Yang X, Gandhi YA, Duignan DB, Marilyn E. Prediction of biliary excretion in rats and humans using molecular weight and quantitative structurepharmacokinetic relationships. 90% of drugs are metabolised by CYP3A5, CYP3A4, CYP2D6, CYP2C19, CYP2C9 and CYP1A2. Cyclosporine, CA2+ channel blockers, and Phenytoin can Cause Chubby Puffy Gums! P450 Inhibitors. Expanded Access: Information for Patients. The theoretical volume a drug would occupy if it was distributed evenly in fluids at plasma concentration. Cimetidine; Diltiazem; Verapamil; Isoniazid; SSRI's ; Grapefruit juice ; Protease inhibitors (PIs) NNRTIs; Ritonavir; Valproic acid . Only 4.3% of the subjects used drugs with inducer activity. Human cytochrome P450 (CYP) 3A subfamily members (mainly CYP3A4 and CYP3A5) mediate the metabolism of approximately half all marketed drugs and thus play a critical role in the drug metabolism. c Strong inhibitor of CYP2C8 and inhibitor of OATP1B1 and OAT3. The most common routes of drug administration are: Injection (the drug is introduced directly into the bloodstream or into tissue), Rectal or sublingual administration bypasses, Drug is stored but over time is released again from, The time it takes for a drug's plasma concentration to reach 50% of its initial value during the most clinically important phase of its kinetics, The relationship between a chemical compound's structure and its biological activity, Allosteric modulator: Binds at a different site than the, The mechanisms responsible for the development of. Consequently, this decreases drug metabolism in the body and increases the potential for toxicity. It inhibits the metabolism and clearance of warfarin, subsequently causing a rapid and extensive increase in warfarin concentration in the body. "INHIBITORS, INDUCERS AND SUBSTRATES OF CYTOCHROME P450 ISOZYMES". At the other extreme, ultrarapid metabolisers metabolise the drug rapidly, resulting in a lack of therapeutic response in these individuals. Note: Sensitive substrates are drugs that demonstrate an increase in AUC of 5-fold with strong index inhibitors of a given metabolic pathway in clinical DDI studies. P450 inhibitors: MacQuin and his friend GemAvir acutely drink alcohol in grapefruit juice with Ise and ASK for Omeprazole and Cimetidine for their stomach ache. a Strong inducer of CYP2C19 and CYP3A, and moderate inducer of CYP1A2, CYP2B6, CYP2C8, CYP2C9.b Strong inducer of CYP2B6 and CYP3A and a weak inducer of CYP2C9.c Strong inducer of CYP3A and a moderate inducer of CYP1A2 and CYP2C19. Note at the concentration inhibiting OAT3, benzylpenicillin also inhibits OATP1B3. Update: clinically significant cytochrome P450 drug interaction. CRAP GPSUSEFUL STUFF FOR MEDICAL STUDENTS:FREE Amazon Prime 6 Months for Students (Including unlimited 2-day shipping on orders of any value)US: https://amzn.to/3gMqh0pUK: https://www.amazon.co.uk/gp/student/signup/info?tag=rhesusmedicin-21Venepuncture Kit:UK: https://amzn.to/3r7txrWPocket Cards: Lab Values / References / ECG / History Taking (Cheatsheets for rotations!) Cytochrome P450 enzymes can be inhibited or induced by drugs, resulting in clinically significant drug-drug interactions that can cause unanticipated adverse reactions or therapeutic failures.. Table 5-1: Examples of clinical substrates for transporters (for use in clinical DDI studies and/or drug labeling), dabigatran etexilate(a), digoxin,edoxaban, fexofenadine(b,c,d), atorvastatin(f,g,h), bosentan(g), docetaxel(d,g,i), elagolix(g,h), fexofenadine(c,d,g), glecaprevir(f,g,h), glyburide(j), grazoprevir(g,h), letermovir, paclitaxel(d,g,k), pitavastatin, pravastatin(c,d), repaglinide(k), rosuvastatin(c,f), simvastatin acid(h), adefovir(l,m), baricitinib(n), bumetanide(n), cefaclor(n), ceftizoxime(n), ciprofloxacin, famotidine(n), furosemide, methotrexate(n), oseltamivir carboxylate(m,n), benzylpenicillin (penicillin G)(n), tenofovir(l,m). - Introduction 00:00 e Strong inhibitor of CYP2C19 and moderate inhibitor of CYP2C9 and CYP3A. Note: This table provides examples of in vitro inhibitors for various transporters and is not intended to be an exhaustive list.a Also an inhibitor of BCRP.b Also an inhibitor of NTCP.c Also an inhibitor of OATPs.d Also an inhibitor of MRP2.e Also an inhibitor of OAT3.f Also an inhibitor of OCT2.g Also an inhibitor of MATEs.h Also an inhibitor of P-gp.i Preincubation with inhibitors prior to inhibition studies causes a decrease of the Ki value.j Selectively inhibit OAT3 at lower concentrations. document.getElementById( "ak_js_1" ).setAttribute( "value", ( new Date() ).getTime() ); This site uses Akismet to reduce spam. Note: Index inhibitors predictably inhibit metabolism via a given pathway and are commonly used in prospective clinical DDI studies. AntiEpiLEpTIC drugs, Penicillin, ALlopurinol and SULFonamides may provoke STEVE JOHNSON (syndrome), an EcLEcTIC PAL who loves SUrF! Changes in cytochrome P450 (CYP) enzyme metabolism are a common cause of drug-drug interactions. BCRP: (1) AUC fold-increase of rosuvastatin or sulfasalazine is 1.5 with co-administration and (2) in vitro inhibitor of BCRP. An antiepileptic agent used in combination with other anticonvulsants to treat seizures associated with Dravet syndrome. Blocking P450 activity by treatment of cells with the antifungal imidazole derivative, ketoconazole, inhibits catabolism and results in 1,25 (OH)2 D . Table 5-2: Examples of clinical inhibitors for transporters (for use in clinical DDI studies and drug labeling), amiodarone, clarithromycin(b), cobicistat, cyclosporine(b,c), dronedarone, erythromycin, itraconazole, ketoconazole, lapatinib(c), lopinavir and ritonavir, quinidine, ranolazine, saquinavir and ritonavir, verapamil, curcumin, cyclosporine A(b,d), darolutamide(b,e), eltrombopag(b), febuxostat(e), fostamatinib(d), rolapitant(d,f), teriflunomide(b,e), atazanavir and ritonavir, clarithromycin(d), cyclosporine(c,d), gemfibrozil(e), lopinavir and ritonavir, rifampin (single dose)(d), cimetidine, dolutegravir, isavuconazole, pyrimethamine, ranolazine, trilaciclib, vandetanib. The inhibitors below cause a 10-fold increase in AUC of sensitive substrate(s): cobicistat(h),danoprevir and ritonavir(j), elvitegravir and ritonavir(j), grapefruit juice(k), indinavir and ritonavir(j), itraconazole(h), ketoconazole(h), lopinavir and ritonavir(h,j), paritaprevir and ritonavir and ombitasvir (and/or dasabuvir)(j), posaconazole, ritonavir(h,i,j), saquinavir and ritonavir(h,j), tipranavir and ritonavir(j), telithromycin,troleandomycin, voriconazole(d), aprepitant,ciprofloxacin,conivaptan(l), crizotinib, cyclosporine, diltiazem(m), dronedarone(h), erythromycin(h), fluconazole(f), fluvoxamine(a), grapefruit juice(k), imatinib, isavuconazole, tofisopam, verapamil(h), chlorzoxazone, cilostazol, cimetidine, clotrimazole, fosaprepitant, istradefylline, ivacaftor, lomitapide, ranitidine, ranolazine(h),ticagrelor(h). St Johns wort should not be taken concurrently with oral contraceptive pills or patients should use alternative methods such as barrier methods, depots and intrauterine devices (IUD). aWe currently do not have sensitive index substrates for CYP2B6.bAlso OATP1B1 substrate.cModerately sensitive substrates.dS-lansoprazole is a sensitive substrate in CYP2C19 EM subjects. Abbreviations: Is there a list of psychotropic agents and their CYP substrates and inducing/inhibiting capabilities? - Timing 03:23 A dose reduction should be considered in these patients. If patients taking Carbamazepine, Cyclophosphamide or SSRI get SIADH, they Can't Concentrate Serum Sodium! In the rest of the world, the prevalence of ultrarapid metaboliser phenotypes is estimated to be 1% in the Chinese, Japanese and Hispanic populations and 5.5% in Western Europe.3,4. CL can be impaired in patients with cardiac, hepatic, or renal dysfunction. b We currently do not have index inhibitors for CYP2B6. Intermediate metabolisers have a reduced metabolism capacity compared to extensive metabolisers (who are classified as normal), therefore are more susceptible to adverse effects. - Associated symptoms 03:04 Preoperative Cardiac Evaluation in Non-cardiac Surgery : Mnemonic, https://epomedicine.com/medical-students/enzyme-inducers-inhibitors-mnemonic/. Can be calculated using the area under curve (AUC) of the plotted graph concentration versus time: (F) = (AUCoral/AUCIV) x 100 CYP3A4 and CYP2D6 are the most significant enzymes. A 5-cm-diameter horizontal jet of water, with velocity 30m/s30 \mathrm{~m} / \mathrm{s}30m/s, strikes the tip of a horizontal cone, which deflects the water by 6060^{\circ}60 from its original direction. Moderately sensitive substrates are drugs that demonstrate an increase in AUC of 2- to <5-fold with strong index inhibitors of a given metabolic pathway in clinical DDI studies. Drug concentration stays constant because the rate of drug elimination equals the rate of drug administration, Defects in renal, hepatic, or cardiac function can impair. In rodents hepatic cytochrome P450 inducers can be grouped into five classes: inducers of CYP1A, CYP2B, CYP2E, CYP3A and CYP4A forms. In previous issues of Pharmacy Times, we have discussed the cytochrome P450 (CYP450) enzymes CYP1A2, CYP2C9, CYP2C19, and CYP2D6 (see www.PharmacyTimes.com/Drug Interactions ). Note: Index inducers predictably induce metabolism via a given pathway and are commonly used in prospective clinical DDI studies. Twitter: http://www.twitter.com/geekymedics OAT1/OAT3: (1) AUC fold-increase is 1.5 with probenecid co-administration; (2) fraction excreted unchanged into urine as an unchanged drug is 0.5; and (3) in vitro transported by OAT1 and/or OAT3 expression systems. Classification is based on studies conducted with ritonavir itself (not with other anti-HIV drugs) at doses of 100-200 mg/day, although larger effects have been reported in literature for high doses of ritonavir.f Moderate inducer of CYP1A2 with a dose of 800 mg/day ritonavir (not with other anti-HIV drugs). The commonly tested ones, at least on that app, were these: Erythromycin, quinidine, rifampin, isoniazid, griseofulvin, cimetidine, carbamazepine, phenytoin, and phenobarbital. ): https://www.youtube.com/channel/UCRks8wB6vgz0E7buP0L_5RQ?sub_confirmation=1LINK TO MORE MNEMONICS:https://www.youtube.com/watch?v=p-XE7PiwGgE\u0026list=PLGNSE_HvIV4t7a33bbHN1fq-j_tge0GmpVideo Timestamps:0:00 Intro0:33 Cytochrome P450 Inhibitors / SICKFACES 2:29 Cytochrome P450 Inducers ? Published in November 2003. TABLE 1.3 Major Pathways for Drug Metabolism, Enzymes, Subcellular Locations, and In Vitro Experimental System Containing Enzymes - "1 IN VITRO EVALUATION OF METABOLIC DRUG - DRUG INTERACTIONS : CONCEPTS AND PRACTICE" tics; the 2-3 year revision cycle of the printed text is among the A Drug Summary Table is placed at the conclusion of . Ionized substances cannot cross renal tubular membranes and are cleared quickly. Studies have shown that it can be classified as a strong CYP3A inhibitor when a certain preparation is used (e.g., high dose, double strength) or as a moderate CYP3A inhibitor when another preparation is used (e.g., low dose, single strength).l The classification is based on studies conducted with intravenously administered conivaptan.m Diltiazem increased the AUC of certain sensitive CYP3A substrates (e.g., buspirone) more than 5-fold. It takes zero PHEN-tAS-E (fantasy) to remember the drugs that are eliminated by zero-order kinetics: PHENytoin, ASpirin, Ethanol. Enzyme substrates are drugs or other substances that bind to and are metabolised by the CYP450 enzymes. Therefore, ultrarapid metabolisers may experience symptoms of opioid overdose (e.g. - Onset 01:48 Should include all the information about the agent (manufacturing process, quality control, formula, Can potentially lead to physical and psychological abuse, Low-to-moderate potential for physical and high potential for psychological abuse, Low potential for both physical and psychological abuse, Low potential for abuse compared to Schedule IV, Primarily consists of preparations that contain narcotic medications, The process by which the drug is released from its pharmaceutical form (e.g., capsule, tablet, suppository, etc.). Every functioning molecule in an organism is a potential site of action for a drug. Procarcinogens - Determination and evaluation by yeast-based biosensor transformed with plasmids incorporating RAD54 reporter construct and cytochrome P450 genes. The expression of CYP450 enzymes varies between populations and will greatly influence drug metabolism and response. CYP enzymes are divided into subtypes (e.g. Drugs that do not have FDA approval for any indication should not be prescribed because the safety, efficacy, and quality of these drugs have not been proven. The selection is not exhaustive. Capdeville R, Buchdunger E, Zimmermann J, Matter A. Glivec (STI571, imatinib), a rationally developed, targeted anticancer drug. "The Life Raft Group: Long List of Inhibitors and Inducers of CYP3A4 and CYP2D6". - Severity 05:32 Van Norman GA. This table provides examples of clinical sensitive or moderately sensitive index substrates and is not intended to be an exhaustive list. (2010), Hum Genomics, 5(1):61)], and the list of references is available here. Index inhibitors listed in this table were selected based on potency and selectivity of inhibition, safety profiles, and an adequate number of reported clinical DDI studies with different in vivo substrates [ 3 for CYP3A, 2 for CYP1A2, 2C9, 2C19, and 2D6, or 1 for CYP2C8 (strong inhibitors)]. Cytochrome P450 Inducers and Inhibitors Mnemonic and Table | CYP450 SICKFACES & CRAP GPS Rhesus Medicine 66.2K subscribers 45K views 2 years ago Medical Mnemonics Learn Cytochrome P450. AUC: area under the concentration-time curve; CYP: cytochrome P450; DDI: drug-drug interaction; EM: extensive metabolizer; OATP1B1: organic anion transporting polypeptide 1B1. Which is not a macromolecule? (2010), Hum Genomics, 5(1):61]. #medicalmnemonic #medicalmnemonics #rhesusmedicine #studymedicine #studygram #medstudent #medicalschool - 150+ PDF OSCE Checklists: https://geekymedics.com/pdf-osce-checklists/ For example, first-generation antipsychotics such as thioridazine haloperidol, chlorpromazine, pimozide, stelazine, and . f Strong inhibitor of CYP2C19 and CYP2D6. Therefore, potential changes in drug concentration may cause treatment failure. What are the muscles of facial expressions? Using SOCRATES in History Taking | OSCE | Communication Skills, A quick overview of key clinical signs you might expect to find when performing a respiratory examination on a patient with chronic obstructive pulmonary disease (COPD). Parkinson-like syndrome and/or tardive dyskinesia. Other elimination pathways can also contribute to the elimination of the substrates listed in the table above and should be considered when assessing the drug interaction potential. Table 1-3. Rifampicin and carbamazepine are some of the strongest inducers of cytochrome P450 enzymes and can thus interact with many drugs. Abbreviations: In this review, we systematically summarized the frequently used CYP3A probe drugs, inducers and inhibitors, and evaluated their current status in . This video demonstrates how to use the SOCRATES acronym when taking a history of pain or other symptoms. Evaluation of the maximum tolerated dose. CYP450 Table Substrates, Inducers, and Inhibitors of Cytochrome P450 Preventing Drug-Drug Interactions in Psychiatry CYP450 Substrates 1A2 asenapine chlorpromazine clonidine clozapine duloxetine fluvoxamine lorcaserin loxapine olanzapine paliperidone propranolol ramelteon selegiline tasimelteon thiothixene Caffeine theophylline warfarin The following terms are used to describe dose-response relationships: The effect of a drug can decrease with repeated dosing: Carbamazepine acts as both substrate and inducer of CYP3A4. Includes information found online including these sites: "Indiana University Department of Medicine Clinical Pharmacology Drug Interactions Flockhart Table ", "INHIBITORS, INDUCERS AND SUBSTRATES OF CYTOCHROME P450 ISOZYMES", "The Life Raft Group: Long List of Inhibitors and Inducers of CYP3A4 and CYP2D6", "DRUGBANK Online: Cytochrome P-450 Enzyme Inhibitors", "MEDICATIONS METABOLIZED BY CYTOCHROME P450 3A4", https://en.wikipedia.org/w/index.php?title=List_of_cytochrome_P450_modulators&oldid=1136878915, This page was last edited on 1 February 2023, at 16:54. Please consult a healthcare professional for medical advice. Protease Inhibitors and Corticosteroids PICk your FAT somewhere else! DDI data were collected based on a search of the University of Washington Metabolism and Transport Drug Interaction Database [Hachad et al. Subscribe to our newsletter to be the first to know about our latest content: https://geekymedics.com/newsletter/ For example, CYP2D6 polymorphisms are expressed in four different phenotypes: Poor metabolisers are characterised by the inability to metabolise drugs via the CYP2D6 metabolic pathway, resulting in an increased risk of adverse effects and toxicity. Note: Index inhibitors predictably inhibit metabolism via a given pathway and are commonly used in prospective clinical DDI studies. Instagram: https://instagram.com/geekymedics A hyperactive variant of the enzyme decreases the drug response. Sulfa Drug Reactions. In the spirit of saving the best for last, in this issue, we will discuss the most important of all CYP450 enzymes: CYP3A4. Chapters: These genetic variabilities are responsible for the inter-individual variability in therapeutic response and toxicity to all major classes of drugs given at the standard dose. Cannot be overcome by increasing the drug dose. Cytochrome P450 3A (including 3A4) inhibitors and inducers For drug interaction purposes, the inhibitors and inducers of CYP3A metabolism listed above can alter serum concentrations of drugs that are dependent upon the CYP3A subfamily of liver enzymes, including CYP3A4, for elimination or activation. Because of inherited (genetic) traits that cause variations in these enzymes, medications may affect each person differently. - Geeky Medics OSCE App: https://geekymedics.com/geeky-medics-app/ Drug Interactions & Labeling, Recalls, Market Withdrawals and Safety Alerts, Drug Development and Drug Interactions | Table of Substrates, Inhibitors and Inducers, Drug Interactions | Relevant Regulatory Guidance and Policy Documents, Drug Development and Drug Interactions | Resources, and the list of references is available here, Examples of clinical substrates, inhibitors, and inducers, Examples of clinical substrates, inhibitors and inducers. What induces CYP450? This enzyme catalyzes the hydroxylation of aryl compounds, thus generating more polar metabolites that can be easily excreted. As a result, patients may experience breakthrough bleeding and potential contraceptive failure. Warfarin is used for the treatment and prevention of life-threatening abnormal blood clots such as deep vein thrombosis, myocardial infarction, and strokes. Read the, Drug reaction with eosinophilia and systemic symptoms, https://www.nccn.org/patients/resources/clinical_trials/phases.aspx, https://prsinfo.clinicaltrials.gov/definitions.html#StudyPhase, https://www.fda.gov/patients/learn-about-expanded-access-and-other-treatment-options/understanding-unapproved-use-approved-drugs-label, https://www.fda.gov/industry/medical-products-rare-diseases-and-conditions/designating-orphan-product-drugs-and-biological-products, https://www.fda.gov/news-events/expanded-access/expanded-access-information-patients, https://www.fda.gov/drugs/enforcement-activities-fda/unapproved-drugs, https://www.deadiversion.usdoj.gov/schedules/, Development of a substance with therapeutic potential or taking a decision to repurpose an existing substance, Research: submitted by a physician representing research or clinical institution, Commercial: submitted by a representative of a commercial organization, e.g., drug company. Moderate number of patients with a specific disease, Final confirmation of safety and evaluation of, against placebo or the current standard of care, control trial with a large number of patients with a specific disease, number of patients with a specific disease after drug approval. CYP3A group (includes 4,5,7) Substrates: Inhibitors: Inducers: Amiodarone: Cimetidine Drugs that cause CYP450 drug interactions are referred to as either inhibitors or inducers. 2D6, 3A4, 2C8) based on their structure. The inhibitors below cause a 5- to 10-fold increase in the AUC of sensitive substrate(s): ceritinib, clarithromycin(h),idelalisib, nefazodone, nelfinavir. YoU'RE Having a MEGA BLAST with Plays, Music, and Snacks! Inhibitors prevent the CYP450 enzymes from working or reduce the rate of an enzyme-catalysed reaction. DDI data were collected based on a search of the University of Washington Metabolism and Transport Drug Interaction Database [Hachad et al. - Over 3000 Free MCQs: https://geekyquiz.com/ Diuretics, Alcohol, Corticosteroids, Valproic acid, Azathioprine and Didanosine are Drugs that Abrupty Cause Violent Abdominal Distress. Pyrazinamide, Furosemide, Niacin, Cyclosporine and Thiazides may induce Pain on your Feet, Needle-shaped Crystals, and Tophi (gout). (2010), Hum Genomics, 5(1):61]. As a result, the anticoagulant effect of warfarin is increased, measured by an increase in the international normalised ratio (INR). Note: A clinical substrate should meet the following criteria: This table provides examples of clinical substrates for various transporters and is not intended to be an exhaustive list. Table 3-1: Examples of clinical substrates forCYP-mediated metabolism (for concomitant use in clinical DDI studies and/or drug labeling), alosetron, caffeine, duloxetine, melatonin, ramelteon, tasimelteon, tizanidine, clozapine, pirfenidone, ramosetron, theophylline, glimepiride, phenytoin, tolbutamide, S-warfarin, diazepam, lansoprazole(d), rabeprazole, voriconazole, atomoxetine, desipramine, dextromethorphan, eliglustat(e), nebivolol, nortriptyline, perphenazine, tolterodine, R-venlafaxine, encainide, imipramine, metoprolol, propafenone, propranolol, tramadol, trimipramine, S-venlafaxine. INHIBITORS - CYTOCHROME P450 (CYP) ENZYMES DRUG TABLE: CYP1A2 : CYP2B6 : CYP2C8 : CYP2C9 : CYP2C19 : CYP2D6 : CYP2E1 : CYP3A4 : Genetic Polymorphisms : Genetic Polymorphisms: Genetic Polymorphisms: Genetic Polymorphisms : Amiodarone Atazanavir Cimetidine Ciprofloxacin Citalopram Clarithromycin Diltiazem Enoxacin Erythromycin Estradiol . Thus, for correct interpretation of clinical DDI results, pre-assessment of the inhibitory effects of an investigational drug on CES activity should be considered. Pharmaceuticals and the cytochrome P450 isoenzymes: A tool for decision making. You can check out our guide to using SOCRATES here: https://geekymedics.com/the-socrates-acronym-in-history-taking/ Structureactivity relationships and drug design. - Examples 05:45 However, the reverse applies to prodrugs (drugs that are converted to their active forms in the body). This table provides examples of clinical index inducers and is not intended to be an exhaustive list. Study with Quizlet and memorize flashcards containing terms like Chronic alcohol use, Modafinil, St John's wart and more. Defects in renal, hepatic, or cardiac function can impair drug clearance. Strong inhibitor being one that causes at least a five-fold increase in the plasma AUC values, or more than 80% decrease in clearance. E.M. de Groene is an academic researcher from Utrecht University. Cytochrome P450 drug interaction. The amount of a certain drug needed to achieve a steady target plasma concentration. A collection of surgery revision notes covering key surgical topics. Drugs that are eliminated by the liver may attain high serum concentrations when hepatic function is impaired, which increases the risk of drug toxicity. Learn how your comment data is processed. Each clinical case scenario allows you to work through history taking, investigations, diagnosis and management. a Strong inhibitor of CYP1A2 and CYP2C19, moderate inhibitor of CYP3A, and weak inhibitor of CYP2D6.b Moderate inhibitor of CYP2C8 and a weak inhibitor of CYP2B6.c Strong inhibitor of CYP2C19 and a weak inhibitor of CYP2B6. Patients should be advised to seek immediate medical attention if they experience any signs of bleeding, which include unexplained bruising, nose bleeds, or blood in their urine.5, Watch this video to find out the most COMMONLY FORGOTTEN components of the cardiovascular history! Save this video to help prepare for your upcoming OSCEs and dont forget to follow Geeky Medics! Abbreviations: properties of the drug, safety and toxicity. You have 3 free member-only articles left this month. > Some Common Substrates, Inhibitors and Inducers of CYP450 Isoenzymes. In poor metabolisers, the metabolism of propranolol is greatly reduced. DDI data were collected based on a search of the University of Washington Metabolism and Transport Drug Interaction Database [Hachad et al. 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