CYP2C19
Cytochrome P450 2C19 is an enzyme. This protein, a member of the CYP2C subfamily of the cytochrome P450 mixed-function oxidase system, is involved in the metabolism of xenobiotics, including many proton pump inhibitors and antiepileptics. In humans, the CYP2C19 protein is encoded by the CYP2C19 gene. CYP2C19 is a liver enzyme that acts on at least 10% of drugs in current clinical use, most notably the antiplatelet treatment clopidogrel, drugs that treat pain associated with ulcers, such as omeprazole, antiseizure drugs such as mephenytoin, the antimalarial proguanil, and the anxiolytic diazepam.
CYP2C19 has been annotated as -limonene 6-monooxygenase and -limonene 6-monooxygenase in UniProt.
Function
The gene encodes a member of the cytochrome P450 superfamily of enzymes. Enzymes in the CYP2C subfamily, including CYP2C19, account for approximately 20% of cytochrome P450 in the adult liver. These proteins are monooxygenases that catalyze many reactions involved in drug metabolism and synthesis of cholesterol, steroids and other lipids. This protein localizes to the endoplasmic reticulum and is known to metabolize many drugs. Polymorphism within this gene is associated with variable ability to metabolize drugs. The gene is located within a cluster of cytochrome P450 genes on chromosome no.10 arm q24.CYP2C19 also possesses epoxygenase activity: it is one of the principal enzymes responsible for attacking various long-chain polyunsaturated fatty acids at their double bonds to form epoxide products that act as signaling agents. It metabolizes:
- arachidonic acid to various epoxyeicosatrienoic acids ;
- linoleic acid to 9,10-epoxy octadecaenoic acids and 12,13-epoxy-octadecaenoic ;
- docosohexaenoic acid to various epoxydocosapentaenoic acids ; and
- eicosapentaenoic acid to various epoxyeicosatetraenoic acids.
Genetic polymorphism and pharmacogenomics
exists for CYP2C19 expression. The Pharmacogene Variation Consortium keeps the and assigns labels to known polymorphysms, the lack of polymorphysm is denoted CYP2C19*1. The variant genotypes of CYP2C19*2, CYP2C19*3 and CYP2C19*17 are major factors attributed to interindividual differences in the pharmacokinetics and response to CYP2C19 substrates. CYP2C19*2 and *3 are associated with diminished enzyme activity, whereas CYP2C19*17 results in increased activity. These three variant alleles are recommended by the Working Group of the Association for Molecular Pathology Clinical Practice Committee to be included in the minimal clinical pharmacogenomic testing panel, called tier 1. The extended panel of variant alleles, called tier 2, additionally indludes the following CYP2C19 alleles: *4.001, *4.002, *5, *6, *7, *8, *9, *10, and *35, all of them associated with diminished enzyme activity. Although these tier 2 alleles are included in many platforms, they were not included in the tier 1 recommendations because of low minor allele frequency, less well-characterized impact on CYP2C19 function, or a lack of reference materials. To meet the need for publicly available characterized reference materials, the Centers for Disease Control and Prevention, in partnership with the clinical testing community, established the Genetic Testing Reference Material Program. Its goal is to improve the supply of publicly available and well-characterized genomic DNA that can be used as reference materials for proficiency testing, quality control, test development/validation, and research studies.The allele frequencies of CYP2C19*2 and *3 are significantly higher in Chinese populations than in European or African populations, and are found at approximately 3–5% of European and 15–20% of Asian populations. The overall frequencies of *2, *3, and *17 were 15.2%, 0.3%, and 20.4%, respectively, but varied by ethnicity. The most common variant diplotypes were *1/*17 at 26% and *1/*2 at 19.4%. The less common *2/*17, *17/*17 and *2/*2 genotypes occurred at 6.0%, 4.4%, and 2.5%, respectively. Overall, 58.3% of participants had at least one increased-function or no-function CYP2C19 allele.
CYP2C19 is involved in processing or metabolizing at least 10% of commonly prescribed drugs. Variations to the enzyme can have a wide range of impacts to drug metabolism. In patients with an abnormal CYP2C19 variant certain benzodiazepines should be avoided, such as diazepam, lorazepam, oxazepam, and temazepam. Other categories of drugs impacted by modified CYP2C19 include proton pump inhibitors, anticonvulsants, hypnotics, sedatives, antimalarial drugs, and antiretroviral drugs.
On the basis of their ability to metabolize -mephenytoin or other CYP2C19 substrates, individuals can be classified as ultrarapid metabolizers, extensive metabolizers or poor metabolizers. In the case of proton pump inhibitors, PMs exhibit a drug exposure that is 3 to 13 times higher than that of EMs. Loss-of-function alleles, CYP2C19*2 and CYP2C19*3 predict PMs, and the gain-of-function CYP2C19*17 allele predicts UMs.
Although the amount of CYP2C19 enzyme produced by the *17 allele is greater than of the *1 allele, whether the carriers of the *17 allele experience any significant difference in response to drugs comparing to the wild-type, is a topic of ongoing research, studies show varying results. Some studies have found that the *17 variant's effect on the metabolism of omeprazole, pantoprazole, escitalopram, sertraline, voriconazole, tamoxifen and clopidogrel is modest, particularly compared to the impact of loss-of-function alleles, therefore, in case of these medications, the EM designation is sometimes applied instead of the UM classification. For example, carriers of the *17 allele did not demonstrate different gastric pH comparing to *1 after taking the proton pump inhibitor omeprazole, a CYP2C19 substrate. Other studies concluded that the *17 allele seems to be the factor responsible for lower response to some drugs, even at higher doses, for example, to escitalopram for symptom remission in major depressive disorder patients. CYP2C19*17 carrier status is significantly associated with enhanced response to clopidogrel and an increased risk of bleeding; the highest risk was observed for CYP2C19*17 homozygous patients. An important limitation of all these stuies is the single-gene analysis, since most drugs that are metabolized by CYP2C19 are also metabolized by CYP2D6 and CYP3A4 enzymes. Besides that, other genes are involved in drug response, for example, escitalopram is transported by P-glycoprotein, encoded by the ABCB1 gene. In order for the studies on CYP2C19*17 to be conclusive, the differences in other genes that affect drug response have to be excluded. The prevalence of the CYP2C19*17 variant is less than 5% in Asian populations and is approximately four times higher in European and African populations.
The alleles CYP2C19*2 and *3 may reduce the efficacy of clopidogrel, an antiplatelet medication. The basis for this reduced effect of clopidogrel in patients who have a gene of reduced activity may seem somewhat paradoxical, but can be understood as follows. Clopidogrel is administered as a “prodrug”, that is, a drug that is inactive when taken, and then depends on the action of an enzyme in the body in order to be activated. In patients who have a gene of reduced activity, clopidogrel may not be metabolized to its active form and therefore not achieve pharmacological effect in the body. The relative risk of major cardiac events among patients treated with clopidogrel is 1.53 to 3.69 times higher for carriers of CYP2C19*2 and CYP2C19*3 compared with non-carriers.
Ligands
The following is a table of selected substrates, inducers and inhibitors of CYP2C19. Where classes of agents are listed, there may be exceptions within the class.Inhibitors of CYP2C19 can be classified by their potency, such as:
- Strong being one that causes at least a 5-fold increase in the plasma AUC values, or more than 80% decrease in clearance of substrates.
- Moderate being one that causes at least a 2-fold increase in the plasma AUC values, or 50-80% decrease in clearance of substrates.
- Weak being one that causes at least a 1.25-fold but less than 2-fold increase in the plasma AUC values, or 20-50% decrease in clearance of substrates.
| Substrates | Inhibitors | Inducers |
| ; Strong ; Moderate ; Weak ; Unspecified potency ; Unspecified potency |