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Appendix

APPENDIX | SUPPLEMENTAL RESOURCES

Chapter 3 - Additional information to supplement

Common Drugs Metabolized by CYP3A4:


Statins: Atorvastatin (Lipitor), Simvastatin (Zocor) | Calcium Channel Blockers: Amlodipine (Norvasc), Diltiazem (Cardizem) | Benzodiazepines: Midazolam, Alprazolam (Xanax) | HIV Protease Inhibitors: Ritonavir (Norvir), Indinavir (Crixivan) | Macrolide Antibiotics: Erythromycin, Clarithromycin (Biaxin) | Immunosuppressants: Cyclosporine, Tacrolimus | Opioids: Fentanyl, Oxycodone | Antidepressants: Venlafaxine (Effexor), Quetiapine (Seroquel) | Antifungals: Ketoconazole, Itraconazole



Common Drugs Metabolized by CYP2C9:

Anticoagulants: Warfarin (Coumadin) | NSAIDs: Ibuprofen, Diclofenac (Voltaren) | Antidiabetic Medications: Glipizide, Glyburide | Antiepileptic Drugs: Phenytoin | Proton Pump Inhibitors: Fluconazole | Beta-Blockers: Metoprolol | SSRIs: Fluvoxamine | ARBs: Losartan, Valsartan | Sulfonylureas: Gliclazide


Which CYPs have the highest amount of activity? ...


  1. CYP3A4 (~35–50% of Drugs) Atorvastatin, Simvastatin, Amlodipine, (some) Omeprazole, Cyclosporine, Midazolam, and many others

    • Weight loss / diabetes: Phentermine (partially via CYP3A4 and other pathways) Some SGLT2 inhibitors (e.g., canagliflozin) → partially via UGT and possibly minor CYP3A4

  2. CYP2D6 (~20–25% of Drugs) Metoprolol, Codeine, Tamoxifen, Paroxetine, Amitriptyline, etc.

    • Weight loss / diabetes: Phentermine can also involve minor CYP2D6 pathways in some individuals

  3. CYP2C9 (~10–15% of Drugs) Losartan, Warfarin, Phenytoin, Ibuprofen, Sulfonylureas, etc.

    • Diabetes: Sulfonylureas (e.g., glipizide, glyburide) → via CYP2C9

  4. CYP2C19 (~5–10% of Drugs) Omeprazole, Clopidogrel, Citalopram, etc. Omeprazole → primarily by CYP2C19 (also minor CYP3A4)

  5. CYP1A2 (~5–10% of Drugs) Caffeine, Theophylline, Clozapine, Olanzapine, etc.

  6. CYP2B6 (~2–5% of Drugs) Bupropion, Efavirenz, Cyclophosphamide, etc.

  7. CYP2E1 (~1–3% of Drugs) Ethanol (at higher concentrations), Acetaminophen (minor), Volatile anesthetics


References on Drug Metabolism:

  1. Mulder TAM, van Eerden RAG, de With M, Elens L, Hesselink DA, Matic M, Bins S, Mathijssen RHJ, van Schaik RHN. CYP3A4∗22 Genotyping in Clinical Practice: Ready for Implementation? Front Genet. 2021 Jul 8;12:711943. doi: 10.3389/fgene.2021.711943. PMID: 34306041; PMCID: PMC8296839.

  2. Taylor C, Crosby I, Yip V, Maguire P, Pirmohamed M, Turner RM. A Review of the Important Role of CYP2D6 in Pharmacogenomics. Genes (Basel). 2020 Oct 30;11(11):1295. doi: 10.3390/genes11111295. PMID: 33143137; PMCID: PMC7692531.

  3. Daly AK, Rettie AE, Fowler DM, Miners JO. Pharmacogenomics of CYP2C9: Functional and Clinical Considerations. J Pers Med. 2017 Dec 28;8(1):1. doi: 10.3390/jpm8010001. PMID: 29283396; PMCID: PMC5872075.

  4. Wang YC, Hsieh TC, Chou CL, Wu JL, Fang TC. Risks of Adverse Events Following Coprescription of Statins and Calcium Channel Blockers: A Nationwide Population-Based Study. Medicine (Baltimore). 2016 Jan;95(2):e2487. doi: 10.1097/MD.0000000000002487. PMID: 26765458; PMCID: PMC4718284.

  5. Rowan CG, Brunelli SM, Munson J, Flory J, Reese PP, Hennessy S, Lewis J, Mines D, Barrett JS, Bilker W, Strom BL. Clinical importance of the drug interaction between statins and CYP3A4 inhibitors: a retrospective cohort study in The Health Improvement Network. Pharmacoepidemiol Drug Saf. 2012 May;21(5):494- 506. doi: 10.1002/pds.3199. Epub 2012 Mar 16. PMID: 22422642; PMCID: PMC3890414.


Resources Chapters 7-8 Cases

Q 28 | Sample Calculations for Tinctures


For 500 mg THC in a 30 mL bottle:

  1. THC per drop: 500 mg ÷ 600 drops = 0.83 mg per drop.

  2. Drops for 2 mg THC: 2 mg ÷ 0.83 mg/drop ≈ 2.4 drops.

Answer: Take 2-3 drops.



For 600 mg THC in a 30 mL bottle:

  1. THC per drop: 600 mg ÷ 600 drops = 1 mg per drop.

  2. Drops for 2 mg THC: 2 mg ÷ 1 mg/drop = 2 drops.

Answer: Take 2 drops.


Q29 | References

Simonian, J. S., Varanasi, S., Richards, G. J., Nguyen, A. V., Diaz-Fong, J. P., & Le, J. (2020). A critical narrative review of medical cannabis in pediatrics beyond epilepsy, part III: Chemotherapy-induced nausea and vomiting and inflammatory bowel disease. Pediatric Medicine, 3.


Holdman R, Vigil D, Robinson K, Shah P, Contreras AE. Safety and Efficacy of Medical Cannabis in Autism Spectrum Disorder Compared with Commonly Used Medications. Cannabis Cannabinoid Res. 2022 Aug;7(4):451-463. doi: 10.1089/can.2020.0154. Epub 2021 Aug 24. PMID: 34432543; PMCID: PMC9418362.

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