Mrs. Gupta is prescribed omeprazole, a proton pump inhibitor metabolized primarily by CYP2C19. Her pharmacogenomic report shows she is a CYP2C19 ultra-rapid metabolizer. Based on this genetic profile, what clinical outcomes should be anticipated, and how should her treatment be adjusted?[Fill in the blank]

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Question restatement: Mrs. Gupta, on omeprazole (a proton pump inhibitor), has a pharmacogenomic profile showing CYP2C19 ultra-rapid metabolizer. Based on this genotype, what clinical outcomes should be anticipated, and how should treatment be adjusted?

Option a: Increased efficacy of omeprazole, consider a lower dose.
- Why it’s not correct: An ultra-rapid metabolizer clears CYP2C19 substrates like omeprazole more quickly, leading to lower, not higher, drug exposure. Therefore, increased efficacy is unlikely, and a lower dose would risk under-treatment.

Option b: Decreased efficacy of omeprazole, consider a higher dose or alternative therapy.
- Why it’s correct: Faster metabolism reduces the drug’s plasma concentration and duration of action, diminishing efficacy. To counteract this, a higher dose or switching to a non-CYP2C19–dependent therapy can help achieve the desired therapeutic effect. This aligns with pharmacogenomic guidance for ultra-rapid metabolizers.

Option c: Increased risk of adverse effects, switch to a non-CYP2C19 substrate drug.
- Why it’s incorrect: The ultra-rapid phenotype typically lowers drug exposure rather than increasing adverse effects. A higher clearance reduces systemic exposure, making adverse effects less likely, not more likely. Switching to a non-substrate may be considered for other reasons, but not because of an increased risk of adverse effects from rapid metabolism.

Option d: No dose adjustments needed, efficacy is unaffected by CYP2C19 genotype.
- Why it’s incorrect: For drugs like omeprazole that are primarily metabolized by CYP2C19, genotype can meaningfully affect pharmacokinetics and efficacy. An ultra-rapid metabolizer phenotype suggests that standard dosing may be insufficient, so assuming no adjustment is inappropriate.

Summary of reasoning across options: The key concept is that CYP2C19 ultra-rapid metabolism accelerates omeprazole clearance, reducing drug exposure and clinical efficacy. Therefore, a higher dose or an alternative therapy not heavily reliant on CYP2C19 metabolism is often considered. The other options misinterpret the impact of rapid metabolism on efficacy or safety, or incorrectly state that genotype has no effect on dosing.

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