Phase II metab

What happens with UGT1A1 with poor metab and Bilirubin?

elevated levels of plasma bilirubin → jaundice and under stress

genetic condition = Gilbert Syndrome

Atazanvir UGT1A1 Intermediate metab

no need to avoid atazanavir

inform pt for jaundice but unlikely

Atazanvir UGT1A1 Poor metab

consider alt agent → jaundice is of concern to the patient

Hydralazine NAT2: Rapid

Consider a starting total daily dose of at least 75mg. Titrate up to 300mg total daily hydralazine dose as tolerated.

NAT2 rapid metabolizers typically require a 50–100% higher

maintenance dose compared to poor metabolizers

Hydralazine NAT2: intermediate

Consider a starting total daily dose of at least 75mg. Titrate up to 300mg total daily hydralazine dose as tolerated. NAT2 intermediate metabolizers typically require a 50–100% higher maintenance dose compared to poor metabolizers

Hydralazine NAT2 Poor

Initiate therapy at a total daily dose of 40–75mg. Carefully

titrate dose upward to clinical effect or guideline-

recommended dose; use caution with total daily hydralazine

doses of 200mg or more

Malignant: TPMT intermediate OR NUDT15 intermediate

Consider dose reduction: 30-80% of standard starting dose

Malignant: TPMT intermediate AND NUDT15 intermediate

Consider dose reduction: 20-50% standard starting dose

Malignant: TPMT poor AND/OR NUDT15 Poor

consider dose reduction: 10% of standard dose, three times weekly

Nonmalignant: TPMT intermediate OR NUDT15 intermediate

Consider dose reduction: 30-80% of standard starting dose

Nonmalignant: TPMT intermediate AND NUDT15 intermediate

Consider dose reduction: 20-50% standard starting dose

Nonmalignant: TPMT poor AND/OR NUDT15 Poor

consider Alt immunosuppressant therapy