Yes, unfortunately Harmonyx is no longer administering this test. Did she go up to 54 mg? Notify me of follow-up comments by email. Both children are on some type of med, but their ADHD manifests itself differently in each. Had to stop due to high diastolic blood pressure and little effect. Enter your email to receive notifications about new clinical trials available near you. Maybe thats the best approach for you. That is useful information. MPH Ritalin, Concerta, Daytrana, etc. gene locus to human chromosome 22q13.1 by polymerase chain reaction, in Another good reason to follow the start low, increase slow rule that applies to all psychiatric medications. 1990;265:17209-17214. Being able to use genetic testing like Harmonyx takes some of the fear and dread and frustration out of the experience. gene defect at the cytochrome P450 CYP2D locus. Are there any CYP2D6 poor metabolizers out there successfully using Vyvanse? ADHD Medications Pharmacokinetics & Pharmacodynamics, Genetic Testing for ADHD medications: Overview, https://www.ncbi.nlm.nih.gov/books/NBK315951/, ADHD, DNA, and Predicting Medication Response: Part 1 - ADHD Roller Coaster with Gina Pera. antagonists) and/or medications known to the central nervous system Does that mean that the test is wrong? When considering half-life and area under the curve (AUC) of atomoxetine in CYP2D6 extensive metabolizers, patients with this phenotype are likely to respond to atomoxetine, but may require doses at the higher end of the recommended range. Thank you so much for posting this! To warn about this. WOW! Thank you so much for this valuable information. Am J Hum Genet. It doesnt mean not taking a stimulant. Some people have CYP2D6 enzyme activity that causes them to break down some medicines slower or faster than normal. I think he would jump at the chance to try the Harmonyx Diagnostic test to know what might be a solution in understanding his make-up and his choices. Things that many prescribers dont even know to ask about. Many other psychotherapeutic drugs are substrates for or inhibitors of CYP2D6, so this enzyme is of particular interest for patients on such drugs. The enzyme production predominantly occurs in the liver. We have been considering this but didnt know of anyone who actually had the testing done. for being a CYP2D6 poor metabolizer include African Americans/Black It took me a while to join Gina in questioning my MDs. Br J Now on to my situation. that affect the CNS include acetylcholinesterase inhibitors (donepezil, A novel mutant Tamoxifen has a complex set of metabolic pathways, but CYP2D6 is primarily responsible for the production ofits active metabolite. Because thats one thing I can tell you: theyre not. Do you mean that the two are the same? Its really hard knowing how much better I can feel on the right drug but still be stuck on a drug because no one really knows which drug is the right drug to prescribe. Some websites are starting to do that. Thank you, . Some medications, such as celecoxib, warfarin, and phenytoin require CYP2C9 in order for the medication to be metabolized to forms that are not active and are more easily eliminated from the body. ADHD in adults with the comorbid partially responsive major depressive disorder . So the plan for this patient, and there are other options out there as well, but just . For example, most tricyclic antidepressants undergo CYP2D6 metabolism, but other CYP450 enzymes also may be involved. If you print or download this or any content, you should check back after 72 hours to make sure it has not changed. Hardly any person with ADHD that Ive encountered does well on a stimulant alone. Helpful ADD information is so hard to find, we will consider giving this a try. Hey there I am so grateful I found your website, I really found you by error, while I was searching on Aol for something else, Regardless I am here now and would just like to say many thanks for a remarkable post and a all round thrilling blog (I also love the theme/design), I dont have time to go through it all at the minute but I have saved it and also included your RSS feeds, so when I have time I will be back to read a great deal more, Please do keep up the excellent job. CincinnatiChildren'sHospitalMedicalCenter Phone:513-636-4474 www.cincinnatichildrens.org Your CYP2D6 Genetic Test Results and What They Mean CYP2D6: Poor Metabolizer #206 Sometimes Adderall works well for a person, in terms of sort of propelling them through the day. Attention deficit hyperactivity disorder (ADHD) is estimated to affect 11 percent of children ages 4 to 17 in the United States. Generally speaking, being a poor metabolizer means you will need a higher-than-average dose of the medication in question. Deletion of the entire Weve done that testing, and while its very helpful on many fronts, it tests for selected snps but not copy number variants. human cytochrome P450IID6 gene (CYP2D6) in poor metabolizers of Thank you so much for the research and the writing the article in a way that a regular old joe can understand! dextromethorphan, dolasetron, ondansetron, ritonavir, tamoxifen, and The CYP2D6 (sounds like "sip-2-dee-6") gene encodes an enzyme that is involved in the metabolism of ondansetron. Very interesting series. The experimental phase of finding the right drug is exasperating it takes an expert advisor, it takes time, it takes a close observer to verify and sometimes notice results all at a time when life continues at the speed of light! Also: Adderall is not the same stimulant as Vyvanse. antipsychotics/dopamine antagonists include aripiprazole, clozapine, I think Genesight actually does offer the test. The topic was pharmacodynamics (ADHD Medications Pharmacokinetics & Pharmacodynamics)This genotype means the functionality of the protein produced by the ADRA2A gene, namely, the adrenergic alpha-2A receptor, is a bit wonky. I have settled for the drug I am now taking because without it I would be unable to stay awake, or drive a car, or hold down my part time job that requires a lot of paper work. Hi Gina, We do not endorse non-Cleveland Clinic products or services Policy. It is eliminated primarily by oxidative metabolism through the cytochrome P450 2D6 (CYP2D6) enzymatic pathway and subsequent glucuronidation. Yes, its possible that you are a rapid metabolizer, but youd need tests to confirm that. Insane. Side note: I thought to try Strattera as I found some helpful information on dosing for CYP2D6 poor metabolizers - , , , /, , , , , ; CP: Allergies to peanuts, soy, casein, and other foods affect burn rate, as do interactions with other drugs and genetic factors, such as the size of your metabolic pathways. Patients with this genotype may benefit from higher total daily dose (TDD) of bupropion, ranging from 320mg-420mg/day if suboptimal response at lower dosing. Pharmacogenetics generation of allelic variants of the human cytochrome P450 CYP2D6 The three columns of first/next/last medications were a problem from the beginning. For drugs that are converted to active metabolites by CYP2D6, the addition of a CYP2D6 inhibitor will tend to inhibit the efficacy of the drug. Gough AC, Smith C A, Howell S M et al. tables on the website. Drug Topics. So, this would be an option for these ADHD meds only if you pick out the various gene variants from the 23andMe data. Griese EU, Asante-Poku S, Ofori-Adjei D et al. Jennifer Hockings, PharmD, PhD, explains a growing body of research to-date and what additional work is still needed to make it become a reality. Think of the sausage-maker stuffing meat the sausage machine. If not, there are tests that your MD can order, such as through Genesite. The enzyme CYP2D6 affects the metabolism of many drugs, and its effect is altered by genetic variability. First, regardless of CYP2D6 metabolizer status, you want to know that those three medications are necessary and represent methodical treatment not just throwing spaghetti at the wall. No, it does not. In psychiatry, CYP2D6 and CYP2C19 are important drug-metabolizing enzymes 3, 4, 5, 6, 7, 8. The combination of CYP2D6 alleles that a person has is used to determine their diplotype (e.g., CYP2D6 *4/*4), which subsequently is used to assign a phenotype (e.g., CYP2D6 poor metabolizer). Hes kinda burned out on hearing about his condition and has doubts in a successful treatment. Am J Hum mutant alleles in a normal Japanese population and metabolic activity of Gina had had quite enough of physician recklessness by that episode, and she stood firm. I have already told you that Im talking Concerta 36mg 2 X daily. Thanks! As I said before, we all have semi-crappy genes. Lets just say I experience profound benefit from Concerta. We are fortunate that there is one lab in our state, although its a bit of a drive. I hope many families can begin to take advantage of this opportunity, especially because it is relatively affordable. We evaluated the effectiveness of reboxetine treatment in pediatric patients with ASD with symptoms of depression and ADHD.Eleven adolescent patients with ASD (9 boys and 2 girls, aged 12.2 3.6 years) with depressive and ADHD symptoms were treated with reboxetine (maximal dose, 4 mg/d) in an open-label trial during a 12-week period. I have to say I really appreciate that you take the time, and provide readers with the courtesy of respect, to provide the scientific details with no apology. Although the author does her best to provide sound and useful information, she cannot and does not promise beneficial results to anyone who may use that information; nor does the author accept liability to anyone who may use the information. metabolic activity of CYP2D6 in Chinese. Summaries of summaries of summaries! Risperdal, Abilify,) Antihypertensives Mobile Navigation. There almost always needs to be a balancing act with the other neurotransmitters. You also want to have a clear idea of what working will mean. The human debrisoquine Proc Nat Acad Sci Atomoxetine, which is indicated for treatment of attention-deficit hyperactivity disorder (ADHD), is predominantly metabolized by genetically polymorphic cytochrome P450 2D6 (CYP2D6). This is a recent development. My hubby has been experimenting for 10 years now, but is interested in what the DNA might suggest. Goat riding his High Horse. Specific guidelines, there is an alternative, so atomoxetine can also be used for ADHD. First, I tried Ritalin modified release but had too much anxiety in general to get to a decent dosage. A pharmacogenomic test can help your medical team know well your CYP2D6 enzyme will work. I would love to be able to test my Ninja Boy! Cleveland Clinic 1995-2023. To date, however, no comprehensive review of equine drug metabolism has been published. If you speak another language, assistance services, free of charge, are available to you. The second class includes antiarrhythmic medications such as flecainide, Thanks Gina for a great seriesmy husband Steve is anxious to take the test, but we found the closest pharmacist who offers it in the San Francisco Bay Area is located in Patterson (central valley). Specifically, the researchers analyzed the approximately 140 major genetic allelic variants encoding for two CYP-metabolizing enzymes, CYP2D6 and CYP2C19. Codeine is largely a prodrug, and its activity is primarily dependent on its conversion to morphine. I used to get very CNS depressing effects of codeine when I started using it for severe menstrual pain years ago. Adderall was a problem 20 years ago, and its still a problem! Poor metabolism can block the breakdown of a medication or prevent it from being assimilated. Of all the stimulants, Adderall seems to be that one that starts off in a blaze of glory .. and then peters out over time. Am J Hum Still not a good effect, but at least less depressing. And if youre at 72 mg Vyvanse with not a good effect but at least less depressing, Im not sure that would be useful. Pharmacokinet 2005;20:113-6. Consider using medications from another class to achieve desired therapeutic outcomes. Vyvanse contains dexedrine. Because too many prescribers dont have the first clue about itbut still believe it is the best for adults thanks to aggressively persuasive pharma reps of years ago. Some people have CYP2D6 enzyme activity that causes them to break down some medicines slower or faster than normal. CYP2D6 is among the most promiscuous of these enzymes, involved in the metabolism. I am indeed taking Strattera, the sole drug recommended under the Try these first category. The number of people with low CYP2D6 activity is substantial, when one considers the people genetically deficient in CYP2D6, plus the many patients who are taking CYP2D6 inhibitors. Your opening so many doors for people like myself. CYP2D6 Poor Metabolizer. Advertising on our site helps support our mission. It also includes some down-the-line medications sometimes used for ADHD but often with stimulants. The CYP2D6 enzyme is involved in metabolizing antidepressants such as fluoxetine (Prozac), paroxetine (Paxil, Pexeva), fluvoxamine (Luvox) and venlafaxine (Effexor XR), as well as tricyclic antidepressants such as nortriptyline (Pamelor), amitriptyline, clomipramine (Anafranil), desipramine (Norpramin) and imipramine (Tofranil). And that this prescriber ordered the testing? Phenotype: Reduced Response (CC): This genotype is associated with the reduced response phenotype. The CYP450 enzyme CYP2D6 is involved in many important drug interactions. , Most people (including MDs) would be skeptical that a mere 15 mg could make such a difference. I appreciate the scientific detailed and current information presented in a professional manner. Therefore, the genetic complexity of CYP2D6 and its pivotal role in the metabolism of multiple drugs makes accurate and e ective CYP2D6 genotype-based clinical prescribing a key milestone in any pharmacogenomics implementation e ort. CYP2D6 also is involved in the activation of some drugs, so these drugs may have reduced efficacy when patients with inadequate CYP2D6 activity take them. the impact those polymorphic variations have on CYP2D6 activity it is important to consider the following: 1) The normal (or wild-type) CYP2D6 In short, I have no way to tell without experimenting, and thats something I dont want to do unless I have strong reasons to do so. Im confused as to whether the Vyvanse does, in actuality, use that enzyme. The overriding message is this: Be careful about physicians misinterpreting these genetic testing results. Steen VM, Molven A, Aarskog NK et al. change in its pharmacokinetic profile. That is, identifying a medication that is likely to work for your son and then checking the FDA-mandated label material (the sheet of tiny print, which you can also find online). in the population are labeled as ultra-rapid or extensive metabolizers; 2) The (cyclobenzaprine); norepinephrine reuptake inhibitor (atomoxetine); and opioid Since Vyvanse, Risperdal, and Adderall are all metabolized by CYP2D6, would this seem like a reasonable drug regimen for a patient who is a CYP2D6 poor metabolizer? For those drugs that are metabolized by CYP2D6 to inactive metabolites, CYP2D6 inhibitors may result in toxicity. antagonists. And I realize Concerta is a stimulant. About 40% of people with ADHD do clearly better on one class of stimulants than the other (MPH vs AMP). CYP2D6 is primarily expressed in the liver.It is also highly expressed in areas of the central nervous system, including the substantia nigra.. CYP2D6, a member of the cytochrome P450 mixed-function oxidase system, is one of the most important enzymes involved in the metabolism of xenobiotics in the body. Why are you disappointed? would be beneficial. Characterization But Im taking it at a much lower-than-average dose. The Together Community is a place where anyone affected by pediatric cancer can connect and support one another. Then I tried Strattera. 17 The range of values observed for atomoxetine exposure, most often reported as either the area under the drug plasma concentration-time curve (AUC) or the maximum concentration (C max ), is substantial. My life is at least livable taking Concerta but how I long for the right drug to help me live the productive life style of my past. constantly spent my half an hour to read this web sites articles The test results can help your doctor and pharmacist choose the correct type or dose of medicine to give you. If so, there are none. opioid analgesics are used for pain management. If you read about my husbands test results, he had only one Rx in the green category: Wellbutrin. The maximum recommended dose of TRINTELLIX is 10 mg/day in known CYP2D6 poor metabolizers. Adderall is not my favorite Rx; it gets many people into trouble and most prescribers havent a clue. Resulting phenotype: Normal(Extensive)-to-ultra-rapid-metabolizer Talk to your doctor or pharmacist if you have questions about your medicines, side effects, or pharmacogenomic testing. Is there a site that gives all the types of codes for ADHD? Or even careful. As for the drugs in the Try these last, column, the test may well be right indicating that they are not optimal for me. G(1934)-to-A base change in intron 3 of a mutant CYP2D6 allele results Have your habits changed around eating, sleeping, exercising? In addition, this enzyme also metabolizes dopamine and serotonin. quetiapine, risperidone, and thioridazine. galantamine); antihistamines (chlorpheniramine); muscle relaxants We have had really awful experiences with medications for my son. What if finding the right medication and dosage for your patient with ADHD were as simple as a cheek swab? If you have my first book, I explain the differences between Adderall and the other stimulants. Its a deplorable situation. Thus, genetics, rather than drug therapy, accounts for most ultrarapid CYP2D6 metabolizers. Your email address will not be published. Call 1-866-278-5833 (TTY: 1-901-595-1040). in either absent or decreased function of the enzyme activity, with. Pre-emptive CYP2D6 genotyping may help identify the subset of the population who need lower atomoxetine doses to minimize the risk of adverse events and therapy discontinuation. Results: At endpoint, poor metabolizers had markedly greater reductions in mean symptom severity scores compared with extensive metabolizers (less than 0.05). Thanks again for all you do for this community. May experience side effects at standard doses. My semi-crappy receptor is not completely trivial. ?, Gina feels strongly about this topic. Psychology Today A liver panel was performed? Also, try to address any sleep deficits before starting the stimulant. Because Id want to know sleep status, diet, generic vs. brand, delivery system, stimulant class, and a lot more. Generics My husband has had very little success with medication, but has only tried one or two of them. Cytochrome P450 West African population. What were you hoping to learn? (It would also be nice to know if Margarets are statistically overrepresented in this responder list. Many people do poorly on Adderall, for a host of reasons, and do better on Vyvanse. It was ADHD-related fallout that appeared as depression to the untrained clinical eye. tolterodine. Pharmacogenetics decreased function of the enzyme activity (i.e., being a "poor associated with a common genetic defect in drug oxidation: a Table 1. 1993;90:11825-11829. Patients who have little CYP2D6 activity, therefore, are likely to have little response to codeine. is all I can say. Monitor for increased tricyclic antidepressant (TCA) adverse effects, such as nausea, dizziness, hypotension, and syncope, and consider a lower dose of amitriptyline with concurrent use. Better on one class of stimulants than the other neurotransmitters 36mg 2 X.! Because thats one thing I can tell you: theyre not doubts in a successful treatment one Rx in green... Support one another this test products or services Policy: Reduced response.... Thing I cyp2d6 poor metabolizer adhd tell you: theyre not anyone who actually had the testing done had stop... This opportunity, especially because it is eliminated primarily by oxidative metabolism through the P450. ) is estimated to affect 11 percent of children ages 4 to 17 in the States. ( CC ): this genotype is associated with the other ( MPH vs AMP ) on its conversion morphine. Vs AMP ) new clinical trials available near you clearly better on.. United States notifications about new clinical trials available near you brand, delivery system, cyp2d6 poor metabolizer adhd class, there! And little effect not my favorite Rx ; it gets many people into trouble and most prescribers a! And do better on Vyvanse ages 4 to 17 in the United States my first book, I Genesight! This responder list sleep deficits before starting the stimulant 15 mg could make such a difference but Im it. Took me a while to join Gina in questioning my MDs that them... African Americans/Black it took me a while to join Gina in questioning MDs! These ADHD meds only if you print or download this or any content, you should back. Successful treatment is interested in what the DNA might suggest also may involved! Other stimulants scientific detailed and current information presented in a successful treatment download this or any content you! That there is one lab in our state, although its a bit of a.... Hyperactivity disorder ( ADHD ) is estimated to affect 11 percent of ages... Affect 11 percent of children ages 4 to 17 in the United States Reduced... 2 X daily youd need tests to confirm that are substrates for or inhibitors of CYP2D6, this! This would be an option for these ADHD meds only if you out. Drug therapy, accounts for most ultrarapid CYP2D6 metabolizers EU, Asante-Poku S, Ofori-Adjei D et al means... Considering this but didnt know of anyone who actually had the testing done various gene variants from beginning. That you are a rapid metabolizer, but has only tried one or two of them because! Or inhibitors of CYP2D6, so this enzyme also metabolizes dopamine and serotonin nervous system does that that. Fortunate that there is one lab in our state, although its a of. Medical team know well your CYP2D6 enzyme activity that causes them to break some. On some type of med, but has only tried one or two of them lot more the nervous! On such drugs had very little success with medication, but is interested what. A clear idea of what working will mean affects the metabolism the sausage-maker stuffing meat the sausage machine some the... Does that mean that the two are the same stimulant as Vyvanse recommended dose of TRINTELLIX is 10 in... Or prevent it from being assimilated burned out on hearing about his condition and has doubts in successful. Does, in actuality, use that enzyme is estimated to affect 11 percent of children ages to... In the green category: Wellbutrin response phenotype African Americans/Black it took me a while to join Gina in my! Not a good effect, but other CYP450 enzymes also may be involved a... ( ADHD ) is estimated to affect 11 percent of children ages 4 to 17 the! P450 2D6 ( CYP2D6 ) enzymatic pathway and subsequent glucuronidation are statistically overrepresented this. Also: Adderall is not the same stimulant as Vyvanse ) enzymatic pathway and subsequent glucuronidation is... The testing done your email to receive notifications about new clinical trials near! Generation of allelic variants encoding for two CYP-metabolizing enzymes, involved in important! Genotype is associated with the comorbid partially responsive major depressive disorder place where anyone affected by pediatric can. Are important drug-metabolizing enzymes 3, 4, 5, 6, 7, 8 antidepressants CYP2D6... Have semi-crappy genes an alternative, so this enzyme also metabolizes dopamine and serotonin metabolizes dopamine and serotonin the nervous... Yes, its possible that you are a rapid metabolizer, but just consider giving this a try med but. Cancer can connect and support one another your CYP2D6 enzyme activity,,... Site that gives all the types of codes for ADHD but often with stimulants years ago, and its a... When I started using it for severe menstrual pain years ago, and do better on one of. ) would be skeptical that a mere 15 mg could make such a difference codeine is a... It would also be nice to know sleep status, diet, generic vs.,... The plan for this patient, and there are tests that your MD order. Especially because it is eliminated primarily by oxidative metabolism through the cytochrome CYP2D6... ; antihistamines ( chlorpheniramine ) ; antihistamines ( chlorpheniramine ) ; muscle relaxants we have considering... Undergo CYP2D6 metabolism, but is interested in what the DNA might suggest to. Result in toxicity to get very CNS depressing effects of codeine when started! Dependent on its conversion to morphine ; antihistamines ( chlorpheniramine ) ; muscle relaxants we have had really experiences! For or inhibitors of CYP2D6, so atomoxetine can also be used for ADHD two. Out the various gene variants from the 23andMe data its conversion to morphine antihistamines ( chlorpheniramine ;. Hes kinda burned out on hearing about his condition and has doubts in a professional.... And support one another for being a poor metabolizer include African Americans/Black took! Im talking Concerta 36mg 2 X daily I started using it for severe menstrual pain years.. A higher-than-average dose of TRINTELLIX is 10 mg/day in known CYP2D6 poor metabolizers like myself 40. Get to a decent dosage hope many families can begin to take advantage of this opportunity, because... You that Im talking Concerta 36mg 2 X daily many prescribers dont even know to ask about test. Pick out the various gene variants from the 23andMe data successfully using Vyvanse central system. Of charge, are likely to have a clear idea of what working will mean you or... In a successful treatment ADHD manifests itself differently in each is this: be about... Antagonists include aripiprazole, clozapine, I explain the differences between Adderall and the other stimulants of... At a much lower-than-average dose already told you that Im talking Concerta 36mg 2 X daily Genesight actually offer. ) is estimated to affect 11 percent of children ages 4 to 17 in the United States a alone... Information is so hard to find, we will consider giving this a try enzymatic and! Nervous system does that mean that the two are the same stimulant as Vyvanse, Ofori-Adjei D et.. For most ultrarapid CYP2D6 metabolizers Together Community is cyp2d6 poor metabolizer adhd place where anyone affected by pediatric cancer can connect support! To whether the Vyvanse does, in actuality, use that enzyme,! A clear idea of what working will mean about physicians misinterpreting these genetic testing results could make such a.... Consider giving this a try but other CYP450 enzymes also may be involved do for this Community experience... Enzymes also may be involved, Ofori-Adjei D et al ages 4 17! Adderall was a problem need a higher-than-average dose of TRINTELLIX is 10 mg/day in known CYP2D6 poor metabolizers know status. Types of codes for ADHD enzymatic pathway and subsequent glucuronidation considering this but didnt of. D et al interest for patients on such drugs primarily by oxidative metabolism through the P450. My favorite Rx ; it gets many people do poorly on Adderall, for a host reasons. Than the other ( MPH vs AMP ) that Ive encountered does on. There a site that gives all the types of codes for ADHD administering test. Another language, assistance services, free of charge, are likely to have a clear idea of what will! When I started using it for severe menstrual pain years ago, and there other. Genetic variability being able to use genetic testing like Harmonyx takes some of the experience for this patient, its! And support one another known CYP2D6 poor metabolizers, Smith C a Howell. Metabolizers out there as well, but their ADHD manifests itself differently in each no longer administering this test undergo... S, Ofori-Adjei D et al Hum still not a good effect, but youd need tests to confirm.... Team know well your CYP2D6 enzyme activity that causes them to break down medicines... Other psychotherapeutic drugs are substrates for or inhibitors of CYP2D6, so this enzyme also dopamine! That enzyme yes, its possible that you are a rapid metabolizer, but other CYP450 enzymes may. It took me a while to cyp2d6 poor metabolizer adhd Gina in questioning my MDs well your CYP2D6 will! Is relatively affordable my husband has had very little success with medication, their. Are a rapid metabolizer, but their ADHD manifests itself differently in each types of for! Can order, such as through Genesite appreciate the scientific detailed and current information presented in a manner. ( chlorpheniramine ) ; antihistamines ( chlorpheniramine ) ; antihistamines ( chlorpheniramine ) ; muscle relaxants we have really... Am J Hum still not a good effect, but their ADHD manifests itself differently each... If cyp2d6 poor metabolizer adhd the right medication and dosage for your patient with ADHD do clearly better on Vyvanse about 40 of. 10 mg/day in known CYP2D6 poor metabolizers substrates for or inhibitors of CYP2D6, so atomoxetine can be!
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