Vivactil) instead. If imipramine is warranted, consider a 50% reductionin the recommended starting dose and utilize therapeutic drug monitoring to further guide dosage adjustment.

Phenytoin (Dilantin) CYP2C19 Poor Metabolizer Actionable

Phenytoin (Dilantin) serum levels may increase in CYP2C19 poor metabolizers. Patients may be at increased risk for adverse effectssuch as ataxia, dizziness, nystagmus, or dermatologic reactions. Adjust dose based upon phenytoin serum levels or consider prescribing


Doe, JohnPATIENT:

SIGNED ON:

Page 21 of 31



Phenytoin (Dilantin) CYP2C19 Poor Metabolizer Actionable

carbamazepine (Tegretol), lamotrigine (Lamictal), or levetiracetam (Keppra) instead.

Sertraline (Zoloft) CYP2C19 Poor Metabolizer Actionable

Sertraline (Zoloft) serum levels may increase in CYP2C19 poor metabolizers. Patients may be at increased risk for CNS or GI adverseeffects. Consider initiating therapy at a 50% reduction in the recommended dose and titrating to response or prescribing duloxetine(Cymbalta), bupropion (Wellbutrin), or paroxetine (Paxil) instead.

Tamoxifen CYP2D6 Intermediate Metabolizer Actionable

Tamoxifen active metabolite endoxifen serum levels may decrease in CYP2D6 intermediate metabolizers. Drug may have decreasedefficacy. In postmenopausal women, consider prescribing an aromatase inhibitor instead.

Thioridazine (Mellaril) CYP2D6 Intermediate Metabolizer Actionable

Thioridazine (Mellaril) is contraindicated in CYP2D6 intermediate metabolizers due to an increased risk of QTc prolongation, Torsadesde pointes, and sudden death.

Voriconazole (Vfend) CYP2C19 Poor Metabolizer Actionable

Voriconazole (Vfend) serum levels may increase in CYP2C19 poor metabolizers. Patients may be at increased risk for adverse effects.Consider prescribing posaconazole (Noxafil), itraconazole (Sporanox), or liposomal amphotericin B (Ambisome) as primary therapy. Inthe event that voriconazole is considered to be the most appropriate agent, administer at a lower than standard dosage with carefultherapeutic drug monitoring.

DRUG TO DRUG INTERACTIONS

Use with Caution

AmitriptylineAmiodarone Artemisinin Carbamazepine Celecoxib

Chloramphenicol Chlorpheniramine Chlorpromazine Cimetidine

Citalopram Clemastine Clomipramine Cocaine

Delavirdine Dexamethasone Diphenhydramine Doxepin

Doxorubicin Duloxetine Efavirenz Escitalopram

Esomeprazole Felbamate Fluoxetine Fluvoxamine

Halofantrine Haloperidol Hydroxyzine Imipramine

Indomethacin Ketoconazole Levomepromazine Methadone

Metoclopramide Mibefradil Midodrine Moclobemide

Modafinil Norethindrone Oral Contraceptives Oxcarbazepine

Pantoprazole Perphenazine Pimozide Prednisone

Probenicid Promethazine Quinine Rabeprazole

Ranitidine Rifampicin Rifampin Ritonavir

Sertraline St john's wort Terbinafine Ticlopidine

Topiramate Tripelennamine

Amphetamine

Below are known drug to drug interactions that may effect the patient.


Doe, JohnPATIENT:

SIGNED ON:

Page 22 of 31

Use with CautionAmiodarone Celecoxib Chlorpheniramine Chlorpromazine

Cimetidine Citalopram Clemastine Clomipramine

Cocaine Dexamethasone Diphenhydramine Doxepin

Doxorubicin Duloxetine Escitalopram Halofantrine

Haloperidol Hydroxyzine Imipramine Levomepromazine

Methadone Metoclopramide Mibefradil Midodrine

Moclobemide Perphenazine Pimozide Promethazine

Quinine Ranitidine Rifampin Ritonavir

Sertraline Terbinafine Ticlopidine Tripelennamine

AripiprazoleAmiodarone Celecoxib Chlorpheniramine Chlorpromazine









AtomoxetineAmiodarone Celecoxib Chlorpheniramine Chlorpromazine









CelecoxibAprepitant Carbamazepine Cimetidine Efavirenz

Fenofibrate Fluoxetine Fluvastatin Fluvoxamine

Isoniazid Ketoconazole Lovastatin Modafinil

Phenobarbital Phenylbutazone Probenicid Rifampin

Secobarbital Sertraline St john's wort Sulfamethoxazole

Sulfaphenazole Teniposide Voriconazole Zafirlukast

CitalopramArtemisinin Carbamazepine Chloramphenicol Cimetidine

Delavirdine Efavirenz Esomeprazole Felbamate

Fluoxetine Fluvoxamine Indomethacin Ketoconazole


Pantoprazole Prednisone Probenicid Rabeprazole

Rifampicin St john's wort Ticlopidine Topiramate


Doe, JohnPATIENT:

SIGNED ON:

Page 23 of 31

Use with Caution

ClomipramineAmiodarone Celecoxib Chlorpheniramine Chlorpromazine









ClozapineAmiodarone Beta-naphthoflavone Broccoli (food) Brussel sprouts (food)

Carbamazepine Char-grilled meat (food) Charbroiled meat Cimetidine

Ciprofloxacin Danshen tincture Fluoroquinolones Fluvoxamine

Furafylline Griseofulvin Insulin Interferon

Marijuana (smoke) Methoxsalen Methylcholanthrene Mibefradil

Modafinil Nafcillin Norfloxacin Ofloxacin

Omeprazole Ritonavir Ticlopidine Tobacco (smoke)

Verapamil Zileuton

CodeineAmiodarone Amitriptyline Androsterone Canrenone

Celecoxib Chlorpheniramine Chlorpromazine Cimetidine


Diclofenac Diphenhydramine Doxepin Doxorubicin

Duloxetine Efavirenz Escitalopram Fluconazole


Levomepromazine Medroxyprogesterone acetate Methadone Metoclopramide

Mibefradil Midodrine Moclobemide Perphenazine

Pimozide Promethazine Quinidine Quinine

Ranitidine Ritonavir Sertraline Spironolactone

Terbinafine Ticlopidine Tripelennamine

DesipramineAmiodarone Celecoxib Chlorpheniramine Chlorpromazine










Doe, JohnPATIENT:

SIGNED ON:

Page 24 of 31

Use with Caution

DiazepamArtemisinin Barbiturates Carbamazepine Chloramphenicol

Cimetidine Delavirdine Efavirenz Esomeprazole

Felbamate Felbamate Fluoxetine Fluvoxamine

Glucocorticoids Indomethacin Ketoconazole Modafinil

Modafinil Nevirapine Norethindrone Oral Contraceptives

Oxcarbazepine Oxcarbazepine Pantoprazole Phenobarbital

Phenytoin Pioglitazone Prednisone Primidone

Probenicid Rabeprazole Rifabutin Rifampicin

Rifampin St john's wort Ticlopidine Topiramate

Topiramate Troglitazone

DiclofenacAmiodarone Aprepitant Carbamazepine Cimetidine

Efavirenz Fenofibrate Fluconazole Fluoxetine

Fluvastatin Fluvoxamine Isoniazid Ketoconazole

Lovastatin Modafinil Phenobarbital Phenylbutazone

Probenicid Rifampin Secobarbital Sertraline

St john's wort Sulfamethoxazole Sulfaphenazole Teniposide

Voriconazole Zafirlukast

DihydrocodeineAmiodarone Amitriptyline Androsterone Canrenone

Celecoxib Chlorpheniramine Chlorpromazine Cimetidine


Diclofenac Diphenhydramine Doxepin Doxorubicin

Duloxetine Efavirenz Escitalopram Fluconazole


Levomepromazine Medroxyprogesterone acetate Methadone Metoclopramide


Pimozide Promethazine Quinidine Quinine

Ranitidine Ritonavir Sertraline Spironolactone

Terbinafine Ticlopidine Tripelennamine

DoxepinAmiodarone Celecoxib Chlorpheniramine Chlorpromazine









Escitalopram


Doe, JohnPATIENT:

SIGNED ON:

Page 25 of 31

Use with CautionArtemisinin Carbamazepine Chloramphenicol Cimetidine






FentanylBarbiturates Carbamazepine Efavirenz Felbamate

Glucocorticoids Modafinil Nevirapine Oxcarbazepine

Phenobarbital Phenytoin Pioglitazone Primidone

Rifabutin Rifampin St john's wort Topiramate

Troglitazone

FluoxetineAmiodarone Aprepitant Carbamazepine Celecoxib

Chlorpheniramine Chlorpromazine Cimetidine Citalopram

Clemastine Clomipramine Cocaine Dexamethasone

Diphenhydramine Doxepin Doxorubicin Duloxetine

Escitalopram Halofantrine Haloperidol Hydroxyzine

Imipramine Levomepromazine Methadone Metoclopramide


Phenobarbital Pimozide Promethazine Quinine

Ranitidine Rifampin Ritonavir Secobarbital


Tripelennamine

FluvoxamineAmiodarone Beta-naphthoflavone Broccoli (food) Brussel sprouts (food)







Verapamil Zileuton

HaloperidolAmiodarone Celecoxib Chlorpheniramine Chlorpromazine










Doe, JohnPATIENT:

SIGNED ON:

Page 26 of 31

Use with Caution

HydrocodoneAmiodarone Aprepitant Barbiturates Boceprevir

Carbamazepine Cimetidine Ciprofloxacin Clarithromycin

Delavirdine Diethyl-dithiocarbamate Diltiazem Efavirenz

Erythromycin Felbamate Fluconazole Fluvoxamine

Gestodene Glucocorticoids Grapefruit (food) Imatinib

Indinavir Itraconazole Ketoconazole Mibefradil

Miconazole Mifepristone Modafinil Nefazodone

Nelfinavir Nevirapine Norfloxacin Norfluoxetine

Oxcarbazepine Phenobarbital Phenytoin Pioglitazone

Primidone Rifabutin Rifampin Ritonavir

Saquinavir St john's wort Starfruit (food) Telaprevir

Telithromycin Topiramate Troglitazone Verapamil

Voriconazole

HydromorphoneAmitriptyline Androsterone Canrenone Diclofenac

Efavirenz Fluconazole Medroxyprogesterone acetate Quinidine

Quinine Rifampin Spironolactone

IbuprofenAmiodarone Aprepitant Carbamazepine Cimetidine







ImipramineAmiodarone Artemisinin Carbamazepine Celecoxib

Chloramphenicol Chlorpheniramine Chlorpromazine Cimetidine


Delavirdine Dexamethasone Diphenhydramine Doxepin

Doxorubicin Duloxetine Efavirenz Escitalopram

Esomeprazole Felbamate Fluoxetine Fluvoxamine


Indomethacin Ketoconazole Levomepromazine Methadone



Pantoprazole Perphenazine Pimozide Prednisone

Probenicid Promethazine Quinine Rabeprazole

Ranitidine Rifampicin Rifampin Ritonavir


Topiramate Tripelennamine


Doe, JohnPATIENT:

SIGNED ON:

Page 27 of 31

Use with Caution

LornoxicamAmiodarone Aprepitant Carbamazepine Cimetidine







MeloxicamAmiodarone Aprepitant Carbamazepine Cimetidine







MethadoneEfavirenz Nelfinavir Phenobarbital Phenytoin

Rifampin Ritonavir

MorphineAmitriptyline Androsterone Canrenone Diclofenac


Quinine Spironolactone

NaloxoneAmitriptyline Androsterone Canrenone Diclofenac


Quinine Spironolactone

NaproxenAmiodarone Aprepitant Carbamazepine Cimetidine







NortriptylineAmiodarone Celecoxib Chlorpheniramine Chlorpromazine







Doe, JohnPATIENT:

SIGNED ON:

Page 28 of 31

Use with CautionMoclobemide Perphenazine Pimozide Promethazine



OlanzepineAmiodarone Beta-naphthoflavone Broccoli (food) Brussel sprouts (food)







Verapamil Zileuton

OxycodoneAmiodarone Aprepitant Barbiturates Boceprevir

Carbamazepine Cimetidine Ciprofloxacin Clarithromycin

Delavirdine Diethyl-dithiocarbamate Diltiazem Efavirenz

Erythromycin Felbamate Fluconazole Fluvoxamine

Gestodene Glucocorticoids Grapefruit (food) Imatinib

Indinavir Itraconazole Ketoconazole Mibefradil

Miconazole Mifepristone Modafinil Nefazodone

Nelfinavir Nevirapine Norfloxacin Norfluoxetine

Oxcarbazepine Phenobarbital Phenytoin Pioglitazone

Primidone Rifabutin Rifampin Ritonavir

Saquinavir St john's wort Starfruit (food) Telaprevir

Telithromycin Topiramate Troglitazone Verapamil

Voriconazole

OxymorphoneAmitriptyline Androsterone Canrenone Diclofenac


Quinine Rifampin Spironolactone

ParoxetineAmiodarone Celecoxib Chlorpheniramine Chlorpromazine









PiroxicamAmiodarone Aprepitant Carbamazepine Cimetidine


Doe, JohnPATIENT:

SIGNED ON:

Page 29 of 31

Use with CautionEfavirenz Fenofibrate Fluconazole Fluoxetine






RisperidoneAmiodarone Celecoxib Chlorpheniramine Chlorpromazine









SertralineArtemisinin Carbamazepine Chloramphenicol Cimetidine






SufentanilBarbiturates Carbamazepine Efavirenz Felbamate

Glucocorticoids Modafinil Nevirapine Oxcarbazepine

Phenobarbital Phenytoin Pioglitazone Primidone

Rifabutin Rifampin St john's wort Topiramate

Troglitazone

SuprofenAmiodarone Aprepitant Carbamazepine Cimetidine







TacrineBeta-naphthoflavone Broccoli (food) Brussel sprouts (food) Carbamazepine

Char-grilled meat (food) Charbroiled meat Cimetidine Danshen tincture

Fluoroquinolones Furafylline Griseofulvin Insulin

Interferon Marijuana (smoke) Methoxsalen Methylcholanthrene


Doe, JohnPATIENT:

SIGNED ON:

Page 30 of 31

Use with CautionMibefradil Modafinil Nafcillin Norfloxacin

Ofloxacin Omeprazole Ritonavir Ticlopidine

Tobacco (smoke) Verapamil Zileuton

TramadolAmiodarone Celecoxib Chlorpheniramine Chlorpromazine


Cocaine Diphenhydramine Doxepin Doxorubicin

Duloxetine Escitalopram Halofantrine Haloperidol

Hydroxyzine Imipramine Levomepromazine Methadone


Perphenazine Pimozide Promethazine Quinine

Ranitidine Ritonavir Sertraline Terbinafine

Ticlopidine Tripelennamine

VenlafaxineAmiodarone Celecoxib Chlorpheniramine Chlorpromazine










Doe, JohnPATIENT:

SIGNED ON:

Page 31 of 31

Documents

GENOTYPE/PHENOTYPE TEST RESULTS - CoreBioLabs