Rs4244285

rs4244285 is a SNP in the CYP2C19 gene, potentially encoding the CYP2C19*2 variant. This variant is the most common reason for poor metabolism of compounds like mephenytoin (an anti-convulsant), some antidepressants, the anti-platelet drug Plavix, and some drugs used for ulcer conditions of various types.

The risk allele is rs4244285(A).

As a nonfunctioning CYP2C19, this variant would be expected to be a poor metabolizer of several commonly prescribed drugs, including anti-ulcer drugs like omeprazole (trade names Losec and Prilosec), esomeprazole (trade name Nexium), and lansoprazole (trade name Prevacid).

In Caucasians, SNPs in CYP2C19 are relatively rare (in contrast to SNPs in CYP2D6), but SNPs in this gene are common in Asians. Ulcer treatment with omeprazole to reduce Helicobacter pylori has been shown to vary depending on a patient's CYP2C19 genotype, varying from 28% in patients homozygous for CYP2C19 alleles encoding fully functional proteins to 100% in patients with variations leading to poor metabolism. The fact that poor metabolizers for many cytochrome p450s achieve higher therapeutic success for some drugs is speculated to be because for some of the drug being broken down (ie metabolized) slower, the effective concentrations are both higher and longer lasting.

However, other drugs clearly work less well in carriers of reduced function CYP2C19 alleles. An example of such a drug is clopidogrel, sold under the brand name Plavix. This has now (2010) been acknowledged by the FDA, who have added a boxed warning to Plavix, alerting patients and health care professionals that the drug can be less effective in people who have CYP2C19 variants and cannot convert the drug as effectively to its active form.

Several recent (December 2008) studies reach similar (though not identical) conclusions about the consequences of CYP2C19*2 allele carriers prescribed clopidogrel to reduce their cardiovascular risk:


 * A study of 245 French patients under 45 years of age prescribed clopidogrel after surviving a first heart attack concluded that rs4244285(A) allele carriers were at 4x higher risk (CI: 1&#183;81&#8212;9&#183;02, p=0&#183;0006) for subsequent adverse cardiovascular events compared to noncarriers.
 * A study of 2,208 French patients prescribed clopidogrel, of which 225 subsequently died and 94 had a nonfatal heart attack or stroke, came to two conclusions :
 * Patients carrying any two CYP2C19 loss-of-function alleles (*2, *3, *4, or *5), had about a 2x increased risk (21.5% vs. 13.3%; adjusted hazard ratio, 1.98; CI: 1.10-3.58) for adverse cardiovascular events than CYP2C19*1 homozygotes.
 * Among the 1,535 patients who underwent percutaneous coronary intervention (angioplasty) during hospitalization, patients with two CYP2C19 loss-of-function alleles were at even higher risk for adverse events: 3.58x (CI: 1.71-7.51) compared to CYP2C19*1 homozygotes.
 * A study of 1,477 subjects with acute coronary syndromes who were treated with clopidogrel as part of the Trial to Assess Improvement in Therapeutic Outcomes by Optimizing Platelet Inhibition with Prasugrel-Thrombolysis in Myocardial Infarction (TRITON-TIMI) 38 study concluded that rs4244285(A) allele carriers had a 1.53x increased risk for death from cardiovascular causes, myocardial infarction, or stroke, as compared with noncarriers (12.1% vs. 8.0%; CI: 1.07-2.19, p=0.01) and were at 3x higher risk of stent thrombosis (2.6% vs. 0.8%; CI: 1.19-8.00, p=0.02).
 * CYP2C19*2 loss-of-function genotypes were associated with diminished platelet response to clopidogrel treatment and poorer cardiovascular outcomes in a study of 429 healthy Amish individuals treated for 7 days (in the first study) and 227 patients undergoing percutaneous coronary intervention (angioplasty) (in the second study).

Clopidogrel Efficacy