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Table of Valid Genomic Biomarkers in the Context of Approved Drug Labels

Pharmacogenomic information is contained in about ten percent of labels for drugs approved by the FDA. A significant increase of labels containing such information has been observed over the last decade. In order to provide a reference for genomic biomarkers in labels of FDA-approved drug products, we created the table shown below. Genomic biomarkers can play an important role in identifying responders and non-responders, avoiding toxicity and adjusting the dosage of drugs to optimize their efficacy and safety. In the context of drug labels, these genomic biomarkers can be classified on the basis of their specific use, for example:

  • Clinical response and differentiation,
  • Risk identification,
  • Dose selection guidance,
  • Susceptibility, resistance and differential disease diagnosis,
  • Polymorphic drug targets.

The table portrays a view on valid genomic biomarkers in the context of FDA-approved drug labels. It provides a comprehensive list of these markers and links to pharmacogenomic data, taking into account multiple regulatory contexts in which these biomarkers were approved. Most drug labels in this table provide pharmacogenomic information with no immediate recommendation for a specific action (i.e. genetic testing); however a few labels recommend or require genetic testing thereby specifying the use of these markers for reaching a therapeutic decision.

The table includes:

  • Context-specific biomarker (column 1)
  • Reference drug label information about the biomarker context within which the drug was approved (column 2 subsection 1)
  • Test criteria (column 2 subsection 2)
  • Prototypic drug associated with the label information defining the biomarker context (column 2 subsection 3)
  • Other drugs in a similar context (column 3)
  • Pertinent references (column 4).

Drugs sharing the context of a specific biomarker in their labels have had their pharmacogenomic information extracted into this table. This information can be accessed by placing the mouse over the symbol under the right side of the drug name. All approved drugs in this table are linked to labels at Drugs@FDA which can be accessed by clicking over symbols under the left side of the drug name. The table will be updated on a quarterly basis.

The information provided in “label context” is taken from different sections of the actual drug labels.

The term “valid” biomarker has been defined in the “Guidance for Industry: Pharmacogenomic Data Submissions”. Therein, a valid biomarker is described as a “biomarker that is measured in an analytical test system with well established performance characteristics and for which there is an established scientific framework or body of evidence that elucidates the physiologic, toxicologic, pharmacologic, or clinical significance of the test results.” The classification of biomarkers is context specific.

A critical aspect of many of these drugs is the role they play in drug-drug interactions.  This list does not address drug-drug interactions.  More information on drug-drug interactions, please see Drug Development and Drug Interactions.

Reference is made to the requirement of testing for the biomarker: 
1 = test required;  
2 = test recommended;  2* test for at risk populations
3 = information only

Biomarker Label Context Examples of other Drugs Associated with this Biomarker References
(PubMed ID)

Representative Label




C-KIT expression

Gastrointestinal stromal tumor c-Kit expressionIn vitro, imatinib inhibits proliferation and induces apoptosis in gastro-intestinal stromal tumor (GIST) cells, which express an activating c-kit mutation.” “Gleevec is also indicated for the treatment of patients with Kit (CD117) positive unresectable and/or metastatic malignant gastrointestinal stromal tumors (GIST).”


Imatinib mesylate



CCR5 -Chemokine C-C motif receptor

CCR5 is a receptor site on the human T-cell that HIV uses to bind to the cell allowing it to enter and begin replication.
 “SELZENTRY, in combination with other antiretroviral agents, is indicated for treatment experienced adult patients infected with only CCR5-tropic HIV-1 detectable, who have evidence of viral replication and HIV-1 strains resistant to multiple antiretroviral agents.”
“SELZENTRY blocks a specific receptor called CCR5 that CCR5-tropic HIV-1 uses to enter CD4 or T-cells in your blood. Your doctor will do a blood test to see if you have been infected with CCR5-tropic HIV-1 before prescribing SELZENTRY for you.” “Pharmacogenomics The impact of CCR5 promoter and coding sequence polymorphisms on the efficacy of maraviroc is being evaluated.”





CYP2C19 Variants

CYP2C19 Variants (Poor Metabolizers-PM and Extensive Metabolizers-EM) with genetic defect leads to change in drug exposure. “In vivo studies indicated that CYP2C19 is significantly involved in the metabolism of voriconazole. This enzyme exhibits genetic polymorphism. For example, 15-20% of Asian populations may be expected to be poor metabolizers. For Caucasians and Blacks, the prevalence of poor metabolizers is 3-5%. Studies conducted in Caucasian and Japanese healthy subjects have shown that poor metabolizers have, on average, 4-fold higher voriconazole exposure (AUCτ) than their homozygous extensive metabolizer counterparts. Subjects who are heterozygous extensive metabolizers have, on average, 2-fold higher voriconazole exposure than their homozygous extensive metabolizer counterparts.”



Pantoprazole [m2]  


CYP2C9 Variants

CYP2C9 Variants PM and EM genotypes and drug exposure; “Patients who are known or suspected to be P450 2C9 poor metabolizers based on a previous history should be administered celecoxib with caution as they may have abnormally high plasma levels due to reduced metabolic clearance.”





CYP2C9 Variants with Alternate Context

CYP2C9 Variant genotypes and drug dose “The analysis suggested an increased bleeding risk for patients carrying either the CYP2C9*2 or CYP2C9*3 alleles. Patients carrying at least one copy of the CYP2C9*2 allele required a mean daily warfarin dose that was 17% less than the mean daily dose for patients homozygous for the CYP2C9*1 allele. For patients carrying at least one copy of the CYP2C9*3 allele, the mean daily warfarin dose was 37% less than the mean daily dose for patients homozygous for the CYP2C9*1 allele”





CYP2D6 Variants

CYP2D6 Variants “Atomoxetine is metabolized primarily through the CYP2D6 enzymatic pathway. People with reduced activity in this pathway (PMs) have higher plasma concentrations of atomoxetine compared with people with normal activity (EMs).”



Tiotropium  bromide inhalation;[m10] 
Timolol Maleate;[m12] 



CYP2D6 with alternate Context

CYP2D6 PM and EM Variants and drug exposure and risk- “population, who are known to have a genetic defect leading to reduced levels of activity of P450 2D6. Fluoxetine, like other agents that are metabolized by P450IID6, inhibits the activity of this isoenzyme, and thus may make normal metabolizers resemble "poor metabolizers." Therapy with medications that are predominantly metabolized by the P450IID6 system and that have a relatively narrow therapeutic index should be initiated at the low end of the dose range if a patient is receiving fluoxetine concurrently or has taken it in the previous 5 weeks.”


Fluoxetine HCL

Fluoxetine HCL and Olanzapine;[m13] 
Cevimeline hydrochloride[m14] 
Tramadol +
   Acetamophen [m17] 
Protriptyline HCl;[m25] 


Deletion of Chromosome 5q(del(5q))

Cytogenetic abnormality in management of Low- or Intermediate-1 risk myelodysplastic syndromes -“Lenalidomide is indicated for the treatment of patients with transfusion dependent anemia due to Low- or Intermediate-1-risk myelodysplastic syndromes associated with a deletion 5q cytogenetic abnormality with or without additional cytogenetic abnormalities.”





DPD Deficiency

Deficiency of Dihydropyrimidine Dehydrogenase: “Rarely, unexpected, severe toxicity (eg, stomatitis, diarrhea, neutropenia and neurotoxicity) associated with 5-fluorouracil has been attributed to a deficiency of dihydropyrimidine dehydrogenase (DPD) activity. A link between decreased levels of DPD and increased, potentially fatal toxic effects of 5-fluorouracil therefore cannot be excluded.



Fluorouracil Cream; [m26] 
Fluorouracil Topical Solution & Cream[m27] 


EGFR expression

Epidermal Growth Factor Receptor presence or absence- “EGFR expression was determined using the EGFR pharmDxTM kit. In contrast to the 1% cut-off specified in the pharmDx kit instructions, a positive EGFR expression status was defined as having at least 10% of cells staining for EGFR. The pharmDx kit has not been validated for use in pancreatic cancer. An apparently larger effect, however, was observed in two subsets: patients with EGFR positive tumors (HR = 0.68) and patients who never smoked (HR = 0.42). Analysis of the impact of EGFR expression status on the treatment effect on clinical outcome is limited because EGFR status is known for 326 NSCLC study patients (45%).”





EGFR expression with alternate Context

Epidermal Growth Factor Receptor presence or absence- “Pretreatment assessment for evidence of EGFR expression is not required for patients with squamous cell carcinoma of head and neck (SCCHN)”


Head and Neck Cancer



EGFR expression with alternate Context

Epidermal Growth Factor Receptor presence or absence- “Patients enrolled in the clinical studies were required to have immuno-histochemical evidence of positive EGFR expression using the DakoCytomation EGFR pharmDx™ test kit.”


Colorectal Cancer

Panitumab [m35] 
Gefitinib [m28] 


Familial Hypercholestremia (deficiency, and/or mutation, of receptors for low density lipoprotein -LDL)

Dosage adjustment for Homozygous and heterozygous Familial Hypercholestremia “Doses should be individualized according to the recommended goal of therapy. Homozygous Familial Hypercholestremia (10-80mg/day)and heterozygous (10-20mg/day) Familial Hypercholestremia dose adjustment needed in pediatric patients”





G6PD Deficiency

G6PD deficiency and risk “Rasburicase administered to patients with glucose- phosphate dehydrogenase (G6PD) deficiency can cause severe hemolysis. ELITK administration should be immediately and permanently discontinued in any patient developing hemolysis. It is recommended that patients at higher risk for G6PD deficiency (e.g., patients of African or Mediterranean ancestry) be screened prior to starting ELITEK therapy (see CONTRANDICATIONS and WARNINGS, Hemolysis).”





G6PD Deficiency with alternate Context

G6PD deficiency and tolerance “Hemolytic reactions (moderate to severe) may occur in glucose-6-phosphate dehydrogenase (G-6-PD) deficient. If primaquine phosphate is prescribed for an individual with erythrocytic glucose-6-phosphatedehydrogenase (G-6-PD) deficiency or nicotinamide adenine dinucleotide (NADH) methemoglobin reductase deficiency, the person should be observed closely for tolerance.”





Her2/neu Over-expression

Overexpresion of Her2/neu necessary for selection of patients appropriate for drug therapy “Detection of HER2 protein overexpression is necessary for selection of patients appropriate for HERCEPTIN therapy (see INDICATIONS).”
“HERCEPTIN should be used in patients whose tumors have been evaluated with an assay validated to predict HER2 protein overexpression (see PRECAUTIONS: HER2 Testing and CLINICAL STUDIES: HER2 Detection).”



Lapatinib [m36] 


HLA-B*1502 allele presence

SERIOUS DERMATOLOGIC REACTIONS AND HLA-B*1502 ALLELE.” “Prior to initiating Tegretol therapy, testing for HLA-B*1502 should be performed in patients with ancestry in populations in which HLA-B*1502 may be present. In deciding which patients to screen, the rates provided above for the prevalence of HLA-B*1502 may offer a rough guide, keeping in mind the limitations of these figures due to wide variability in rates even within ethnic groups, the difficulty in ascertaining ethnic ancestry, and the likelihood of mixed ancestry. Tegretol should not be used in patients positive for HLA-B*1502 unless the benefits clearly outweigh the risks. Tested patients who are found to be negative for the allele are thought to have a low risk of SJS/TEN (see WARNINGS and PRECAUTIONS/Laboratory Tests).” ”For genetically at-risk patients (See WARNINGS), high-resolution ‘HLA-B*1502 typing’ is recommended. The test is positive if either one or two HLA-B*1502 alleles are detected and negative if no HLA-B*1502 alleles are detected.”





HLA-B*5701 allele presence

Patients who carry the HLA-B*5701 allele are at high risk for experiencing a hypersensitivity reaction to abacavir. Prior to initiating therapy with abacavir, screening for the HLA-B*5701 allele is recommended; this approach has been found to decrease the risk of hypersensitivity reaction. Screening is also recommended prior to reinitiation of abacavir in patients of unknown HLA-B*5701 status who have previously tolerated abacavir. HLA-B*5701-negative patients may develop a suspected hypersensitivity reaction to abacavir; however, this occurs significantly less frequently than in HLA-B*5701-positive patients. Regardless of HLA-B*5701 status, permanently discontinue ZIAGEN if hypersensitivity cannot be ruled out, even when other diagnoses are possible
Risk Factor: HLA-B*5701 Allele: Studies have shown that carriage of the HLA-B*5701 allele is associated with a significantly increased risk of a hypersensitivity reaction to abacavir.

Before starting ZIAGEN, tell your doctor about all of your medical conditions, including if you: have been tested and know whether or not you have a particular gene variation called HLA-B*5701.
2 Abacavir pdf  


NAT Variants

N-acetyltransferase slow and fast acetylators and toxicity- “slow acetylation may lead to higher blood levels of the drug, and thus, an increase in toxic reactions.”


Rifampin, isoniazid,  and pyrazinamide

Isosorbide dinitrate and Hydralazine hydrochloride[m31] 


Philadelphia Chromosome-positive responders

Philadelphia (Ph1) chromosome presence (effective) -“Busulfan is clearly less effective in patients with chronic myelogenous leukemia who lack the Philadelphia (Ph1) chromosome. Also, the so-called “juvenile” type of chronic myelogenous leukemia, typically occurring in young children and associated with the absence of a Philadelphia chromosome, responds poorly to busulfan. The drug is of no benefit in patients whose chronic myelogenous leukemia has entered a “blastic” phase.”





Philadelphia Chromosome- positive responders with alternate context

Philadelphia (Ph1) chromosome presence (effective) “Dasatinib is indicated for the treatment of adults with Philadelphia chromosome-positive acute lymphoblastic leukemia (Ph+ ALL) with resistance or intolerance to prior therapy”





PML/RAR alpha gene expression (Retinoic acid receptor responder and non-responders)

PML/ RAR (alpha) fusion gene presence “Initiation of therapy with VESANOID may be based on the morphological diagnosis of acute promyelocytic leukemia (APL). Confirmation of the diagnosis of APL should be sought by detection of the t (15; 17) genetic marker by cytogenetic studies. If these are negative, PML/ RAR (alpha) fusion should be sought using molecular diagnostic techniques. The response rate of other AML subtypes to VESANOID has not been demonstrated; therefore, patients who lack the genetic marker should be considered for alternative treatment.”



Arsenic Oxide [m32] 


Protein C deficiencies (hereditary or acquired)

Hereditary or acquired deficiencies of protein C or its cofactor, protein S, has been associated with tissue necrosis following warfarin administration. “Not all patients with these conditions develop necrosis, and tissue necrosis occurs in patients without these deficiencies. Inherited resistance to activated protein C has been described in many patients with venous thrombosis-embolic disorders but has not yet been evaluated as a risk factor for tissue necrosis. The risk associated with these conditions, both for recurrent thrombosis and for adverse reactions, is difficult to evaluate since it does not appear to be the same for everyone. Decisions about testing and therapy must be made on an individual basis.”





TPMT Variants

Thiopurine methyltransferase deficiency or lower activity due to mutation at increased risk of myelotoxicity. TPMT testing is recommended and consideration be given to either genotype or phenotype patients for TPMT”



Mercaptopurine [m34] 




UGT1A1 mutation in patients, exposure to drug and hence their susceptibility to toxicity. “Individuals who are homozygous for the UGT1A*28 allele are at increased risk for neutropenia following initiation of camptosar treatment. A reduced initial dose should be considered for patients known to be homozygous for the UGT1A*28 allele. Heterozygous patients may be at increased risk of neutropenia; however clinical results have been variable and such patients have been shown to tolerate normal starting doses”





UGT1A1 variants with alternate context

Pharmacogenomics (safety)
“Tasigna can increase bilirubin levels. A pharmacogenetic analysis of 97 patients evaluated the polymorphisms of UGT1A1 and its potential association with hyperbilirubinemia during Tasigna treatment. In this study, the (TA)7/(TA)7 genotype was associated with a statistically significant increase in the risk of
hyperbilirubinemia relative to the (TA)6/(TA)6 and (TA)6/(TA)7 genotypes. However, the largest increases in bilirubin were observed in the (TA)7/(TA)7 genotype (UGT1A1*28) patients [See Warnings and Precautions





Urea Cycle Disorder (UCD) Deficiency

Urea cycle disorders – “Prior to the initiation of valproate therapy, evaluation for UCD should be considered”


Valproic acid

Sodium Phenylacetate and Sodium Benzoate; sodium phenyl butyrate


Vitamin K epoxide reductase (VKORC1) Variants

Vitamin K epoxide reductase (VKOR) Variant- ““Certain single nucleotide polymorphisms in the VKORC1 gene (especially the -1639G).A allele) have been associated with lower dose requirements for warfarin.  About 55% of the variability in warfarin dose could be explained by the combination of VKORC 1 and CYP2C9 genotypes, age, height, body weight, interacting drugs, and indication for warfarin therapy in Caucasian patients. Similar observations have been reported in Asian patients.”






Cited by:

Frueh FW, Amur S, Mummaneni P, Epstein RS, Aubert RE, Deluca TM, Verbrugge RR, Burckart GJ, Lesko LJ.
Pharmacogenomic biomarker information in drug labels approved by the United States food and drug administration: prevalence of related drug use.
Pharmacotherapy. 2008 Aug;28(8):992-8

Nakamura Y.
Pharmacogenomics and Drug Toxicity.
N Engl J Med. 2008 Jul 23

Shashi Amur, Felix Frueh, Lawrence Lesko and Shiew-Mei Huang
Integration and use of biomarkers in drug development, regulation and clinical practice: a US regulatory perspective
Biomarkers in Medicine, June 2008; Vol. 2, No. 3, Pages 305-311 (doi:10.2217/17520363.2.3.305), http://www.futuremedicine.com/doi/abs/10.2217/17520363.2.3.305

Marrer E, Dieterle F.
Promises of biomarkers in drug development--a reality check.
Chem Biol Drug Des. 2007 Jun; 69(6):381-94

Goodsaid F, Frueh F.
Biomarker qualification pilot process at the US Food and Drug Administration.
AAPS J. 2007 Mar 23;9(1):E105-8


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Date created: September 15, 2006, Updated September 10, 2008

 [m1]“Although in normal subjects no interaction with theophylline or propranolol was found, there have been clinical reports of interaction with other drugs metabolized via the cytochrome P450 system (eg, cyclosporine, disulfiram, benzodiazepines). Patients should be monitored to determine if it is necessary to adjust the dosage of these drugs when taken concomitantly with PRILOSEC.”

 [m2]“The main metabolic pathway is demethylation, by CYP2C19, with subsequent sulfation; other metabolic pathways include oxidation by CYP3A4. There is no evidence that any of the pantoprazole metabolites have significant pharmacologic activity. CYP2C19 displays a known genetic polymorphism due to its deficiency in some sub-populations (e.g. 3  of Caucasians and African-Americans and 17-23  of Asians). Although these sub-populations of slow pantoprazole metabolizers have elimination half-life values of 3.5 to 10.0 hours, they still have minimal accumulation (≤ 23 ) with once daily dosing."

 [m3]“The major part of esomeprazole’smetabolism is dependent upon the CYP2C19 isoenzyme, which forms the hydroxy and desmethyl metabolites. The remaining amount is dependent on CYP3A4 which forms the sulphone metabolite. CYP2C19 isoenzyme exhibits polymorphism in the metabolism of esomeprazole, since some 3% of Caucasians and 15-20% of Asians lack CYP2C19 and are termed Poor metabolizers. At steady state,the ratio of AUC in Poor metabolizers to AUC in the rest of the population (Extensive metabolizers) is approximately 2."

 [m4]"The metabolism of diazepam is primarily hepatic and involves demethylation (involving primarily CYP2C19 and CYP3A4) and 3-hydroxylation (involving primarily CYP3A4), followed by glucuronidation. The marked inter-individual variability in the clearance of diazepam reported in the literature is probably attributable to variability of CYP2C19 (which is known to exhibit genetic polymorphism; about 3-5% of Caucasians have little or no activity and are “poor metabolizers”)"

 [m5]"In vitro, multiple cytochrome P-450 enzymes including CYP3A and CYP2C19 are responsible for metabolism of nelfinavir. CYP2C19 may decrease nelfinavir plasma concentrations and reduce its therapeutic effect. Nelfinavir is metabolized by CYP3A and CYP2C19. Coadministration of VIRACEPT and drugs that induce CYP3A or CYP2C19, such as rifampin, may decrease nelfinavir plasma concentrations and reduce its therapeutic effect. Coadministration of VIRACEPT and drugs that inhibit CYP3A or CYP2C19 may increase nelfinavir plasma concentrations."

 [m6]“In a clinical study in Japan evaluating rabeprazole in patients categorized by CYP2C19 genotype (n=6 per genotype category), gastric acid suppression was higher in poor metabolizers as compared to extensive metabolizers.”

 [m7]"The cytochrome P- 450 isozymes involved in the metabolism of warfarin include 2C9, 2C19, 2C8, 2C18, 1A2, and 3A4. 2C9 is likely to be the principal form of human liver P-450 which modulates the in vivo anticoagulant activity of warfarin."

 [m8] “In vitro and in vivo studies indicate that venlafaxine is metabolized to its active metabolite, ODV, by CYP2D6, the isoenzyme that is responsible for the genetic polymorphism seen in the metabolism of many antidepressants. Therefore, the potential exists for a drug interaction between drugs that inhibit CYP2D6-mediated metabolism and venlafaxine. However, although imipramine partially inhibited the CYP2D6-mediated metabolism of venlafaxine, resulting in higher plasma concentrations of venlafaxine and lower plasma concentrations of ODV, the total concentration of active compounds (venlafaxine plus ODV) was not affected. Additionally, in a clinical study involving CYP2D6-poor and -extensive metabolizers, the total concentration of active compounds (venlafaxine plus ODV), was similar in the two metabolizer groups. Therefore, no dosage adjustment is required when venlafaxine is coadministered with a CYP2D6 inhibitor."

 [m9]“Risperidone is metabolized to 9-hydroxyrisperidone by CYP 2D6, an enzyme that is polymorphic in the population and that can be inhibited by a variety of psychotropic and other drugs (see CLINICAL PHARMACOLOGY). Drug interactions that reduce

the metabolism of risperidone to 9-hydroxyrisperidone would increase the plasma concentrations of risperidone and lower the concentrations of 9-hydroxyrisperidone. Analysis of clinical studies involving a modest number of poor metabolizers does not suggest that poor and extensive metabolizers have different rates of adverse effects."

 [m10]“CYP450 2D6 and 3A4 are involved in the metabolic pathway that is responsible for the elimination of a small part of the administered dose. In vitro studies using human liver microsomes showed that  tiotropium  in supra-therapeutic concentrations does not inhibit CYP450 1A1, 1A2, 2B6, 2C9, 2C19, 2D6, 2E1, or 3A4.”

 [m11]“Tamoxifen is a substrate of cytochrome P-450 3A, 2C9 and 2D6, and an inhibitor of P-glycoprotein.”

 [m12]“Potentiated systemic beta-blockade (e.g., decreased heart rate) has been reported during combined treatment with quinidine and timolol, possibly because quinidine inhibits the metabolism of timolol via the P-450 enzyme, CYP2D6.”

 [m13]"Direct glucuronidation and CYP450-mediated oxidation are the primary metabolic pathways for olanzapine. In vitro studies suggest that CYP1A2, CYP2D6, and the flavin-containing monooxygenase system are involved in olanzapine oxidation. CYP2D6-mediated oxidation appears to be a minor metabolic pathway in vivo, because the clearance of olanzapine is not reduced in subjects who are deficient in this enzyme. Fluoxetine is extensively metabolized in the liver to its only identified active metabolite, norfluoxetine, via the CYP2D6 pathway. Thus, this study suggests that drugs that inhibit CYP2D6, such as certain SSRIs, including fluoxetine, will produce elevated plasma levels of thioridazine. Thioridazine administration produces a dose-related prolongation of the QTc interval"

 [m14]"ISOZYMES CYP2D6 AND CYP3A3/4 ARE RESPONSIBLE FOR THE METABOLISM OF CEVIMELINE. Drugs which inhibit CYP2D6 and CYP3A3/4 also inhibit the metabolism of cevimeline. Cevimeline should be used with caution in individuals known or suspected to be deficient in CYP2D6 activity, based on previous experience, as they may be at a higher risk of adverse events."

 [m15]"The primary metabolic route involves the oxidation of the 5-methyl group and is mediated by the cytochrome P450 2D6 (CYP2D6) A subset (about 7%) of the population is devoid of CYP2D6, the enzyme responsible for the formation of the 5-hydroxymethyl metabolite of tolterodine. The identified pathway of metabolism for these individuals (“poor metabolizers”) is dealkylation via cytochrome P450 3A4 (CYP3A4) to N-dealkylated tolterodine. The remainder of the population is referred to as “extensive metabolizers.” Pharmacokinetic studies revealed that tolterodine is metabolized at a slower rate in poor metabolizers than in extensive metabolizers; this results in significantly higher serum concentrations of tolterodine and in negligible concentrations of the 5-hydroxymethyl metabolite."

 [m16]"In vivo studies have shown that terbinafine is an inhibitor of the CYP450 2D6 isozyme."

 [m17]"Tramadol is extensively metabolized by a number of pathways, including CYP2D6 and CYP3A4, as well as by conjugation of parent and metabolites. One metabolite, M1, is pharmacologically active in animal models. The formation of M1 is dependent upon CYP2D6 and as such is subject to inhibition, which may affect the therapeutic response (see PRECAUTIONS, Drug Interactions)."

 [m18]"Clozapine is a substrate for many CYP 450 isozymes, in particular 1A2, 2D6, and 3A4. The risk of metabolic interactions caused by an effect on an individual isoform is therefore minimized. Nevertheless, caution should be used in patients receiving concomitant treatment with other drugs that are either inhibitors or inducers of these enzymes."

 [m19]"Elimination of aripiprazole is mainly through hepatic metabolism involving two P450 isozymes, CYP2D6 and CYP3A4. Approximately 8% of Caucasians lack the capacity to metabolize CYP2D6 substrates and are classified as poor metabolizers (PM), whereas the rest are extensive compared to EMs. Coadministration of ABILIFY with known inhibitors of CYP2D6, like quinidine in EMs, results in a 112% increase in aripiprazole plasma exposure, and dosing adjustment is needed (see PRECAUTIONS: Drug-Drug Interactions). The mean elimination half-lives are about 75 hours and 146 hours for aripiprazole in EMs and PMs, respectively. Aripiprazole does not inhibit or induce the CYP2D6 pathway. metabolizers (EM). PMs have about an 80% increase in aripiprazole exposure and about a 30% decrease in exposure to the active metabolite compared to EMs, resulting in about a 60% higher exposure to the total active moieties from a given dose of aripiprazole When the CYP2D6 inhibitor is withdrawn from the combination therapy, aripiprazole dose should then be increased."

 [m20]"Metoprolol is a racemic mixture of R- and Senantiomers, and is primarily metabolized byCYP2D6. Metoprolol is metabolized predominantly by CYP2D6, an enzyme that is absent in about 8% of Caucasians (poor metabolizers) and about 2% of most other populations. CYP2D6 can be inhibited by a number of drugs. Concomitant use of inhibiting drugs in poor metabolizers will increase blood levels of metoprolol several-fold, decreasing metoprolol's cardioselectivity."

 [m21]"In vitro studies have indicated that the aromatic hydroxylation of propranolol is catalyzed mainly by polymorphic CYP2D6. Side-chain oxidation is mediated mainly by CYP1A2 and to some extent by CYP2D6. 4-hydroxy  propranolol  is a weak inhibitor of CYP2D6.  Propranolol  is also a substrate for CYP2C19 and a substrate for the intestinal efflux transporter, p-glycoprotein (p-gp). Studies suggest however that p-gp is not dose-limiting for intestinal absorption of  propranolol  in the usual therapeutic dose range. In healthy subjects no difference was observed between CYP2D6 extensive metabolizers ( EMs) and poor metabolizers (PMs) with respect to oral clearance or elimination half-life. Partial clearance to 4-hydroxy  propranolol  was significantly higher and to naphthyloxylactic acid was significantly lower in EMs than PMs."

 [m22]"The primary P450 enzymes responsible for the metabolism of both R(+) and S(-)-carvedilol in human liver microsomes were CYP2D6 and CYP2C9 and to a lesser extent CYP3A4, 2C19, 1A2, and 2E1. CYP2D6 is thought to be the major enzyme in the 4’- and 5’-hydroxylation of carvedilol, with a potential contribution from 3A4. CYP2C9 is thought to be of primary importance in the O-methylation pathway of S(-)-carvedilol.

Carvedilol is subject to the effects of genetic polymorphism with poor metabolizers of debrisoquin (a marker for cytochrome P450 2D6) exhibiting 2- to 3-fold higher plasma concentrations of R(+)-carvedilol compared to extensive metabolizers. In contrast, plasma levels of S(-)-carvedilol are increased only about 20% to 25% in poor metabolizers, indicating this enantiomer is metabolized to a lesser extent by cytochrome P450 2D6 than R(+)-carvedilol. The pharmacokinetics of carvedilol do not appear to be different in poor metabolizers of S-mephenytoin (patients deficient in cytochrome P450 2C19)."

 [m23]“There are two genetically determined patterns of  propafenone  metabolism. In over 90% of patients, the drug is rapidly and extensively metabolized with an elimination half-life from 2-10 hours. These patients metabolize  propafenone  into two active metabolites: 5-hydroxypropafenone which is formed by CYP2D6 and N-depropylpropafenone (norpropafenone) which is formed by both CYP3A4 and CYP1A2. In less than 10% of patients, metabolism of  propafenone  is slower because the 5-hydroxy metabolite is not formed or is minimally formed. In these patients, the estimated  propafenone  elimination half-life ranges from 10-32 hours. Decreased ability to form the 5-hydroxy metabolite of  propafenone  is associated with a diminished ability to metabolize debrisoquine and a variety of other drugs such as encainide, metoprolol, and dextromethorphan whose metabolism is mediated by the CYP2D6 isozyme. In these patients, the N-depropylpropafenone metabolite occurs in quantities comparable to the levels occurring in extensive metabolizers. As a consequence of the observed differences in metabolism, administration of RYTHMOL SR to slow and extensive metabolizers results in significant differences in plasma concentrations of  propafenone , with slow metabolizers achieving concentrations about twice those of the extensive metabolizers at daily doses of 850 mg/day. At low doses the differences are greater, with slow metabolizers attaining concentrations about three to four times higher than extensive metabolizers. In extensive metabolizers, saturation of the hydroxylation pathway (CYP2D6) results in greater-than-linear increases in plasma levels following administration of RYTHMOL SR capsules. In slow metabolizers,  propafenone  pharmacokinetics are linear. Because the difference decreases at high doses and is mitigated by the lack of the active 5-hydroxy metabolite in the slow metabolizers, and because steady-state conditions are achieved after four to five days of dosing in all patients, the recommended dosing regimen of RYTHMOL SR is the same for all patients. The large intersubject variability in blood levels require that the dose of the drug be titrated carefully in patients with close attention paid to clinical and ECG evidence of toxicity"

 [m24]“Reduced cytochrome P450 2D6 isozyme activity drugs that inhibit this isozyme (e.g., fluoxetine and paroxetine) and certain other drugs (e.g., fluvoxamine, propranolol, and pindolol) appear to appreciably inhibit the metabolism of  thioridazine . The resulting elevated levels of  thioridazine  would be expected to augment the prolongation of the QTc interval associated with  thioridazine  and may increase the risk of serious, potentially fatal, cardiac arrhythmias, such as torsade de pointes-type arrhythmias. Such an increased risk may result also from the additive effect of coadministering  thioridazine  with other agents that prolong the QTc interval. Thioridazine is contraindicated with these drugs as well as in patients, comprising about 7% of the normal population, who are known to have a genetic defect leading to reduced levels of activity of P450 2D6."

 [m25]"The biochemical activity of the drug metabolizing isozyme cytochrome P450 2D6 (debrisoquine hydroxylase) is reduced in a subset of the Caucasian population (about 7% to 10% of Caucasians are so called "poor metabolizers"); reliable estimates of the prevalence of reduced P450 2D6 isozyme activity among Asian, African, and other populations are not yet available. Poor metabolizers have higher than expected plasma concentrations of tricyclic antidepressants (TCAs) when given usual doses. Depending on the fraction of drug metabolized by P450 2D6, the increase in plasma concentration may be small or quite large (8 fold increase in plasma AUC of the TCA). In addition, certain drugs inhibit the activity of this isozyme and make normal metabolizers resemble poor metabolizers. An individual who is stable on a given dose of TCA may become abruptly toxic when given one of these inhibiting drugs as concomitant therapy. The drugs that inhibit cytochrome P450 2D6 include some that are not metabolized by the enzyme (quinidine; cimetidine) and many that are substrates for P450 2D6 (many other antidepressants, pheno-thiazines, and the Type 1C antiarrhythmics, propafenone and flecainide). While all the selective serotonin reuptake inhibitors (SSRIs), e.g., fluoxetine, sertraline, and paroxetine, inhibit P450 2D6, they may vary in the extent of inhibition. The extent to which SSRI-TCA interactions may pose clinical problems will depend on the degree of inhibition and the pharmacokinetics of the SSRI involved. Nevertheless, caution is indicated in the coadministration of TCAs with any of the SSRIs and also in switching from one class to the other. Of particular importance, sufficient time must elapse before initiating TCA treatment in a patient being withdrawn from fluoxetine, given the long half-life of the parent and active metabolite (at least 5 weeks may be necessary). Concomitant use of tricyclic antidepressants with drugs that can inhibit cytochrome P450 2D6 may require lower doses than usually prescribed for either the tricyclic antidepressant or the other drug. Furthermore, whenever one of these other drugs is withdrawn from cotherapy, an increased dose of tricyclic antidepressant may be required. It is desirable to monitor TCA plasma levels whenever a TCA is going to be coadministered with another drug known to be an inhibitor of P450 2D6. "

 [m26]“Carac should not be used in patients with dihydropyrimidine dehydrogenase (DPD) enzyme deficiency. A large percentage of fluorouracil is catabolized by the enzyme dihydropyrimidine  dehydrogenase (DPD). DPD enzyme deficiency can result in shunting of fluorouracil to the anabolic pathway, leading to cytotoxic activity and potential toxicities. Patients should discontinue therapy with Carac if symptoms of DPD enzyme deficiency develop.”

 [m27]“Efudex should not be in patients with dihydropyrimidine dehydrogenase (DPD) enzyme deficiency. Patients should discontinue therapy with Efudex if symptoms of DPD enzyme deficiency develop.”

 [m28]““No clinical studies have been performed that demonstrated a correlation between EGFR receptor expression and response to gefitinib.”

 [m29]“Glucose 6-phosphate dehydrogenase (G6PD) levels should be obtained prior to initiatingtherapy with ACZONETM Gel, 5%. In patients with a history of anemia and predisposition to increased hemolytic effect with dapsone (e.g., glucose-6-phosphate dehydrogenase deficiency), closer follow-up for blood hemoglobin levels and reticulocyte counts should be implemented (see PRECAUTIONS). Alternatively, other therapies for acne than ACZONETM Gel, 5%, may be considered.”

 [m30]“The drug should be administered with caution to patients having G-6-PD (glucose-6 phosphate dehydrogenase) deficiency.”

 [m31]“Hydralazine is metabolized by acetylation, ring oxidation and conjugation with endogenous compounds including pyruvic acid. Acetylation occurs predominantly during the first pass after oral administration which explains the dependence of the absolute bioavailability on the acetylator phenotype. About 50% of patients are fast acetylators and have lower exposure.”

 [m32]“TRISENOX™ is indicated for induction of remission and consolidation in patients with acute promyelocytic leukemia (APL) who are refractory to, or have relapsed from, retinoid and anthracycline chemotherapy, and whose APL is characterized by the presence of the t(15;17)translocation or PML/RAR-alpha gene expression.”

 [m33]“There are individuals with an inherited deficiency of the enzyme thiopurine methyltransferase (TPMT) who may be unusually sensitive to the myelosuppressive effects of thioguanine and prone to developing rapid bone marrow suppression following the initiation of treatment. Substantial dosage reductions may be required to avoid the development of life-threatening bone marrow suppression in these patients. Prescribers should be aware that some laboratories offer testing for TPMT deficiency. Since bone marrow suppression may be associated with factors other than TPMT deficiency, TPMT testing may not identify all patients at risk for severe toxicity. Therefore, close monitoring of clinical and hematologic parameters is important. Bone marrow suppression could be exacerbated by coadministration with drugs that inhibit TPMT,such as olsalazine, mesalazine, or sulphasalazine”

 [m34]“TPMT activity is highly variable in patients because of genetic polymorphism in the TPMT gene.

For Caucasians and African Americans, approxi mately 0.3% (1:300) of patients have two non-functional alleles (homozygous-deficient) of the TPMT and have little or no detectable enzyme activity. Approximately 10% of patients have one TPMT non-functional allele (heterozygous) leading to low or intermediate TPMT activity and 90% of individuals have normal activity with two functional alleles. TPMT genotyping or phenotyping (red blood cell TPMT activity) can identify patients who are homozygous deficient or have low or intermediate TPMT activity (see WARNINGS, PRECAUTIONS: Laboratory Tests, and DOSAGE and ADMINISTRATION sections).  Individuals who are homozygous for an inherited defect in the TPMT (thiopurine-S gene are unusually sensitive to the myelosuppressive effects of mercaptopurine and rapid bone marrow suppression following the initiati on of treatment. Laboratory tests are available, both genotypic and phenotypic, to determine the TPMT status. Substantial dose reductions are generally required for homozygous-TPMT deficiency patients (two non functional alleles) to avoid the development of life threatening bone marrow suppression.”

 [m35]“EGFR Expression and Response

Patients enrolled in the colorectal cancer clinical studies were required to have immunohistochemical evidence ofEGFR expression; these are the only patients studied and for whom benefit has been shown (see INDICATIONS AND USAGE and PRECAUTIONS: EGF Receptor Testing). EGFR tumor expression was determined using the Dako EGFR pharmDxCI test kit. Specimens were scored based on the percentage of cells expressing EGFR and staining intensity (3+, 2+, and 1 +)


TYKERB is indicated in combination with capecitabine for the treatment of patients with advanced or metastatic breast cancer whose tumors overexpress HER2 and who have received prior therapy including an anthracycline, a taxane, and trastuzumab.