| rosuvastatin | ABCG2 + SLCO1B1 | A | General | Normal Function | Prescribe desired starting dose and adjust doses of rosuvastatin based on disease-specific and specific population guidelines. Prescriber should be aware of possible increased risk for myopathy especially for doses >20mg. | Strong | No alternative offered — CPIC’s guidance here is a dosing adjustment |
| rosuvastatin | ABCG2 + SLCO1B1 | A | General | Normal Function | Prescribe ≤20mg as a starting dose and adjust doses of rosuvastatin based on disease-specific and specific population guidelines. If dose > 20mg needed for desired efficacy, consider combination therapy (i.e., rosuvastatin plus non-statin guideline directed medical therapy) (PMID: 30423391). | Moderate | No alternative offered — CPIC’s guidance here is a dosing adjustment |
| rosuvastatin | ABCG2 + SLCO1B1 | A | General | Normal Function | Prescribe desired starting dose and adjust doses of rosuvastatin based on disease-specific and specific population guidelines. | Strong | No alternative offered — CPIC’s guidance here is a dosing adjustment |
| rosuvastatin | ABCG2 + SLCO1B1 | A | General | Normal Function | Based on ABCG2 status, prescribe desired starting dose and adjust doses of rosuvastatin based on disease-specific and specific population guidelines. SLCO1B1 phenotype could not be assigned based on genotyping. | Strong | No alternative offered — CPIC’s guidance here is a dosing adjustment |
| rosuvastatin | ABCG2 + SLCO1B1 | A | General | Normal Function | Based on ABCG2 status, prescribe desired starting dose and adjust doses of rosuvastatin based on disease-specific and specific population guidelines. SLCO1B1 genotype result is not available. | Strong | No alternative offered — CPIC’s guidance here is a dosing adjustment |
| rosuvastatin | ABCG2 + SLCO1B1 | A | General | Decreased Function | Prescribe ≤20mg as a starting dose and adjust doses of rosuvastatin based on disease-specific and specific population guidelines. If dose >20mg needed for desired efficacy, consider combination therapy (i.e., rosuvastatin plus non-statin guideline directed medical therapy) (PMID: 30423391). | Moderate | No alternative offered — CPIC’s guidance here is a dosing adjustment |
| rosuvastatin | ABCG2 + SLCO1B1 | A | General | Decreased Function | Prescribe desired starting dose and adjust doses of rosuvastatin based on disease-specific and specific population guidelines. | Moderate | No alternative offered — CPIC’s guidance here is a dosing adjustment |
| rosuvastatin | ABCG2 + SLCO1B1 | A | General | Decreased Function | Prescribe desired starting dose and adjust doses of rosuvastatin based on disease-specific and specific population guidelines. Prescriber should be aware of possible increased risk for myopathy especially for doses >20mg. | Moderate | No alternative offered — CPIC’s guidance here is a dosing adjustment |
| rosuvastatin | ABCG2 + SLCO1B1 | A | General | Decreased Function | Based on ABCG2 status, prescribe desired starting dose and adjust doses of rosuvastatin based on disease-specific guidelines and specific population guidelines. SLCO1B1 phenotype could not be assigned based on genotyping. | Moderate | No alternative offered — CPIC’s guidance here is a dosing adjustment |
| rosuvastatin | ABCG2 + SLCO1B1 | A | General | Decreased Function | Based on ABCG2 status, prescribe desired starting dose and adjust doses of rosuvastatin based on disease-specific guidelines and specific population guidelines. SLCO1B1 genotype result is not available. | Moderate | No alternative offered — CPIC’s guidance here is a dosing adjustment |
| rosuvastatin | ABCG2 + SLCO1B1 | A | General | Poor Function | Prescribe ≤10mg as a starting dose and adjust doses of rosuvastatin based on disease-specific and specific population guidelines. If dose >10mg needed for desired efficacy, consider an alternative statin or combination therapy (i.e., rosuvastatin plus non-statin guideline directed medical therapy) (PMID: 30423391). | Optional | No alternative offered — CPIC’s guidance here is a dosing adjustment |
| rosuvastatin | ABCG2 + SLCO1B1 | A | General | Poor Function | Prescribe ≤10mg as a starting dose and adjust doses of rosuvastatin based on disease-specific and specific population guidelines. If dose >10mg needed for desired efficacy, consider combination therapy (i.e., rosuvastatin plus non-statin guideline directed medical therapy) (PMID: 30423391). | Optional | No alternative offered — CPIC’s guidance here is a dosing adjustment |
| rosuvastatin | ABCG2 + SLCO1B1 | A | General | Poor Function | Prescribe ≤20mg as a starting dose and adjust doses of rosuvastatin based on disease-specific and specific population guidelines. If dose >20mg needed for desired efficacy, consider an alternative statin or combination therapy (i.e., rosuvastatin plus non-statin guideline directed medical therapy) (PMID: 30423391). | Optional | No alternative offered — CPIC’s guidance here is a dosing adjustment |
| rosuvastatin | ABCG2 + SLCO1B1 | A | General | Poor Function | Based on ABCG2 status, prescribe ≤20mg as a starting dose and adjust doses of rosuvastatin based on disease-specific and specific population guidelines. If dose >20mg needed for desired efficacy, consider an alternative statin or combination therapy (i.e., rosuvastatin plus non-statin guideline directed medical therapy) (PMID: 30423391). SLCO1B1 phenotype could not be assigned based on genotyping. | Moderate | No alternative offered — CPIC’s guidance here is a dosing adjustment |
| rosuvastatin | ABCG2 + SLCO1B1 | A | General | Poor Function | Based on ABCG2 status, prescribe ≤20mg as a starting dose and adjust doses of rosuvastatin based on disease-specific and specific population guidelines. If dose >20mg needed for desired efficacy, consider an alternative statin or combination therapy (i.e., rosuvastatin plus non-statin guideline directed medical therapy) (PMID: 30423391). SLCO1B1 genotype result is not available. | Moderate | No alternative offered — CPIC’s guidance here is a dosing adjustment |
| rosuvastatin | ABCG2 + SLCO1B1 | A | General | No Result | Based on SLCO1B1 status, prescribe desired starting dose and adjust doses of rosuvastatin based on disease-specific and specific population guidelines. Prescriber should be aware of possible increased risk for myopathy especially for doses >20mg. ABCG2 genotype result is not available. | Strong | No alternative offered — CPIC’s guidance here is a dosing adjustment |
| rosuvastatin | ABCG2 + SLCO1B1 | A | General | No Result | Based on SLCO1B1 status, prescribe desired starting dose and adjust doses based on disease-specific guidelines. ABCG2 genotype result is not available. | Strong | No alternative offered — CPIC’s guidance here is a dosing adjustment |
| rosuvastatin | ABCG2 + SLCO1B1 | A | General | No Result | Based on SLCO1B1 status, prescribe ≤20mg as a starting dose and adjust doses of rosuvastatin based on disease-specific and specific population guidelines If dose >20mg needed for desired efficacy, consider combination therapy (i.e. rosuvastatin plus non-statin guideline directed medical therapy) (PMID: 30423391). ABCG2 genotype result is not available. | Moderate | No alternative offered — CPIC’s guidance here is a dosing adjustment |
| amitriptyline | CYP2C19 + CYP2D6 | A | General | Ultrarapid Metabolizer / Rapid Metabolizer / Likely Intermediate Metabolizer / Intermediate Metabolizer / Likely Poor Metabolizer / Poor Metabolizer | Avoid amitriptyline use; If amitriptyline is warranted, utilize therapeutic drug monitoring to guide dose adjustment. Utilizing therapeutic drug monitoring to guide dose adjustments is strongly recommended. | Optional | No alternative offered — CPIC’s guidance here is a dosing adjustment |
| amitriptyline | CYP2C19 + CYP2D6 | A | General | Ultrarapid Metabolizer / Rapid Metabolizer | Consider alternative drug not metabolized by CYP2C19; If amitriptyline is warranted, utilize therapeutic drug monitoring to guide dose adjustment. Utilizing therapeutic drug monitoring to guide dose adjustments is strongly recommended. | Optional | Derived from CPIC data — ATC N06A agents with no actionable CYP2C19 guidance: amoxapine, bupropion, desipramine, desvenlafaxine, duloxetine, fluoxetine, fluvoxamine, levomilnacipran, milnacipran, mirtazapine, nortriptyline, paroxetine, protriptyline, venlafaxine, vilazodone, vortioxetine |
| amitriptyline | CYP2C19 + CYP2D6 | A | General | Ultrarapid Metabolizer / Rapid Metabolizer | Consider alternative drug not metabolized by CYP2C19; If amitriptyline is warranted, utilize therapeutic drug monitoring to guide dose adjustment. | Optional | Derived from CPIC data — ATC N06A agents with no actionable CYP2C19 guidance: amoxapine, bupropion, desipramine, desvenlafaxine, duloxetine, fluoxetine, fluvoxamine, levomilnacipran, milnacipran, mirtazapine, nortriptyline, paroxetine, protriptyline, venlafaxine, vilazodone, vortioxetine |
| amitriptyline | CYP2C19 + CYP2D6 | A | General | Ultrarapid Metabolizer / Rapid Metabolizer | Avoid tertiary amine use due to potential for sub-optimal response. Consider alternative drug not metabolized by CYP2C19. TCAs without major CYP2C19 metabolism include the secondary amines nortriptyline and desipramine. If a tertiary amine is warranted, utilize therapeutic drug monitoring to guide dose adjustments. | Optional | Derived from CPIC data — ATC N06A agents with no actionable CYP2C19 guidance: amoxapine, bupropion, desipramine, desvenlafaxine, duloxetine, fluoxetine, fluvoxamine, levomilnacipran, milnacipran, mirtazapine, nortriptyline, paroxetine, protriptyline, venlafaxine, vilazodone, vortioxetine |
| amitriptyline | CYP2C19 + CYP2D6 | A | General | Normal Metabolizer / Likely Intermediate Metabolizer / Intermediate Metabolizer / No Result | Initiate therapy with recommended starting dose. | Strong | No alternative offered — CPIC’s guidance here is a dosing adjustment |
| amitriptyline | CYP2C19 + CYP2D6 | A | General | Normal Metabolizer | Avoid amitriptyline use; If amitriptyline is warranted, consider titrating to a higher target dose (compared to normal metabolizers). Utilize therapeutic drug monitoring to guide dose adjustment. | Strong | No alternative offered — CPIC’s guidance here is a dosing adjustment |
| amitriptyline | CYP2C19 + CYP2D6 | A | General | Normal Metabolizer | Consider a 25% reduction of recommended starting dose. Utilize therapeutic drug monitoring to guide dose adjustments. | Moderate | No alternative offered — CPIC’s guidance here is a dosing adjustment |
| amitriptyline | CYP2C19 + CYP2D6 | A | General | Normal Metabolizer | Avoid amitriptyline use. If a amitripyline is warranted, consider a 50% reduction of recommended starting dose. Utilize therapeutic drug monitoring to guide dose adjustments. | Strong | No alternative offered — CPIC’s guidance here is a dosing adjustment |
| amitriptyline | CYP2C19 + CYP2D6 | A | General | Likely Intermediate Metabolizer / Intermediate Metabolizer | Consider a 25% reduction of recommended starting dose. Utilizing therapeutic drug monitoring to guide dose adjustments is strongly recommended. | Optional | No alternative offered — CPIC’s guidance here is a dosing adjustment |
| amitriptyline | CYP2C19 + CYP2D6 | A | General | Likely Intermediate Metabolizer / Intermediate Metabolizer | Avoid amitriptyline use. If a amitripyline is warranted, consider a 50% reduction of recommended starting dose. Utilizing therapeutic drug monitoring to guide dose adjustments is strongly recommended. | Optional | No alternative offered — CPIC’s guidance here is a dosing adjustment |
| amitriptyline | CYP2C19 + CYP2D6 | A | General | Likely Poor Metabolizer / Poor Metabolizer | Avoid amitriptyline use. If amitripyline is warranted, consider a 50% reduction of recommended starting dose. Utilize therapeutic drug monitoring to guide dose adjustments. | Moderate | No alternative offered — CPIC’s guidance here is a dosing adjustment |
| amitriptyline | CYP2C19 + CYP2D6 | A | General | Likely Poor Metabolizer / Poor Metabolizer | Avoid tertiary amine use due to potential for sub-optimal response. Consider alternative drug not metabolized by CYP2C19. TCAs without major CYP2C19 metabolism include the secondary amines nortriptyline and desipramine. For tertiary amines, consider a 50% reduction of the recommended starting dose. Utilize therapeutic drug monitoring to guide dose adjustments. Titrate dose to observed clinical response with symptom improvement and minimal (if any) side effects. | Moderate | Derived from CPIC data — ATC N06A agents with no actionable CYP2C19 guidance: amoxapine, bupropion, desipramine, desvenlafaxine, duloxetine, fluoxetine, fluvoxamine, levomilnacipran, milnacipran, mirtazapine, nortriptyline, paroxetine, protriptyline, venlafaxine, vilazodone, vortioxetine |
| amitriptyline | CYP2C19 + CYP2D6 | A | General | Indeterminate / No Result | Avoid tricyclic use due to potential lack of efficacy. Consider alternative drug not metabolized by CYP2D6. If a TCA is warranted, consider titrating to a higher target dose (compared to normal metabolizers). Utilize therapeutic drug monitoring to guide dose adjustments. Titrate dose to observed clinical response with symptom improvement and minimal (if any) side effects. | Strong | Derived from CPIC data — ATC N06A agents with no actionable CYP2C19 guidance: bupropion, citalopram, desvenlafaxine, duloxetine, escitalopram, fluoxetine, levomilnacipran, milnacipran, sertraline, vilazodone |
| amitriptyline | CYP2C19 + CYP2D6 | A | General | Indeterminate / No Result | Consider a 25% reduction of recommended starting dose. Utilize therapeutic drug monitoring to guide dose adjustments. Titrate dose to observed clinical response with symptom improvement and minimal (if any) side effects. | Moderate | No alternative offered — CPIC’s guidance here is a dosing adjustment |
| amitriptyline | CYP2C19 + CYP2D6 | A | General | Indeterminate / No Result | Avoid tricyclic use due to potential for side effects. Consider alternative drug not metabolized by CYP2D6. If a TCA is warranted, consider a 50% reduction of recommended starting dose. Utilize therapeutic drug monitoring to guide dose adjustments. Titrate dose to observed clinical response with symptom improvement and minimal (if any) side effects. | Strong | Derived from CPIC data — ATC N06A agents with no actionable CYP2C19 guidance: bupropion, citalopram, desvenlafaxine, duloxetine, escitalopram, fluoxetine, levomilnacipran, milnacipran, sertraline, vilazodone |
| citalopram | CYP2C19 | A | General | Ultrarapid Metabolizer | Consider a clinically appropriate alternative antidepressant not predominantly metabolized by CYP2C19. If citalopram or escitalopram are clinically appropriate, and adequate efficacy is not achieved at standard maintenance dosing, consider titrating to a higher maintenance dose. | Strong | Derived from CPIC data — ATC N06A agents with no actionable CYP2C19 guidance: amoxapine, bupropion, desipramine, desvenlafaxine, duloxetine, fluoxetine, fluvoxamine, levomilnacipran, milnacipran, mirtazapine, nortriptyline, paroxetine, protriptyline, venlafaxine, vilazodone, vortioxetine |
| citalopram | CYP2C19 | A | General | Rapid Metabolizer | Initiate therapy with recommended starting dose. If patient does not adequately respond to recommended maintenance dosing, consider titrating to a higher maintenance dose or switching to a clinically appropriate alternative antidepressant not predominantly metabolized by CYP2C19. | Optional | Derived from CPIC data — ATC N06A agents with no actionable CYP2C19 guidance: amoxapine, bupropion, desipramine, desvenlafaxine, duloxetine, fluoxetine, fluvoxamine, levomilnacipran, milnacipran, mirtazapine, nortriptyline, paroxetine, protriptyline, venlafaxine, vilazodone, vortioxetine |
| citalopram | CYP2C19 | A | General | Normal Metabolizer | Initiate therapy with recommended starting dose | Strong | No alternative offered — CPIC’s guidance here is a dosing adjustment |
| citalopram | CYP2C19 | A | General | Likely Intermediate Metabolizer / Intermediate Metabolizer | Initiate therapy with recommended starting dose. Consider a slower titration schedule and lower maintenance dose than normal metabolizers. | Moderate | No alternative offered — CPIC’s guidance here is a dosing adjustment |
| citalopram | CYP2C19 | A | General | Likely Poor Metabolizer / Poor Metabolizer | Consider a clinically appropriate antidepressant not predominantly metabolized by CYP2C19. If citalopram or escitalopram are clinically appropriate, consider a lower starting dose, slower titration schedule and 50% reduction of the standard maintenance dose as compared to normal metabolizers. | Strong | No alternative offered — CPIC’s guidance here is a dosing adjustment |
| clomipramine | CYP2C19 + CYP2D6 | B | General | Ultrarapid Metabolizer / Rapid Metabolizer / Likely Intermediate Metabolizer / Intermediate Metabolizer / Likely Poor Metabolizer / Poor Metabolizer | Avoid clomipramine use; If clomipramine is warranted, utilize therapeutic drug monitoring to guide dose adjustment. Utilizing therapeutic drug monitoring to guide dose adjustments is strongly recommended. | Optional | No alternative offered — CPIC’s guidance here is a dosing adjustment |
| clomipramine | CYP2C19 + CYP2D6 | B | General | Ultrarapid Metabolizer / Rapid Metabolizer | Consider alternative drug not metabolized by CYP2C19; If clomipramine is warranted, utilize therapeutic drug monitoring to guide dose adjustment. Utilizing therapeutic drug monitoring to guide dose adjustments is strongly recommended. | Optional | Derived from CPIC data — ATC N06A agents with no actionable CYP2C19 guidance: amoxapine, bupropion, desipramine, desvenlafaxine, duloxetine, fluoxetine, fluvoxamine, levomilnacipran, milnacipran, mirtazapine, nortriptyline, paroxetine, protriptyline, venlafaxine, vilazodone, vortioxetine |
| clomipramine | CYP2C19 + CYP2D6 | B | General | Ultrarapid Metabolizer / Rapid Metabolizer | Consider alternative drug not metabolized by CYP2C19; If clomipramine is warranted, utilize therapeutic drug monitoring to guide dose adjustment. | Optional | Derived from CPIC data — ATC N06A agents with no actionable CYP2C19 guidance: amoxapine, bupropion, desipramine, desvenlafaxine, duloxetine, fluoxetine, fluvoxamine, levomilnacipran, milnacipran, mirtazapine, nortriptyline, paroxetine, protriptyline, venlafaxine, vilazodone, vortioxetine |
| clomipramine | CYP2C19 + CYP2D6 | B | General | Ultrarapid Metabolizer / Rapid Metabolizer | Avoid tertiary amine use due to potential for sub-optimal response. Consider alternative drug not metabolized by CYP2C19. TCAs without major CYP2C19 metabolism include the secondary amines nortriptyline and desipramine. If a tertiary amine is warranted, utilize therapeutic drug monitoring to guide dose adjustments. | Optional | Derived from CPIC data — ATC N06A agents with no actionable CYP2C19 guidance: amoxapine, bupropion, desipramine, desvenlafaxine, duloxetine, fluoxetine, fluvoxamine, levomilnacipran, milnacipran, mirtazapine, nortriptyline, paroxetine, protriptyline, venlafaxine, vilazodone, vortioxetine |
| clomipramine | CYP2C19 + CYP2D6 | B | General | Normal Metabolizer / No Result | Initiate therapy with recommended starting dose. | Strong | No alternative offered — CPIC’s guidance here is a dosing adjustment |
| clomipramine | CYP2C19 + CYP2D6 | B | General | Normal Metabolizer | Consider a 25% reduction of recommended starting dose. Utilize therapeutic drug monitoring to guide dose adjustments. | Optional | No alternative offered — CPIC’s guidance here is a dosing adjustment |
| clomipramine | CYP2C19 + CYP2D6 | B | General | Normal Metabolizer | Avoid clomipramine use. If a clomipramine is warranted, consider a 50% reduction of recommended starting dose. Utilize therapeutic drug monitoring to guide dose adjustments. | Optional | No alternative offered — CPIC’s guidance here is a dosing adjustment |
| clomipramine | CYP2C19 + CYP2D6 | B | General | Normal Metabolizer | Avoid clomipramine use; If clomipramine is warranted, consider titrating to a higher target dose (compared to normal metabolizers). Utilize therapeutic drug monitoring to guide dose adjustment. | Optional | No alternative offered — CPIC’s guidance here is a dosing adjustment |
| clomipramine | CYP2C19 + CYP2D6 | B | General | Likely Intermediate Metabolizer / Intermediate Metabolizer | Consider a 25% reduction of recommended starting dose. Utilizing therapeutic drug monitoring to guide dose adjustments is strongly recommended. | Optional | No alternative offered — CPIC’s guidance here is a dosing adjustment |
| clomipramine | CYP2C19 + CYP2D6 | B | General | Likely Intermediate Metabolizer / Intermediate Metabolizer | Initiate therapy with recommended starting dose. | Optional | No alternative offered — CPIC’s guidance here is a dosing adjustment |
| clomipramine | CYP2C19 + CYP2D6 | B | General | Likely Intermediate Metabolizer / Intermediate Metabolizer | Avoid clomipramine use. If a clomipramine is warranted, consider a 50% reduction of recommended starting dose. Utilizing therapeutic drug monitoring to guide dose adjustments is strongly recommended. | Optional | No alternative offered — CPIC’s guidance here is a dosing adjustment |
| clomipramine | CYP2C19 + CYP2D6 | B | General | Likely Poor Metabolizer / Poor Metabolizer | Avoid clomipramine use. If clomipramine is warranted, consider a 50% reduction of recommended starting dose. Utilize therapeutic drug monitoring to guide dose adjustments. | Optional | No alternative offered — CPIC’s guidance here is a dosing adjustment |
| clomipramine | CYP2C19 + CYP2D6 | B | General | Likely Poor Metabolizer / Poor Metabolizer | Avoid tertiary amine use due to potential for sub-optimal response. Consider alternative drug not metabolized by CYP2C19. TCAs without major CYP2C19 metabolism include the secondary amines nortriptyline and desipramine. For tertiary amines, consider a 50% reduction of the recommended starting dose. Utilize therapeutic drug monitoring to guide dose adjustments. Titrate dose to observed clinical response with symptom improvement and minimal (if any) side effects. | Optional | Derived from CPIC data — ATC N06A agents with no actionable CYP2C19 guidance: amoxapine, bupropion, desipramine, desvenlafaxine, duloxetine, fluoxetine, fluvoxamine, levomilnacipran, milnacipran, mirtazapine, nortriptyline, paroxetine, protriptyline, venlafaxine, vilazodone, vortioxetine |
| clomipramine | CYP2C19 + CYP2D6 | B | General | Indeterminate / No Result | Consider a 25% reduction of recommended starting dose. Utilize therapeutic drug monitoring to guide dose adjustments. Titrate dose to observed clinical response with symptom improvement and minimal (if any) side effects. | Optional | No alternative offered — CPIC’s guidance here is a dosing adjustment |
| clomipramine | CYP2C19 + CYP2D6 | B | General | Indeterminate / No Result | Avoid tricyclic use due to potential for side effects. Consider alternative drug not metabolized by CYP2D6. If a TCA is warranted, consider a 50% reduction of recommended starting dose. Utilize therapeutic drug monitoring to guide dose adjustments. Titrate dose to observed clinical response with symptom improvement and minimal (if any) side effects. | Optional | Derived from CPIC data — ATC N06A agents with no actionable CYP2C19 guidance: bupropion, citalopram, desvenlafaxine, duloxetine, escitalopram, fluoxetine, levomilnacipran, milnacipran, sertraline, vilazodone |
| clomipramine | CYP2C19 + CYP2D6 | B | General | Indeterminate / No Result | Avoid tricyclic use due to potential lack of efficacy. Consider alternative drug not metabolized by CYP2D6. If a TCA is warranted, consider titrating to a higher target dose (compared to normal metabolizers). Utilize therapeutic drug monitoring to guide dose adjustments. Titrate dose to observed clinical response with symptom improvement and minimal (if any) side effects. | Optional | Derived from CPIC data — ATC N06A agents with no actionable CYP2C19 guidance: bupropion, citalopram, desvenlafaxine, duloxetine, escitalopram, fluoxetine, levomilnacipran, milnacipran, sertraline, vilazodone |
| clopidogrel | CYP2C19 | A | Cardiovascular — ACS and/or PCI | Ultrarapid Metabolizer / Rapid Metabolizer / Normal Metabolizer | If considering clopidogrel, use at standard dose (75 mg/day) | Strong | No alternative offered — CPIC’s guidance here is a dosing adjustment |
| clopidogrel | CYP2C19 | A | Cardiovascular — ACS and/or PCI | Likely Intermediate Metabolizer | Avoid standard dose clopidogrel (75 mg) if possible. Use prasugrel or ticagrelor at standard dose if no contraindication. | Strong | CPIC names: prasugrel or ticagrelor |
| clopidogrel | CYP2C19 | A | Cardiovascular — ACS and/or PCI | Intermediate Metabolizer | Avoid standard dose (75 mg) clopidogrel if possible. Use prasugrel or ticagrelor at standard dose if no contraindication. | Strong | CPIC names: prasugrel or ticagrelor |
| clopidogrel | CYP2C19 | A | Cardiovascular — ACS and/or PCI | Likely Poor Metabolizer / Poor Metabolizer | Avoid clopidogrel if possible. Use prasugrel or ticagrelor at standard dose if no contraindication. | Strong | CPIC names: prasugrel or ticagrelor |
| clopidogrel | CYP2C19 | A | Cardiovascular — non-ACS, non-PCI | Normal Metabolizer | If considering clopidogrel, use at standard dose (75 mg/day) | Strong | No alternative offered — CPIC’s guidance here is a dosing adjustment |
| clopidogrel | CYP2C19 | A | Cardiovascular — non-ACS, non-PCI | Likely Poor Metabolizer / Poor Metabolizer | Avoid clopidogrel if possible. Use prasugrel or ticagrelor at standard dose if no contraindication. | Moderate | CPIC names: prasugrel or ticagrelor |
| clopidogrel | CYP2C19 | A | Neurovascular | Normal Metabolizer | If considering clopidogrel, use at standard dose (75 mg/day) | Strong | No alternative offered — CPIC’s guidance here is a dosing adjustment |
| clopidogrel | CYP2C19 | A | Neurovascular | Likely Intermediate Metabolizer / Intermediate Metabolizer | Consider an alternative P2Y12 inhibitor at standard dose if clinically indicated and no contraindication. | Moderate | No alternative offered — CPIC’s guidance here is a dosing adjustment |
| clopidogrel | CYP2C19 | A | Neurovascular | Likely Poor Metabolizer / Poor Metabolizer | Avoid clopidogrel if possible. Consider an alternative P2Y12 inhibitor at standard dose if clinically indicated and no contraindication. | Moderate | No alternative offered — CPIC’s guidance here is a dosing adjustment |
| doxepin | CYP2C19 + CYP2D6 | B | General | Ultrarapid Metabolizer / Rapid Metabolizer / Likely Intermediate Metabolizer / Intermediate Metabolizer / Likely Poor Metabolizer / Poor Metabolizer | Avoid doxepin use; If doxepin is warranted, utilize therapeutic drug monitoring to guide dose adjustment. Utilizing therapeutic drug monitoring to guide dose adjustments is strongly recommended. | Optional | No alternative offered — CPIC’s guidance here is a dosing adjustment |
| doxepin | CYP2C19 + CYP2D6 | B | General | Ultrarapid Metabolizer / Rapid Metabolizer | Consider alternative drug not metabolized by CYP2C19; If doxepin is warranted, utilize therapeutic drug monitoring to guide dose adjustment. Utilizing therapeutic drug monitoring to guide dose adjustments is strongly recommended. | Optional | Derived from CPIC data — ATC N06A agents with no actionable CYP2C19 guidance: amoxapine, bupropion, desipramine, desvenlafaxine, duloxetine, fluoxetine, fluvoxamine, levomilnacipran, milnacipran, mirtazapine, nortriptyline, paroxetine, protriptyline, venlafaxine, vilazodone, vortioxetine |
| doxepin | CYP2C19 + CYP2D6 | B | General | Ultrarapid Metabolizer / Rapid Metabolizer | Consider alternative drug not metabolized by CYP2C19; If doxepin is warranted, utilize therapeutic drug monitoring to guide dose adjustment. | Optional | Derived from CPIC data — ATC N06A agents with no actionable CYP2C19 guidance: amoxapine, bupropion, desipramine, desvenlafaxine, duloxetine, fluoxetine, fluvoxamine, levomilnacipran, milnacipran, mirtazapine, nortriptyline, paroxetine, protriptyline, venlafaxine, vilazodone, vortioxetine |
| doxepin | CYP2C19 + CYP2D6 | B | General | Ultrarapid Metabolizer / Rapid Metabolizer | Avoid tertiary amine use due to potential for sub-optimal response. Consider alternative drug not metabolized by CYP2C19. TCAs without major CYP2C19 metabolism include the secondary amines nortriptyline and desipramine. If a tertiary amine is warranted, utilize therapeutic drug monitoring to guide dose adjustments. | Optional | Derived from CPIC data — ATC N06A agents with no actionable CYP2C19 guidance: amoxapine, bupropion, desipramine, desvenlafaxine, duloxetine, fluoxetine, fluvoxamine, levomilnacipran, milnacipran, mirtazapine, nortriptyline, paroxetine, protriptyline, venlafaxine, vilazodone, vortioxetine |
| doxepin | CYP2C19 + CYP2D6 | B | General | Normal Metabolizer / No Result | Initiate therapy with recommended starting dose. | Strong | No alternative offered — CPIC’s guidance here is a dosing adjustment |
| doxepin | CYP2C19 + CYP2D6 | B | General | Normal Metabolizer | Consider a 25% reduction of recommended starting dose. Utilize therapeutic drug monitoring to guide dose adjustments. | Optional | No alternative offered — CPIC’s guidance here is a dosing adjustment |
| doxepin | CYP2C19 + CYP2D6 | B | General | Normal Metabolizer | Avoid doxepin use. If a doxepin is warranted, consider a 50% reduction of recommended starting dose. Utilize therapeutic drug monitoring to guide dose adjustments. | Optional | No alternative offered — CPIC’s guidance here is a dosing adjustment |
| doxepin | CYP2C19 + CYP2D6 | B | General | Normal Metabolizer | Avoid doxepin use; If doxepin is warranted, consider titrating to a higher target dose (compared to normal metabolizers). Utilize therapeutic drug monitoring to guide dose adjustment. | Optional | No alternative offered — CPIC’s guidance here is a dosing adjustment |
| doxepin | CYP2C19 + CYP2D6 | B | General | Likely Intermediate Metabolizer / Intermediate Metabolizer | Initiate therapy with recommended starting dose. | Optional | No alternative offered — CPIC’s guidance here is a dosing adjustment |
| doxepin | CYP2C19 + CYP2D6 | B | General | Likely Intermediate Metabolizer / Intermediate Metabolizer | Consider a 25% reduction of recommended starting dose. Utilizing therapeutic drug monitoring to guide dose adjustments is strongly recommended. | Optional | No alternative offered — CPIC’s guidance here is a dosing adjustment |
| doxepin | CYP2C19 + CYP2D6 | B | General | Likely Intermediate Metabolizer / Intermediate Metabolizer | Avoid doxepin use. If a doxepin is warranted, consider a 50% reduction of recommended starting dose. Utilizing therapeutic drug monitoring to guide dose adjustments is strongly recommended. | Optional | No alternative offered — CPIC’s guidance here is a dosing adjustment |
| doxepin | CYP2C19 + CYP2D6 | B | General | Likely Poor Metabolizer / Poor Metabolizer | Avoid doxepin use. If doxepin is warranted, consider a 50% reduction of recommended starting dose. Utilize therapeutic drug monitoring to guide dose adjustments. | Optional | No alternative offered — CPIC’s guidance here is a dosing adjustment |
| doxepin | CYP2C19 + CYP2D6 | B | General | Likely Poor Metabolizer / Poor Metabolizer | Avoid tertiary amine use due to potential for sub-optimal response. Consider alternative drug not metabolized by CYP2C19. TCAs without major CYP2C19 metabolism include the secondary amines nortriptyline and desipramine. For tertiary amines, consider a 50% reduction of the recommended starting dose. Utilize therapeutic drug monitoring to guide dose adjustments. Titrate dose to observed clinical response with symptom improvement and minimal (if any) side effects. | Optional | Derived from CPIC data — ATC N06A agents with no actionable CYP2C19 guidance: amoxapine, bupropion, desipramine, desvenlafaxine, duloxetine, fluoxetine, fluvoxamine, levomilnacipran, milnacipran, mirtazapine, nortriptyline, paroxetine, protriptyline, venlafaxine, vilazodone, vortioxetine |
| doxepin | CYP2C19 + CYP2D6 | B | General | Indeterminate / No Result | Consider a 25% reduction of recommended starting dose. Utilize therapeutic drug monitoring to guide dose adjustments. Titrate dose to observed clinical response with symptom improvement and minimal (if any) side effects. | Optional | No alternative offered — CPIC’s guidance here is a dosing adjustment |
| doxepin | CYP2C19 + CYP2D6 | B | General | Indeterminate / No Result | Avoid tricyclic use due to potential for side effects. Consider alternative drug not metabolized by CYP2D6. If a TCA is warranted, consider a 50% reduction of recommended starting dose. Utilize therapeutic drug monitoring to guide dose adjustments. Titrate dose to observed clinical response with symptom improvement and minimal (if any) side effects. | Optional | Derived from CPIC data — ATC N06A agents with no actionable CYP2C19 guidance: bupropion, citalopram, desvenlafaxine, duloxetine, escitalopram, fluoxetine, levomilnacipran, milnacipran, sertraline, vilazodone |
| doxepin | CYP2C19 + CYP2D6 | B | General | Indeterminate / No Result | Avoid tricyclic use due to potential lack of efficacy. Consider alternative drug not metabolized by CYP2D6. If a TCA is warranted, consider titrating to a higher target dose (compared to normal metabolizers). Utilize therapeutic drug monitoring to guide dose adjustments. Titrate dose to observed clinical response with symptom improvement and minimal (if any) side effects. | Optional | Derived from CPIC data — ATC N06A agents with no actionable CYP2C19 guidance: bupropion, citalopram, desvenlafaxine, duloxetine, escitalopram, fluoxetine, levomilnacipran, milnacipran, sertraline, vilazodone |
| escitalopram | CYP2C19 | A | General | Ultrarapid Metabolizer | Consider a clinically appropriate alternative antidepressant not predominantly metabolized by CYP2C19. If citalopram or escitalopram are clinically appropriate, and adequate efficacy is not achieved at standard maintenance dosing, consider titrating to a higher maintenance dose. | Strong | Derived from CPIC data — ATC N06A agents with no actionable CYP2C19 guidance: amoxapine, bupropion, desipramine, desvenlafaxine, duloxetine, fluoxetine, fluvoxamine, levomilnacipran, milnacipran, mirtazapine, nortriptyline, paroxetine, protriptyline, venlafaxine, vilazodone, vortioxetine |
| escitalopram | CYP2C19 | A | General | Rapid Metabolizer | Initiate therapy with recommended starting dose. If patient does not adequately respond to recommended maintenance dosing, consider titrating to a higher maintenance dose or switching to a clinically appropriate alternative antidepressant not predominantly metabolized by CYP2C19. | Optional | Derived from CPIC data — ATC N06A agents with no actionable CYP2C19 guidance: amoxapine, bupropion, desipramine, desvenlafaxine, duloxetine, fluoxetine, fluvoxamine, levomilnacipran, milnacipran, mirtazapine, nortriptyline, paroxetine, protriptyline, venlafaxine, vilazodone, vortioxetine |
| escitalopram | CYP2C19 | A | General | Normal Metabolizer | Initiate therapy with recommended starting dose | Strong | No alternative offered — CPIC’s guidance here is a dosing adjustment |
| escitalopram | CYP2C19 | A | General | Likely Intermediate Metabolizer / Intermediate Metabolizer | Initiate therapy with recommended starting dose. Consider a slower titration schedule and lower maintenance dose than normal metabolizers. | Moderate | No alternative offered — CPIC’s guidance here is a dosing adjustment |
| escitalopram | CYP2C19 | A | General | Likely Poor Metabolizer / Poor Metabolizer | Consider a clinically appropriate antidepressant not predominantly metabolized by CYP2C19. If citalopram or escitalopram are clinically appropriate, consider a lower starting dose, slower titration schedule and 50% reduction of the standard maintenance dose as compared to normal metabolizers. | Strong | No alternative offered — CPIC’s guidance here is a dosing adjustment |
| imipramine | CYP2C19 + CYP2D6 | B | General | Ultrarapid Metabolizer / Rapid Metabolizer / Likely Intermediate Metabolizer / Intermediate Metabolizer / Likely Poor Metabolizer / Poor Metabolizer | Avoid imipramine use; If imipramine is warranted, utilize therapeutic drug monitoring to guide dose adjustment. Utilizing therapeutic drug monitoring to guide dose adjustments is strongly recommended. | Optional | No alternative offered — CPIC’s guidance here is a dosing adjustment |
| imipramine | CYP2C19 + CYP2D6 | B | General | Ultrarapid Metabolizer / Rapid Metabolizer | Consider alternative drug not metabolized by CYP2C19; If imipramine is warranted, utilize therapeutic drug monitoring to guide dose adjustment. Utilizing therapeutic drug monitoring to guide dose adjustments is strongly recommended. | Optional | Derived from CPIC data — ATC N06A agents with no actionable CYP2C19 guidance: amoxapine, bupropion, desipramine, desvenlafaxine, duloxetine, fluoxetine, fluvoxamine, levomilnacipran, milnacipran, mirtazapine, nortriptyline, paroxetine, protriptyline, venlafaxine, vilazodone, vortioxetine |
| imipramine | CYP2C19 + CYP2D6 | B | General | Ultrarapid Metabolizer / Rapid Metabolizer | Consider alternative drug not metabolized by CYP2C19; If imipramine is warranted, utilize therapeutic drug monitoring to guide dose adjustment. | Optional | Derived from CPIC data — ATC N06A agents with no actionable CYP2C19 guidance: amoxapine, bupropion, desipramine, desvenlafaxine, duloxetine, fluoxetine, fluvoxamine, levomilnacipran, milnacipran, mirtazapine, nortriptyline, paroxetine, protriptyline, venlafaxine, vilazodone, vortioxetine |
| imipramine | CYP2C19 + CYP2D6 | B | General | Ultrarapid Metabolizer / Rapid Metabolizer | Avoid tertiary amine use due to potential for sub-optimal response. Consider alternative drug not metabolized by CYP2C19. TCAs without major CYP2C19 metabolism include the secondary amines nortriptyline and desipramine. If a tertiary amine is warranted, utilize therapeutic drug monitoring to guide dose adjustments. | Optional | Derived from CPIC data — ATC N06A agents with no actionable CYP2C19 guidance: amoxapine, bupropion, desipramine, desvenlafaxine, duloxetine, fluoxetine, fluvoxamine, levomilnacipran, milnacipran, mirtazapine, nortriptyline, paroxetine, protriptyline, venlafaxine, vilazodone, vortioxetine |
| imipramine | CYP2C19 + CYP2D6 | B | General | Normal Metabolizer | Avoid imipramine use. If a imipramine is warranted, consider a 50% reduction of recommended starting dose. Utilize therapeutic drug monitoring to guide dose adjustments. | Optional | No alternative offered — CPIC’s guidance here is a dosing adjustment |
| imipramine | CYP2C19 + CYP2D6 | B | General | Normal Metabolizer | Consider a 25% reduction of recommended starting dose. Utilize therapeutic drug monitoring to guide dose adjustments. | Optional | No alternative offered — CPIC’s guidance here is a dosing adjustment |
| imipramine | CYP2C19 + CYP2D6 | B | General | Normal Metabolizer / No Result | Initiate therapy with recommended starting dose. | Strong | No alternative offered — CPIC’s guidance here is a dosing adjustment |
| imipramine | CYP2C19 + CYP2D6 | B | General | Normal Metabolizer | Avoid imipramine use; If imipramine is warranted, consider titrating to a higher target dose (compared to normal metabolizers). Utilize therapeutic drug monitoring to guide dose adjustment. | Optional | No alternative offered — CPIC’s guidance here is a dosing adjustment |
| imipramine | CYP2C19 + CYP2D6 | B | General | Likely Intermediate Metabolizer / Intermediate Metabolizer | Avoid imipramine use. If a imipramine is warranted, consider a 50% reduction of recommended starting dose. Utilizing therapeutic drug monitoring to guide dose adjustments is strongly recommended. | Optional | No alternative offered — CPIC’s guidance here is a dosing adjustment |
| imipramine | CYP2C19 + CYP2D6 | B | General | Likely Intermediate Metabolizer / Intermediate Metabolizer | Consider a 25% reduction of recommended starting dose. Utilizing therapeutic drug monitoring to guide dose adjustments is strongly recommended. | Optional | No alternative offered — CPIC’s guidance here is a dosing adjustment |
| imipramine | CYP2C19 + CYP2D6 | B | General | Likely Intermediate Metabolizer / Intermediate Metabolizer | Initiate therapy with recommended starting dose. | Optional | No alternative offered — CPIC’s guidance here is a dosing adjustment |
| imipramine | CYP2C19 + CYP2D6 | B | General | Likely Poor Metabolizer / Poor Metabolizer | Avoid imipramine use. If imipramine is warranted, consider a 50% reduction of recommended starting dose. Utilize therapeutic drug monitoring to guide dose adjustments. | Optional | No alternative offered — CPIC’s guidance here is a dosing adjustment |
| imipramine | CYP2C19 + CYP2D6 | B | General | Likely Poor Metabolizer / Poor Metabolizer | Avoid tertiary amine use due to potential for sub-optimal response. Consider alternative drug not metabolized by CYP2C19. TCAs without major CYP2C19 metabolism include the secondary amines nortriptyline and desipramine. For tertiary amines, consider a 50% reduction of the recommended starting dose. Utilize therapeutic drug monitoring to guide dose adjustments. Titrate dose to observed clinical response with symptom improvement and minimal (if any) side effects. | Optional | Derived from CPIC data — ATC N06A agents with no actionable CYP2C19 guidance: amoxapine, bupropion, desipramine, desvenlafaxine, duloxetine, fluoxetine, fluvoxamine, levomilnacipran, milnacipran, mirtazapine, nortriptyline, paroxetine, protriptyline, venlafaxine, vilazodone, vortioxetine |
| imipramine | CYP2C19 + CYP2D6 | B | General | Indeterminate / No Result | Avoid tricyclic use due to potential lack of efficacy. Consider alternative drug not metabolized by CYP2D6. If a TCA is warranted, consider titrating to a higher target dose (compared to normal metabolizers). Utilize therapeutic drug monitoring to guide dose adjustments. Titrate dose to observed clinical response with symptom improvement and minimal (if any) side effects. | Optional | Derived from CPIC data — ATC N06A agents with no actionable CYP2C19 guidance: bupropion, citalopram, desvenlafaxine, duloxetine, escitalopram, fluoxetine, levomilnacipran, milnacipran, sertraline, vilazodone |
| imipramine | CYP2C19 + CYP2D6 | B | General | Indeterminate / No Result | Avoid tricyclic use due to potential for side effects. Consider alternative drug not metabolized by CYP2D6. If a TCA is warranted, consider a 50% reduction of recommended starting dose. Utilize therapeutic drug monitoring to guide dose adjustments. Titrate dose to observed clinical response with symptom improvement and minimal (if any) side effects. | Optional | Derived from CPIC data — ATC N06A agents with no actionable CYP2C19 guidance: bupropion, citalopram, desvenlafaxine, duloxetine, escitalopram, fluoxetine, levomilnacipran, milnacipran, sertraline, vilazodone |
| imipramine | CYP2C19 + CYP2D6 | B | General | Indeterminate / No Result | Consider a 25% reduction of recommended starting dose. Utilize therapeutic drug monitoring to guide dose adjustments. Titrate dose to observed clinical response with symptom improvement and minimal (if any) side effects. | Optional | No alternative offered — CPIC’s guidance here is a dosing adjustment |
| sertraline | CYP2C19 + CYP2B6 | A | General | Ultrarapid Metabolizer / Rapid Metabolizer / Normal Metabolizer / Likely Intermediate Metabolizer / Intermediate Metabolizer / Indeterminate / No Result | Initiate therapy with recommended starting dose. | Moderate | No alternative offered — CPIC’s guidance here is a dosing adjustment |
| sertraline | CYP2C19 + CYP2B6 | A | General | Ultrarapid Metabolizer / Rapid Metabolizer / Normal Metabolizer / No Result | Initiate therapy with recommended starting dose. | Strong | No alternative offered — CPIC’s guidance here is a dosing adjustment |
| sertraline | CYP2C19 + CYP2B6 | A | General | Ultrarapid Metabolizer / Rapid Metabolizer | Initiate therapy with recommended starting dose. If patient does not adequately respond to recommended maintenance dosing, consider titrating to a higher
maintenance dose or switching to a clinically appropriate alternative antidepressant not predominantly metabolized by CYP2C19 or CYP2B6. | Optional | Derived from CPIC data — ATC N06A agents with no actionable CYP2C19 guidance: amoxapine, bupropion, desipramine, desvenlafaxine, duloxetine, fluoxetine, fluvoxamine, levomilnacipran, milnacipran, mirtazapine, nortriptyline, paroxetine, protriptyline, venlafaxine, vilazodone, vortioxetine |
| sertraline | CYP2C19 + CYP2B6 | A | General | Ultrarapid Metabolizer / Rapid Metabolizer | Initiate therapy with recommended starting dose. | Optional | No alternative offered — CPIC’s guidance here is a dosing adjustment |
| sertraline | CYP2C19 + CYP2B6 | A | General | Normal Metabolizer / Likely Intermediate Metabolizer / Intermediate Metabolizer / Indeterminate | Initiate therapy with recommended starting dose. Consider a slower titration schedule and lower maintenance dose. | Moderate | No alternative offered — CPIC’s guidance here is a dosing adjustment |
| sertraline | CYP2C19 + CYP2B6 | A | General | Normal Metabolizer | Initiate therapy with recommended starting dose | Strong | No alternative offered — CPIC’s guidance here is a dosing adjustment |
| sertraline | CYP2C19 + CYP2B6 | A | General | Normal Metabolizer / No Result | Consider a lower starting dose, slower titration schedule and 25% reduction of standard maintenance dose as compared to CYP2B6 normal metabolizers or select a clinically appropriate alternative antidepressant not predominantly metabolized by CYP2B6. | Optional | Derived from CPIC data — ATC N06A agents with no actionable CYP2C19 guidance: amitriptyline, amoxapine, citalopram, clomipramine, desipramine, desvenlafaxine, doxepin, duloxetine, escitalopram, fluoxetine, fluvoxamine, imipramine, levomilnacipran, milnacipran, mirtazapine, nortriptyline, paroxetine, protriptyline, trimipramine, venlafaxine, vilazodone, vortioxetine |
| sertraline | CYP2C19 + CYP2B6 | A | General | Likely Intermediate Metabolizer | Initiate therapy with recommended starting dose. Consider a slower titration schedule and lower maintenance dose than normal metabolizers. | Moderate | No alternative offered — CPIC’s guidance here is a dosing adjustment |
| sertraline | CYP2C19 + CYP2B6 | A | General | Likely Intermediate Metabolizer / Intermediate Metabolizer | Initiate therapy with recommended starting dose. Consider a slower titration schedule and lower maintenance dose than normal metabolizers. | Optional | No alternative offered — CPIC’s guidance here is a dosing adjustment |
| sertraline | CYP2C19 + CYP2B6 | A | General | Likely Intermediate Metabolizer / Intermediate Metabolizer | Consider a lower starting dose, slower titration schedule and 50% reduction of standard maintenance dose as compared to CYP2B6 normal metabolizers | Optional | No alternative offered — CPIC’s guidance here is a dosing adjustment |
| sertraline | CYP2C19 + CYP2B6 | A | General | Intermediate Metabolizer | Initiate therapy with recommended starting dose. Consider a slower titration schedule and lower maintenance dose than CYP2C19 normal metabolizers. | Moderate | No alternative offered — CPIC’s guidance here is a dosing adjustment |
| sertraline | CYP2C19 + CYP2B6 | A | General | Likely Poor Metabolizer / Poor Metabolizer | Consider a lower starting dose, slower titration schedule and 50% reduction of standard maintenance dose as compared to CYP2C19 normal metabolizers or select a clinically appropriate alternative antidepressant not predominantly metabolized by CYP2C19. | Moderate | Derived from CPIC data — ATC N06A agents with no actionable CYP2C19 guidance: amoxapine, bupropion, desipramine, desvenlafaxine, duloxetine, fluoxetine, fluvoxamine, levomilnacipran, milnacipran, mirtazapine, nortriptyline, paroxetine, protriptyline, venlafaxine, vilazodone, vortioxetine |
| sertraline | CYP2C19 + CYP2B6 | A | General | Likely Poor Metabolizer / Poor Metabolizer | Consider a lower starting dose, slower titration schedule and 50% reduction of standard maintenance dose as compared to CYP2C19 normal metabolizers or select a clinically appropriate alternative antidepressant not predominantly metabolized by CYP2C19. | Optional | Derived from CPIC data — ATC N06A agents with no actionable CYP2C19 guidance: amoxapine, bupropion, desipramine, desvenlafaxine, duloxetine, fluoxetine, fluvoxamine, levomilnacipran, milnacipran, mirtazapine, nortriptyline, paroxetine, protriptyline, venlafaxine, vilazodone, vortioxetine |
| sertraline | CYP2C19 + CYP2B6 | A | General | Likely Poor Metabolizer / Poor Metabolizer | Select an alternative antidepressant not primarily metabolized by CYP2C19 or CYP2B6. | Optional | No alternative offered — CPIC’s guidance here is a dosing adjustment |
| sertraline | CYP2C19 + CYP2B6 | A | General | Indeterminate | Consider a lower starting dose, slower titration schedule and 25% reduction of standard maintenance dose as CYP2B6 normal metabolizers or select a clinically appropriate alternative antidepressant not predominantly metabolized by CYP2B6. | Optional | Derived from CPIC data — ATC N06A agents with no actionable CYP2C19 guidance: amitriptyline, amoxapine, citalopram, clomipramine, desipramine, desvenlafaxine, doxepin, duloxetine, escitalopram, fluoxetine, fluvoxamine, imipramine, levomilnacipran, milnacipran, mirtazapine, nortriptyline, paroxetine, protriptyline, trimipramine, venlafaxine, vilazodone, vortioxetine |
| sertraline | CYP2C19 + CYP2B6 | A | General | No Result | Initiate therapy with recommended starting dose. Consider a slower titration schedule and lower maintenance dose than CYP2B6 normal metabolizers. | Optional | No alternative offered — CPIC’s guidance here is a dosing adjustment |
| trimipramine | CYP2C19 + CYP2D6 | B | General | Ultrarapid Metabolizer / Rapid Metabolizer / Likely Intermediate Metabolizer / Intermediate Metabolizer / Likely Poor Metabolizer / Poor Metabolizer | Avoid trimipramine use; If trimipramine is warranted, utilize therapeutic drug monitoring to guide dose adjustment. Utilizing therapeutic drug monitoring to guide dose adjustments is strongly recommended. | Optional | No alternative offered — CPIC’s guidance here is a dosing adjustment |
| trimipramine | CYP2C19 + CYP2D6 | B | General | Ultrarapid Metabolizer / Rapid Metabolizer | Consider alternative drug not metabolized by CYP2C19; If trimipramine is warranted, utilize therapeutic drug monitoring to guide dose adjustment. Utilizing therapeutic drug monitoring to guide dose adjustments is strongly recommended. | Optional | Derived from CPIC data — ATC N06A agents with no actionable CYP2C19 guidance: amoxapine, bupropion, desipramine, desvenlafaxine, duloxetine, fluoxetine, fluvoxamine, levomilnacipran, milnacipran, mirtazapine, nortriptyline, paroxetine, protriptyline, venlafaxine, vilazodone, vortioxetine |
| trimipramine | CYP2C19 + CYP2D6 | B | General | Ultrarapid Metabolizer / Rapid Metabolizer | Consider alternative drug not metabolized by CYP2C19; If trimipramine is warranted, utilize therapeutic drug monitoring to guide dose adjustment. | Optional | Derived from CPIC data — ATC N06A agents with no actionable CYP2C19 guidance: amoxapine, bupropion, desipramine, desvenlafaxine, duloxetine, fluoxetine, fluvoxamine, levomilnacipran, milnacipran, mirtazapine, nortriptyline, paroxetine, protriptyline, venlafaxine, vilazodone, vortioxetine |
| trimipramine | CYP2C19 + CYP2D6 | B | General | Ultrarapid Metabolizer / Rapid Metabolizer | Avoid tertiary amine use due to potential for sub-optimal response. Consider alternative drug not metabolized by CYP2C19. TCAs without major CYP2C19 metabolism include the secondary amines nortriptyline and desipramine. If a tertiary amine is warranted, utilize therapeutic drug monitoring to guide dose adjustments. | Optional | Derived from CPIC data — ATC N06A agents with no actionable CYP2C19 guidance: amoxapine, bupropion, desipramine, desvenlafaxine, duloxetine, fluoxetine, fluvoxamine, levomilnacipran, milnacipran, mirtazapine, nortriptyline, paroxetine, protriptyline, venlafaxine, vilazodone, vortioxetine |
| trimipramine | CYP2C19 + CYP2D6 | B | General | Normal Metabolizer | Consider a 25% reduction of recommended starting dose. Utilize therapeutic drug monitoring to guide dose adjustments. | Optional | No alternative offered — CPIC’s guidance here is a dosing adjustment |
| trimipramine | CYP2C19 + CYP2D6 | B | General | Normal Metabolizer / No Result | Initiate therapy with recommended starting dose. | Strong | No alternative offered — CPIC’s guidance here is a dosing adjustment |
| trimipramine | CYP2C19 + CYP2D6 | B | General | Normal Metabolizer | Avoid trimipramine use. If a trimipramine is warranted, consider a 50% reduction of recommended starting dose. Utilize therapeutic drug monitoring to guide dose adjustments. | Optional | No alternative offered — CPIC’s guidance here is a dosing adjustment |
| trimipramine | CYP2C19 + CYP2D6 | B | General | Normal Metabolizer | Avoid trimipramine use; If trimipramine is warranted, consider titrating to a higher target dose (compared to normal metabolizers). Utilize therapeutic drug monitoring to guide dose adjustment. | Optional | No alternative offered — CPIC’s guidance here is a dosing adjustment |
| trimipramine | CYP2C19 + CYP2D6 | B | General | Likely Intermediate Metabolizer / Intermediate Metabolizer | Consider a 25% reduction of recommended starting dose. Utilizing therapeutic drug monitoring to guide dose adjustments is strongly recommended. | Optional | No alternative offered — CPIC’s guidance here is a dosing adjustment |
| trimipramine | CYP2C19 + CYP2D6 | B | General | Likely Intermediate Metabolizer / Intermediate Metabolizer | Initiate therapy with recommended starting dose. | Optional | No alternative offered — CPIC’s guidance here is a dosing adjustment |
| trimipramine | CYP2C19 + CYP2D6 | B | General | Likely Intermediate Metabolizer / Intermediate Metabolizer | Avoid trimipramine use. If a trimipramine is warranted, consider a 50% reduction of recommended starting dose. Utilizing therapeutic drug monitoring to guide dose adjustments is strongly recommended. | Optional | No alternative offered — CPIC’s guidance here is a dosing adjustment |
| trimipramine | CYP2C19 + CYP2D6 | B | General | Likely Poor Metabolizer / Poor Metabolizer | Avoid trimipramine use. If trimipramine is warranted, consider a 50% reduction of recommended starting dose. Utilize therapeutic drug monitoring to guide dose adjustments. | Optional | No alternative offered — CPIC’s guidance here is a dosing adjustment |
| trimipramine | CYP2C19 + CYP2D6 | B | General | Likely Poor Metabolizer / Poor Metabolizer | Avoid tertiary amine use due to potential for sub-optimal response. Consider alternative drug not metabolized by CYP2C19. TCAs without major CYP2C19 metabolism include the secondary amines nortriptyline and desipramine. For tertiary amines, consider a 50% reduction of the recommended starting dose. Utilize therapeutic drug monitoring to guide dose adjustments. Titrate dose to observed clinical response with symptom improvement and minimal (if any) side effects. | Optional | Derived from CPIC data — ATC N06A agents with no actionable CYP2C19 guidance: amoxapine, bupropion, desipramine, desvenlafaxine, duloxetine, fluoxetine, fluvoxamine, levomilnacipran, milnacipran, mirtazapine, nortriptyline, paroxetine, protriptyline, venlafaxine, vilazodone, vortioxetine |
| trimipramine | CYP2C19 + CYP2D6 | B | General | Indeterminate / No Result | Consider a 25% reduction of recommended starting dose. Utilize therapeutic drug monitoring to guide dose adjustments. Titrate dose to observed clinical response with symptom improvement and minimal (if any) side effects. | Optional | No alternative offered — CPIC’s guidance here is a dosing adjustment |
| trimipramine | CYP2C19 + CYP2D6 | B | General | Indeterminate / No Result | Avoid tricyclic use due to potential for side effects. Consider alternative drug not metabolized by CYP2D6. If a TCA is warranted, consider a 50% reduction of recommended starting dose. Utilize therapeutic drug monitoring to guide dose adjustments. Titrate dose to observed clinical response with symptom improvement and minimal (if any) side effects. | Optional | Derived from CPIC data — ATC N06A agents with no actionable CYP2C19 guidance: bupropion, citalopram, desvenlafaxine, duloxetine, escitalopram, fluoxetine, levomilnacipran, milnacipran, sertraline, vilazodone |
| trimipramine | CYP2C19 + CYP2D6 | B | General | Indeterminate / No Result | Avoid tricyclic use due to potential lack of efficacy. Consider alternative drug not metabolized by CYP2D6. If a TCA is warranted, consider titrating to a higher target dose (compared to normal metabolizers). Utilize therapeutic drug monitoring to guide dose adjustments. Titrate dose to observed clinical response with symptom improvement and minimal (if any) side effects. | Optional | Derived from CPIC data — ATC N06A agents with no actionable CYP2C19 guidance: bupropion, citalopram, desvenlafaxine, duloxetine, escitalopram, fluoxetine, levomilnacipran, milnacipran, sertraline, vilazodone |
| fluvastatin | CYP2C9 + SLCO1B1 | A | General | Normal Metabolizer | Prescribe desired starting dose and adjust doses of fluvastatin based on disease-specific guidelines. | Strong | No alternative offered — CPIC’s guidance here is a dosing adjustment |
| fluvastatin | CYP2C9 + SLCO1B1 | A | General | Normal Metabolizer | Based on CYP2C9 status, prescribe desired starting dose and adjust doses of fluvastatin based on disease-specific guidelines. SLCO1B1 phenotype could not be assigned based on genotyping. | Strong | No alternative offered — CPIC’s guidance here is a dosing adjustment |
| fluvastatin | CYP2C9 + SLCO1B1 | A | General | Normal Metabolizer | Based on CYP2C9 status, prescribe desired starting dose and adjust doses of fluvastatin based on disease-specific guidelines. SLCO1B1 genotype result is not available. | Strong | No alternative offered — CPIC’s guidance here is a dosing adjustment |
| fluvastatin | CYP2C9 + SLCO1B1 | A | General | Normal Metabolizer | Prescribe ≤40mg per day as a starting dose and adjust doses of fluvastatin based on disease-specific guidelines. If patient is tolerating 40mg per day but higher potency is needed, a higher dose (>40mg) or an alternative statin or combination therapy (i.e. fluvastatin plus non-statin guideline directed medical therapy) (PMID: 30423391) could be considered. Prescriber should be aware of possible increased risk for myopathy with fluvastatin especially with doses >40mg per day. | Moderate | No alternative offered — CPIC’s guidance here is a dosing adjustment |
| fluvastatin | CYP2C9 + SLCO1B1 | A | General | Normal Metabolizer | Prescribe desired starting dose and adjust doses of fluvastatin based on disease-specific guidelines. Prescriber should be aware of possible increased risk for myopathy especially for doses >40mg per day. | Moderate | No alternative offered — CPIC’s guidance here is a dosing adjustment |
| fluvastatin | CYP2C9 + SLCO1B1 | A | General | Intermediate Metabolizer | Prescribe ≤20mg per day as a starting dose and adjust doses of fluvastatin based on disease-specific guidelines. If dose >20mg needed for desired efficacy, consider an alternative statin or combination therapy (i.e., fluvastatin plus non-statin guideline directed medical therapy) (PMID: 30423391). | Optional | No alternative offered — CPIC’s guidance here is a dosing adjustment |
| fluvastatin | CYP2C9 + SLCO1B1 | A | General | Intermediate Metabolizer | Prescribe ≤40mg per day as a starting dose and adjust doses of fluvastatin based on disease-specific guidelines. If dose >40mg needed for desired efficacy, consider an alternative statin or combination therapy (i.e., fluvastatin plus non-statin guideline directed medical therapy) (PMID: 30423391). | Moderate | No alternative offered — CPIC’s guidance here is a dosing adjustment |
| fluvastatin | CYP2C9 + SLCO1B1 | A | General | Intermediate Metabolizer | Prescribe an alternative statin depending on the desired potency. (see Table 2 and Figure 1 of PMID: 35152405 for recommendations for alternative statins). | Optional | No alternative offered — CPIC’s guidance here is a dosing adjustment |
| fluvastatin | CYP2C9 + SLCO1B1 | A | General | Intermediate Metabolizer | Based on CYP2C9 status, prescribe ≤40mg per day as a starting dose and adjust doses of fluvastatin based on disease-specific guidelines. If dose >40mg needed for desired efficacy, consider an alternative statin or combination therapy (i.e., fluvastatin plus non-statin guideline directed medical therapy) (PMID: 30423391). SLCO1B1 phenotype could not be assigned based on genotyping. | Moderate | No alternative offered — CPIC’s guidance here is a dosing adjustment |
| fluvastatin | CYP2C9 + SLCO1B1 | A | General | Intermediate Metabolizer | Based on CYP2C9 status, prescribe ≤40mg per day as a starting dose and adjust doses of fluvastatin based on disease-specific guidelines. If dose >40mg needed for desired efficacy, consider an alternative statin or combination therapy (i.e., fluvastatin plus non-statin guideline directed medical therapy) (PMID: 30423391). SLCO1B1 genotype result is not available. | Moderate | No alternative offered — CPIC’s guidance here is a dosing adjustment |
| fluvastatin | CYP2C9 + SLCO1B1 | A | General | Poor Metabolizer | Prescribe ≤20mg per day as a starting dose and adjust doses of fluvastatin based on disease-specific guidelines. If dose >20mg needed for desired efficacy, consider an alternative statin or combination therapy (i.e., fluvastatin plus non-statin guideline directed medical therapy) (PMID: 30423391). | Moderate | No alternative offered — CPIC’s guidance here is a dosing adjustment |
| fluvastatin | CYP2C9 + SLCO1B1 | A | General | Poor Metabolizer | Prescribe an alternative statin depending on the desired potency (see Figure 1 of PMID: 35152405 for recommendations for alternative statins). | Optional | No alternative offered — CPIC’s guidance here is a dosing adjustment |
| fluvastatin | CYP2C9 + SLCO1B1 | A | General | Poor Metabolizer | Prescribe an alternative statin depending on the desired potency (see Table 2 and Figure 1 of PMID: 35152405 for recommendations for alternative statins). | Optional | No alternative offered — CPIC’s guidance here is a dosing adjustment |
| fluvastatin | CYP2C9 + SLCO1B1 | A | General | Poor Metabolizer | Based on CYP2C9 status, prescribe ≤20mg per day as a starting dose and adjust doses of fluvastatin based on disease-specific guidelines. If dose >20mg needed for desired efficacy, consider an alternative statin or combination therapy (i.e., fluvastatin plus non-statin guideline directed medical therapy) (PMID: 30423391). SLCO1B1 phenotype could not be assigned based on genotyping. | Moderate | No alternative offered — CPIC’s guidance here is a dosing adjustment |
| fluvastatin | CYP2C9 + SLCO1B1 | A | General | Poor Metabolizer | Based on CYP2C9 status, prescribe ≤20mg per day as a starting dose and adjust doses of fluvastatin based on disease-specific guidelines. If dose >20mg needed for desired efficacy, consider an alternative statin or combination therapy (i.e., fluvastatin plus non-statin guideline directed medical therapy) (PMID: 30423391). SLCO1B1 genotype result is not available. | Moderate | No alternative offered — CPIC’s guidance here is a dosing adjustment |
| fluvastatin | CYP2C9 + SLCO1B1 | A | General | Indeterminate | Based on SLCO1B1 status, prescribe desired starting dose and adjust doses of fluvastatin based on disease-specific guidelines. Prescriber should be aware of possible increased risk for myopathy especially for doses >40mg per day. CYP2C9 phenotype could not be assigned based on genotyping. | Moderate | No alternative offered — CPIC’s guidance here is a dosing adjustment |
| fluvastatin | CYP2C9 + SLCO1B1 | A | General | Indeterminate | Based on SLCO1B1 status, prescribe desired starting dose and adjust doses based on disease-specific guidelines. CYP2C9 phenotype could not be assigned based on genotyping. | Strong | No alternative offered — CPIC’s guidance here is a dosing adjustment |
| fluvastatin | CYP2C9 + SLCO1B1 | A | General | Indeterminate | Based on SLCO1B1 status, prescribe ≤40mg per day as a starting dose and adjust doses of fluvastatin based on disease-specific guidelines. If patient is tolerating 40mg per day but higher potency is needed, a higher dose (>40mg) or an alternative statin (see Figure 1 of PMID: 35152405 for recommendations for alternative statins) or combination therapy (i.e. fluvastatin plus non-statin guideline directed medical therapy)(PMID: 30423391) could be considered. Prescriber should be aware of possible increased risk for myopathy with fluvastatin especially with doses >40mg per day. CYP2C9 phenotype could not be assigned based on genotyping. | Moderate | No alternative offered — CPIC’s guidance here is a dosing adjustment |
| fluvastatin | CYP2C9 + SLCO1B1 | A | General | No Result | Based on SLCO1B1 status, prescribe desired starting dose and adjust doses of fluvastatin based on disease-specific guidelines. Prescriber should be aware of possible increased risk for myopathy especially for doses >40mg per day. CYP2C9 genotype result is not available. | Moderate | No alternative offered — CPIC’s guidance here is a dosing adjustment |
| fluvastatin | CYP2C9 + SLCO1B1 | A | General | No Result | Based on SLCO1B1 status, prescribe desired starting dose and adjust doses based on disease-specific guidelines. CYP2C9 genotype result is not available. | Strong | No alternative offered — CPIC’s guidance here is a dosing adjustment |
| fluvastatin | CYP2C9 + SLCO1B1 | A | General | No Result | Based on SLCO1B1 status, prescribe ≤40mg per day as a starting dose and adjust doses of fluvastatin based on disease-specific guidelines. If patient is tolerating 40mg per day but higher potency is needed, a higher dose (>40mg) or an alternative statin (see Figure 1 of PMID: 35152405 for recommendations for alternative statins) or combination therapy (i.e. fluvastatin plus non-statin guideline directed medical therapy) (PMID: 30423391) could be considered. Prescriber should be aware of possible increased risk for myopathy with fluvastatin especially with doses >40mg per day. CYP2C9 genotype result is not available. | Moderate | No alternative offered — CPIC’s guidance here is a dosing adjustment |
| fosphenytoin | CYP2C9 | A | PHT naive | Normal Metabolizer / No Result | No adjustments needed from typical dosing strategies. Subsequent doses should be adjusted according to therapeutic drug monitoring, response, and side effects. An HLA-B*15:02 negative test does not eliminate the risk of phenytoin-induced SJS/TEN and patients should be carefully monitored according to a usual standard. | Strong | No alternative offered — CPIC’s guidance here is a dosing adjustment |
| fosphenytoin | CYP2C9 | A | PHT naive | Normal Metabolizer / Intermediate Metabolizer / Poor Metabolizer / Indeterminate / No Result | If patient is phenytoin-naive, do not use phenytoin/fosphenytoin. Avoid carbamazepine and oxcarbazepine. | Strong | No alternative offered — CPIC’s guidance here is a dosing adjustment |
| fosphenytoin | CYP2C9 | A | PHT naive | Intermediate Metabolizer | No adjustments needed from typical dosing strategies. Subsequent doses should be adjusted according to therapeutic drug monitoring, response and side effects. An HLA-B*15:02 negative test does not eliminate the risk of phenytoin-induced SJS/TEN and patients should be carefully monitored according to a usual standard. | Moderate | No alternative offered — CPIC’s guidance here is a dosing adjustment |
| fosphenytoin | CYP2C9 | A | PHT naive | Intermediate Metabolizer | For first dose, use typical initial or loading dose. For subsequent doses, use approximately 25% less than typical maintenance dose. Subsequent doses should be adjusted according to therapeutic drug monitoring, response and side effects. An HLA-B*15:02 negative test does not eliminate the risk of phenytoin-induced SJS/TEN, and patients should be carefully monitored according to a usual standard. | Moderate | No alternative offered — CPIC’s guidance here is a dosing adjustment |
| fosphenytoin | CYP2C9 | A | PHT naive | Poor Metabolizer | For first dose, use typical initial or loading dose. For subsequent doses use approximately 50% less than typical maintenance dose. Subsequent doses should be adjusted according to therapeutic drug monitoring, response, and side effects. An HLA-B*15:02 negative test does not eliminate the risk of phenytoin-induced SJS/TEN, and patients should be carefully monitored according to a usual standard. | Strong | No alternative offered — CPIC’s guidance here is a dosing adjustment |
| fosphenytoin | CYP2C9 | A | PHT use >3mos | Normal Metabolizer / No Result | No adjustments needed from typical dosing strategies. Subsequent doses should be adjusted according to therapeutic drug monitoring, response, and side effects. An HLA-B*15:02 negative test does not eliminate the risk of phenytoin-induced SJS/TEN and patients should be carefully monitored according to a usual standard. | Strong | No alternative offered — CPIC’s guidance here is a dosing adjustment |
| fosphenytoin | CYP2C9 | A | PHT use >3mos | Normal Metabolizer / Intermediate Metabolizer / Poor Metabolizer / Indeterminate / No Result | If the patient has previously used phenytoin continuously for longer than three months without incidence of cutaneous adverse reactions, cautiously consider use of phenytoin in the future. The latency period for drug-induced SJS/TEN is short with continuous dosing and adherence to therapy (4-28 days), and cases usually occur within three months of dosing. | Optional | No alternative offered — CPIC’s guidance here is a dosing adjustment |
| fosphenytoin | CYP2C9 | A | PHT use >3mos | Intermediate Metabolizer | No adjustments needed from typical dosing strategies. Subsequent doses should be adjusted according to therapeutic drug monitoring, response and side effects. An HLA-B*15:02 negative test does not eliminate the risk of phenytoin-induced SJS/TEN and patients should be carefully monitored according to a usual standard. | Moderate | No alternative offered — CPIC’s guidance here is a dosing adjustment |
| fosphenytoin | CYP2C9 | A | PHT use >3mos | Intermediate Metabolizer | For first dose, use typical initial or loading dose. For subsequent doses, use approximately 25% less than typical maintenance dose. Subsequent doses should be adjusted according to therapeutic drug monitoring, response and side effects. An HLA-B*15:02 negative test does not eliminate the risk of phenytoin-induced SJS/TEN, and patients should be carefully monitored according to a usual standard. | Moderate | No alternative offered — CPIC’s guidance here is a dosing adjustment |
| fosphenytoin | CYP2C9 | A | PHT use >3mos | Poor Metabolizer | For first dose, use typical initial or loading dose. For subsequent doses use approximately 50% less than typical maintenance dose. Subsequent doses should be adjusted according to therapeutic drug monitoring, response, and side effects. An HLA-B*15:02 negative test does not eliminate the risk of phenytoin-induced SJS/TEN, and patients should be carefully monitored according to a usual standard. | Strong | No alternative offered — CPIC’s guidance here is a dosing adjustment |
| phenytoin | CYP2C9 | A | PHT naive | Normal Metabolizer / No Result | No adjustments needed from typical dosing strategies. Subsequent doses should be adjusted according to therapeutic drug monitoring, response, and side effects. An HLA-B*15:02 negative test does not eliminate the risk of phenytoin-induced SJS/TEN and patients should be carefully monitored according to a usual standard. | Strong | No alternative offered — CPIC’s guidance here is a dosing adjustment |
| phenytoin | CYP2C9 | A | PHT naive | Normal Metabolizer / Intermediate Metabolizer / Poor Metabolizer / Indeterminate / No Result | If patient is phenytoin-naive, do not use phenytoin/fosphenytoin. Avoid carbamazepine and oxcarbazepine. | Strong | No alternative offered — CPIC’s guidance here is a dosing adjustment |
| phenytoin | CYP2C9 | A | PHT naive | Intermediate Metabolizer | No adjustments needed from typical dosing strategies. Subsequent doses should be adjusted according to therapeutic drug monitoring, response and side effects. An HLA-B*15:02 negative test does not eliminate the risk of phenytoin-induced SJS/TEN and patients should be carefully monitored according to a usual standard. | Moderate | No alternative offered — CPIC’s guidance here is a dosing adjustment |
| phenytoin | CYP2C9 | A | PHT naive | Intermediate Metabolizer | For first dose, use typical initial or loading dose. For subsequent doses, use approximately 25% less than typical maintenance dose. Subsequent doses should be adjusted according to therapeutic drug monitoring, response and side effects. An HLA-B*15:02 negative test does not eliminate the risk of phenytoin-induced SJS/TEN, and patients should be carefully monitored according to a usual standard. | Moderate | No alternative offered — CPIC’s guidance here is a dosing adjustment |
| phenytoin | CYP2C9 | A | PHT naive | Poor Metabolizer | For first dose, use typical initial or loading dose. For subsequent doses use approximately 50% less than typical maintenance dose. Subsequent doses should be adjusted according to therapeutic drug monitoring, response, and side effects. An HLA-B*15:02 negative test does not eliminate the risk of phenytoin-induced SJS/TEN, and patients should be carefully monitored according to a usual standard. | Strong | No alternative offered — CPIC’s guidance here is a dosing adjustment |
| phenytoin | CYP2C9 | A | PHT use >3mos | Normal Metabolizer / No Result | No adjustments needed from typical dosing strategies. Subsequent doses should be adjusted according to therapeutic drug monitoring, response, and side effects. An HLA-B*15:02 negative test does not eliminate the risk of phenytoin-induced SJS/TEN and patients should be carefully monitored according to a usual standard. | Strong | No alternative offered — CPIC’s guidance here is a dosing adjustment |
| phenytoin | CYP2C9 | A | PHT use >3mos | Normal Metabolizer / Intermediate Metabolizer / Poor Metabolizer / Indeterminate / No Result | If the patient has previously used phenytoin continuously for longer than three months without incidence of cutaneous adverse reactions, cautiously consider use of phenytoin in the future. The latency period for drug-induced SJS/TEN is short with continuous dosing and adherence to therapy (4-28 days), and cases usually occur within three months of dosing. | Optional | No alternative offered — CPIC’s guidance here is a dosing adjustment |
| phenytoin | CYP2C9 | A | PHT use >3mos | Intermediate Metabolizer | No adjustments needed from typical dosing strategies. Subsequent doses should be adjusted according to therapeutic drug monitoring, response and side effects. An HLA-B*15:02 negative test does not eliminate the risk of phenytoin-induced SJS/TEN and patients should be carefully monitored according to a usual standard. | Moderate | No alternative offered — CPIC’s guidance here is a dosing adjustment |
| phenytoin | CYP2C9 | A | PHT use >3mos | Intermediate Metabolizer | For first dose, use typical initial or loading dose. For subsequent doses, use approximately 25% less than typical maintenance dose. Subsequent doses should be adjusted according to therapeutic drug monitoring, response and side effects. An HLA-B*15:02 negative test does not eliminate the risk of phenytoin-induced SJS/TEN, and patients should be carefully monitored according to a usual standard. | Moderate | No alternative offered — CPIC’s guidance here is a dosing adjustment |
| phenytoin | CYP2C9 | A | PHT use >3mos | Poor Metabolizer | For first dose, use typical initial or loading dose. For subsequent doses use approximately 50% less than typical maintenance dose. Subsequent doses should be adjusted according to therapeutic drug monitoring, response, and side effects. An HLA-B*15:02 negative test does not eliminate the risk of phenytoin-induced SJS/TEN, and patients should be carefully monitored according to a usual standard. | Strong | No alternative offered — CPIC’s guidance here is a dosing adjustment |
| amitriptyline | CYP2D6 + CYP2C19 | A | General | Ultrarapid Metabolizer / Intermediate Metabolizer / Poor Metabolizer | Avoid amitriptyline use; If amitriptyline is warranted, utilize therapeutic drug monitoring to guide dose adjustment. Utilizing therapeutic drug monitoring to guide dose adjustments is strongly recommended. | Optional | No alternative offered — CPIC’s guidance here is a dosing adjustment |
| amitriptyline | CYP2D6 + CYP2C19 | A | General | Ultrarapid Metabolizer | Avoid amitriptyline use; If amitriptyline is warranted, consider titrating to a higher target dose (compared to normal metabolizers). Utilize therapeutic drug monitoring to guide dose adjustment. | Strong | No alternative offered — CPIC’s guidance here is a dosing adjustment |
| amitriptyline | CYP2D6 + CYP2C19 | A | General | Ultrarapid Metabolizer | Avoid tricyclic use due to potential lack of efficacy. Consider alternative drug not metabolized by CYP2D6. If a TCA is warranted, consider titrating to a higher target dose (compared to normal metabolizers). Utilize therapeutic drug monitoring to guide dose adjustments. Titrate dose to observed clinical response with symptom improvement and minimal (if any) side effects. | Strong | Derived from CPIC data — ATC N06A agents with no actionable CYP2D6 guidance: bupropion, citalopram, desvenlafaxine, duloxetine, escitalopram, fluoxetine, levomilnacipran, milnacipran, sertraline, vilazodone |
| amitriptyline | CYP2D6 + CYP2C19 | A | General | Normal Metabolizer / No Result | Initiate therapy with recommended starting dose. | Strong | No alternative offered — CPIC’s guidance here is a dosing adjustment |
| amitriptyline | CYP2D6 + CYP2C19 | A | General | Normal Metabolizer | Avoid amitriptyline use. If amitripyline is warranted, consider a 50% reduction of recommended starting dose. Utilize therapeutic drug monitoring to guide dose adjustments. | Moderate | No alternative offered — CPIC’s guidance here is a dosing adjustment |
| amitriptyline | CYP2D6 + CYP2C19 | A | General | Normal Metabolizer | Consider alternative drug not metabolized by CYP2C19; If amitriptyline is warranted, utilize therapeutic drug monitoring to guide dose adjustment. | Optional | Derived from CPIC data — ATC N06A agents with no actionable CYP2D6 guidance: amoxapine, bupropion, desipramine, desvenlafaxine, duloxetine, fluoxetine, fluvoxamine, levomilnacipran, milnacipran, mirtazapine, nortriptyline, paroxetine, protriptyline, venlafaxine, vilazodone, vortioxetine |
| amitriptyline | CYP2D6 + CYP2C19 | A | General | Intermediate Metabolizer | Consider a 25% reduction of recommended starting dose. Utilizing therapeutic drug monitoring to guide dose adjustments is strongly recommended. | Optional | No alternative offered — CPIC’s guidance here is a dosing adjustment |
| amitriptyline | CYP2D6 + CYP2C19 | A | General | Intermediate Metabolizer | Consider a 25% reduction of recommended starting dose. Utilize therapeutic drug monitoring to guide dose adjustments. | Moderate | No alternative offered — CPIC’s guidance here is a dosing adjustment |
| amitriptyline | CYP2D6 + CYP2C19 | A | General | Intermediate Metabolizer | Consider alternative drug not metabolized by CYP2C19; If amitriptyline is warranted, utilize therapeutic drug monitoring to guide dose adjustment. Utilizing therapeutic drug monitoring to guide dose adjustments is strongly recommended. | Optional | Derived from CPIC data — ATC N06A agents with no actionable CYP2D6 guidance: amoxapine, bupropion, desipramine, desvenlafaxine, duloxetine, fluoxetine, fluvoxamine, levomilnacipran, milnacipran, mirtazapine, nortriptyline, paroxetine, protriptyline, venlafaxine, vilazodone, vortioxetine |
| amitriptyline | CYP2D6 + CYP2C19 | A | General | Intermediate Metabolizer | Consider a 25% reduction of recommended starting dose. Utilize therapeutic drug monitoring to guide dose adjustments. Titrate dose to observed clinical response with symptom improvement and minimal (if any) side effects. | Moderate | No alternative offered — CPIC’s guidance here is a dosing adjustment |
| amitriptyline | CYP2D6 + CYP2C19 | A | General | Poor Metabolizer | Avoid amitriptyline use. If a amitripyline is warranted, consider a 50% reduction of recommended starting dose. Utilizing therapeutic drug monitoring to guide dose adjustments is strongly recommended. | Optional | No alternative offered — CPIC’s guidance here is a dosing adjustment |
| amitriptyline | CYP2D6 + CYP2C19 | A | General | Poor Metabolizer | Avoid amitriptyline use. If a amitripyline is warranted, consider a 50% reduction of recommended starting dose. Utilize therapeutic drug monitoring to guide dose adjustments. | Strong | No alternative offered — CPIC’s guidance here is a dosing adjustment |
| amitriptyline | CYP2D6 + CYP2C19 | A | General | Poor Metabolizer | Avoid tricyclic use due to potential for side effects. Consider alternative drug not metabolized by CYP2D6. If a TCA is warranted, consider a 50% reduction of recommended starting dose. Utilize therapeutic drug monitoring to guide dose adjustments. Titrate dose to observed clinical response with symptom improvement and minimal (if any) side effects. | Strong | Derived from CPIC data — ATC N06A agents with no actionable CYP2D6 guidance: bupropion, citalopram, desvenlafaxine, duloxetine, escitalopram, fluoxetine, levomilnacipran, milnacipran, sertraline, vilazodone |
| amitriptyline | CYP2D6 + CYP2C19 | A | General | Indeterminate / No Result | Avoid tertiary amine use due to potential for sub-optimal response. Consider alternative drug not metabolized by CYP2C19. TCAs without major CYP2C19 metabolism include the secondary amines nortriptyline and desipramine. For tertiary amines, consider a 50% reduction of the recommended starting dose. Utilize therapeutic drug monitoring to guide dose adjustments. Titrate dose to observed clinical response with symptom improvement and minimal (if any) side effects. | Moderate | Derived from CPIC data — ATC N06A agents with no actionable CYP2D6 guidance: amoxapine, bupropion, desipramine, desvenlafaxine, duloxetine, fluoxetine, fluvoxamine, levomilnacipran, milnacipran, mirtazapine, nortriptyline, paroxetine, protriptyline, venlafaxine, vilazodone, vortioxetine |
| amitriptyline | CYP2D6 + CYP2C19 | A | General | Indeterminate / No Result | Avoid tertiary amine use due to potential for sub-optimal response. Consider alternative drug not metabolized by CYP2C19. TCAs without major CYP2C19 metabolism include the secondary amines nortriptyline and desipramine. If a tertiary amine is warranted, utilize therapeutic drug monitoring to guide dose adjustments. | Optional | Derived from CPIC data — ATC N06A agents with no actionable CYP2D6 guidance: amoxapine, bupropion, desipramine, desvenlafaxine, duloxetine, fluoxetine, fluvoxamine, levomilnacipran, milnacipran, mirtazapine, nortriptyline, paroxetine, protriptyline, venlafaxine, vilazodone, vortioxetine |
| atomoxetine | CYP2D6 | A | Paediatrics | Ultrarapid Metabolizer | Initiate with a dose of 0.5 mg/kg/day and increase to 1.2 mg/kg/day after 3 days. If no clinical response and in the absence of adverse events after 2 weeks, consider obtaining a peak plasma concentration (1 to 2 hours after dose administered). If <200 ng/mL, consider a proportional increase in dose to approach 400 ng/mL. | Moderate | No alternative offered — CPIC’s guidance here is a dosing adjustment |
| atomoxetine | CYP2D6 | A | Paediatrics | Ultrarapid Metabolizer | Initiate with a dose of 0.5 mg/kg and increase to 1.2 mg/kg/day after 3 days. If no clinical response and in the absence of adverse events after 2 weeks, consider obtaining a peak plasma concentration (1 to 2 hours after dose administered). If < 200 ng/mL, consider a proportional increase in dose to approach 400 ng/mL. | Moderate | No alternative offered — CPIC’s guidance here is a dosing adjustment |
| atomoxetine | CYP2D6 | A | Paediatrics | Normal Metabolizer / Intermediate Metabolizer | Initiate with a dose of 0.5 mg/kg/day and increase to 1.2 mg/kg/day after 3 days. If no clinical response and in the absence of adverse events after 2 weeks, consider obtaining a peak plasma concentration (1 to 2 hours after dose administered). If < 200 ng/mL, consider a proportional increase in dose to approach 400 ng/mL. | Moderate | No alternative offered — CPIC’s guidance here is a dosing adjustment |
| atomoxetine | CYP2D6 | A | Paediatrics | Intermediate Metabolizer | Initiate with a dose of 0.5 mg/kg/day and if no clinical response and in the absence of adverse events after 2 weeks, consider obtaining a plasma concentration 2 to 4 hours after dosing. If response is inadequate and concentration is < 200 ng/mL, consider a proportional dose increase to achieve a concentration to approach 400 ng/mL. If unacceptable side effects are present at any time, consider a reduction in dose. | Moderate | No alternative offered — CPIC’s guidance here is a dosing adjustment |
| atomoxetine | CYP2D6 | A | Paediatrics | Poor Metabolizer | Initiate with a dose of 0.5 mg/kg/day and if no clinical response and in the absence of adverse events after 2 weeks, consider obtaining a plasma concentration 4 hours after dosing. If response is inadequate and concentration is < 200 ng/mL, consider a proportional dose increase to achieve a concentration to approach 400 ng/mL. If unacceptable side effects are present at any time, consider a reduction in dose. | Strong | No alternative offered — CPIC’s guidance here is a dosing adjustment |
| atomoxetine | CYP2D6 | A | Adults | Ultrarapid Metabolizer / Normal Metabolizer / Intermediate Metabolizer | Initiate with a dose of 40 mg/day and increase to 80 mg/day after 3 days. If no clinical response and in the absence of adverse events after 2 weeks, consider increasing dose to 100 mg/day. If no clinical response observed after 2 weeks, consider obtaining a peak plasma concentration (1 to 2 hours after dose administered). If <200 ng/mL, consider a proportional increase in dose to approach 400 ng/mL. Dosages greater than 100 mg/day may be needed to achieve target concentrations. | Moderate | No alternative offered — CPIC’s guidance here is a dosing adjustment |
| atomoxetine | CYP2D6 | A | Adults | Intermediate Metabolizer | Initiate with a dose of 40 mg/day and if no clinical response and in the absence of adverse events after 2 weeks increase dose to 80 mg/day. If response is inadequate after 2 weeks consider obtaining a plasma concentration 2-4 h after dosing. If concentration is <200 ng/mL, consider a proportional dose increase to achieve a concentration to approach 400 ng/mL. If unacceptable side effects are present at any time, consider a reduction in dose. | Moderate | No alternative offered — CPIC’s guidance here is a dosing adjustment |
| atomoxetine | CYP2D6 | A | Adults | Poor Metabolizer | Initiate with a dose of 40 mg/day and if no clinical response and in the absence of adverse events after 2 weeks increase dose to 80 mg/day. If response is inadequate after 2 weeks, consider obtaining a plasma concentration 2 to 4 hours after dosing. If concentration is <200 ng/mL, consider a proportional dose increase to achieve a concentration to approach 400 ng/mL. If unacceptable side effects are present at any time, consider a reduction in dose. | Moderate | No alternative offered — CPIC’s guidance here is a dosing adjustment |
| clomipramine | CYP2D6 + CYP2C19 | B | General | Ultrarapid Metabolizer / Intermediate Metabolizer / Poor Metabolizer | Avoid clomipramine use; If clomipramine is warranted, utilize therapeutic drug monitoring to guide dose adjustment. Utilizing therapeutic drug monitoring to guide dose adjustments is strongly recommended. | Optional | No alternative offered — CPIC’s guidance here is a dosing adjustment |
| clomipramine | CYP2D6 + CYP2C19 | B | General | Ultrarapid Metabolizer | Avoid clomipramine use; If clomipramine is warranted, consider titrating to a higher target dose (compared to normal metabolizers). Utilize therapeutic drug monitoring to guide dose adjustment. | Optional | No alternative offered — CPIC’s guidance here is a dosing adjustment |
| clomipramine | CYP2D6 + CYP2C19 | B | General | Ultrarapid Metabolizer | Avoid tricyclic use due to potential lack of efficacy. Consider alternative drug not metabolized by CYP2D6. If a TCA is warranted, consider titrating to a higher target dose (compared to normal metabolizers). Utilize therapeutic drug monitoring to guide dose adjustments. Titrate dose to observed clinical response with symptom improvement and minimal (if any) side effects. | Optional | Derived from CPIC data — ATC N06A agents with no actionable CYP2D6 guidance: bupropion, citalopram, desvenlafaxine, duloxetine, escitalopram, fluoxetine, levomilnacipran, milnacipran, sertraline, vilazodone |
| clomipramine | CYP2D6 + CYP2C19 | B | General | Normal Metabolizer / No Result | Initiate therapy with recommended starting dose. | Strong | No alternative offered — CPIC’s guidance here is a dosing adjustment |
| clomipramine | CYP2D6 + CYP2C19 | B | General | Normal Metabolizer / No Result | Initiate therapy with recommended starting dose. | Optional | No alternative offered — CPIC’s guidance here is a dosing adjustment |
| clomipramine | CYP2D6 + CYP2C19 | B | General | Normal Metabolizer | Avoid clomipramine use. If clomipramine is warranted, consider a 50% reduction of recommended starting dose. Utilize therapeutic drug monitoring to guide dose adjustments. | Optional | No alternative offered — CPIC’s guidance here is a dosing adjustment |
| clomipramine | CYP2D6 + CYP2C19 | B | General | Normal Metabolizer | Consider alternative drug not metabolized by CYP2C19; If clomipramine is warranted, utilize therapeutic drug monitoring to guide dose adjustment. | Optional | Derived from CPIC data — ATC N06A agents with no actionable CYP2D6 guidance: amoxapine, bupropion, desipramine, desvenlafaxine, duloxetine, fluoxetine, fluvoxamine, levomilnacipran, milnacipran, mirtazapine, nortriptyline, paroxetine, protriptyline, venlafaxine, vilazodone, vortioxetine |
| clomipramine | CYP2D6 + CYP2C19 | B | General | Intermediate Metabolizer | Consider a 25% reduction of recommended starting dose. Utilize therapeutic drug monitoring to guide dose adjustments. | Optional | No alternative offered — CPIC’s guidance here is a dosing adjustment |
| clomipramine | CYP2D6 + CYP2C19 | B | General | Intermediate Metabolizer | Consider a 25% reduction of recommended starting dose. Utilizing therapeutic drug monitoring to guide dose adjustments is strongly recommended. | Optional | No alternative offered — CPIC’s guidance here is a dosing adjustment |
| clomipramine | CYP2D6 + CYP2C19 | B | General | Intermediate Metabolizer | Consider alternative drug not metabolized by CYP2C19; If clomipramine is warranted, utilize therapeutic drug monitoring to guide dose adjustment. Utilizing therapeutic drug monitoring to guide dose adjustments is strongly recommended. | Optional | Derived from CPIC data — ATC N06A agents with no actionable CYP2D6 guidance: amoxapine, bupropion, desipramine, desvenlafaxine, duloxetine, fluoxetine, fluvoxamine, levomilnacipran, milnacipran, mirtazapine, nortriptyline, paroxetine, protriptyline, venlafaxine, vilazodone, vortioxetine |
| clomipramine | CYP2D6 + CYP2C19 | B | General | Intermediate Metabolizer | Consider a 25% reduction of recommended starting dose. Utilize therapeutic drug monitoring to guide dose adjustments. Titrate dose to observed clinical response with symptom improvement and minimal (if any) side effects. | Optional | No alternative offered — CPIC’s guidance here is a dosing adjustment |
| clomipramine | CYP2D6 + CYP2C19 | B | General | Poor Metabolizer | Avoid clomipramine use. If a clomipramine is warranted, consider a 50% reduction of recommended starting dose. Utilizing therapeutic drug monitoring to guide dose adjustments is strongly recommended. | Optional | No alternative offered — CPIC’s guidance here is a dosing adjustment |
| clomipramine | CYP2D6 + CYP2C19 | B | General | Poor Metabolizer | Avoid clomipramine use. If a clomipramine is warranted, consider a 50% reduction of recommended starting dose. Utilize therapeutic drug monitoring to guide dose adjustments. | Optional | No alternative offered — CPIC’s guidance here is a dosing adjustment |
| clomipramine | CYP2D6 + CYP2C19 | B | General | Poor Metabolizer | Avoid tricyclic use due to potential for side effects. Consider alternative drug not metabolized by CYP2D6. If a TCA is warranted, consider a 50% reduction of recommended starting dose. Utilize therapeutic drug monitoring to guide dose adjustments. Titrate dose to observed clinical response with symptom improvement and minimal (if any) side effects. | Optional | Derived from CPIC data — ATC N06A agents with no actionable CYP2D6 guidance: bupropion, citalopram, desvenlafaxine, duloxetine, escitalopram, fluoxetine, levomilnacipran, milnacipran, sertraline, vilazodone |
| clomipramine | CYP2D6 + CYP2C19 | B | General | Indeterminate / No Result | Avoid tertiary amine use due to potential for sub-optimal response. Consider alternative drug not metabolized by CYP2C19. TCAs without major CYP2C19 metabolism include the secondary amines nortriptyline and desipramine. For tertiary amines, consider a 50% reduction of the recommended starting dose. Utilize therapeutic drug monitoring to guide dose adjustments. Titrate dose to observed clinical response with symptom improvement and minimal (if any) side effects. | Optional | Derived from CPIC data — ATC N06A agents with no actionable CYP2D6 guidance: amoxapine, bupropion, desipramine, desvenlafaxine, duloxetine, fluoxetine, fluvoxamine, levomilnacipran, milnacipran, mirtazapine, nortriptyline, paroxetine, protriptyline, venlafaxine, vilazodone, vortioxetine |
| clomipramine | CYP2D6 + CYP2C19 | B | General | Indeterminate / No Result | Avoid tertiary amine use due to potential for sub-optimal response. Consider alternative drug not metabolized by CYP2C19. TCAs without major CYP2C19 metabolism include the secondary amines nortriptyline and desipramine. If a tertiary amine is warranted, utilize therapeutic drug monitoring to guide dose adjustments. | Optional | Derived from CPIC data — ATC N06A agents with no actionable CYP2D6 guidance: amoxapine, bupropion, desipramine, desvenlafaxine, duloxetine, fluoxetine, fluvoxamine, levomilnacipran, milnacipran, mirtazapine, nortriptyline, paroxetine, protriptyline, venlafaxine, vilazodone, vortioxetine |
| desipramine | CYP2D6 | B | General | Ultrarapid Metabolizer | Avoid tricyclic use due to potential lack of efficacy. Consider alternative drug not metabolized by CYP2D6. If a TCA is warranted, consider titrating to a higher target dose (compared to normal metabolizers). Titrate dose to observed clinical response with symptom improvement and minimal (if any) side effects. Utilize therapeutic drug monitoring to guide dose adjustments. | Optional | Derived from CPIC data — ATC N06A agents with no actionable CYP2D6 guidance: bupropion, citalopram, desvenlafaxine, duloxetine, escitalopram, fluoxetine, levomilnacipran, milnacipran, sertraline, vilazodone |
| desipramine | CYP2D6 | B | General | Normal Metabolizer | Initiate therapy with recommended starting dose | Strong | No alternative offered — CPIC’s guidance here is a dosing adjustment |
| desipramine | CYP2D6 | B | General | Intermediate Metabolizer | Consider a 25% reduction of recommended starting dose. Titrate dose to observed clinical response with symptom improvement and minimal (if any) side effects. Utilize therapeutic drug monitoring to guide dose adjustments. | Optional | No alternative offered — CPIC’s guidance here is a dosing adjustment |
| desipramine | CYP2D6 | B | General | Poor Metabolizer | Avoid tricyclic use due to potential for side effects. Consider alternative drug not metabolized by CYP2D6. If a TCA is warranted, consider a 50% reduction of recommended starting dose. Titrate dose to observed clinical response with symptom improvement and minimal (if any) side effects. Utilize therapeutic drug monitoring to guide dose adjustments. | Optional | Derived from CPIC data — ATC N06A agents with no actionable CYP2D6 guidance: bupropion, citalopram, desvenlafaxine, duloxetine, escitalopram, fluoxetine, levomilnacipran, milnacipran, sertraline, vilazodone |
| doxepin | CYP2D6 + CYP2C19 | B | General | Ultrarapid Metabolizer / Intermediate Metabolizer / Poor Metabolizer | Avoid doxepin use; If doxepin is warranted, utilize therapeutic drug monitoring to guide dose adjustment. Utilizing therapeutic drug monitoring to guide dose adjustments is strongly recommended. | Optional | No alternative offered — CPIC’s guidance here is a dosing adjustment |
| doxepin | CYP2D6 + CYP2C19 | B | General | Ultrarapid Metabolizer | Avoid doxepin use; If doxepin is warranted, consider titrating to a higher target dose (compared to normal metabolizers). Utilize therapeutic drug monitoring to guide dose adjustment. | Optional | No alternative offered — CPIC’s guidance here is a dosing adjustment |
| doxepin | CYP2D6 + CYP2C19 | B | General | Ultrarapid Metabolizer | Avoid tricyclic use due to potential lack of efficacy. Consider alternative drug not metabolized by CYP2D6. If a TCA is warranted, consider titrating to a higher target dose (compared to normal metabolizers). Utilize therapeutic drug monitoring to guide dose adjustments. Titrate dose to observed clinical response with symptom improvement and minimal (if any) side effects. | Optional | Derived from CPIC data — ATC N06A agents with no actionable CYP2D6 guidance: bupropion, citalopram, desvenlafaxine, duloxetine, escitalopram, fluoxetine, levomilnacipran, milnacipran, sertraline, vilazodone |
| doxepin | CYP2D6 + CYP2C19 | B | General | Normal Metabolizer / No Result | Initiate therapy with recommended starting dose. | Strong | No alternative offered — CPIC’s guidance here is a dosing adjustment |
| doxepin | CYP2D6 + CYP2C19 | B | General | Normal Metabolizer / No Result | Initiate therapy with recommended starting dose. | Optional | No alternative offered — CPIC’s guidance here is a dosing adjustment |
| doxepin | CYP2D6 + CYP2C19 | B | General | Normal Metabolizer | Avoid doxepin use. If doxepin is warranted, consider a 50% reduction of recommended starting dose. Utilize therapeutic drug monitoring to guide dose adjustments. | Optional | No alternative offered — CPIC’s guidance here is a dosing adjustment |
| doxepin | CYP2D6 + CYP2C19 | B | General | Normal Metabolizer | Consider alternative drug not metabolized by CYP2C19; If doxepin is warranted, utilize therapeutic drug monitoring to guide dose adjustment. | Optional | Derived from CPIC data — ATC N06A agents with no actionable CYP2D6 guidance: amoxapine, bupropion, desipramine, desvenlafaxine, duloxetine, fluoxetine, fluvoxamine, levomilnacipran, milnacipran, mirtazapine, nortriptyline, paroxetine, protriptyline, venlafaxine, vilazodone, vortioxetine |
| doxepin | CYP2D6 + CYP2C19 | B | General | Intermediate Metabolizer | Consider a 25% reduction of recommended starting dose. Utilizing therapeutic drug monitoring to guide dose adjustments is strongly recommended. | Optional | No alternative offered — CPIC’s guidance here is a dosing adjustment |
| doxepin | CYP2D6 + CYP2C19 | B | General | Intermediate Metabolizer | Consider a 25% reduction of recommended starting dose. Utilize therapeutic drug monitoring to guide dose adjustments. | Optional | No alternative offered — CPIC’s guidance here is a dosing adjustment |
| doxepin | CYP2D6 + CYP2C19 | B | General | Intermediate Metabolizer | Consider alternative drug not metabolized by CYP2C19; If doxepin is warranted, utilize therapeutic drug monitoring to guide dose adjustment. Utilizing therapeutic drug monitoring to guide dose adjustments is strongly recommended. | Optional | Derived from CPIC data — ATC N06A agents with no actionable CYP2D6 guidance: amoxapine, bupropion, desipramine, desvenlafaxine, duloxetine, fluoxetine, fluvoxamine, levomilnacipran, milnacipran, mirtazapine, nortriptyline, paroxetine, protriptyline, venlafaxine, vilazodone, vortioxetine |
| doxepin | CYP2D6 + CYP2C19 | B | General | Intermediate Metabolizer | Consider a 25% reduction of recommended starting dose. Utilize therapeutic drug monitoring to guide dose adjustments. Titrate dose to observed clinical response with symptom improvement and minimal (if any) side effects. | Optional | No alternative offered — CPIC’s guidance here is a dosing adjustment |
| doxepin | CYP2D6 + CYP2C19 | B | General | Poor Metabolizer | Avoid doxepin use. If a doxepin is warranted, consider a 50% reduction of recommended starting dose. Utilizing therapeutic drug monitoring to guide dose adjustments is strongly recommended. | Optional | No alternative offered — CPIC’s guidance here is a dosing adjustment |
| doxepin | CYP2D6 + CYP2C19 | B | General | Poor Metabolizer | Avoid doxepin use. If a doxepin is warranted, consider a 50% reduction of recommended starting dose. Utilize therapeutic drug monitoring to guide dose adjustments. | Optional | No alternative offered — CPIC’s guidance here is a dosing adjustment |
| doxepin | CYP2D6 + CYP2C19 | B | General | Poor Metabolizer | Avoid tricyclic use due to potential for side effects. Consider alternative drug not metabolized by CYP2D6. If a TCA is warranted, consider a 50% reduction of recommended starting dose. Utilize therapeutic drug monitoring to guide dose adjustments. Titrate dose to observed clinical response with symptom improvement and minimal (if any) side effects. | Optional | Derived from CPIC data — ATC N06A agents with no actionable CYP2D6 guidance: bupropion, citalopram, desvenlafaxine, duloxetine, escitalopram, fluoxetine, levomilnacipran, milnacipran, sertraline, vilazodone |
| doxepin | CYP2D6 + CYP2C19 | B | General | Indeterminate / No Result | Avoid tertiary amine use due to potential for sub-optimal response. Consider alternative drug not metabolized by CYP2C19. TCAs without major CYP2C19 metabolism include the secondary amines nortriptyline and desipramine. For tertiary amines, consider a 50% reduction of the recommended starting dose. Utilize therapeutic drug monitoring to guide dose adjustments. Titrate dose to observed clinical response with symptom improvement and minimal (if any) side effects. | Optional | Derived from CPIC data — ATC N06A agents with no actionable CYP2D6 guidance: amoxapine, bupropion, desipramine, desvenlafaxine, duloxetine, fluoxetine, fluvoxamine, levomilnacipran, milnacipran, mirtazapine, nortriptyline, paroxetine, protriptyline, venlafaxine, vilazodone, vortioxetine |
| doxepin | CYP2D6 + CYP2C19 | B | General | Indeterminate / No Result | Avoid tertiary amine use due to potential for sub-optimal response. Consider alternative drug not metabolized by CYP2C19. TCAs without major CYP2C19 metabolism include the secondary amines nortriptyline and desipramine. If a tertiary amine is warranted, utilize therapeutic drug monitoring to guide dose adjustments. | Optional | Derived from CPIC data — ATC N06A agents with no actionable CYP2D6 guidance: amoxapine, bupropion, desipramine, desvenlafaxine, duloxetine, fluoxetine, fluvoxamine, levomilnacipran, milnacipran, mirtazapine, nortriptyline, paroxetine, protriptyline, venlafaxine, vilazodone, vortioxetine |
| fluvoxamine | CYP2D6 | B | General | Ultrarapid Metabolizer | No recommendation due to lack of evidence | No Recommendation | No alternative offered — CPIC’s guidance here is a dosing adjustment |
| fluvoxamine | CYP2D6 | B | General | Normal Metabolizer | Initiate therapy with recommended starting dose. | Strong | No alternative offered — CPIC’s guidance here is a dosing adjustment |
| fluvoxamine | CYP2D6 | B | General | Intermediate Metabolizer | Initiate therapy with recommended starting dose. | Moderate | No alternative offered — CPIC’s guidance here is a dosing adjustment |
| fluvoxamine | CYP2D6 | B | General | Poor Metabolizer | Consider a 25-50% lower starting dose and slower titration schedule as compared to normal metabolizers or consider a clinically appropriate alternative antidepressant not predominantly metabolized by CYP2D6. | Optional | Derived from CPIC data — ATC N06A agents with no actionable CYP2D6 guidance: bupropion, citalopram, desvenlafaxine, duloxetine, escitalopram, fluoxetine, levomilnacipran, milnacipran, sertraline, vilazodone |
| imipramine | CYP2D6 + CYP2C19 | B | General | Ultrarapid Metabolizer / Intermediate Metabolizer / Poor Metabolizer | Avoid imipramine use; If imipramine is warranted, utilize therapeutic drug monitoring to guide dose adjustment. Utilizing therapeutic drug monitoring to guide dose adjustments is strongly recommended. | Optional | No alternative offered — CPIC’s guidance here is a dosing adjustment |
| imipramine | CYP2D6 + CYP2C19 | B | General | Ultrarapid Metabolizer | Avoid imipramine use; If imipramine is warranted, consider titrating to a higher target dose (compared to normal metabolizers). Utilize therapeutic drug monitoring to guide dose adjustment. | Optional | No alternative offered — CPIC’s guidance here is a dosing adjustment |
| imipramine | CYP2D6 + CYP2C19 | B | General | Ultrarapid Metabolizer | Avoid tricyclic use due to potential lack of efficacy. Consider alternative drug not metabolized by CYP2D6. If a TCA is warranted, consider titrating to a higher target dose (compared to normal metabolizers). Utilize therapeutic drug monitoring to guide dose adjustments. Titrate dose to observed clinical response with symptom improvement and minimal (if any) side effects. | Optional | Derived from CPIC data — ATC N06A agents with no actionable CYP2D6 guidance: bupropion, citalopram, desvenlafaxine, duloxetine, escitalopram, fluoxetine, levomilnacipran, milnacipran, sertraline, vilazodone |
| imipramine | CYP2D6 + CYP2C19 | B | General | Normal Metabolizer / No Result | Initiate therapy with recommended starting dose. | Optional | No alternative offered — CPIC’s guidance here is a dosing adjustment |
| imipramine | CYP2D6 + CYP2C19 | B | General | Normal Metabolizer / No Result | Initiate therapy with recommended starting dose. | Strong | No alternative offered — CPIC’s guidance here is a dosing adjustment |
| imipramine | CYP2D6 + CYP2C19 | B | General | Normal Metabolizer | Avoid imipramine use. If imipramine is warranted, consider a 50% reduction of recommended starting dose. Utilize therapeutic drug monitoring to guide dose adjustments. | Optional | No alternative offered — CPIC’s guidance here is a dosing adjustment |
| imipramine | CYP2D6 + CYP2C19 | B | General | Normal Metabolizer | Consider alternative drug not metabolized by CYP2C19; If imipramine is warranted, utilize therapeutic drug monitoring to guide dose adjustment. | Optional | Derived from CPIC data — ATC N06A agents with no actionable CYP2D6 guidance: amoxapine, bupropion, desipramine, desvenlafaxine, duloxetine, fluoxetine, fluvoxamine, levomilnacipran, milnacipran, mirtazapine, nortriptyline, paroxetine, protriptyline, venlafaxine, vilazodone, vortioxetine |
| imipramine | CYP2D6 + CYP2C19 | B | General | Intermediate Metabolizer | Consider a 25% reduction of recommended starting dose. Utilizing therapeutic drug monitoring to guide dose adjustments is strongly recommended. | Optional | No alternative offered — CPIC’s guidance here is a dosing adjustment |
| imipramine | CYP2D6 + CYP2C19 | B | General | Intermediate Metabolizer | Consider a 25% reduction of recommended starting dose. Utilize therapeutic drug monitoring to guide dose adjustments. | Optional | No alternative offered — CPIC’s guidance here is a dosing adjustment |
| imipramine | CYP2D6 + CYP2C19 | B | General | Intermediate Metabolizer | Consider alternative drug not metabolized by CYP2C19; If imipramine is warranted, utilize therapeutic drug monitoring to guide dose adjustment. Utilizing therapeutic drug monitoring to guide dose adjustments is strongly recommended. | Optional | Derived from CPIC data — ATC N06A agents with no actionable CYP2D6 guidance: amoxapine, bupropion, desipramine, desvenlafaxine, duloxetine, fluoxetine, fluvoxamine, levomilnacipran, milnacipran, mirtazapine, nortriptyline, paroxetine, protriptyline, venlafaxine, vilazodone, vortioxetine |
| imipramine | CYP2D6 + CYP2C19 | B | General | Intermediate Metabolizer | Consider a 25% reduction of recommended starting dose. Utilize therapeutic drug monitoring to guide dose adjustments. Titrate dose to observed clinical response with symptom improvement and minimal (if any) side effects. | Optional | No alternative offered — CPIC’s guidance here is a dosing adjustment |
| imipramine | CYP2D6 + CYP2C19 | B | General | Poor Metabolizer | Avoid imipramine use. If a imipramine is warranted, consider a 50% reduction of recommended starting dose. Utilizing therapeutic drug monitoring to guide dose adjustments is strongly recommended. | Optional | No alternative offered — CPIC’s guidance here is a dosing adjustment |
| imipramine | CYP2D6 + CYP2C19 | B | General | Poor Metabolizer | Avoid imipramine use. If a imipramine is warranted, consider a 50% reduction of recommended starting dose. Utilize therapeutic drug monitoring to guide dose adjustments. | Optional | No alternative offered — CPIC’s guidance here is a dosing adjustment |
| imipramine | CYP2D6 + CYP2C19 | B | General | Poor Metabolizer | Avoid tricyclic use due to potential for side effects. Consider alternative drug not metabolized by CYP2D6. If a TCA is warranted, consider a 50% reduction of recommended starting dose. Utilize therapeutic drug monitoring to guide dose adjustments. Titrate dose to observed clinical response with symptom improvement and minimal (if any) side effects. | Optional | Derived from CPIC data — ATC N06A agents with no actionable CYP2D6 guidance: bupropion, citalopram, desvenlafaxine, duloxetine, escitalopram, fluoxetine, levomilnacipran, milnacipran, sertraline, vilazodone |
| imipramine | CYP2D6 + CYP2C19 | B | General | Indeterminate / No Result | Avoid tertiary amine use due to potential for sub-optimal response. Consider alternative drug not metabolized by CYP2C19. TCAs without major CYP2C19 metabolism include the secondary amines nortriptyline and desipramine. For tertiary amines, consider a 50% reduction of the recommended starting dose. Utilize therapeutic drug monitoring to guide dose adjustments. Titrate dose to observed clinical response with symptom improvement and minimal (if any) side effects. | Optional | Derived from CPIC data — ATC N06A agents with no actionable CYP2D6 guidance: amoxapine, bupropion, desipramine, desvenlafaxine, duloxetine, fluoxetine, fluvoxamine, levomilnacipran, milnacipran, mirtazapine, nortriptyline, paroxetine, protriptyline, venlafaxine, vilazodone, vortioxetine |
| imipramine | CYP2D6 + CYP2C19 | B | General | Indeterminate / No Result | Avoid tertiary amine use due to potential for sub-optimal response. Consider alternative drug not metabolized by CYP2C19. TCAs without major CYP2C19 metabolism include the secondary amines nortriptyline and desipramine. If a tertiary amine is warranted, utilize therapeutic drug monitoring to guide dose adjustments. | Optional | Derived from CPIC data — ATC N06A agents with no actionable CYP2D6 guidance: amoxapine, bupropion, desipramine, desvenlafaxine, duloxetine, fluoxetine, fluvoxamine, levomilnacipran, milnacipran, mirtazapine, nortriptyline, paroxetine, protriptyline, venlafaxine, vilazodone, vortioxetine |
| metoprolol | CYP2D6 | B | General | Ultrarapid Metabolizer | No recommendation for metoprolol therapy due to insufficient evidence regarding diminished metoprolol effectiveness clinically | No Recommendation | No alternative offered — CPIC’s guidance here is a dosing adjustment |
| metoprolol | CYP2D6 | B | General | Normal Metabolizer | Initiate standard dosing | Strong | No alternative offered — CPIC’s guidance here is a dosing adjustment |
| metoprolol | CYP2D6 | B | General | Intermediate Metabolizer | Initiate standard dosing | Moderate | No alternative offered — CPIC’s guidance here is a dosing adjustment |
| metoprolol | CYP2D6 | B | General | Poor Metabolizer | Initiate therapy with lowest recommended starting dose. Carefully titrate dose upward to clinical effect or guideline-recommended dose; monitor more closely for bradycardia. Alternatively, consider selecting another beta-blocker. | Moderate | No alternative offered — CPIC’s guidance here is a dosing adjustment |
| nortriptyline | CYP2D6 | A | General | Ultrarapid Metabolizer | Avoid tricyclic use due to potential lack of efficacy. Consider alternative drug not metabolized by CYP2D6. If a tricyclic antidepressant is warranted, consider titrating to a higher target dose (compared to normal metabolizers). Titrate dose to observed clinical response with symptom improvement and minimal (if any) side effects. Utilize therapeutic drug monitoring to guide dose adjustments. | Strong | Derived from CPIC data — ATC N06A agents with no actionable CYP2D6 guidance: bupropion, citalopram, desvenlafaxine, duloxetine, escitalopram, fluoxetine, levomilnacipran, milnacipran, sertraline, vilazodone |
| nortriptyline | CYP2D6 | A | General | Normal Metabolizer | Initiate therapy with recommended starting dose | Strong | No alternative offered — CPIC’s guidance here is a dosing adjustment |
| nortriptyline | CYP2D6 | A | General | Intermediate Metabolizer | Consider a 25% reduction of recommended starting dose. Titrate dose to observed clinical response with symptom improvement and minimal (if any) side effects. Utilize therapeutic drug monitoring to guide dose adjustments. | Optional | No alternative offered — CPIC’s guidance here is a dosing adjustment |
| nortriptyline | CYP2D6 | A | General | Intermediate Metabolizer | Consider a 25% reduction of recommended starting dose. Titrate dose to observed clinical response with symptom improvement and minimal (if any) side effects. Utilize therapeutic drug monitoring to guide dose adjustments. | Moderate | No alternative offered — CPIC’s guidance here is a dosing adjustment |
| nortriptyline | CYP2D6 | A | General | Poor Metabolizer | Avoid tricyclic use due to potential for side effects. Consider alternative drug not metabolized by CYP2D6. If a tricyclic antidepressant is warranted, consider a 50% reduction of recommended starting dose. Titrate dose to observed clinical response with symptom improvement and minimal (if any) side effects. Utilize therapeutic drug monitoring to guide dose adjustments. | Strong | Derived from CPIC data — ATC N06A agents with no actionable CYP2D6 guidance: bupropion, citalopram, desvenlafaxine, duloxetine, escitalopram, fluoxetine, levomilnacipran, milnacipran, sertraline, vilazodone |
| paroxetine | CYP2D6 | A | General | Ultrarapid Metabolizer | Select alternative drug not predominantly metabolized by CYP2D6. | Moderate | Derived from CPIC data — ATC N06A agents with no actionable CYP2D6 guidance: bupropion, citalopram, desvenlafaxine, duloxetine, escitalopram, fluoxetine, levomilnacipran, milnacipran, sertraline, vilazodone |
| paroxetine | CYP2D6 | A | General | Normal Metabolizer | Initiate therapy with recommended starting dose | Strong | No alternative offered — CPIC’s guidance here is a dosing adjustment |
| paroxetine | CYP2D6 | A | General | Intermediate Metabolizer | Consider a lower starting dose and slower titration schedule as compared to normal metabolizers. | Optional | No alternative offered — CPIC’s guidance here is a dosing adjustment |
| paroxetine | CYP2D6 | A | General | Poor Metabolizer | Consider a 50% reduction in recommended starting dose, slower titration schedule, and a 50% lower maintenance dose as compared to normal metabolizers. | Moderate | No alternative offered — CPIC’s guidance here is a dosing adjustment |
| trimipramine | CYP2D6 + CYP2C19 | B | General | Ultrarapid Metabolizer / Intermediate Metabolizer / Poor Metabolizer | Avoid trimipramine use; If trimipramine is warranted, utilize therapeutic drug monitoring to guide dose adjustment. Utilizing therapeutic drug monitoring to guide dose adjustments is strongly recommended. | Optional | No alternative offered — CPIC’s guidance here is a dosing adjustment |
| trimipramine | CYP2D6 + CYP2C19 | B | General | Ultrarapid Metabolizer | Avoid trimipramine use; If trimipramine is warranted, consider titrating to a higher target dose (compared to normal metabolizers). Utilize therapeutic drug monitoring to guide dose adjustment. | Optional | No alternative offered — CPIC’s guidance here is a dosing adjustment |
| trimipramine | CYP2D6 + CYP2C19 | B | General | Ultrarapid Metabolizer | Avoid tricyclic use due to potential lack of efficacy. Consider alternative drug not metabolized by CYP2D6. If a TCA is warranted, consider titrating to a higher target dose (compared to normal metabolizers). Utilize therapeutic drug monitoring to guide dose adjustments. Titrate dose to observed clinical response with symptom improvement and minimal (if any) side effects. | Optional | Derived from CPIC data — ATC N06A agents with no actionable CYP2D6 guidance: bupropion, citalopram, desvenlafaxine, duloxetine, escitalopram, fluoxetine, levomilnacipran, milnacipran, sertraline, vilazodone |
| trimipramine | CYP2D6 + CYP2C19 | B | General | Normal Metabolizer / No Result | Initiate therapy with recommended starting dose. | Optional | No alternative offered — CPIC’s guidance here is a dosing adjustment |
| trimipramine | CYP2D6 + CYP2C19 | B | General | Normal Metabolizer / No Result | Initiate therapy with recommended starting dose. | Strong | No alternative offered — CPIC’s guidance here is a dosing adjustment |
| trimipramine | CYP2D6 + CYP2C19 | B | General | Normal Metabolizer | Avoid trimipramine use. If trimipramine is warranted, consider a 50% reduction of recommended starting dose. Utilize therapeutic drug monitoring to guide dose adjustments. | Optional | No alternative offered — CPIC’s guidance here is a dosing adjustment |
| trimipramine | CYP2D6 + CYP2C19 | B | General | Normal Metabolizer | Consider alternative drug not metabolized by CYP2C19; If trimipramine is warranted, utilize therapeutic drug monitoring to guide dose adjustment. | Optional | Derived from CPIC data — ATC N06A agents with no actionable CYP2D6 guidance: amoxapine, bupropion, desipramine, desvenlafaxine, duloxetine, fluoxetine, fluvoxamine, levomilnacipran, milnacipran, mirtazapine, nortriptyline, paroxetine, protriptyline, venlafaxine, vilazodone, vortioxetine |
| trimipramine | CYP2D6 + CYP2C19 | B | General | Intermediate Metabolizer | Consider a 25% reduction of recommended starting dose. Utilizing therapeutic drug monitoring to guide dose adjustments is strongly recommended. | Optional | No alternative offered — CPIC’s guidance here is a dosing adjustment |
| trimipramine | CYP2D6 + CYP2C19 | B | General | Intermediate Metabolizer | Consider a 25% reduction of recommended starting dose. Utilize therapeutic drug monitoring to guide dose adjustments. | Optional | No alternative offered — CPIC’s guidance here is a dosing adjustment |
| trimipramine | CYP2D6 + CYP2C19 | B | General | Intermediate Metabolizer | Consider alternative drug not metabolized by CYP2C19; If trimipramine is warranted, utilize therapeutic drug monitoring to guide dose adjustment. Utilizing therapeutic drug monitoring to guide dose adjustments is strongly recommended. | Optional | Derived from CPIC data — ATC N06A agents with no actionable CYP2D6 guidance: amoxapine, bupropion, desipramine, desvenlafaxine, duloxetine, fluoxetine, fluvoxamine, levomilnacipran, milnacipran, mirtazapine, nortriptyline, paroxetine, protriptyline, venlafaxine, vilazodone, vortioxetine |
| trimipramine | CYP2D6 + CYP2C19 | B | General | Intermediate Metabolizer | Consider a 25% reduction of recommended starting dose. Utilize therapeutic drug monitoring to guide dose adjustments. Titrate dose to observed clinical response with symptom improvement and minimal (if any) side effects. | Optional | No alternative offered — CPIC’s guidance here is a dosing adjustment |
| trimipramine | CYP2D6 + CYP2C19 | B | General | Poor Metabolizer | Avoid trimipramine use. If a trimipramine is warranted, consider a 50% reduction of recommended starting dose. Utilizing therapeutic drug monitoring to guide dose adjustments is strongly recommended. | Optional | No alternative offered — CPIC’s guidance here is a dosing adjustment |
| trimipramine | CYP2D6 + CYP2C19 | B | General | Poor Metabolizer | Avoid trimipramine use. If a trimipramine is warranted, consider a 50% reduction of recommended starting dose. Utilize therapeutic drug monitoring to guide dose adjustments. | Optional | No alternative offered — CPIC’s guidance here is a dosing adjustment |
| trimipramine | CYP2D6 + CYP2C19 | B | General | Poor Metabolizer | Avoid tricyclic use due to potential for side effects. Consider alternative drug not metabolized by CYP2D6. If a TCA is warranted, consider a 50% reduction of recommended starting dose. Utilize therapeutic drug monitoring to guide dose adjustments. Titrate dose to observed clinical response with symptom improvement and minimal (if any) side effects. | Optional | Derived from CPIC data — ATC N06A agents with no actionable CYP2D6 guidance: bupropion, citalopram, desvenlafaxine, duloxetine, escitalopram, fluoxetine, levomilnacipran, milnacipran, sertraline, vilazodone |
| trimipramine | CYP2D6 + CYP2C19 | B | General | Indeterminate / No Result | Avoid tertiary amine use due to potential for sub-optimal response. Consider alternative drug not metabolized by CYP2C19. TCAs without major CYP2C19 metabolism include the secondary amines nortriptyline and desipramine. For tertiary amines, consider a 50% reduction of the recommended starting dose. Utilize therapeutic drug monitoring to guide dose adjustments. Titrate dose to observed clinical response with symptom improvement and minimal (if any) side effects. | Optional | Derived from CPIC data — ATC N06A agents with no actionable CYP2D6 guidance: amoxapine, bupropion, desipramine, desvenlafaxine, duloxetine, fluoxetine, fluvoxamine, levomilnacipran, milnacipran, mirtazapine, nortriptyline, paroxetine, protriptyline, venlafaxine, vilazodone, vortioxetine |
| trimipramine | CYP2D6 + CYP2C19 | B | General | Indeterminate / No Result | Avoid tertiary amine use due to potential for sub-optimal response. Consider alternative drug not metabolized by CYP2C19. TCAs without major CYP2C19 metabolism include the secondary amines nortriptyline and desipramine. If a tertiary amine is warranted, utilize therapeutic drug monitoring to guide dose adjustments. | Optional | Derived from CPIC data — ATC N06A agents with no actionable CYP2D6 guidance: amoxapine, bupropion, desipramine, desvenlafaxine, duloxetine, fluoxetine, fluvoxamine, levomilnacipran, milnacipran, mirtazapine, nortriptyline, paroxetine, protriptyline, venlafaxine, vilazodone, vortioxetine |
| venlafaxine | CYP2D6 | B | General | Ultrarapid Metabolizer / Intermediate Metabolizer | No action recommended based on genotype for venlafaxine because of minimal evidence regarding the impact on efficacy or side effects. | No Recommendation | No alternative offered — CPIC’s guidance here is a dosing adjustment |
| venlafaxine | CYP2D6 | B | General | Normal Metabolizer | Initiate therapy with recommended starting dose. | Strong | No alternative offered — CPIC’s guidance here is a dosing adjustment |
| venlafaxine | CYP2D6 | B | General | Poor Metabolizer | Consider a clinically appropriate alternative antidepressant not predominantly metabolized by CYP2D6. | Optional | Derived from CPIC data — ATC N06A agents with no actionable CYP2D6 guidance: bupropion, citalopram, desvenlafaxine, duloxetine, escitalopram, fluoxetine, levomilnacipran, milnacipran, sertraline, vilazodone |
| vortioxetine | CYP2D6 | A | General | Ultrarapid Metabolizer | Select alternative drug not predominantly metabolized by CYP2D6. If vortioxetine use is warranted, initiate therapy at standard starting dose and titrate to maintenance dose based on efficacy and side effects. Increasing the target maintenance dose by 50% or more may be needed for efficacy. | Optional | Derived from CPIC data — ATC N06A agents with no actionable CYP2D6 guidance: bupropion, citalopram, desvenlafaxine, duloxetine, escitalopram, fluoxetine, levomilnacipran, milnacipran, sertraline, vilazodone |
| vortioxetine | CYP2D6 | A | General | Normal Metabolizer | Initiate therapy with recommended starting dose. | Strong | No alternative offered — CPIC’s guidance here is a dosing adjustment |
| vortioxetine | CYP2D6 | A | General | Intermediate Metabolizer | Initiate therapy with recommended starting dose. | Moderate | No alternative offered — CPIC’s guidance here is a dosing adjustment |
| vortioxetine | CYP2D6 | A | General | Poor Metabolizer | Initiate 50% of starting dose (e.g., 5 mg) and titrate to the maximum recommended dose of 10 mg or consider a clinically appropriate alternative antidepressant not predominantly metabolized by CYP2D6. | Moderate | Derived from CPIC data — ATC N06A agents with no actionable CYP2D6 guidance: bupropion, citalopram, desvenlafaxine, duloxetine, escitalopram, fluoxetine, levomilnacipran, milnacipran, sertraline, vilazodone |
| atorvastatin | SLCO1B1 | A | General | Increased Function / Normal Function | Prescribe desired starting dose and adjust doses based on disease-specific guidelines. | Strong | No alternative offered — CPIC’s guidance here is a dosing adjustment |
| atorvastatin | SLCO1B1 | A | General | Possible Decreased Function / Decreased Function | Prescribe ≤40mg as a starting dose and adjust doses of atorvastatin based on disease-specific guidelines. Prescriber should be aware of possible increased risk for myopathy especially for 40mg dose. If dose >40mg needed for desired efficacy, consider combination therapy (i.e., atorvastatin plus non-statin guideline directed medical therapy) (PMID: 30423391). | Moderate | No alternative offered — CPIC’s guidance here is a dosing adjustment |
| atorvastatin | SLCO1B1 | A | General | Poor Function | Prescribe ≤20mg as a starting dose and adjust doses of atorvastatin based on disease-specific guidelines. If dose >20mg is needed for desired efficacy, consider rosuvastatin or combination therapy (i.e., atorvastatin plus non-statin guideline directed medical therapy) (PMID: 30423391). | Moderate | No alternative offered — CPIC’s guidance here is a dosing adjustment |
| fluvastatin | SLCO1B1 + CYP2C9 | A | General | Increased Function / Normal Function | Prescribe desired starting dose and adjust doses of fluvastatin based on disease-specific guidelines. | Strong | No alternative offered — CPIC’s guidance here is a dosing adjustment |
| fluvastatin | SLCO1B1 + CYP2C9 | A | General | Increased Function / Normal Function | Prescribe ≤20mg per day as a starting dose and adjust doses of fluvastatin based on disease-specific guidelines. If dose >20mg needed for desired efficacy, consider an alternative statin or combination therapy (i.e., fluvastatin plus non-statin guideline directed medical therapy) (PMID: 30423391). | Moderate | No alternative offered — CPIC’s guidance here is a dosing adjustment |
| fluvastatin | SLCO1B1 + CYP2C9 | A | General | Increased Function / Normal Function | Prescribe ≤40mg per day as a starting dose and adjust doses of fluvastatin based on disease-specific guidelines. If dose >40mg needed for desired efficacy, consider an alternative statin or combination therapy (i.e., fluvastatin plus non-statin guideline directed medical therapy) (PMID: 30423391). | Moderate | No alternative offered — CPIC’s guidance here is a dosing adjustment |
| fluvastatin | SLCO1B1 + CYP2C9 | A | General | Increased Function / Normal Function | Based on SLCO1B1 status, prescribe desired starting dose and adjust doses based on disease-specific guidelines. CYP2C9 phenotype could not be assigned based on genotyping. | Strong | No alternative offered — CPIC’s guidance here is a dosing adjustment |
| fluvastatin | SLCO1B1 + CYP2C9 | A | General | Increased Function / Normal Function | Based on SLCO1B1 status, prescribe desired starting dose and adjust doses based on disease-specific guidelines. CYP2C9 genotype result is not available. | Strong | No alternative offered — CPIC’s guidance here is a dosing adjustment |
| fluvastatin | SLCO1B1 + CYP2C9 | A | General | Possible Decreased Function / Decreased Function | Prescribe ≤20mg per day as a starting dose and adjust doses of fluvastatin based on disease-specific guidelines. If dose >20mg needed for desired efficacy, consider an alternative statin or combination therapy (i.e., fluvastatin plus non-statin guideline directed medical therapy) (PMID: 30423391). | Optional | No alternative offered — CPIC’s guidance here is a dosing adjustment |
| fluvastatin | SLCO1B1 + CYP2C9 | A | General | Possible Decreased Function / Decreased Function | Prescribe an alternative statin depending on the desired potency (see Figure 1 of PMID: 35152405 for recommendations for alternative statins). | Optional | No alternative offered — CPIC’s guidance here is a dosing adjustment |
| fluvastatin | SLCO1B1 + CYP2C9 | A | General | Possible Decreased Function / Decreased Function | Prescribe desired starting dose and adjust doses of fluvastatin based on disease-specific guidelines. Prescriber should be aware of possible increased risk for myopathy especially for doses >40mg per day. | Moderate | No alternative offered — CPIC’s guidance here is a dosing adjustment |
| fluvastatin | SLCO1B1 + CYP2C9 | A | General | Possible Decreased Function / Decreased Function | Based on SLCO1B1 status, prescribe desired starting dose and adjust doses of fluvastatin based on disease-specific guidelines. Prescriber should be aware of possible increased risk for myopathy especially for doses >40mg per day. CYP2C9 phenotype could not be assigned based on genotyping. | Moderate | No alternative offered — CPIC’s guidance here is a dosing adjustment |
| fluvastatin | SLCO1B1 + CYP2C9 | A | General | Possible Decreased Function / Decreased Function | Based on SLCO1B1 status, prescribe desired starting dose and adjust doses of fluvastatin based on disease-specific guidelines. Prescriber should be aware of possible increased risk for myopathy especially for doses >40mg per day. CYP2C9 genotype result is not available. | Moderate | No alternative offered — CPIC’s guidance here is a dosing adjustment |
| fluvastatin | SLCO1B1 + CYP2C9 | A | General | Poor Function | Prescribe ≤40mg per day as a starting dose and adjust doses of fluvastatin based on disease-specific guidelines. If patient is tolerating 40mg per day but higher potency is needed, a higher dose (>40mg) or an alternative statin or combination therapy (i.e. fluvastatin plus non-statin guideline directed medical therapy) (PMID: 30423391) could be considered. Prescriber should be aware of possible increased risk for myopathy with fluvastatin especially with doses >40mg per day. | Moderate | No alternative offered — CPIC’s guidance here is a dosing adjustment |
| fluvastatin | SLCO1B1 + CYP2C9 | A | General | Poor Function | Prescribe an alternative statin depending on the desired potency (see Table 2 and Figure 1 of PMID: 35152405 for recommendations for alternative statins). | Optional | No alternative offered — CPIC’s guidance here is a dosing adjustment |
| fluvastatin | SLCO1B1 + CYP2C9 | A | General | Poor Function | Prescribe an alternative statin depending on the desired potency. (see Table 2 and Figure 1 of PMID: 35152405 for recommendations for alternative statins). | Optional | No alternative offered — CPIC’s guidance here is a dosing adjustment |
| fluvastatin | SLCO1B1 + CYP2C9 | A | General | Poor Function | Based on SLCO1B1 status, prescribe ≤40mg per day as a starting dose and adjust doses of fluvastatin based on disease-specific guidelines. If patient is tolerating 40mg per day but higher potency is needed, a higher dose (>40mg) or an alternative statin (see Figure 1 of PMID: 35152405 for recommendations for alternative statins) or combination therapy (i.e. fluvastatin plus non-statin guideline directed medical therapy)(PMID: 30423391) could be considered. Prescriber should be aware of possible increased risk for myopathy with fluvastatin especially with doses >40mg per day. CYP2C9 phenotype could not be assigned based on genotyping. | Moderate | No alternative offered — CPIC’s guidance here is a dosing adjustment |
| fluvastatin | SLCO1B1 + CYP2C9 | A | General | Poor Function | Based on SLCO1B1 status, prescribe ≤40mg per day as a starting dose and adjust doses of fluvastatin based on disease-specific guidelines. If patient is tolerating 40mg per day but higher potency is needed, a higher dose (>40mg) or an alternative statin (see Figure 1 of PMID: 35152405 for recommendations for alternative statins) or combination therapy (i.e. fluvastatin plus non-statin guideline directed medical therapy) (PMID: 30423391) could be considered. Prescriber should be aware of possible increased risk for myopathy with fluvastatin especially with doses >40mg per day. CYP2C9 genotype result is not available. | Moderate | No alternative offered — CPIC’s guidance here is a dosing adjustment |
| fluvastatin | SLCO1B1 + CYP2C9 | A | General | Indeterminate | Based on CYP2C9 status, prescribe desired starting dose and adjust doses of fluvastatin based on disease-specific guidelines. SLCO1B1 phenotype could not be assigned based on genotyping. | Strong | No alternative offered — CPIC’s guidance here is a dosing adjustment |
| fluvastatin | SLCO1B1 + CYP2C9 | A | General | Indeterminate | Based on CYP2C9 status, prescribe ≤40mg per day as a starting dose and adjust doses of fluvastatin based on disease-specific guidelines. If dose >40mg needed for desired efficacy, consider an alternative statin or combination therapy (i.e., fluvastatin plus non-statin guideline directed medical therapy) (PMID: 30423391). SLCO1B1 phenotype could not be assigned based on genotyping. | Moderate | No alternative offered — CPIC’s guidance here is a dosing adjustment |
| fluvastatin | SLCO1B1 + CYP2C9 | A | General | Indeterminate | Based on CYP2C9 status, prescribe ≤20mg per day as a starting dose and adjust doses of fluvastatin based on disease-specific guidelines. If dose >20mg needed for desired efficacy, consider an alternative statin or combination therapy (i.e., fluvastatin plus non-statin guideline directed medical therapy) (PMID: 30423391). SLCO1B1 phenotype could not be assigned based on genotyping. | Moderate | No alternative offered — CPIC’s guidance here is a dosing adjustment |
| fluvastatin | SLCO1B1 + CYP2C9 | A | General | No Result | Based on CYP2C9 status, prescribe desired starting dose and adjust doses of fluvastatin based on disease-specific guidelines. SLCO1B1 genotype result is not available. | Strong | No alternative offered — CPIC’s guidance here is a dosing adjustment |
| fluvastatin | SLCO1B1 + CYP2C9 | A | General | No Result | Based on CYP2C9 status, prescribe ≤40mg per day as a starting dose and adjust doses of fluvastatin based on disease-specific guidelines. If dose >40mg needed for desired efficacy, consider an alternative statin or combination therapy (i.e., fluvastatin plus non-statin guideline directed medical therapy) (PMID: 30423391). SLCO1B1 genotype result is not available. | Moderate | No alternative offered — CPIC’s guidance here is a dosing adjustment |
| fluvastatin | SLCO1B1 + CYP2C9 | A | General | No Result | Based on CYP2C9 status, prescribe ≤20mg per day as a starting dose and adjust doses of fluvastatin based on disease-specific guidelines. If dose >20mg needed for desired efficacy, consider an alternative statin or combination therapy (i.e., fluvastatin plus non-statin guideline directed medical therapy) (PMID: 30423391). SLCO1B1 genotype result is not available. | Moderate | No alternative offered — CPIC’s guidance here is a dosing adjustment |
| lovastatin | SLCO1B1 | A | General | Increased Function / Normal Function | Prescribe desired starting dose and adjust doses based on disease-specific guidelines. | Strong | No alternative offered — CPIC’s guidance here is a dosing adjustment |
| lovastatin | SLCO1B1 | A | General | Possible Decreased Function / Decreased Function | Prescribe an alternative statin depending on the desired potency (see Figure 1 of PMID: 35152405 for recommendations for alternative statins). If lovastatin therapy is warranted, limit dose to ≤20mg/day. | Moderate | No alternative offered — CPIC’s guidance here is a dosing adjustment |
| lovastatin | SLCO1B1 | A | General | Poor Function | Prescribe an alternative statin depending on the desired potency (see Figure 1 of PMID: 35152405 for recommendations for alternative statins). | Moderate | No alternative offered — CPIC’s guidance here is a dosing adjustment |
| pitavastatin | SLCO1B1 | A | General | Increased Function / Normal Function | Prescribe desired starting dose and adjust doses based on disease-specific guidelines. | Strong | No alternative offered — CPIC’s guidance here is a dosing adjustment |
| pitavastatin | SLCO1B1 | A | General | Possible Decreased Function / Decreased Function | Prescribe ≤ 2mg as a starting dose and adjust doses of pitavastatin based on disease-specific guidelines. Prescriber should be aware of possible increased risk for myopathy especially for doses >1mg. If dose >2mg needed for desired efficacy, consider an alternative statin (see Figure 1 of PMID: 35152405 for recommendations for alternative statins) or combination therapy (i.e. pitavastatin plus non-statin guideline directed medical therapy) (PMID: 30423391). | Moderate | No alternative offered — CPIC’s guidance here is a dosing adjustment |
| pitavastatin | SLCO1B1 | A | General | Poor Function | Prescribe ≤1mg as a starting dose and adjust doses of pitavastatin based on disease-specific guidelines. If dose >1mg needed for desired efficacy, consider an alternative statin (see Figure 1 of PMID: 35152405 for recommendations for alternative statins) or combination therapy (i.e. pitavastatin plus non-statin guideline directed medical therapy)(PMID: 30423391). | Moderate | No alternative offered — CPIC’s guidance here is a dosing adjustment |
| pravastatin | SLCO1B1 | A | General | Increased Function / Normal Function | Prescribe desired starting dose and adjust doses based on disease-specific guidelines. | Strong | No alternative offered — CPIC’s guidance here is a dosing adjustment |
| pravastatin | SLCO1B1 | A | General | Possible Decreased Function / Decreased Function | Prescribe desired starting dose and adjust doses of pravastatin based on disease-specific guidelines. Prescriber should be aware of possible increased risk for myopathy with pravastatin especially with doses >40mg per day. | Moderate | No alternative offered — CPIC’s guidance here is a dosing adjustment |
| pravastatin | SLCO1B1 | A | General | Poor Function | Prescribe ≤40mg as a starting dose and adjust doses of pravastatin based on disease-specific guidelines. If patient is tolerating 40mg dose but higher potency is needed, a higher dose (>40mg) or an alternative statin (see Figure 1 of of PMID: 35152405 for recommendations for alternative statins) or combination therapy (i.e. pravastatin plus non-statin guideline directed medical therapy)(PMID: 30423391) could be considered. Prescriber should be aware of possible increased risk for myopathy especially with pravastatin doses >40mg. | Moderate | No alternative offered — CPIC’s guidance here is a dosing adjustment |
| rosuvastatin | SLCO1B1 + ABCG2 | A | General | Increased Function / Normal Function | Prescribe ≤20mg as a starting dose and adjust doses of rosuvastatin based on disease-specific and specific population guidelines. If dose >20mg needed for desired efficacy, consider an alternative statin or combination therapy (i.e., rosuvastatin plus non-statin guideline directed medical therapy) (PMID: 30423391). | Optional | No alternative offered — CPIC’s guidance here is a dosing adjustment |
| rosuvastatin | SLCO1B1 + ABCG2 | A | General | Increased Function / Normal Function | Prescribe desired starting dose and adjust doses of rosuvastatin based on disease-specific and specific population guidelines. | Moderate | No alternative offered — CPIC’s guidance here is a dosing adjustment |
| rosuvastatin | SLCO1B1 + ABCG2 | A | General | Increased Function / Normal Function | Prescribe desired starting dose and adjust doses of rosuvastatin based on disease-specific and specific population guidelines. | Strong | No alternative offered — CPIC’s guidance here is a dosing adjustment |
| rosuvastatin | SLCO1B1 + ABCG2 | A | General | Increased Function / Normal Function | Based on SLCO1B1 status, prescribe desired starting dose and adjust doses based on disease-specific guidelines. ABCG2 genotype result is not available. | Strong | No alternative offered — CPIC’s guidance here is a dosing adjustment |
| rosuvastatin | SLCO1B1 + ABCG2 | A | General | Possible Decreased Function / Decreased Function | Prescribe desired starting dose and adjust doses of rosuvastatin based on disease-specific and specific population guidelines. Prescriber should be aware of possible increased risk for myopathy especially for doses >20mg. | Strong | No alternative offered — CPIC’s guidance here is a dosing adjustment |
| rosuvastatin | SLCO1B1 + ABCG2 | A | General | Possible Decreased Function / Decreased Function | Prescribe ≤10mg as a starting dose and adjust doses of rosuvastatin based on disease-specific and specific population guidelines. If dose >10mg needed for desired efficacy, consider an alternative statin or combination therapy (i.e., rosuvastatin plus non-statin guideline directed medical therapy) (PMID: 30423391). | Optional | No alternative offered — CPIC’s guidance here is a dosing adjustment |
| rosuvastatin | SLCO1B1 + ABCG2 | A | General | Possible Decreased Function / Decreased Function | Prescribe desired starting dose and adjust doses of rosuvastatin based on disease-specific and specific population guidelines. Prescriber should be aware of possible increased risk for myopathy especially for doses >20mg. | Moderate | No alternative offered — CPIC’s guidance here is a dosing adjustment |
| rosuvastatin | SLCO1B1 + ABCG2 | A | General | Possible Decreased Function / Decreased Function | Based on SLCO1B1 status, prescribe desired starting dose and adjust doses of rosuvastatin based on disease-specific and specific population guidelines. Prescriber should be aware of possible increased risk for myopathy especially for doses >20mg. ABCG2 genotype result is not available. | Strong | No alternative offered — CPIC’s guidance here is a dosing adjustment |
| rosuvastatin | SLCO1B1 + ABCG2 | A | General | Poor Function | Prescribe ≤10mg as a starting dose and adjust doses of rosuvastatin based on disease-specific and specific population guidelines. If dose >10mg needed for desired efficacy, consider combination therapy (i.e., rosuvastatin plus non-statin guideline directed medical therapy) (PMID: 30423391). | Optional | No alternative offered — CPIC’s guidance here is a dosing adjustment |
| rosuvastatin | SLCO1B1 + ABCG2 | A | General | Poor Function | Prescribe ≤20mg as a starting dose and adjust doses of rosuvastatin based on disease-specific and specific population guidelines. If dose > 20mg needed for desired efficacy, consider combination therapy (i.e., rosuvastatin plus non-statin guideline directed medical therapy) (PMID: 30423391). | Moderate | No alternative offered — CPIC’s guidance here is a dosing adjustment |
| rosuvastatin | SLCO1B1 + ABCG2 | A | General | Poor Function | Prescribe ≤20mg as a starting dose and adjust doses of rosuvastatin based on disease-specific and specific population guidelines. If dose >20mg needed for desired efficacy, consider combination therapy (i.e., rosuvastatin plus non-statin guideline directed medical therapy) (PMID: 30423391). | Moderate | No alternative offered — CPIC’s guidance here is a dosing adjustment |
| rosuvastatin | SLCO1B1 + ABCG2 | A | General | Poor Function | Based on SLCO1B1 status, prescribe ≤20mg as a starting dose and adjust doses of rosuvastatin based on disease-specific and specific population guidelines If dose >20mg needed for desired efficacy, consider combination therapy (i.e. rosuvastatin plus non-statin guideline directed medical therapy) (PMID: 30423391). ABCG2 genotype result is not available. | Moderate | No alternative offered — CPIC’s guidance here is a dosing adjustment |
| rosuvastatin | SLCO1B1 + ABCG2 | A | General | Indeterminate | Based on ABCG2 status, prescribe desired starting dose and adjust doses of rosuvastatin based on disease-specific guidelines and specific population guidelines. SLCO1B1 phenotype could not be assigned based on genotyping. | Moderate | No alternative offered — CPIC’s guidance here is a dosing adjustment |
| rosuvastatin | SLCO1B1 + ABCG2 | A | General | Indeterminate | Based on ABCG2 status, prescribe desired starting dose and adjust doses of rosuvastatin based on disease-specific and specific population guidelines. SLCO1B1 phenotype could not be assigned based on genotyping. | Strong | No alternative offered — CPIC’s guidance here is a dosing adjustment |
| rosuvastatin | SLCO1B1 + ABCG2 | A | General | Indeterminate | Based on ABCG2 status, prescribe ≤20mg as a starting dose and adjust doses of rosuvastatin based on disease-specific and specific population guidelines. If dose >20mg needed for desired efficacy, consider an alternative statin or combination therapy (i.e., rosuvastatin plus non-statin guideline directed medical therapy) (PMID: 30423391). SLCO1B1 phenotype could not be assigned based on genotyping. | Moderate | No alternative offered — CPIC’s guidance here is a dosing adjustment |
| rosuvastatin | SLCO1B1 + ABCG2 | A | General | No Result | Based on ABCG2 status, prescribe desired starting dose and adjust doses of rosuvastatin based on disease-specific guidelines and specific population guidelines. SLCO1B1 genotype result is not available. | Moderate | No alternative offered — CPIC’s guidance here is a dosing adjustment |
| rosuvastatin | SLCO1B1 + ABCG2 | A | General | No Result | Based on ABCG2 status, prescribe desired starting dose and adjust doses of rosuvastatin based on disease-specific and specific population guidelines. SLCO1B1 genotype result is not available. | Strong | No alternative offered — CPIC’s guidance here is a dosing adjustment |
| rosuvastatin | SLCO1B1 + ABCG2 | A | General | No Result | Based on ABCG2 status, prescribe ≤20mg as a starting dose and adjust doses of rosuvastatin based on disease-specific and specific population guidelines. If dose >20mg needed for desired efficacy, consider an alternative statin or combination therapy (i.e., rosuvastatin plus non-statin guideline directed medical therapy) (PMID: 30423391). SLCO1B1 genotype result is not available. | Moderate | No alternative offered — CPIC’s guidance here is a dosing adjustment |
| simvastatin | SLCO1B1 | A | General | Increased Function / Normal Function | Prescribe desired starting dose and adjust doses based on disease-specific guidelines. | Strong | No alternative offered — CPIC’s guidance here is a dosing adjustment |
| simvastatin | SLCO1B1 | A | General | Possible Decreased Function / Decreased Function | Prescribe an alternative statin depending on the desired potency (see Figure 1 of PMID: 35152405 for recommendations for alternative statins). If simvastatin therapy is warranted, limit dose to <20mg/day. | Strong | No alternative offered — CPIC’s guidance here is a dosing adjustment |
| simvastatin | SLCO1B1 | A | General | Poor Function | Prescribe an alternative statin depending on the desired potency (see Figure 1 of PMID: 35152405 for recommendations for alternative statins). | Strong | No alternative offered — CPIC’s guidance here is a dosing adjustment |