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Ho V, Pasquet R, Luo S, Chen G, Goss P, Tu D, Lazarus P, Richardson H. Variation in the UGT2B17 genotype, exemestane metabolism and menopause-related toxicities in the CCTG MAP.3 trial. Breast Cancer Res Treat 2020; 183:705-716. [PMID: 32715442 DOI: 10.1007/s10549-020-05812-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2020] [Accepted: 07/15/2020] [Indexed: 10/23/2022]
Abstract
PURPOSE To examine associations between the UGT2B17 gene deletion and exemestane metabolites, and commonly reported side effects (fatigue, hot flashes, and joint pain) among postmenopausal women participating in the MAP.3 chemoprevention trial. METHODS The analytical samples for the UGT2B17 analysis comprised 1752 women on exemestane and 1721 women on placebo; the exemestane metabolite analysis included 1360 women on exemestane with one-year serum samples. Both the UGT2B17 gene deletion and metabolites were measured in blood. The metabolites were conceptualized as a ratio (17-DHE-Gluc:17-DHE). Symptoms were assessed using the CTCAE v4.0 at approximately 1-year intervals. Log-binomial regression was used to examine the associations between UGT2B17 deletion, exemestane metabolites and each side effect at 1 and up to 5-year follow-up, adjusting for potential confounders. RESULTS Among individuals on exemestane with the UGT2B17 gene deletion (i.e., lower detoxification), a higher risk of severe fatigue (RR = 2.59 95% CI: 1.14-5.89) was observed at up to 5-year follow-up. Among individuals on placebo, those with the UGT2B17 gene deletion had a higher risk of any fatigue (RR = 1.39, 95% CI: 1.02-1.89) at year 1. A lower metabolite ratio (poor detoxification) was associated with a higher risk of any fatigue, hot flashes and joint pain at year 1 (fatigue: RR = 1.89, 95% CI: 1.16-3.09; hot flashes: RR = 1.77, 95% CI: 1.40-2.24; joint pain: RR = 2.05, 95% CI: 1.35-3.12); similar associations were observed at 5-year follow-up. CONCLUSION Variation in the metabolism of exemestane through the UGT2B17-mediated pathway is associated with subsequent risk of commonly reported symptoms in MAP.3.
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Affiliation(s)
- Vikki Ho
- Department of Social and Preventive Medicine, University of Montreal, 850 rue Saint-Denis, Tour Saint-Antoine, 3rd Floor, S03.412, Montréal, QC, H2X0A9, Canada.,Health Innovation and Evaluation Hub, University of Montreal Hospital Research Centre (CRCHUM), 850 rue Saint-Denis, Tour Saint-Antoine, 3rd Floor, S03.424, Montréal, QC, H2X0A9, Canada
| | - Romain Pasquet
- Department of Social and Preventive Medicine, University of Montreal, 850 rue Saint-Denis, Tour Saint-Antoine, 3rd Floor, S03.412, Montréal, QC, H2X0A9, Canada
| | - Shaman Luo
- Department of Pharmaceutical Sciences, College of Pharmacy and Pharmaceutical Sciences, Washington State University, 412 E. Spokane Falls Blvd., PBS 431, Spokane, WA, 99202-2131, USA
| | - Gang Chen
- Department of Pharmaceutical Sciences, College of Pharmacy and Pharmaceutical Sciences, Washington State University, 412 E. Spokane Falls Blvd., PBS 431, Spokane, WA, 99202-2131, USA
| | - Paul Goss
- Harvard Medical School, MGH Cancer Center, Massachusetts General Hospital, 55 Fruit St, Boston, MA, 02114, USA
| | - Dongsheng Tu
- Division Canadian Cancer Trials Group, Queen's University, 10 Stuart Street, Kingston, ON, K7L 3N6, Canada.,Department of Public Health Sciences, Cancer Research Institute, Queen's University, 10 Stuart Street, Kingston, ON, K7L 3N6, Canada
| | - Philip Lazarus
- Department of Pharmaceutical Sciences, College of Pharmacy and Pharmaceutical Sciences, Washington State University, 412 E. Spokane Falls Blvd., PBS 431, Spokane, WA, 99202-2131, USA
| | - Harriet Richardson
- Divisions of Canadian Cancer Trials Group and Cancer Care and Epidemiology, Cancer Research Institute, Queen's University, 10 Stuart Street, Room 220, Kingston, ON, K7L 3N6, Canada.
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Luo S, Chen G, Truica CI, Baird CC, Xia Z, Lazarus P. Identification and Quantification of Novel Major Metabolites of the Steroidal Aromatase Inhibitor, Exemestane. Drug Metab Dispos 2018; 46:1867-1878. [PMID: 30257855 PMCID: PMC7333658 DOI: 10.1124/dmd.118.081166] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2018] [Accepted: 09/14/2018] [Indexed: 01/03/2023] Open
Abstract
Exemestane (EXE) is an aromatase inhibitor used for the prevention and treatment of estrogen receptor–positive breast cancer. Although the known major metabolic pathway for EXE is reduction to form the active 17β-dihydro-EXE (17β-DHE) and subsequent glucuronidation to 17β-hydroxy-EXE-17-O-β-D-glucuronide (17β-DHE-Gluc), previous studies have suggested that other major metabolites exist for exemestane. In the present study, a liquid chromatography–mass spectrometry (LC-MS) approach was used to acquire accurate mass data in MSE mode, in which precursor ion and fragment ion data were obtained simultaneously to screen novel phase II EXE metabolites in urine specimens from women taking EXE. Two major metabolites predicted to be cysteine conjugates of EXE and 17β-DHE by elemental composition were identified. The structures of the two metabolites were confirmed to be 6-methylcysteinylandrosta-1,4-diene-3,17-dione (6-EXE-cys) and 6-methylcysteinylandrosta-1,4-diene-17β-hydroxy-3-one (6-17β-DHE-cys) after comparison with their chemically synthesized counterparts. Both underwent biosynthesis in vitro in three stepwise enzymatic reactions, with the first involving glutathione conjugation. The cysteine conjugates of EXE and 17β-DHE were subsequently quantified by liquid chromatography–mass spectrometry in the urine and matched plasma samples of 132 subjects taking EXE. The combined 6-EXE-cys plus 6-17β-DHE-cys made up 77% of total EXE metabolites in urine (vs. 1.7%, 0.14%, and 21% for EXE, 17β-DHE, and 17β-DHE-Gluc, respectively) and 35% in plasma (vs. 17%, 12%, and 36% for EXE, 17β-DHE, and 17β-DHE-Gluc, respectively). Therefore, cysteine conjugates of EXE and 17β-DHE appear to be major metabolites of EXE in both urine and plasma.
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Affiliation(s)
- Shaman Luo
- Department of Pharmaceutical Sciences, College of Pharmacy and Pharmaceutical Sciences, Washington State University, Spokane, Washington (S.L., G.C., Z.X., P.L.); Department of Medicine, Penn State University College of Medicine, Hershey, Pennsylvania (C.I.T., C.C.B.); and Alkali Soil Natural Environmental Science Center, Northeast Forestry University, Harbin, Heilongjiang, China (S.L.)
| | - Gang Chen
- Department of Pharmaceutical Sciences, College of Pharmacy and Pharmaceutical Sciences, Washington State University, Spokane, Washington (S.L., G.C., Z.X., P.L.); Department of Medicine, Penn State University College of Medicine, Hershey, Pennsylvania (C.I.T., C.C.B.); and Alkali Soil Natural Environmental Science Center, Northeast Forestry University, Harbin, Heilongjiang, China (S.L.)
| | - Cristina I Truica
- Department of Pharmaceutical Sciences, College of Pharmacy and Pharmaceutical Sciences, Washington State University, Spokane, Washington (S.L., G.C., Z.X., P.L.); Department of Medicine, Penn State University College of Medicine, Hershey, Pennsylvania (C.I.T., C.C.B.); and Alkali Soil Natural Environmental Science Center, Northeast Forestry University, Harbin, Heilongjiang, China (S.L.)
| | - Cynthia C Baird
- Department of Pharmaceutical Sciences, College of Pharmacy and Pharmaceutical Sciences, Washington State University, Spokane, Washington (S.L., G.C., Z.X., P.L.); Department of Medicine, Penn State University College of Medicine, Hershey, Pennsylvania (C.I.T., C.C.B.); and Alkali Soil Natural Environmental Science Center, Northeast Forestry University, Harbin, Heilongjiang, China (S.L.)
| | - Zuping Xia
- Department of Pharmaceutical Sciences, College of Pharmacy and Pharmaceutical Sciences, Washington State University, Spokane, Washington (S.L., G.C., Z.X., P.L.); Department of Medicine, Penn State University College of Medicine, Hershey, Pennsylvania (C.I.T., C.C.B.); and Alkali Soil Natural Environmental Science Center, Northeast Forestry University, Harbin, Heilongjiang, China (S.L.)
| | - Philip Lazarus
- Department of Pharmaceutical Sciences, College of Pharmacy and Pharmaceutical Sciences, Washington State University, Spokane, Washington (S.L., G.C., Z.X., P.L.); Department of Medicine, Penn State University College of Medicine, Hershey, Pennsylvania (C.I.T., C.C.B.); and Alkali Soil Natural Environmental Science Center, Northeast Forestry University, Harbin, Heilongjiang, China (S.L.)
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Bhatt DK, Basit A, Zhang H, Gaedigk A, Lee SB, Claw KG, Mehrotra A, Chaudhry AS, Pearce RE, Gaedigk R, Broeckel U, Thornton TA, Nickerson DA, Schuetz EG, Amory JK, Leeder JS, Prasad B. Hepatic Abundance and Activity of Androgen- and Drug-Metabolizing Enzyme UGT2B17 Are Associated with Genotype, Age, and Sex. Drug Metab Dispos 2018; 46:888-896. [PMID: 29602798 PMCID: PMC5938891 DOI: 10.1124/dmd.118.080952] [Citation(s) in RCA: 36] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2018] [Accepted: 03/29/2018] [Indexed: 01/06/2023] Open
Abstract
The major objective of this study was to investigate the association of genetic and nongenetic factors with variability in protein abundance and in vitro activity of the androgen-metabolizing enzyme UGT2B17 in human liver microsomes (n = 455). UGT2B17 abundance was quantified by liquid chromatography-tandem mass spectrometry proteomics, and enzyme activity was determined by using testosterone and dihydrotestosterone as in vitro probe substrates. Genotyping or gene resequencing and mRNA expression were also evaluated. Multivariate analysis was used to test the association of UGT2B17 copy number variation, single nucleotide polymorphisms (SNPs), age, and sex with its mRNA expression, abundance, and activity. UGT2B17 gene copy number and SNPs (rs7436962, rs9996186, rs28374627, and rs4860305) were associated with gene expression, protein levels, and androgen glucuronidation rates in a gene dose-dependent manner. UGT2B17 protein (mean ± S.D. picomoles per milligram of microsomal protein) is sparsely expressed in children younger than 9 years (0.12 ± 0.24 years) but profoundly increases from age 9 years to adults (∼10-fold) with ∼2.6-fold greater abundance in males than in females (1.2 vs. 0.47). Association of androgen glucuronidation with UGT2B15 abundance was observed only in the low UGT2B17 expressers. These data can be used to predict variability in the metabolism of UGT2B17 substrates. Drug companies should include UGT2B17 in early phenotyping assays during drug discovery to avoid late clinical failures.
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Affiliation(s)
- Deepak Kumar Bhatt
- Departments of Pharmaceutics (D.K.B., A.B., H.Z., K.G.C., A.M., B.P.), Genome Sciences (S.L., D.A.N.), Biostatistics (T.A.T.), and Medicine (J.K.A.), University of Washington, Seattle, Washington; Division of Pediatric Pharmacology and Medical Toxicology, Department of Pediatrics, Children's Mercy Hospitals and Clinics, Kansas City, Missouri (A.G., R.E.P., R.G., J.S.L.); Department of Pharmaceutical Sciences, St. Jude Children's Research Hospital, Memphis, Tennessee (A.S.C., E.G.S.); and Section of Genomic Pediatrics, Department of Pediatrics, and Human and Molecular Genetics Center, Medical College of Wisconsin, Milwaukee, Wisconsin (U.B.)
| | - Abdul Basit
- Departments of Pharmaceutics (D.K.B., A.B., H.Z., K.G.C., A.M., B.P.), Genome Sciences (S.L., D.A.N.), Biostatistics (T.A.T.), and Medicine (J.K.A.), University of Washington, Seattle, Washington; Division of Pediatric Pharmacology and Medical Toxicology, Department of Pediatrics, Children's Mercy Hospitals and Clinics, Kansas City, Missouri (A.G., R.E.P., R.G., J.S.L.); Department of Pharmaceutical Sciences, St. Jude Children's Research Hospital, Memphis, Tennessee (A.S.C., E.G.S.); and Section of Genomic Pediatrics, Department of Pediatrics, and Human and Molecular Genetics Center, Medical College of Wisconsin, Milwaukee, Wisconsin (U.B.)
| | - Haeyoung Zhang
- Departments of Pharmaceutics (D.K.B., A.B., H.Z., K.G.C., A.M., B.P.), Genome Sciences (S.L., D.A.N.), Biostatistics (T.A.T.), and Medicine (J.K.A.), University of Washington, Seattle, Washington; Division of Pediatric Pharmacology and Medical Toxicology, Department of Pediatrics, Children's Mercy Hospitals and Clinics, Kansas City, Missouri (A.G., R.E.P., R.G., J.S.L.); Department of Pharmaceutical Sciences, St. Jude Children's Research Hospital, Memphis, Tennessee (A.S.C., E.G.S.); and Section of Genomic Pediatrics, Department of Pediatrics, and Human and Molecular Genetics Center, Medical College of Wisconsin, Milwaukee, Wisconsin (U.B.)
| | - Andrea Gaedigk
- Departments of Pharmaceutics (D.K.B., A.B., H.Z., K.G.C., A.M., B.P.), Genome Sciences (S.L., D.A.N.), Biostatistics (T.A.T.), and Medicine (J.K.A.), University of Washington, Seattle, Washington; Division of Pediatric Pharmacology and Medical Toxicology, Department of Pediatrics, Children's Mercy Hospitals and Clinics, Kansas City, Missouri (A.G., R.E.P., R.G., J.S.L.); Department of Pharmaceutical Sciences, St. Jude Children's Research Hospital, Memphis, Tennessee (A.S.C., E.G.S.); and Section of Genomic Pediatrics, Department of Pediatrics, and Human and Molecular Genetics Center, Medical College of Wisconsin, Milwaukee, Wisconsin (U.B.)
| | - Seung-Been Lee
- Departments of Pharmaceutics (D.K.B., A.B., H.Z., K.G.C., A.M., B.P.), Genome Sciences (S.L., D.A.N.), Biostatistics (T.A.T.), and Medicine (J.K.A.), University of Washington, Seattle, Washington; Division of Pediatric Pharmacology and Medical Toxicology, Department of Pediatrics, Children's Mercy Hospitals and Clinics, Kansas City, Missouri (A.G., R.E.P., R.G., J.S.L.); Department of Pharmaceutical Sciences, St. Jude Children's Research Hospital, Memphis, Tennessee (A.S.C., E.G.S.); and Section of Genomic Pediatrics, Department of Pediatrics, and Human and Molecular Genetics Center, Medical College of Wisconsin, Milwaukee, Wisconsin (U.B.)
| | - Katrina G Claw
- Departments of Pharmaceutics (D.K.B., A.B., H.Z., K.G.C., A.M., B.P.), Genome Sciences (S.L., D.A.N.), Biostatistics (T.A.T.), and Medicine (J.K.A.), University of Washington, Seattle, Washington; Division of Pediatric Pharmacology and Medical Toxicology, Department of Pediatrics, Children's Mercy Hospitals and Clinics, Kansas City, Missouri (A.G., R.E.P., R.G., J.S.L.); Department of Pharmaceutical Sciences, St. Jude Children's Research Hospital, Memphis, Tennessee (A.S.C., E.G.S.); and Section of Genomic Pediatrics, Department of Pediatrics, and Human and Molecular Genetics Center, Medical College of Wisconsin, Milwaukee, Wisconsin (U.B.)
| | - Aanchal Mehrotra
- Departments of Pharmaceutics (D.K.B., A.B., H.Z., K.G.C., A.M., B.P.), Genome Sciences (S.L., D.A.N.), Biostatistics (T.A.T.), and Medicine (J.K.A.), University of Washington, Seattle, Washington; Division of Pediatric Pharmacology and Medical Toxicology, Department of Pediatrics, Children's Mercy Hospitals and Clinics, Kansas City, Missouri (A.G., R.E.P., R.G., J.S.L.); Department of Pharmaceutical Sciences, St. Jude Children's Research Hospital, Memphis, Tennessee (A.S.C., E.G.S.); and Section of Genomic Pediatrics, Department of Pediatrics, and Human and Molecular Genetics Center, Medical College of Wisconsin, Milwaukee, Wisconsin (U.B.)
| | - Amarjit Singh Chaudhry
- Departments of Pharmaceutics (D.K.B., A.B., H.Z., K.G.C., A.M., B.P.), Genome Sciences (S.L., D.A.N.), Biostatistics (T.A.T.), and Medicine (J.K.A.), University of Washington, Seattle, Washington; Division of Pediatric Pharmacology and Medical Toxicology, Department of Pediatrics, Children's Mercy Hospitals and Clinics, Kansas City, Missouri (A.G., R.E.P., R.G., J.S.L.); Department of Pharmaceutical Sciences, St. Jude Children's Research Hospital, Memphis, Tennessee (A.S.C., E.G.S.); and Section of Genomic Pediatrics, Department of Pediatrics, and Human and Molecular Genetics Center, Medical College of Wisconsin, Milwaukee, Wisconsin (U.B.)
| | - Robin E Pearce
- Departments of Pharmaceutics (D.K.B., A.B., H.Z., K.G.C., A.M., B.P.), Genome Sciences (S.L., D.A.N.), Biostatistics (T.A.T.), and Medicine (J.K.A.), University of Washington, Seattle, Washington; Division of Pediatric Pharmacology and Medical Toxicology, Department of Pediatrics, Children's Mercy Hospitals and Clinics, Kansas City, Missouri (A.G., R.E.P., R.G., J.S.L.); Department of Pharmaceutical Sciences, St. Jude Children's Research Hospital, Memphis, Tennessee (A.S.C., E.G.S.); and Section of Genomic Pediatrics, Department of Pediatrics, and Human and Molecular Genetics Center, Medical College of Wisconsin, Milwaukee, Wisconsin (U.B.)
| | - Roger Gaedigk
- Departments of Pharmaceutics (D.K.B., A.B., H.Z., K.G.C., A.M., B.P.), Genome Sciences (S.L., D.A.N.), Biostatistics (T.A.T.), and Medicine (J.K.A.), University of Washington, Seattle, Washington; Division of Pediatric Pharmacology and Medical Toxicology, Department of Pediatrics, Children's Mercy Hospitals and Clinics, Kansas City, Missouri (A.G., R.E.P., R.G., J.S.L.); Department of Pharmaceutical Sciences, St. Jude Children's Research Hospital, Memphis, Tennessee (A.S.C., E.G.S.); and Section of Genomic Pediatrics, Department of Pediatrics, and Human and Molecular Genetics Center, Medical College of Wisconsin, Milwaukee, Wisconsin (U.B.)
| | - Ulrich Broeckel
- Departments of Pharmaceutics (D.K.B., A.B., H.Z., K.G.C., A.M., B.P.), Genome Sciences (S.L., D.A.N.), Biostatistics (T.A.T.), and Medicine (J.K.A.), University of Washington, Seattle, Washington; Division of Pediatric Pharmacology and Medical Toxicology, Department of Pediatrics, Children's Mercy Hospitals and Clinics, Kansas City, Missouri (A.G., R.E.P., R.G., J.S.L.); Department of Pharmaceutical Sciences, St. Jude Children's Research Hospital, Memphis, Tennessee (A.S.C., E.G.S.); and Section of Genomic Pediatrics, Department of Pediatrics, and Human and Molecular Genetics Center, Medical College of Wisconsin, Milwaukee, Wisconsin (U.B.)
| | - Timothy A Thornton
- Departments of Pharmaceutics (D.K.B., A.B., H.Z., K.G.C., A.M., B.P.), Genome Sciences (S.L., D.A.N.), Biostatistics (T.A.T.), and Medicine (J.K.A.), University of Washington, Seattle, Washington; Division of Pediatric Pharmacology and Medical Toxicology, Department of Pediatrics, Children's Mercy Hospitals and Clinics, Kansas City, Missouri (A.G., R.E.P., R.G., J.S.L.); Department of Pharmaceutical Sciences, St. Jude Children's Research Hospital, Memphis, Tennessee (A.S.C., E.G.S.); and Section of Genomic Pediatrics, Department of Pediatrics, and Human and Molecular Genetics Center, Medical College of Wisconsin, Milwaukee, Wisconsin (U.B.)
| | - Deborah A Nickerson
- Departments of Pharmaceutics (D.K.B., A.B., H.Z., K.G.C., A.M., B.P.), Genome Sciences (S.L., D.A.N.), Biostatistics (T.A.T.), and Medicine (J.K.A.), University of Washington, Seattle, Washington; Division of Pediatric Pharmacology and Medical Toxicology, Department of Pediatrics, Children's Mercy Hospitals and Clinics, Kansas City, Missouri (A.G., R.E.P., R.G., J.S.L.); Department of Pharmaceutical Sciences, St. Jude Children's Research Hospital, Memphis, Tennessee (A.S.C., E.G.S.); and Section of Genomic Pediatrics, Department of Pediatrics, and Human and Molecular Genetics Center, Medical College of Wisconsin, Milwaukee, Wisconsin (U.B.)
| | - Erin G Schuetz
- Departments of Pharmaceutics (D.K.B., A.B., H.Z., K.G.C., A.M., B.P.), Genome Sciences (S.L., D.A.N.), Biostatistics (T.A.T.), and Medicine (J.K.A.), University of Washington, Seattle, Washington; Division of Pediatric Pharmacology and Medical Toxicology, Department of Pediatrics, Children's Mercy Hospitals and Clinics, Kansas City, Missouri (A.G., R.E.P., R.G., J.S.L.); Department of Pharmaceutical Sciences, St. Jude Children's Research Hospital, Memphis, Tennessee (A.S.C., E.G.S.); and Section of Genomic Pediatrics, Department of Pediatrics, and Human and Molecular Genetics Center, Medical College of Wisconsin, Milwaukee, Wisconsin (U.B.)
| | - John K Amory
- Departments of Pharmaceutics (D.K.B., A.B., H.Z., K.G.C., A.M., B.P.), Genome Sciences (S.L., D.A.N.), Biostatistics (T.A.T.), and Medicine (J.K.A.), University of Washington, Seattle, Washington; Division of Pediatric Pharmacology and Medical Toxicology, Department of Pediatrics, Children's Mercy Hospitals and Clinics, Kansas City, Missouri (A.G., R.E.P., R.G., J.S.L.); Department of Pharmaceutical Sciences, St. Jude Children's Research Hospital, Memphis, Tennessee (A.S.C., E.G.S.); and Section of Genomic Pediatrics, Department of Pediatrics, and Human and Molecular Genetics Center, Medical College of Wisconsin, Milwaukee, Wisconsin (U.B.)
| | - J Steven Leeder
- Departments of Pharmaceutics (D.K.B., A.B., H.Z., K.G.C., A.M., B.P.), Genome Sciences (S.L., D.A.N.), Biostatistics (T.A.T.), and Medicine (J.K.A.), University of Washington, Seattle, Washington; Division of Pediatric Pharmacology and Medical Toxicology, Department of Pediatrics, Children's Mercy Hospitals and Clinics, Kansas City, Missouri (A.G., R.E.P., R.G., J.S.L.); Department of Pharmaceutical Sciences, St. Jude Children's Research Hospital, Memphis, Tennessee (A.S.C., E.G.S.); and Section of Genomic Pediatrics, Department of Pediatrics, and Human and Molecular Genetics Center, Medical College of Wisconsin, Milwaukee, Wisconsin (U.B.)
| | - Bhagwat Prasad
- Departments of Pharmaceutics (D.K.B., A.B., H.Z., K.G.C., A.M., B.P.), Genome Sciences (S.L., D.A.N.), Biostatistics (T.A.T.), and Medicine (J.K.A.), University of Washington, Seattle, Washington; Division of Pediatric Pharmacology and Medical Toxicology, Department of Pediatrics, Children's Mercy Hospitals and Clinics, Kansas City, Missouri (A.G., R.E.P., R.G., J.S.L.); Department of Pharmaceutical Sciences, St. Jude Children's Research Hospital, Memphis, Tennessee (A.S.C., E.G.S.); and Section of Genomic Pediatrics, Department of Pediatrics, and Human and Molecular Genetics Center, Medical College of Wisconsin, Milwaukee, Wisconsin (U.B.)
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