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Liu M, Hernandez S, Aquilante CL, Deininger KM, Lindenfeld J, Schlendorf KH, Van Driest SL. Composite CYP3A (CYP3A4 and CYP3A5) phenotypes and influence on tacrolimus dose adjusted concentrations in adult heart transplant recipients. THE PHARMACOGENOMICS JOURNAL 2024; 24:4. [PMID: 38360955 DOI: 10.1038/s41397-024-00325-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/03/2023] [Revised: 01/18/2024] [Accepted: 01/31/2024] [Indexed: 02/17/2024]
Abstract
CYP3A5 genetic variants are associated with tacrolimus metabolism. Controversy remains on whether CYP3A4 increased [*1B (rs2740574), *1 G (rs2242480)] and decreased function [*22 (rs35599367)] genetic variants provide additional information. This retrospective cohort study aims to address whether tacrolimus dose-adjusted trough concentrations differ between combined CYP3A (CYP3A5 and CYP3A4) phenotype groups. Heart transplanted patients (n = 177, between 2008 and 2020) were included and median age was 54 years old. Significant differences between CYP3A phenotype groups in tacrolimus dose-adjusted trough concentrations were found in the early postoperative period and continued to 6 months post-transplant. In CYP3A5 nonexpressers, carriers of CYP3A4*1B or *1 G variants (Group 3) compared to CYP3A4*1/*1 (Group 2) patients were found to have lower tacrolimus dose-adjusted trough concentrations at 2 months. In addition, significant differences were found among CYP3A phenotype groups in the dose at discharge and time to therapeutic range while time in therapeutic range was not significantly different. A combined CYP3A phenotype interpretation may provide more nuanced genotype-guided TAC dosing in heart transplant recipients.
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Affiliation(s)
- Michelle Liu
- Department of Pharmacy, Vanderbilt University Medical Center, Nashville, TN, USA.
| | - Savine Hernandez
- Department of Pharmacy, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Christina L Aquilante
- Department of Pharmaceutical Sciences, University of Colorado, Skaggs School of Pharmacy and Pharmaceutical Sciences, Aurora, CO, USA
| | - Kimberly M Deininger
- Department of Pharmaceutical Sciences, University of Colorado, Skaggs School of Pharmacy and Pharmaceutical Sciences, Aurora, CO, USA
| | - Joann Lindenfeld
- Division of Cardiology, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Kelly H Schlendorf
- Division of Cardiology, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Sara L Van Driest
- Division of General Pediatrics, Department of Pediatrics, and Division of Clinical Pharmacology, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
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Pei L, Li R, Zhou H, Du W, Gu Y, Jiang Y, Wang Y, Chen X, Sun J, Zhu J. A Physiologically Based Pharmacokinetic Approach to Recommend an Individual Dose of Tacrolimus in Adult Heart Transplant Recipients. Pharmaceutics 2023; 15:2580. [PMID: 38004558 PMCID: PMC10675244 DOI: 10.3390/pharmaceutics15112580] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2023] [Revised: 09/07/2023] [Accepted: 10/30/2023] [Indexed: 11/26/2023] Open
Abstract
Tacrolimus is the principal immunosuppressive drug which is administered after heart transplantation. Managing tacrolimus therapy is challenging due to a narrow therapeutic index and wide pharmacokinetic (PK) variability. We aimed to establish a physiologically based pharmacokinetic (PBPK) model of tacrolimus in adult heart transplant recipients to optimize dose regimens in clinical practice. A 15-compartment full-PBPK model (Simbiology® Simulator, version 5.8.2) was developed using clinical observations from 115 heart transplant recipients. This study detected 20 genotypes associated with tacrolimus metabolism. CYP3A5*3 (rs776746), CYP3A4*18B (rs2242480), and IL-10 G-1082A (rs1800896) were identified as significant genetic covariates in tacrolimus pharmacokinetics. The PBPK model was evaluated using goodness-of-fit (GOF) and external evaluation. The predicted peak blood concentration (Cmax) and area under the drug concentration-time curve (AUC) were all within a two-fold value of the observations (fold error of 0.68-1.22 for Cmax and 0.72-1.16 for AUC). The patients with the CYP3A5*3/*3 genotype had a 1.60-fold increase in predicted AUC compared to the patients with the CYP3A5*1 allele, and the ratio of the AUC with voriconazole to alone was 5.80 when using the PBPK model. Based on the simulation results, the tacrolimus dosing regimen after heart transplantation was optimized. This is the first PBPK model used to predict the PK of tacrolimus in adult heart transplant recipients, and it can serve as a starting point for research on immunosuppressive drug therapy in heart transplant patients.
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Affiliation(s)
- Ling Pei
- Department of Pharmacy, Nanjing First Hospital, China Pharmaceutical University, Nanjing 210006, China
- Department of Pharmacy, Nanjing First Hospital, Nanjing Hospital Affiliated to Nanjing Medical University, Nanjing 210006, China
| | - Run Li
- Key Laboratory of Drug Metabolism and Pharmacokinetics, China Pharmaceutical University, Nanjing 210009, China
| | - Hong Zhou
- Department of Pharmacy, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430022, China
| | - Wenxin Du
- Department of Pharmacy, Nanjing First Hospital, China Pharmaceutical University, Nanjing 210006, China
- Department of Pharmacy, Nanjing First Hospital, Nanjing Hospital Affiliated to Nanjing Medical University, Nanjing 210006, China
| | - Yajie Gu
- Department of Pharmacy, Nanjing First Hospital, China Pharmaceutical University, Nanjing 210006, China
- Department of Pharmacy, Nanjing First Hospital, Nanjing Hospital Affiliated to Nanjing Medical University, Nanjing 210006, China
| | - Yingshuo Jiang
- Department of Cardiothoracic Surgery, Nanjing First Hospital, Nanjing Hospital Affiliated to Nanjing Medical University, Nanjing 210006, China
| | - Yongqing Wang
- Research Division of Clinical Pharmacology, First Affiliated Hospital of Nanjing Medical University, Nanjing 210029, China
| | - Xin Chen
- Department of Cardiothoracic Surgery, Nanjing First Hospital, Nanjing Hospital Affiliated to Nanjing Medical University, Nanjing 210006, China
| | - Jianguo Sun
- Key Laboratory of Drug Metabolism and Pharmacokinetics, China Pharmaceutical University, Nanjing 210009, China
| | - Junrong Zhu
- Department of Pharmacy, Nanjing First Hospital, China Pharmaceutical University, Nanjing 210006, China
- Department of Pharmacy, Nanjing First Hospital, Nanjing Hospital Affiliated to Nanjing Medical University, Nanjing 210006, China
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Rower JE, McKnite A, Hong B, Daly KP, Hope KD, Cabrera AG, Molina KM. External assessment and refinement of a population pharmacokinetic model to guide tacrolimus dosing in pediatric heart transplant. Pharmacotherapy 2023; 43:650-658. [PMID: 37328271 PMCID: PMC10527671 DOI: 10.1002/phar.2836] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2022] [Revised: 05/03/2023] [Accepted: 05/03/2023] [Indexed: 06/18/2023]
Abstract
STUDY OBJECTIVE The immunosuppressant tacrolimus is a first-line agent to prevent graft rejection following pediatric heart transplant; however, it suffers from extensive inter-patient variability and a narrow therapeutic window. Personalized tacrolimus dosing may improve transplant outcomes by more efficiently achieving and maintaining therapeutic tacrolimus concentrations. We sought to externally validate a previously published population pharmacokinetic (PK) model that was constructed with data from a single site. DATA SOURCE Data were collected from Seattle, Texas, and Boston Children's Hospitals, and assessed using standard population PK modeling techniques in NONMEMv7.2. MAIN RESULTS While the model was not successfully validated for use with external data, further covariate searching identified weight (p < 0.0001 on both volume and elimination rate) as a model-significant covariate. This refined model acceptably predicted future tacrolimus concentrations when guided by as few as three concentrations (median prediction error = 7%; median absolute prediction error = 27%). CONCLUSION These findings support the potential clinical utility of a population PK model to provide personalized tacrolimus dosing guidance.
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Affiliation(s)
- Joseph E. Rower
- Department of Pharmacology and Toxicology, University of Utah College of Pharmacy, Salt Lake City, Utah, USA
- Center for Human Toxicology, University of Utah College of Pharmacy, Salt Lake City, Utah, USA
| | - Autumn McKnite
- Department of Pharmacology and Toxicology, University of Utah College of Pharmacy, Salt Lake City, Utah, USA
| | - Borah Hong
- Division of Pediatric Cardiology, University of Washington and Seattle Children’s Hospital, Seattle, Washington, USA
| | - Kevin P. Daly
- Department of Pediatric Cardiology, Harvard Medical School/Boston Children’s Hospital, Boston, Massachusetts, USA
| | - Kyle D. Hope
- Lillie Frank Abercrombie Division of Pediatric Cardiology, Department of Pediatrics, Texas Children’s Hospital, Baylor College of Medicine, Houston, Texas, USA
| | - Antonio G. Cabrera
- Lillie Frank Abercrombie Division of Pediatric Cardiology, Department of Pediatrics, Texas Children’s Hospital, Baylor College of Medicine, Houston, Texas, USA
- Division of Pediatric Cardiology, University of Utah/Intermountain Primary Children’s Hospital, Salt Lake City, Utah, USA
| | - Kimberly M. Molina
- Division of Pediatric Cardiology, University of Utah/Intermountain Primary Children’s Hospital, Salt Lake City, Utah, USA
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Hernandez S, Aquilante C, Deininger K, Lindenfeld J, Schlendorf K, Van Driest S, Liu M. Composite CYP3A (CYP3A4 and CYP3A5) phenotypes and influences on tacrolimus dose adjusted concentration in adult heart transplant recipients. RESEARCH SQUARE 2023:rs.3.rs-2921796. [PMID: 37292893 PMCID: PMC10246090 DOI: 10.21203/rs.3.rs-2921796/v1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Abstract
CYP3A5 genetic variants are associated with tacrolimus metabolism. Controversy remains on whether CYP3A4 increased [* 1B (rs2740574), *1G (rs2242480)] and decreased function [*22 (rs35599367)] genetic variants provide additional information. This study aims to address whether tacrolimus dose-adjusted trough concentrations differ between combined CYP3A (CYP3A5 and CYP3A4) phenotype groups. Significant differences between CYP3A phenotype groups in tacrolimus dose-adjusted trough concentrations were found in the early postoperative period and continued to 6 months post-transplant. In CYP3A5 nonexpressers, carriers of CYP3A4*7Bor *7G variants (Group 3) compared to CYP3A4*1/*1 (Group 2) patients were found to have lower tacrolimus dose-adjusted trough concentrations at 2 months. In addition, significant differences were found among CYP3A phenotype groups in the dose at discharge and time to therapeutic range while time in therapeutic range was not significantly different. A combined CYP3A phenotype interpretation may provide more nuanced genotype-guided TAC dosing in heart transplant recipients.
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Resál T, Mangó K, Bacsur P, Szántó K, Pigniczki D, Keresztes C, Rutka M, Bálint A, Milassin Á, Bor R, Fábián A, Szepes Z, Farkas K, Monostory K, Molnár T. Possible genetical predictors of efficacy and safety of budesonide-MMX in patients with mild-to-moderate ulcerative colitis, and safety comparison with methylprednisolone. Expert Opin Drug Saf 2023; 22:517-524. [PMID: 36811412 DOI: 10.1080/14740338.2023.2181336] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2022] [Accepted: 01/23/2023] [Indexed: 02/24/2023]
Abstract
BACKGROUND Budesonide-MMX is a topically active corticosteroid degraded by cytochrome-P450 enzymes, resulting in favorable side-effect profile. We aimed to assess the effect of CYP genotypes on safety and efficacy, and make a direct comparison with systemic corticosteroids. RESEARCH DESIGN AND METHODS We enrolled UC patients receiving budesonide-MMX and IBD patients on methylprednisolone in our prospective, observational-cohort study. Before and after treatment regimen clinical activity indexes, laboratory parameters (electrolytes, CRP, cholesterol, triglyceride, dehydroepiandrosterone, cortisol, beta-crosslaps, osteocalcin), and body composition measurements were assessed. CYP3A4 and CYP3A5 genotypes were determined in the budesonide-MMX group. RESULTS 71 participants were enrolled (budesonide-MMX: 52; methylprednisolone: 19). CAI decreased (p<0.05) in both groups. Cortisol decreased (p<0.001), and the level of cholesterol was elevated in both groups (p<0.001). Body composition altered only following methylprednisolone. Bone homeostasis (osteocalcin; p<0.05) and DHEA (p<0.001) changed more prominently after methylprednisolone. Glucocorticoid-related adverse events were more common following methylprednisolone treatment (47.4% compared to 1.9%). CYP3A5(*1/*3) genotype positively influenced efficacy, but not safety. Only one patient's CYP3A4 genotype differed. CONCLUSIONS CYP genotypes can affect the efficacy of budesonide-MMX; however, further studies would be needed with analyses of gene expression. Although budesonide-MMX is safer than methylprednisolone, due to glucocorticoid-related side effects, admission should require greater precaution.
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Affiliation(s)
- Tamás Resál
- Gastroenterology, Department of Medicine, Albert Szent-Györgyi Medical School, University of Szeged, Szeged, Hungary
| | - Katalin Mangó
- Institute of Enzymology, Research Centre for Natural Sciences, Budapest, Hungary
| | - Péter Bacsur
- Gastroenterology, Department of Medicine, Albert Szent-Györgyi Medical School, University of Szeged, Szeged, Hungary
| | - Kata Szántó
- Gastroenterology, Department of Medicine, Albert Szent-Györgyi Medical School, University of Szeged, Szeged, Hungary
| | - Daniella Pigniczki
- Gastroenterology, Department of Medicine, Albert Szent-Györgyi Medical School, University of Szeged, Szeged, Hungary
- Department of Surgery, Albert Szent-Györgyi Medical School, University of Szeged, Szeged, Hungary
| | - Csilla Keresztes
- Department for Medical Communication and Translation Studies, Albert Szent-Györgyi Medical School, University of Szeged, Szeged, Hungary
| | - Mariann Rutka
- Gastroenterology, Department of Medicine, Albert Szent-Györgyi Medical School, University of Szeged, Szeged, Hungary
| | - Anita Bálint
- Gastroenterology, Department of Medicine, Albert Szent-Györgyi Medical School, University of Szeged, Szeged, Hungary
| | - Ágnes Milassin
- Gastroenterology, Department of Medicine, Albert Szent-Györgyi Medical School, University of Szeged, Szeged, Hungary
| | - Renáta Bor
- Gastroenterology, Department of Medicine, Albert Szent-Györgyi Medical School, University of Szeged, Szeged, Hungary
| | - Anna Fábián
- Gastroenterology, Department of Medicine, Albert Szent-Györgyi Medical School, University of Szeged, Szeged, Hungary
| | - Zoltán Szepes
- Gastroenterology, Department of Medicine, Albert Szent-Györgyi Medical School, University of Szeged, Szeged, Hungary
| | - Klaudia Farkas
- Gastroenterology, Department of Medicine, Albert Szent-Györgyi Medical School, University of Szeged, Szeged, Hungary
| | - Katalin Monostory
- Institute of Enzymology, Research Centre for Natural Sciences, Budapest, Hungary
| | - Tamás Molnár
- Gastroenterology, Department of Medicine, Albert Szent-Györgyi Medical School, University of Szeged, Szeged, Hungary
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Nagy I, Baráth BR, Mangó K, Shemirani AH, Monostory K, Nemes B. The Prognostic Role of CYP Enzyme in Kidney Transplantation: A Single Centre Experience. Transplant Proc 2022; 54:2584-2588. [PMID: 36396462 DOI: 10.1016/j.transproceed.2022.10.046] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND The main goal of immunosuppressive agents is to reach a balance of preserving allograft function while minimizing adverse effects. The purpose of our research is to corroborate the role of CYP3A enzyme in developing individual medication therapy via measuring medicine levels in patients' blood samples. METHODS This retrospective analysis studies 15 kidney transplant recipients. We carried out genotyping (CYP3A5, CYP3A4) after isolating DNA and RNA in patient and donor blood samples; we also determined CYP3A4 messenger RNA expression in case of recipients. Tacrolimus blood levels, dosage, and tacrolimus concentration normalized by dose and the body weight (C0/D ratio) were evaluated. RESULTS In this research, recipients were divided into 2 groups based on their CYP3A5 genotype. Those who carry CYP3A5*1 allele (*1/*1 or *1/*3) are CYP3A5 expressors, whereas those who are homozygous for the nonfunctional CYP3A5*3 allele are CYP3A5 nonexpressors. There were 3 patients with functioning CYP3A5 enzyme (patients with CYP3A5*1/*3 genotype) where increased tacrolimus metabolism was expected. Our data show that C0/D ratio of CYP3A5 nonexpressors was around 3 times higher than of CYP3A5 expressors. Looking at CYP3A4 enzyme, we found 1 patient carried CYP3A4*22/*22 genotype where we expected decreased CYP3A4 expression. It is clear that this patient had adequate therapy medication levels (9.50 μg/L) despite having received very low dosage of tacrolimus (0.03 mg/weight/d). CONCLUSIONS Our results confirmed the importance of determining CYP status of recipients after a transplant because individual differences were observed in tacrolimus treatment that were partly influenced by CYP status of recipients.
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Affiliation(s)
- Ildikó Nagy
- Department of Transplantation, Institute of Surgery, Faculty of Medicine, University of Debrecen, Debrecen, Hungary.
| | - Benjámin Regő Baráth
- Department of Transplantation, Institute of Surgery, Faculty of Medicine, University of Debrecen, Debrecen, Hungary
| | - Katalin Mangó
- Metabolic Drug Interactions Research Group, Institute of Enzymology, Research Centre for Natural Sciences, Budapest, Hungary
| | - Amir-Houshang Shemirani
- Division of Clinical Laboratory Science, Department of Laboratory Medicine, Faculty of Medicine, University of Debrecen, Debrecen, Hungary
| | - Katalin Monostory
- Metabolic Drug Interactions Research Group, Institute of Enzymology, Research Centre for Natural Sciences, Budapest, Hungary
| | - Balázs Nemes
- Department of Transplantation, Institute of Surgery, Faculty of Medicine, University of Debrecen, Debrecen, Hungary
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Calcineurin Inhibitors Synergize with Manogepix to Kill Diverse Human Fungal Pathogens. J Fungi (Basel) 2022; 8:jof8101102. [PMID: 36294667 PMCID: PMC9605145 DOI: 10.3390/jof8101102] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2022] [Revised: 10/13/2022] [Accepted: 10/15/2022] [Indexed: 11/17/2022] Open
Abstract
Invasive fungal infections have mortality rates of 30–90%, depending on patient co-morbidities and the causative pathogen. The frequent emergence of drug resistance reduces the efficacy of currently approved treatment options, highlighting an urgent need for antifungals with new modes of action. Addressing this need, fosmanogepix (N-phosphonooxymethylene prodrug of manogepix; MGX) is the first in a new class of gepix drugs, and acts as a broad-spectrum, orally bioavailable inhibitor of the essential fungal glycosylphosphatidylinositol (GPI) acyltransferase Gwt1. MGX inhibits the growth of diverse fungal pathogens and causes accumulation of immature GPI-anchored proteins in the fungal endoplasmic reticulum. Relevant to the ongoing clinical development of fosmanogepix, we report a synergistic, fungicidal interaction between MGX and inhibitors of the protein phosphatase calcineurin against important human fungal pathogens. To investigate this synergy further, we evaluated a library of 124 conditional expression mutants covering 95% of the genes encoding proteins involved in GPI-anchor biosynthesis or proteins predicted to be GPI-anchored. Strong negative chemical-genetic interactions between the calcineurin inhibitor FK506 and eleven GPI-anchor biosynthesis genes were identified, indicating that calcineurin signalling is required for fungal tolerance to not only MGX, but to inhibition of the GPI-anchor biosynthesis pathway more broadly. Depletion of these GPI-anchor biosynthesis genes, like MGX treatment, also exposed fungal cell wall (1→3)-β-D-glucans. Taken together, these findings suggest the increased risk of invasive fungal infections associated with use of calcineurin inhibitors as immunosuppressants may be mitigated by their synergistic fungicidal interaction with (fos)manogepix and its ability to enhance exposure of immunostimulatory glucans.
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Šimičević L, Canjuga I, Zibar L, Borić-Bilušić A, Ganoci L, Božina N. Rapid clearance of tacrolimus blood concentration triggered by variant pharmacogenes. J Clin Pharm Ther 2022; 47:1461-1465. [PMID: 35342959 DOI: 10.1111/jcpt.13650] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2022] [Revised: 02/21/2022] [Accepted: 03/04/2022] [Indexed: 11/28/2022]
Abstract
WHAT IS KNOWN AND OBJECTIVE Tacrolimus (TAC) is an immunosuppressant with large interpatient pharmacokinetic variability and a narrow therapeutic index. We report a case of acute cellular rejection (ACR) type IB with insufficient TAC blood concentrations (TAC C0 ). CASE SUMMARY ACR developed on the eighth postoperative day of kidney transplantation. During this period, TAC C0 were insufficient. This referred pharmacogenetic assessment disclosed the patient as a CYP3A5 expresser and CYP3A4*1B carrier. According to the genotype, higher doses of TAC, 15 mg twice daily, were administered and targeted TAC C0 were achieved. WHAT IS NEW AND CONCLUSION Our case presents an association of TAC rapid clearance and two alleles modifying greater CYP3A enzyme activity.
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Affiliation(s)
- Livija Šimičević
- Department of Laboratory Diagnostics, Division of Pharmacogenomics & Therapy Individualization, University Hospital Centre Zagreb, Zagreb, Croatia
| | - Iva Canjuga
- Department of Nephrology, University Hospital Merkur, Internal Clinic, Zagreb, Croatia
| | - Lada Zibar
- Department of Nephrology, University Hospital Merkur, Internal Clinic, Zagreb, Croatia
| | - Ana Borić-Bilušić
- Croatian Agency for Medicinal Products and Medical Devices, Zagreb, Croatia
| | - Lana Ganoci
- Department of Laboratory Diagnostics, Division of Pharmacogenomics & Therapy Individualization, University Hospital Centre Zagreb, Zagreb, Croatia
| | - Nada Božina
- School of Medicine, University of Zagreb, Zagreb, Croatia
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