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21 February 2023: Articles

Pharmacogenetic Testing in a 70-Year-Old Woman with Polypharmacy and Multiple Comorbidities: A Case Report

Unknown etiology, Adverse events of drug therapy

Jayson P. Jessop A , Joshua Russell A , Adriana DeJesus A , Chandni Bardolia A , Abeer Hanna B , Jacques Turgeon A* , Veronique Michaud A , Nishita S. Amin A

DOI: 10.12659/AJCR.938850

Am J Case Rep 2023; 24:e938850

Table 2. Recommendations made by pharmacists over the course of care.

Atorvastatin 20 mgChange to pravastatin 40 mgIncreased risk of ADEs (eg, myalgia) with atorvastatin due to diltiazem-induced competitive inhibition of CYP3A4Accepted
Diltiazem 120 mgDiscontinue therapyTherapy duplication with both carvedilol and diltiazem, resulting in increased risk of bradycardia and/or orthostatic hypotensionRejected
Ezetimibe 10 mgDiscontinue therapyIncreased risk of myalgia with non-optimized statin therapy and a general concern of increased pill burden with a lack of therapeutic benefitAccepted
Fluoxetine 20 mgChange to citalopram 10 mgIncreased risk of orthostatic hypotension and/or bradycardia due to fluoxetine-induced competitive inhibition of CYP2D6 (with carvedilol) and increased risk of ADEs (eg, bone fractures, GI inflammation, and hypomagnesemia) due to noncompetitive inhibition of CYP2C19 (with lansoprazole). Additionally, greater than 8 weeks of fluoxetine therapy has not resulted in major improvementsAccepted
Lansoprazole 30 mgChange time of administration to bedtimeDecreased therapeutic benefit from levothyroxine due to lansoprazole-impaired absorption.Accepted
Lorazepam 0.5 mgDiscontinue therapy if used infrequentlyPatients who are 65 years or older are more likely to experience significant sedative and CNS effects with benzodiazepinesRejected
Carvedilol 12.5 mgMonitor symptoms and adjust dose as necessaryIncreased risk for ADEs due to the presence of a DGI (CYP2D6 intermediate metabolizer)Accepted
Lansoprazole 30 mgDiscontinue therapy or switch to an H2-receptor antagonistIncreased risk of ADEs associated with long-term use of PPIs (e.g., bone loss, fractures, C. difficile infections, and gastritis). The patient is on long-term antibiotics for bacteremia/endocarditis, increasing the risk factors for C. diff infectionsRejected
Pravastatin 40 mgReduce dose to 20 mgIncreased risk for ADEs due to the presence of a DGI (SLCO1B1 decreased function). CPIC guidance notes typical myopathy risk with doses ≤40 mg and possible increased risk for myopathy with pravastatin especially with doses >40 mg. Participant is currently on 40 mg/day and noted muscle weakness and stiffness during participant counseling callRejected
WarfarinUse frequent INR assessments to guide dose adjustments of warfarinIncreased sensitivity to warfarin and potential ADEs due to the presence of DGIs (CYP2C9 intermediate metabolizer, VKORC1 low activity, CYP4F2 reduced activity). Closely monitor for ADEs (eg, increased INR, bleeding)Accepted
Additional therapy: ACEiStart lisinopril 2.5 mgGeneral renal benefits in participants with type II DMAccepted
ACEi – angiotensin converting enzyme inhibitor; ADE – adverse drug event; CPIC – Clinical Pharmacogenetics Implementation Consortium; CNS – central nervous system; DGI – drug–gene interaction; DM – diabetes mellitus; INR – international normalization ratio; PPI – proton pump inhibitors.

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American Journal of Case Reports eISSN: 1941-5923
American Journal of Case Reports eISSN: 1941-5923