CYP Enzymes

In vitro

Table 1: Chemical inhibitors for in vitro experiments* (9/25/2006)

Inhibitor (1) Ki Inhibitor (1) Ki

CYP
Preferred (µM) Acceptable (µM)
1A2 furafylline (2) 0.6-0.73 a -naphthoflavone 0.01
2A6 tranylcypromine 0.02-0.2 pilocarpine 4
methoxsalen (2) 0.01-0.2 tryptamine 1.7 (3)
2B6 3-isopropenyl-3-methyl diamantane (4) 2.2
2-isopropenyl-2-methyl adamantane (4) 5.3
sertraline 3.2 (5)
phencyclidine 10
triethylenethiophosphoramide (thiotepa) 4.8
clopidogrel 0.5
ticlopidine 0.2
2C8 montelukast trimethoprim 32
quercetin 1.1 gemfibrozil 69-75
rosiglitazone 5.6
pioglitazone 1.7
2C9 sulfaphenazole 0.3 fluconazole 7
fluvoxamine 6.4-19
fluoxetine 18-41
2C19 ticlopidine 1.2
nootkatone 0.5
2D6 quinidine 0.027-0.4
2E1 diethyldithiocarbamate 9.8-34
clomethiazole 12
diallyldisulfide 150
(6)
3A4/5 ketoconazole 0.0037- 0.18 azamulin
itraconazole 0.27, 2.3 troleandomycin 17
verapamil 10, 24

* Note that this is not an exhaustive list which was created May 1, 2006.

1. Substrates used for inhibition studies include: CYP1A2, phenacetin-o-deethylation, theophylline-N-

demethylation; CYP2A6, coumarin-7-hydroxylation; CYP2B6, 7-pentoxyresorufin-O-
depentylation, bupropion hydroxylation, 7-ethoxy-4-(trifluoromethyl)-coumarin O-deethylation, S-
mephenytoin-N-demethylation; Bupropion-hydroxylation; CYP2C8, taxol 6-alpha-hydroxylation;
CYP2C9, tolbutamide 4-methylhydroxylation, S-warfarin-7-hydroxylation, phenytoin 4-
hydroxylation; 2CYP2C19, (S)-mephenytoin 4-hydroxylation CYP2D6, dextramethorphan O-
demethylation, desbrisoquine hyddroxylase; CYP2E1, chlorzoxazone 6-hydroxylation, aniline 4-
 hydroxylase; CYP3A4/5, testosterone-6ß-hydroxylation, midazolam-1-hydroxylation; cyclosporine
hydroxylase; nefedipine dehydrogenation.
2. Furafylline and methoxsalen are mechanism-based inhibitors and should be pre-incubated before
adding substrate.
3. cDNA expressing microsomes from human lymphoblast cells.
4. Supersomes, microsomal isolated from insect cells transfected with baculovirus containing CYP2B6.
5. IC50 values.
6. Specific time-dependent inhibitor.

Table 2. Preferred and acceptable chemical substrates for in vitro experiments* (9/25/2006)

CYP Substrate Km Substrate Km

Preferred (µM) Acceptable (µM)
1A2 phenacetin-O-deethylation 1.7-152 7-ethoxyresorufin-O-deethylation 0.18-0.21
theophylline-N-demethylation 280-1230
caffeine-3-N-demethylation 220-1565
tacrine 1-hydroxylation 2.8, 16
2A6 coumarin-7-hydroxylation 0.30-2.3
nicotine C-oxidation 13-162
2B6 efavirenz hydroxylase 17-23 propofol hydroxylati on 3.7-94
bupropion-hydroxylation 67-168 S-mephenytoin-N-demethylation 1910
2C8 Taxol 6-hydroxylation 5.4-19 amodiaquine N-deethylation 2.4,
rosiglitazone para-hydroxylation 4.3-7.7
2C9 tolbutamide methyl-hydroxylation 67-838 flurbiprofen 4’-hydroxylation 6-42
S-warfarin 7-hydroxylation 1.5-4.5 phenytoin-4-hydroxylation 11.5-117
diclofenac 4’-hydroxylation 3.4-52
2C19 S-mephenytoin 4’-hydroxylation 13-35 omeprazole 5-hydroxylation 17-26
fluoxetine O-dealkylation 3.7-104
2D6 ( ± )-bufuralol 1’-hydroxylation 9-15 debrisoquine 4-hydroxylation 5.6
dextromethorphan O-demethylation 0.44-8.5
2E1 chlorzoxazone 6-hydroxylation 39-157 p-nitrophenol 3-hydroxylation 3.3
lauric acid 11-hydroxylation 130
aniline 4-hydroxylation 6.3-24
3A4/5** midazolam 1-hydroxylation 1-14 erythromycin N-demethylation 33 – 88
dextromethorphan N-demethylation 133-710
triazolam 4-hydroxylation 234
testosterone 6 b -hydroxylation 52-94 terfenadine C-hydroxylation 15
nifedipine oxidation 5.1- 47

* Note that this is not an exhaustive list (created May 1, 2006).

** Recommend use of 2 structurally unrelated CYP3A4/5 substrates for evaluation of in vitro CYP3A
inhibition. If the drug inhibits at least one CYP3A substrate in vitro, then in vivo evaluation is warranted.
Table 3. In Vitro CYP Inducers (7/28/2011)

Recommended Reported
CYP In Vitro Inducer * Concentration Fold Induction
as Positive Controls (µM) of the Positive In Enzyme Activities
Controls
1A2 omeprazole 25-100 14-24
lansoprazole 10 10
2B6 phenobarbital 500-1000 5-10
2C8 rifampin 10 2-4
2C9 rifampin 10 3.7
2C19 rifampin 10 20
2D6 none identified
3A4 rifampin 10-50 4-31

In vivo

Table 4. Examples of in vivo substrate, inhibitor, and inducer of specific CYP enzymes
for evaluation (oral administration) (1) * (5/1/2006)

CYP Substrate Inhibitor Inducer

1A2 theophylline, caffeine fluvoxamine smokers versus
non-smokers (2)
2B6 efavirenz rifampin
2C8 repaglinide, rosiglitazone gemfibrozil rifampin
2C9 warfarin, tolbutamide fluconazole, amiodarone rifampin
(use of PM versus EM subjects) (3)
2C19 omeprazole, esoprazole, omeprazole, fluvoxamine, moclobemide rifampin
lansoprazole, pantoprazole (use of PM versus EM subjects) (3)
2D6 desipramine, paroxetine, quinidine, fluoxetine none identified
dextromethorphan, (use of PM versus EM subjects) (3)
atomoxetine
2E1 chlorzoxazone disulfirum ethanol
3A4/ midazolam, buspirone, atazanavir, clarithromycin, indinavir, rifampin,
3A5 felodipine, itraconazole, ketoconazole, nefazodone, carbamazepine
lovastatin, eletriptan, nelfinavir, ritonavir, saquinavir, telithromycin
sildenafil, simvastatin,
triazolam

* Note that this is not an exhaustive list (created May 1, 2006).

 1. Substrates for any particular CYP enzyme listed in this table are those with plasma AUC values
increased by 2-fold or higher when co-administered with inhibitors of that CYP enzyme; for
CYP3A, only those with plasma AUC increased by 5-fold or higher are listed. Inhibitors listed are
those that increase plasma AUC values of substrates for that CYP enzyme by 2-fold or higher.
2. For CYP3A inhibitors, only those that increase AUC of CYP3A substrates by 5-fold or higher are
listed. Inducers listed are those that decrease plasma AUC values of substrates for that CYP enzyme
by 30% or higher.
3. A clinical study can be conducted in smokers as compared to non-smokers (in lieu of an interaction
study with an inducer), when appropriate.
4. A clinical study can be conducted in poor metabolizers (PM) as compared to extensive metabolizers
(EM) for the specific CYP enzyme (in lieu of an interaction study with an inhibitor), when
appropriate.

Classification of Inhibitors

Table 5. Classification of In Vivo Inhibitors of CYP Enzymes(1) (7/28/2011)

Strong Inhibitors(2) Moderate inhibitors(3) Weak inhibitors(4)

CYP Enzymes ≥ 5-fold increase in AUC ≥ 2 but < 5-fold increase in ≥ 1.25 but < 2-fold increase in
or > 80% decrease in CL AUC AUC
or 50-80% decrease in CL or 20-50% decrease in CL
CYP1A2 Ciprofloxacin, enoxacin, Methoxsalen, mexiletine, Acyclovir, allopurinol, caffeine,
fluvoxamine oral contraceptives, cimetidine,
phenylpropanolamine, Daidzein,(5), disulfiram,
thiabendazole, zileuton Echinacea,(5) famotidine,
norfloxacin, propafenone,
propranolol, terbinafine,
ticlopidine, verapamil
CYP2B6 Clopidogrel, ticlopidine
prasugrel
CYP2C8 Gemfibrozil(6) Fluvoxamine, ketoconazole,
trimethoprim
CYP2C9 Amiodarone, fluconazole, Capecitabine, cotrimoxazole,
miconazole, oxandrolone etravirine, fluvastatin,
fluvoxamine, metronidazole,
sulfinpyrazone, tigecycline,
voriconazole, zafirlukast
CYP2C19 Fluconazole,(7) Esomeprazole, fluoxetine, Allicin (garlic derivative),
Fluvoxamine,(8) moclobemide, armodafinil, carbamazepine,
ticlopidine(9) omeprazole, voriconazole cimetidine,
etravirine,
human growth hormone
(rhGH),
felbamate,
ketoconazole,
oral contraceptives(10)
CYP3A Boceprevir, Amprenavir, aprepitant, Alprazolam, amiodarone,
clarithromycin, conivaptan, atazanavir, ciprofloxacin, amlodipine, atorvastatin,
 grapefruit juice,(11) darunavir/ritonavir, diltiazem, bicalutamide, cilostazol,
indinavir, itraconazole, erythromycin, fluconazole, cimetidine,
ketoconazole, fosamprenavir, grapefruit cyclosporine, fluoxetine,
lopinavir/ritonavir, juice,(11) fluvoxamine, ginkgo,(5)
mibefradil, (12) imatinib, verapamil goldenseal,(5)
nefazodone, nelfinavir, isoniazid, nilotinib,
posaconazole, ritonavir, oral contraceptives, ranitidine,
saquinavir, ranolazine,
telaprevir, tipranavir/ritonavir, zileuton
telithromycin,
voriconazole
CYP2D6 Bupropion, fluoxetine, Cinacalcet, duloxetine, Amiodarone, celecoxib,
paroxetine, quinidine terbinafine cimetidine, desvenlafaxine,
diltiazem, diphenhydramine,
Echinacea,(5) escitalopram,
febuxostat, gefitinib,
hydralazine,
hydroxychloroquine,
imatinib, methadone,
oral contraceptives,
propafenone, ranitidine,
ritonavir, sertraline,
telithromycin, verapamil
1. Please note the following: This is not an exhaustive list. For an updated list, see the following link
2. A strong inhibitor for a specific CYP is defined as an inhibitor that increases the AUC of a substrate
for that CYP by equal or more than 5-fold.
3. A moderate inhibitor for a specific CYP is defined as an inhibitor that increases the AUC of a
sensitive substrate for that CYP by less than 5-fold but equal to or more than 2-fold.
4. A weak inhibitor for a specific CYP is defined as an inhibitor that increases the AUC of a sensitive
substrate for that CYP by less than 2-fold but equal to or more than 5-fold.
5. Herbal product.
6. Gemfibrozil also inhibits OATP1B1.
7. Fluconazole is listed as a strong CYP2C19 inhibitor based on the AUC ratio of omeprazole, which is
also metabolized by CYP3A; fluconazole is a moderate CYP3A inhibitor.
8. Fluvoxamine strongly inhibits CYP1A2 and CYP2C19, but also inhibits CYP2C8/2C9 and CYP3A;
9. Ticlopidine strongly inhibits CYP2C19, but also inhibits CYP3A, CYP2B6, and CYP1A2.
10. Effect seems to be due to CYP2C19 inhibition by ethinyl estradiol.
11. The effect of grapefruit juice varies widely among brands and is concentration-, dose-, and
preparation-dependent. Studies have shown that it can be classified as a “strong CYP3A inhibitor”
when a certain preparation was used (e.g., high dose, double strength) or as a “moderate CYP3A
inhibitor” when another preparation was used (e.g., low dose, single strength).
12. Withdrawn from the United States market because of safety reasons.

Table 6. Classification of In Vivo Inducers of CYP Enzymes(1) (7/28/2011)

CYP Enzymes Strong Inducers Moderate Inducers Weak Inducers

≥ 80% decrease in AUC 50-80% decrease in AUC 20-50% decrease in AUC
CYP1A2 Montelukast, phenytoin, Moricizine, omeprazole,
smokers versus non- phenobarbital,
smokers(2)
CYP2B6 Efavirenz, rifampin Nevirapine
CYP2C8 Rifampin
CYP2C9 Carbamazepine, Aprepitant, bosentan,
rifampin phenobarbital, St. John’s
Wort(3,4)
CYP2C19 Rifampin Artemisinin
CYP3A Avasimibe,(5) Bosentan, efavirenz, etravirine, Amprenavir, aprepitant,
carbamazepine, phenytoin, modafinil, nafcillin armodafinil, echinacea,(4)
rifampin, St. John’s wort(3) pioglitazone, prednisone,
rufinamide
CYP2D6 None known None known None known

(1) For a drug that is a substrate of CYP1A2, the evaluation of the effect of induction of CYP1A2 can be
carried out by comparative PK studies in smokers vs. non-smokers.
(2) The effect of St. John’s wort varies widely and is preparation-dependent.
(3) Herbal product.
(4) Not a marketed drug.

Classification of Substrates

Table 7. Examples(1) of Sensitive In Vivo CYP Substrates and CYP Substrates with Narrow
Therapeutic Range (7/28/2011)

CYP Enzymes Sensitive substrates(2) Substrates with

narrow therapeutic range(3)
CYP1A2 Alosetron, caffeine, Theophylline, tizanidine
duloxetine, melatonin, ramelteon,
tacrine, tizanidine
CYP2B6 (4) Bupropion, efavirenz
CYP2C8 Repaglinide(5) Paclitaxel
CYP2C9 Celecoxib Warfarin, phenytoin
CYP2C19 Lansoprazole, omeprazole, S-mephenytoin S-mephenytoin
CYP3A(6) Alfentanil, aprepitant, budesonide, buspirone, Alfentanil, astemizole,(7)
conivaptan, darifenacin, darunavir, dasatinib, cisapride,(7) cyclosporine,
dronedarone, eletriptan, eplerenone, everolimus, dihydroergotamine,
felodipine, indinavir, fluticasone, lopinavir, lovastatin, ergotamine, fentanyl,
lurasidone, maraviroc, midazolam, nisoldipine, pimozide, quinidine,
quetiapine, saquinavir, sildenafil, simvastatin, sirolimus, sirolimus, tacrolimus,
tolvaptan, tipranavir, triazolam, vardenafil terfenadine(7)
CYP2D6 Atomoxetine, desipramine, Thioridazine
dextromethorphan, metoprolol,
nebivolol, perphenazine, tolterodine,
venlafaxine
(1) Sensitive CYP substrates refers to drugs whose plasma AUC values have been shown to increase 5-fold
or higher when co-administered with a known CYP inhibitor.
(2) CYP substrates with narrow therapeutic range refers to drugs whose exposure-response relationship
indicates that small increases in their exposure levels by the concomitant use of CYP inhibitors may lead to
serious safety concerns (e.g., Torsades de Pointes).
(3) The AUC of these substrates were not increased by 5-fold or more with a CYP2B6 inhibitor, but they
represent the most sensitive substrates studied with available inhibitors evaluated to date.
(4) Repaglinide is also a substrate for OATP1B1, and it is only suitable as a CYP2C8 substrate if the
inhibition of OATP1B1 by the investigational drug has been ruled out.
(5) Because a number of CYP3A substrates (e.g., darunavir, maraviroc) are also substrates of P-gp, the
observed increase in exposure could be due to inhibition of both CYP3A and P-gp.
(6) Withdrawn from the United States market because of safety reasons.